OR Connection Magazine - Volume 2; Issue 3

TheAligning practice with policy to improve patient care

Volume 2, Issue 3

2008

FREE CE CREDIT!See page 32

Slaying the“SUPERBUGS”

CMS

Make

Your Best YearEVER!

Back to Basics:Perioperative

Patient Positioning

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Aligning practice with policy to improve patient care 3

PATIENT SAFETY

8 Three Important National Initiatives for Improving Patient Care19 Handwashing vs. Hand Antisepsis26 Back to Basics: Perioperative Patient Positioning35 Counting & Accountability56 Imagine Ensuring Patient Safety with Standardized Sterile

Procedure Packs

OR ISSUES

18 APIC Grand Rounds38 Hypothermia41 Airborne Disease and Surgical Site Infection45 Preventing Mediastinitis50 SSIs and Prosthetics

SPECIAL FEATURES

5 Rule Denying Payments for “Never Events”Will Force a Close Look at Current Practice

48 Tips for “Going Green” in the Operating Room59 Competency-Based Learning65 When Healthcare Facilities Need Partners ...

Look to Your Vendors80 “Dr. Marla” Battles Breast Cancer88 Conquering Cancer with a Nurse Hero91 Aurora’s History Lesson

CARING FOR YOURSELF

72 How to Make 2008 Your Best Year Ever78 How Does Your Body’s Shape Influence Your Health?86 Best Day/Worst Day92 Recipes for Strong, Healthy Living

FORMS & TOOLS

94 Injury Risks and Safety Considerations whenPositioning Patients

96 How Well Do You Know Pressure Points?98 Patient Positioning Policy & Procedure101 Indications for Hand Hygiene103 Tips for Building a Safe Pack

©2007 Medline Industries, Inc.The OR Connection is publishedby Medline Industries, Inc. OneMedline Place, Mundelein, IL 60060.1-800-MEDLINE (633-5463)

OR ConnectionThe

Aligning practice with policy to improve patient care

EditorSue MacInnes, RD, LD

Clinical EditorAlecia Cooper, RN, BS, MBA, CNOR

Clinical TeamJayne Barkman, RN, BSN, CNORRhonda J. Frick, RN, CNORAnita Gill, RNKimberly Haines, RN, Certified OR NurseCarla Nitz, RN, BSNConnie Sackett, RN, Nurse ConsultantClaudia Sanders, RN, CFAAngel Trichak, RN, BSN, CNOR

Perioperative Advisory BoardCathy Crandall, RNHealthTrust Purchasing Group, Tennessee

Larry Creech, RN, MBA, CDTCarilion Clinic, Virginia

Barbara Fahey, RNCleveland Clinic Foundation, Ohio

Susan Garrett, RNHughston Orthopedic Hospital, Georgia

Zaida Jacoby, RN, MA, M.EdNYU Medical Center, New York

Diane Thompson, RN, MSNurse Consultant, Kansas

Margie Voyles, RN, MS, CNORLakeland Regional Medical Center, Florida

Donna Watson, RN, MSN, CNOR, ARNP, FNPSt. Joseph’s Medical Pavilion, Washington

Yvette West, RN, MSN, CNORDuke University Hospital, North Carolina

Margery Woll, RN, MSN, CNORRush North Shore, Illinois

About MedlineMedline, headquartered in Mundelein, IL,manufactures and distributes more than 100,000products to hospitals, extended care facilities,surgery centers, home care dealers and agenciesand other markets. Medline has more than 700dedicated sales representatives nationwide tosupport its broad product line and costmanagement services.

Meeting the highest level of national andinternational quality standards, Medline isFDA QSR compliant and ISO 13485 registered.Medline serves on major industry qualitycommittees to develop guidelines and standardsfor medical product use including the FDAMidwest Steering Committee, AAMI Sterilizationand Packaging Committee and various ASTMcommittees. For more information on Medline,visit our Web site, www.medline.com.

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Page 48

Page 45

4 THE OR CONNECTION

Dear Reader,

Our world in health care as we’ve known it is chang-ing. This past August, the final rule for the InpatientProspective Payment System (IPPS) was released.This marks the beginning of change in reimburse-ment for hospitals. As a result of the new ruling, thehospital-acquired conditions (HAC) provision will gointo effect October 1, 2008. Eight conditions wereselected by the Centers for Medicare and MedicaidServices (CMS) based on three criteria: 1) thecondition was high cost, high volume, or both; 2) itwas assigned a higher paying DRG when presentas a secondary diagnosis; 3) it was reasonablyprevented through the application of evidence-basedguidelines. These newly announced conditions areas follows:1

1-3 Serious preventable events– Objects left in during surgery– Air embolism– Blood incompatibility

4 Catheter-associated urinary tract infection5 Pressure ulcers6 Vascular catheter-associated infection7 Surgical site infection8 Falls and trauma

There was strong public support for CMS to pay lessfor conditions that are acquired during a hospital stay.And so, in less than a year from now, there will be afinancial impact if a patient acquires any one of theseeight conditions after they have been admitted.

Recently, we invited a group of perioperative direc-tors and infection control practitioners to discussinnovations in health care, ways to improve perform-ance and challenges that they faced on a day-to-daybasis. We asked the group to rank their biggestconcerns as they relate to HACs. Interestingly wefound many similarities in their answers. Here wasthe result of the perioperative rankings:

1 Objects left in surgery (62 percent)2 Surgical site infections (62 percent)3 Pressure ulcers/vascular catheter-associated

infections (25 percent each)

This edition begins our journey in educating themasses on the issue and offering potential solutionsthat you can bring back to your facility. You will findarticles on three of your top four rankings (objects leftin surgery, SSI and pressure ulcers). We need to bethe ambassadors of change and make prevention apart of our everyday practice.

Sincerely,

Sue MacInnes, RD, LDEditor

“

Content KeyWe've coded the articles and information in this magazine to indicate which patientcare initiatives they pertain to. Throughout the publication, when you see theseicons you'll know immediately that the subject matter on that page relates to oneor more of the following national initiatives:

• IHI's 5 Million Lives Campaign• Joint Commission 2007 National Patient Safety Goals• Surgical Care Improvement Project (SCIP)

We've tried to include content that clarifies the initiatives or gives you ideas andtools for implementing their recommendations. For a summary of each of the aboveinitiatives, see pages 8 and 9.

THE OR CONNECTION I Letter from the Editor

We all can agreethat we should dothings right … butit is our goal tomake it hard forthe healthcareworker to dothings wrong.”

1.Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions. Available at: http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired%20Conditions.asp. Accessed November 26, 2007.

Special Feature

Rule denying payments for'never events' will force a closelook at current practiceBy George E. BrandonAORN Management Connections

Under a mandate established by Con-gress in the Deficit Reduction Act of 2005,hospitals that provide Medicare and Medi-caid services were required to beginreporting on Oct. 1 secondary diagnoses“present on admission” of patients. Thenew data-collection requirement setsthe stage for the next major step in thefederal government’s continuing pushtoward Pay for Performance—beginningOct. 1, 2008, hospitals no longer will bereimbursed for eight preventable “hospital-acquired conditions,” several of which areassociated with surgical procedures.

The Fiscal Year 2008 InpatientProspective Payment System (IPPS)rules adopted by the federal Centers forMedicare and Medicaid Services (CMS)in August go beyond previous require-ments that hospitals report on an arrayof quality-of-care measures in order toreceive full annual cost updates forMedicare and Medicaid reimbursements.For the eight avoidable “hospital-acquiredconditions” identified by CMS, the outcomeof care— rather than the quality of careprovided during a patient’s stay—willbe the determinant, noted Paul Keckley,Ph.D., executive director of DeloitteCenter for Health Solutions inWashington. D.C.

Continued

6 THE OR CONNECTION

Reimbursements won’t just be reduced 2%annually for failing to report on quality measures;they will be denied altogether when hospitalsfail to take steps needed to ward off the eightconditions that are, as CMS put it in a FactSheet on its FY 2008 IPPS final paymentrules, "reasonably preventable throughapplication of evidence-based guidelines."

“Traditionally, we have been keen on what wedo and our processes, but we have taken theposition that outcomes are out of our control,”Keckley observed. “This ruling is a step inthe direction of saying the results of whatwe do should be how we are judged, howwe are paid.”

How will the policy shift affect perioperativepractice? "If we are following our standardsto ensure patients are getting the best carepossible, then these new [CMS] rules for non-payment shouldn't be an issue. Unfortunately,these ‘never events’ do occur," acknowledgedJane Kusler-Jensen, RN, BSN, MBA, CNOR,FABC, director of perioperative services withColumbia St. Mary's Healthcare system inWisconsin and a member of AORN's Boardof Directors. "This new ruling may force allhealthcare professionals to take a closer lookat their practice and lead to greater support from riskmanagers and other hospital quality departments."

Keckley believes the new IPPS rules and a host of outcome-based reimbursement policies to follow in future years willpose a challenge for hospital administrators and departmentmanagers to move beyond “the old model in which the doctoror surgeon says what goes, and the manager’s job is toaccommodate them, even though we know that in somecases it may lead to substandard outcomes.”

Under the old model of perioperative practice, “the surgeon iscaptain of the ship,” Keckley explained. “Under the new model,the focus is on optimal outcomes, and the surgeon becomespart of a team, working in a coordinated effort to establishevidence-based processes of care and measure the outcomeof those processes,” he said.

The focus on outcomes adds the concept of “effective care”to the ongoing healthcare industry focus on “safe care,” Keckleynoted. The goal isn’t just to avoid harm to the patient or care-givers but to use evidence-based practices to develop treatmentplans that will yield optimal outcomes, he said. “The systemnow rewards doctors for making these judgments (about

treatment), but the balance of evidence maypoint in a different direction,” Keckley added.

Under the new rules, CMS will not pay hospitalsfor the higher costs of treating patients for theeight “hospital-acquired conditions” assignedas secondary diagnoses, unless the secondarydiagnoses were “present on admission.” Theeight conditions subject to the new policyOct. 1, 2008, are:

1. Catheter-associated urinarytract infections

2. Vascular catheter-associated infections3. Mediastinitis, a surgical site infection

following coronary artery bypassgraft surgery

4. Pressure ulcers5. Falls6. Retained objects in surgical patients7. Blood incompatibility8. Air embolisms

Also included in the FY 2008 IPPS final rulewere five new quality measures that hospitalswill have to report in order to qualify forthe full annual payment schedule updates.Several will directly affect perioperativemanagers, including reporting cardiac surgery

patients with controlled 6 a.m. postoperative serum glucose,reporting surgery patients with appropriate hair removal andreporting surgical patients on beta blocker therapy beforeadmission who received a beta blocker during theperioperative period.

CMS will also be working to create codes to identify ventilator-associated pneumonia and to determine when septicemia anddeep vein thrombosis are not present on admission and preventa-ble in the hospital. These additional conditions may be addedto CMS' list of nonpayable conditions for the next fiscal year.

Carina Stanton and Cathy Sparkman contributed to this story.

Reprinted with permission from AORN (www.aorn.org) AORN Manage-ment Connections (October 2007) online newsletter. Copyright © AORN,Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231.

The Association of periOperative Registered Nurses (AORN) is the nationalassociation committed to improving patient safety in the surgical setting.With over 41,000 members, AORN is the premier resource for perioperativenurses, advancing the profession and the perioperative professional withvaluable guidance as well as networking and resource-sharing opportunities.AORN is recognized as an authority for safe operating room practicesand a definitive source for information and guiding principles that supportday-to-day perioperative nursing practice. For more information, visitwww.aorn.org.

“This rulingis a step in the

direction of sayingthe results of what

we do should behow we are judged,how we are paid.”

The NationalQuality Forum

OriginIn a report issued in 1998, a Presidential Commissionrecommended the creation of a national forum in whichhealthcare’s many stakeholders could, together, findways to improve the quality and safety of Americanhealthcare. The National Quality Forum (NQF) wasincorporated as a new organization in May 1999.

PurposeTo improve the quality of American healthcare by settingnational priorities and goals for performance improvement,endorsing national consensus standards for measuringand publicly reporting on performance, and promotingthe attainment of national goals through education andoutreach programs.

The National Quality Forum has broad participationfrom all branches of the healthcare system, includingnational, state, regional and local groups representingconsumers, public and private purchasers, employers,healthcare professionals, provider organizations, healthplans, accrediting bodies, labor unions, supportingindustries and organizations involved in health careresearch or quality improvement.

Strategic goals1.NQF-endorsed standards will become the primary

standards used to measure the quality of healthcarein the United States.

2.NQF will be the principal body that endorses nationalhealthcare performance measures, quality indicatorsand/or quality of care standards.

3.NQF will increase the demand for high-qualityhealthcare.

4.NQF will be recognized as a major driving force forand facilitator of continuous quality improvement ofAmerican healthcare quality.

Organizational goals1.Promote collaborative efforts to improve the quality

of the nation's healthcare through performancemeasurement and public reporting.

2.Develop a national strategy for measuring andreporting healthcare quality.

3.Standardize healthcare performance measures sothat comparable data is available across the nation.

4.Promote consumer understanding and use ofhealthcare performance measures and otherquality information.

5.Promote and encourage the enhancement of systemcapacity to evaluate and report on healthcare quality.

To learn more, visit www.qualityforum.org.

Facts at a glance


Strengthening the “NationalLearning Network”: The [5 MillionLives] Campaign currently has fieldoffices (often consisting of statehospital associations, qualityimprovement organizations andother state-level stakeholders inquality and safety) in every state,and several affinity groups for rural,pediatric and public facilities. Thesefield offices, together with localmentor hospitals, provide energyand support to area facilities asthey pursue improved quality. In thenext year, the Campaign willstrengthen the national learningnetwork that these organizationscomprise byfocusing on several levels:

• Seeking, at the national level,to better coordinate improvementpriorities and support activitieswith partners like AHA, AMA,ANA, CMS, CDC and theJoint Commission.

• Seeking, at the state level, toempower local field offices tobetter support local improvementactivities through an infusion ofexpert support, quality improve-ment training and other helpfulresources. In addition, invitingthe most successful state effortsto document their “recipes forsuccess” and act as laboratoriesfor improvement to lead the restof the nation.

• Seeking, in large public andprivate systems, to establishand support ambitious aimsfor improvement.

• Seeking, at the hospital level,to create a critical mass ofsuccessful facilities on eachintervention in each state.

• Connecting with new audiencesand stakeholders (e.g., payers,purchasers, policymakers,patients and families)

Execution: We must transfer thepractical approaches and methodsof those hospitals that succeedmost rapidly and completely to allparticipating facilities, with a specificemphasis on the leadership roles,management structures and skillsets that enable significant change.A major activity here includes theidentification of at least one mentorhospital (i.e., a high-achieving hos-pital willing to coach other facilities)for every intervention in every state,taking us to a critical mass of suc-cessful facilities across the nation.

Enrolling 4,000 hospitals

Conducting measurementstudies: In order to thoroughlyassess national progress, theCampaign will be conducting orhelping to design several studiesto track national change in mortality,harm and performance on theCampaign interventions.

To learn more,visit www.ihi.org

Checking in with IHIWhat’s ahead

in 2008

8 THE OR CONNECTION

Three Important National Initiativesfor Improving Patient Care

Achieving better outcomes starts with an understanding of currentpatient-care initiatives. Here’s what you need to know about national

projects and policies that are driving changes in care.

Origin: Launched by the Institute for Healthcare Improvement (IHI) in December of 2006

Purpose: To prevent unintended physical injury resulting from or contributed to by medical care that requires

additional monitoring, treatment or hospitalization, or that results in death

Goal: To prevent five million incidents of medical harm over the next two years and to enroll more than4,000 hospitals and their communities in the project.

Hospitals sign up through IHI and can choose to implement some or all of the recommended changes. IHI provides how-to guides andtools for data measurement and submission. IHI tracks Acute Care Inpatient Mortality rates for all participating hospitals.

The new campaign incorporates the six original planks from the 100,000 Lives Campaign and adds six additional planks to prevent harm.

Origin: Developed by Joint Commission staff and a Sentinel Event Advisory Group

Purpose: To promote specific improvements in patient safety, particularly in problematic areas

Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commissionoffers guidance to help organizations meet goal requirements.

This year’s new requirements have a one-year phase-in period that includes defined expectations for planning,development and testing (“milestones”) at 3, 6 and 9 months in 2008, with the expectation of full implementationby January 2009.

Origin: Initiated in 2003 as a national partnership. Steering committee includes the following

organizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the Joint Commission

Purpose: To improve patient safety by reducing postoperative complications

Goal: To reduce nationally by 25 percent the incidence of surgical complications by 2010

SCIP aims to reduce surgical complications in four target areas. Participating hospitals collect data on specific processand outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000surgical complications annually (just in Medicare patients) by getting performance up to benchmark levels.

5 MILLION LIVES CAMPAIGN1

JOINT COMMISSION 2008 NATIONAL PATIENT SAFETY GOALS2

SURGICAL CARE IMPROVEMENT PROJECT (SCIP)3

1. Prevent pressure ulcers

2. Reduce methicillin-resistant staphylococcus

aureus (MRSA) infection

3. Prevent harm from high-alert medications

4. Reduce surgical complications

5. Deliver evidence-based care for congestive heart failure

6. Get boards on board

7. Deploy rapid response teams

8. Prevent adverse drug events (ADEs)

9. Deliver evidence–based care for acute myocardial infarction

10. Prevent surgical-site infections

11. Prevent central-line infections

12. Prevent ventilator-associated pneumonia

By the numbers:

• >3,600 hospitals currently enrolled

• The Top 3 Interventions:

1. Adverse Drug Events (ADEs) – >2,834

2. Acute Myocardial Infarction (AMI) – 2,749

3. Surgical Site Infection (SSI) – 2,746


1. Surgical-site infections• Antibiotics, blood sugar control, hair removal, normothermia

2. Perioperative cardiac events• Use of perioperative beta-blockers

3. Venous thromboembolism• Use of appropriate prophylaxis

4. Ventilator-associated pneumonia has been removedand data is being collected by the Joint Commission

SCIP is eagerly awaiting the official draft of CMS’s 9th Scope of Work to determine futureprogram updates and changes.

To learn more visit www.medqic.org/scip.

Patient Safety

5 MILLION LIVES CAMPAIGN: TWELVE INTERVENTIONS

JOINT COMMISSION 2008 NATIONAL PATIENT SAFETY GOALS

SURGICAL CARE IMPROVEMENT PROJECT (SCIP): THREE TARGET AREAS

By the numbers:• 3,740 hospitals are submitting

data on SCIP measures, representing75 percent of all U.S. hospitals

• Currently, SCIP has more than 36association and business partners

NEW FOR

2008!

NEW FOR

2008!

• Comprehensive Execution Strategy• Increasing enrollment to 4,000• Strengthening the “National Learning Network”• Conducting Measurement Studies To learn more, visit www.ihi.org

FOCUS FOR

2008!

• Improve accuracy of patient identification• Improve effectiveness of communication

among caregivers• Improve medication safety• Reduce risk of healthcare-associated infections

(Expanded in 2008 to include either WHOor CDC Hand Hygiene Guidelines)

• Reduce risk of patient harm from falls• Reduce risk of influenza and pneumoccocal disease

through immunization

• Reduce risk of surgical fires• Encourage patient’s active involvement in their care• Prevent healthcare-associated pressure ulcers

(decubitus ulcers)• Identify safety risks inherent in patient population

(suicide, home fires)• Rapid response to changes in patient condition

(new for 2008)• Implementation of Universal Protocol for preventing

wrong-site, wrong-person, wrong-procedure surgery

To learn more about the potential goals in their entirety, go to www.jointcommission.org.

Surgical technology is one of the fastest-growingprofessions in the country. It is projected togrow faster than the average of all otheroccupations through the year 2012. As babyboomers approach retirement age, the volumeof surgery will increase exponentially.

To view statistical information about the profession,including a map of the average hourly pay rateof AST members by state, go to www.ast.org.

Council on Surgical &Perioperative SafetyFormed by the AST, the Council is a coalitionof seven professional organizations involvedin surgical patient care has incorporated as theCouncil on Surgical & Perioperative Safety.The mission of the group is to promote a cultureof patient safety with members of the surgicalteam working together to provide optimalpatient care and a caring perioperative work-place environment.

The seven organizations include the AmericanAssociation of Nurse Anesthetists, AmericanAssociation of Surgical Physician Assistants,American College of Surgeons, AmericanSociety of Anesthesiologists, American Societyof PeriAnesthesia Nurses, Association ofperiOperative Registered Nurses and theAssociation of Surgical Technologists.

For more information related to the Councilon Surgical & Perioperative Safety, go towww.cspsteam.org.

News from AORNAssociation of periOperative Registered Nurses

Register for Congress now!Start looking forward to Congress 2008 and register online using thenew Congress Online Registration System! Visit the newly designedCongress Web site (www.aorn.org/Education/EducationEvents/ Congress)and explore the many education sessions, events and other activitiesplanned for Congress 2008 in Anaheim, California. Register now andsave big!

Revised PNDS on the wayA revised, updated second edition of the Perioperative Nursing DataSet (PNDS) – the structured vocabulary used in uniformly documentingthe practice decisions and interventions that lead to positive outcomesfor patients undergoing surgical and/or invasive procedures – will soonbe available at AORNBookstore.org.

While the underlying standardized PNDS data set hasn't changed,the newly Revised Second Edition of PNDS contains a set of powerfulexamples illustrating how several perioperative nursing and informaticsteams have benefited from implementing PNDS. The examples coveruse of PNDS in various clinical settings, in orientation and educationalprograms for perioperative RNs, as well as in electronic health recordsystems and other record-keeping applications, including staff jobdescriptions and documenting staff competencies.

To learn more about AORN and the Recommended Practices forperiOperative Services, go to www.aorn.org.


News from AST – Associationfor Surgical Technologists

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14 THE OR CONNECTION

Putting SUPERBUGSon the DEFENSIVE

Hospitals begin to tout ability to control infection;Mining the available data

By Theo FrancisThe Wall Street Journal


Hospitals are prime breeding groundsfor antibiotic-resistant "superbugs" thatkill tens of thousands of Americans eachyear. But most people have had no wayof knowing how well their hospital keepsthese bacteria – and infections in general– under control.

That is starting to change. Nineteen stateshave adopted laws in recent yearsrequiring hospitals to report overallinfection rates publicly, with more likelyto follow suit. And Thursday, nearly twodozen federal lawmakers, headed byPennsylvania Rep. Tim Murphy,proposed legislation requiringnationwide public reporting.

So far, just four states have publishedsome infection rates for individual hospitals,and only one state, Pennsylvania, breaksout different types of infections. But evenwhere patients can't find state-mandatedinfection reports, they can increasinglyget information from their local hospitalabout practices to prevent super-bugs

and other infections. Some hospitalshave found a marketing opportunity ininfection prevention: They are pushingoverall infection rates toward zero – andadvertising it. They are trumpeting preven-tion efforts, such as campaigns to improvehand washing. And some are trackingpatients who have been infected withsuperbugs such as methicillin-resistantStaphylococcus aureus, or MRSA, andmonitoring them to prevent the spread.

"This is one of those cases wherequality is also the best business case,"says Jonathan Perlin, chief medicalofficer at hospital chain HCA Inc., whichhas enlisted staffers and visitors alike inits own campaign to keep germs awayfrom patients.

While antibiotic-resistant infections havegotten the attention of late, hospitals havelong struggled with infections of all kinds.Common bacteria including Staphylococ-cus aureus can infect the bloodstream,urinary tract, lungs or surgical incisionsof patients whose immune systems arealready compromised. Over time, somestrains of these bacteria have developedpowerful defenses against antibiotics,leaving them harder to kill.

Hospitals have long attempted to keepinfection rates low, but the spread ofresistant strains has made the fight thatmuch more urgent in recent years. Lastweek, concerns came to a head with anew study showing that antibiotic-resistantinfections are probably far more extensivethan previously thought. The study pub-lished in JAMA, the Journal of the Ameri-can Medical Association, concluded thatMRSA causes 94,000 infections a year.The study estimated that MRSA, one ofthe biggest infection concerns in hospitals,contributes to nearly 19,000 deaths. Thevast majority were linked to health care,including hospitals, nursing homes,dialysis and others.

At the same time, recent studentillnesses and deaths have promptedschool closings in some states. Andstarting next year, Medicare will no longerreimburse hospitals for some infectionsacquired after admission, in an effortboth to encourage vigilance and tosave money.

Continued

Special Feature


BUG OFFHospital chain HCA has taken its campaignagainst antibiotic-resistant infections tothe public as well as its medical staff. Goto www.hcahealthcare.com to find:

• Handout: Stopping Infections IsIn Your Hands2

• Poster: Stopping MRSA Is InYour Hands3

Among the four states that have publishedinfection rates, Missouri and Vermont letconsumers learn the number of bloodinfections related to central lines – tubesinserted into or near the heart, often togive medications or fluids – and how thatcompares with state or national averages.Pennsylvania provides multiple reports ondifferent kinds of infections, and lets con-sumers look up infection-related mortality,length-of-stay and cost data for severalkinds of infections. A Web site fromConsumers Union, www.stophospitalin-fections.org, has links to reports fromeach state, including Florida, accordingto Lisa McGiffert, director of the StopHospital Infections Campaign.

“Ahead of the Curve”Information from Florida is nearly two yearsold, and Missouri's dates to December2006. But the information released so faris an important start, say public-healthexperts, since most of the hospital-infectionreports mandated by the new state lawswon't be available before about 2009."Those states that have alreadyreleased data are ahead of the curve,"says John Jernigan, a medical epidemiol-ogist with the Centers for DiseaseControl and Prevention in Atlanta.

So far, infection reports available to thepublic aren't consistent enough to allowconsumers to compare hospitals acrossstate lines, and even comparing facilitieswithin a state can be tricky. Some facilitiesmay treat sicker patients, for example,who are more likely to become infected

when exposed to MRSA or otherresistant bugs.

Indeed, the data are probably too technicalfor most consumers, says Carlene Muto,medical director of infection control at theUniversity of Pittsburgh Medical Center.Still, she is a strong supporter of thereporting requirements as a way to pushhospitals to improve. "Clearly, it's agood idea just to measure adverseevents," she says. "You can't changewhat you do not measure, becauseyou won't know that it's broken."

In areas where patients can't learn actualinfection rates, they can watch for keysigns that a hospital is on top of preventingboth superbugs and infections generally.National studies suggest, for example,that hospital personnel don't wash theirhands nearly as often as they should.

Nashville, Tenn.-based HCA has beenputting up posters exhorting doctors towash their hands, and is even distributinga card to visitors that explains the impor-tance of hand washing when coming incontact with patients. The company saysits purchases of hand-sanitizing alcoholgel -- available from dispensers through-out its hospitals -- have risen 600% sinceearly this year. (Company officials saythey didn't measure infection rates at thestart of the campaign and so don't knowhow much infections have fallen.)

Other hospitals say they have pushedantibiotic-resistant-infection rates downsharply through a combination of tech-niques. The University of PittsburghMedical Center, for example, has cut

MRSA infection rates in halfat its main hospital since 2001in part by screening all intensive-carepatients to see if they are carrying thebug; it is now expanding use of the tests.

To reduce certain kinds of bloodstreaminfections, the 19-hospital system bundlessterile material needed to insert centrallines and has stepped up training; central-line associated blood-infection rates havefallen by 80% since 2002, to fewer thanone per thousand such procedures.

It also has taken steps to deal with theemergence of a different strain of bacteriathat can cause potentially fatal diarrhea.The hospital lets nurses order tests for thebug; requires longer isolation periods forthose infected with it; gives their roomsan additional cleaning with bleach; andrequires physicians to get approval froman antibiotic-management team whenusing certain high-powered antimicrobialsthat could affect the body's natural de-fenses against the bacteria. UPMC's in-fection rates for the organism, Clostridiumdifficile, have fallen two-thirds since a spikein 2000.

Intermountain Healthcare, a Salt LakeCity-based chain of 21 hospitals, keeps adatabase of every patient who has beeninfected with MRSA. Those who return tothe hospital for some other reason areimmediately monitored by an infection-control nurse and tested to see if theyare carrying the bacteria.

"Those patients are at higher riskof potentially getting it again, and athigher risk of spreading it to otherpatients," says the hospital's chief medicalofficer, Brent Wallace. Together with aconcerted campaign to improve hand-washing, the database has helped stopan increase in the number of MRSAinfections at the hospital over the pastyear, he says.


Broader TestingSome states are also beginning to mandatebroader testing specifically for MRSA,since patients can carry the bug andspread it without showing signs of infection.Pennsylvania will soon require hospitalsto test high-risk patients, including thoseadmitted from nursing homes. In August,New Jersey and Illinois adopted legisla-tion requiring hospitals to identify patientscarrying MRSA and isolate them,among other provisions.

Don Goldmann, senior vice president ofthe Institute for Health Care Improvementand a Harvard Medical School pediatricsprofessor, says that factors beyond infec-tion rates should play into picking a hos-pital. "There may be a lot ofinformation to weigh."

On their own, some hospitals have beenturning to a variety of new technologies totry to cut down on infections, particularlysuperbugs, ranging from antibiotic-coatedcatheters to work surfaces made of copper,which has antimicrobial properties, aswell as software. For several years, manyhospitals have also participated in federallysponsored programs to reduce surgicalcomplications, including infections acquiredin the hospital.

Write to Theo Francis at [email protected]

URL for this article:http://online.wsj.com/article/SB119309446460567619.htmlHyperlinks in this Article:(1) http://online.wsj.com/article/SB119309360318867665.html(2) http://www.hcahealthcare.com/CPM/PATIENT-VISITOR_HANDOUT.pdf(3) http://www.hcahealthcare.com/CPM/CLINICIAN_AD_SINGLE_PAGE_lg.pdf(4) mailto:[email protected]

Reprinted with permission of The Wall Street Journal


By Shawn Boynes

APIC Grand Rounds

The Association for Professionals in InfectionControl and Epidemiology, Inc. (APIC)launched a nationwide series of educationalprograms this past spring to showcase bestpractices related to preventing surgical siteinfections. The APIC Grand Rounds: ProtectingPatients from the Risk of SSIs is underwrittenby an unrestricted educational grant fromETHICON, INC. and provides a comprehensiveapproach to understanding the nature andrisks associated with surgical site infections.This programming is particularly importantgiven CMS’s recent decision that reimburse-ment for SSIs will cease as of October 2008.

Preventing surgical site infections requiresengaging professionals across the continuumof health care, including infection preventionand control professionals, operating roomnurses, physicians and hospital administrators.For this reason, the SSI Grand Roundsemphasizes a team approach to the reductionof SSIs, concentrating on the partnershipbetween the operating room and infectionprevention and control.

The Grand Rounds program provides aframework for addressing clinical impact ofSSIs as well as the financial impact onhealthcare facilities. Practical presentationsprovide ways to develop a program for theelimination of SSIs using evidence-basedpractices and include:

• Sustaining System-Wide SSIRate Reductions

• Reducing the Risks of SSI:Medical Techniques

• View from the OR: Partneringfor Prevention

• Working Towards A ZeroInfection Rate

Featured presenters are nationallyrecognized experts, including:

• Marilyn Jones, RN, MPH, CIC, BJCHealthcare (St. Louis, Mo.)

• Charles Edmiston Jr. PhD, MS, CIC,Froedtert Hospital (Milwaukee, Wis.)

• Sina Matin, MD, Baylor Health CareSystems (Irving, Texas)

• Maureen Spencer, RN, M.Ed, CIC,New England Baptist Hospital(Boston, Mass.)

• Lillian Burns, MT, MPH, CIC,Greenwich Hospital(Greenwich, Conn.)

• Elizabeth Duthie, RN, PhD,NYU Hospitals Center (New York, N.Y.)

• Kristina Dreifuerst, MSN, RN,APRN-BC, CWOCN,University of Wisconsin School ofNursing (Madison, Wis.)

• Michael McGuire, MD, FACS,St. Johns Hospital (Santa Monica, Calif.)

• Ramon Berguer, MD, FACS,Contra Costa Regional Medical Center(Martinez, Calif.)

About the authorShawn Boynes is the senior director ofeducation for the Association for Professionalsin Infection Control and Epidemiology, Inc.

About APICAPIC’s mission is to improve healthand patient safety by reducing risksof infection and other adverseoutcomes. The Association’s morethan 11,000 members have primaryresponsibility for infection prevention,control and hospital epidemiologyin healthcare settings aroundthe globe, and include nurses,epidemiologists, physicians, micro-biologists, clinical pathologists,laboratory technologists and publichealth practitioners. APIC advancesits mission through education,research, collaboration, public policy,practice guidance and credentialing.

For more information about theGrand Rounds, including the2008 schedule,visit www.apic.org.

SURGICALSITE

INFECTIONS

OR Issues

Perioperative professionals who routinelyscrub in surgical procedures are well awareof the protocols and procedures for surgicalhand antisepsis. Those who scrub are familiarwith the debate over whether to use water-aided brush scrubs or alcohol-based handrubs. These people also know that manyfacilities are choosing alcohol-based rubsfor their efficacy, tolerability, staff acceptanceand cost.1

But what about those healthcare professionalswho don’t scrub on a routine basis? Do youknow the difference between handwashingand hand antisepsis? And, if you do, areyou following all of the current guidelines,recommendations and standards to preventthe spread in infection, as well asprotect yourself?

In patient care, hand hygiene is regarded asessential. It is important to understand thateach element of hand hygiene has clearindications in clinical practice. There are manyorganizations and governing bodies that haveestablished guidelines and recommendationsfor appropriate hand hygiene, including theCDC (Centers for Disease Control and

Prevention), WHO (World Health Organization)and APIC (Association for Professionals inInfection Control and Epidemiology), to namea few. Overall, the guidelines are similar.Safety of both healthcare worker and patientsis the overarching goal.

PreconditionsBefore taking a closer look at the differenthand hygiene measures, it is important toknow that hand hygiene begins with thepersonal hygiene of each healthcare worker.Personnel need to meet several crucialprerequisites in order to perform optimalhealth care.

Clean, short nailsSeveral studies have documented that thearea beneath the fingernails can be colonizedwith high concentrations of bacteria.2,3

Even after careful washing or the use ofsoap-based surgical scrubs, personnel oftenharbor substantial numbers of potentialpathogens under their fingernails.4-6

Intact skinHealthcare providers should rememberthat maintaining intact skin is a professional

Do you know the difference? By Lillian Burns, MPH, CIC


responsibility. Cracked, scaly skin providesmicroorganisms with ideal niches in which tohide – thus, antiseptics have a difficult timereaching the hidden microorganisms andhand antisepsis is at danger of not beingeffective enough.7 Additionally, open soreson hands could potentially be carryingStaphylococcus aureus.8

No artificial nailsWhether artificial nails contribute to thetransmission of healthcare-associated infec-tions has not been determined.14 However,healthcare personnel who wear artificialnails are more likely to harbor gram-negativepathogens on their fingertips than thosewith natural nails, both before and afterhandwashing.5,6,9

Minimal jewelrySeveral studies demonstrate that skinunderneath rings is more heavily colonizedthan comparable areas of skin on fingerswithout rings.10-13 Moreover, the wearingof rings increases the frequency of handcontamination with potential healthcare-associated pathogens.13 Nevertheless,the CDC does not make a recommendationregarding the wearing of rings in healthcaresettings.14 APIC states that rings and nailjewelry can make donning gloves moredifficult and might cause gloves to tearmore easily.15

Wearing of rings or other jewelry whenproviding routine care might be acceptable,but in high-risk settings, such as the operatingroom, all rings and other jewelry should beremoved. A simple and practical solution isto suggest that healthcare workers wear theirring(s) on necklaces as pendants like manydo who scrub in surgical procedures.16

Hand antisepsisThe term “hand antisepsis” is commonlydefined as “disinfection of hands with anantiseptic agent that prohibits growth anddevelopment of microorganisms.” In line withthis definition, the CDC, IHI (Institute ofHealthcare Improvement) and WHO recom-mend using an alcohol-based hand antisepticfor disinfecting hands.14,16,17 Therefore, ifan indication requires hand antisepsis,handwashing with antimicrobial soap and

water should only be a last resort, e.g., ifalcohol-based hand rubs are not available.

If hands are not visibly soiled, hand antisepsisshould be performed for routinely disinfectinghands. The clinical situations requiring handantisepsis are:

Before any direct contact withpatients, including:

• Before donning exam and sterile gloves• Before donning and removing PPE such

as gown and mask• Before inserting indwelling urinary

catheters or other invasive devices thatdo not require a surgical procedure

During patient care:• Moving to a clean body site during pa-

tient care coming from a contaminatedbody site

After any contact with the patient or thepatient’s environment, including:

• After contact with a patient’s intact skin• After contact with body fluids or excre-

tions, mucous membranes, non-intactskin and wound dressings if hands arenot visibly soiled

• After contact with inanimate objects(including medical equipment) in theimmediate vicinity of the patient

• After removing gloves

There are a few clinical situations thatalso require an additional handwash.The exceptions and appropriate measuresare as follows:

• Heavily soiled hands should be carefullyrinsed, then washed with soap andwater, being careful not to spread con-taminants on clothing or surroundings.When wearing a gown, the gown shouldbe changed and then the hands shouldbe disinfected.18

• If contamination occurs due to a punctureor glove perforation, gloves should beremoved, hands should be disinfectedand new gloves should be applied.

• Other than with the above exceptions,the following applies: If an additionalhandwash is desired, it should be per-formed after antisepsis.18 If hands arewashed prior to using a hand antiseptic,


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Add comfort for complianceSterillium Comfort Gel’s incredible bactericidal effect doesn’t matter if the product isn’t being used!You’ll want to reach for Sterillium Comfort Gel again and again because it includes a balanced blendof moisturizing emollients that leverages technology shared with BODE Chemie by its parentcompany Beiersdorf AG,makers of well-known skincare products NIVEA® and Eucerin®.The result is a product proven to increase skin hydration by 14 percent in just two weeks.*

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microorganisms are distributed whereverthe water splashes during the hand-washing process and are transmitted tothe environment and/or the clothing ofthe personnel.

• Contamination with spore-forming bacteria:It is suggested to disinfect hands first inorder to reduce the vegetative cell of thespore-forming bacterium. Then handsshould be washed to reduce the remain-ing spores.18 The physical action ofwashing and rinsing hands under suchcircumstances is recommended becausealcohols, chlorhexidine, iodophorsand other antiseptic agents have pooractivity against bacterial spores.14

HandwashingGuidelines state that either a non-antimicro-bial or an antimicrobial soap can be used if asituation requires a handwash.14-17 The WHOalso states that antimicrobial soap should notbe used when an alcohol-based hand rubis already in use.16 Hence, why not washwith plain (non-antimicrobial) soap whena situation requires handwashing?

Handwashing should be performed:14

• When hands are visibly dirty or contami-nated with infectious material or are visiblysoiled with blood or other body fluids

• Before eating• After using the restroom

GlovesWearing gloves during patient care is anadditional intervention to help reduce thetransmission of infectious organisms. Glovesprotect patients by reducing contaminationof the healthcare worker’s hands and subse-quent transmission of potentially pathogenicmicroorganisms to other patients.

Having more than one type of glove (i.e.,latex, synthetic and powder-free) is desirablebecause it allows personnel to select thebest match for their personal needs.14 Theuse of therapeutic gloves that have beenshown to moisturize and soothe dry, chappedhands can also assist in hand hygiene com-pliance by improving overall skin care.

However, gloves must be used properly. Likehands, gloves can become contaminatedduring care, so they have to be removedafter use. Also, gloved hands can becomecontaminated by tiny punctures or duringglove removal – therefore, hands must bedisinfected immediately after glove use.14,16,17

Skin careSkin care is a preventive measure, supportingthe skin’s natural barrier and regenerationprocess. Skin care has two components:

1. Prevention of skin-stressing activitiesThe following activities contribute to skinirritation and should be avoided, as theyare the most common causes of skinirritations in healthcare workers:

• Too-frequent handwashing• Handwashing times exceeding

one minute• Use of brushes19

• Handwashing before hand antisepsis(unless hands are visibly soiled)

• Prolonged wearing of gloves• Contact with irritant substances19

2. Use of skincare productsSkincare products (such as lotions andcreams) should be utilized frequently,such as:

• Before shift• After breaks• When required or desired• After shift and in leisure time as needed

Putting it all together• Appropriate hand hygiene in healthcare

settings is key to protecting patients andpersonnel against possibly pathogenicmicroorganisms.

• Frequent handwashing can damage theskin. Alcohol-based hand antisepsis iseffective and less irritating to the hands.Handwashing should therefore be keptto a minimum and only performed whenhands are visibly soiled.

• Alcohol-based hand antiseptics have arapid and broad-spectrum effect againstmicroorganisms.

• Each healthcare provider must fulfillvarious preconditions in order to performand ensure optimal hand hygiene.


Sensicare® Surgical GlovesLet us care for your hands and change your opinion on latex-free gloves

THE CLINICAL RATIONALEDryness and irritation are the top barriers to hand hygiene protocolcompliance, according to published reports. Based on this data, the CDCstrongly recommends the regular use of products designed to prevent andtreat dryness and irritation.

Medline’s Sensicare surgical gloves with aloe have demonstrated the abilityto moisturize and soothe dry, chapped hands.When these conditions areimproved, hand hygiene rates increase.

Sensicare surgical gloves with aloe are specially formulated with ISOLEX®, aproprietary synthetic polyisoprene that has the physical properties of naturalrubber latex.

“Hand hygiene is the most important step to preventing nosocomial infection.”5

-Elaine Larson, Ph.D., RN, Columbia University professor

Skin irritation is the biggest barrierto hand hygiene compliance.1,2

Gloves containing aloe are clinicallyproven to reduce skin irritation.3

Reduced skin irritation leads tobetter hand hygiene compliance.4

References1 Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection ControlPractices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand HygieneTask Force.American Journal of Infection Control.2002 Dec;30(8):S1-46.

2 Larson E, Kretzer EK. Compliance with handwashing and barrier precautions. Journal of Hospital Infection. 1995;30:88-106.3West D, ZhuYF. Evaluation of aloe vera gel gloves in the treatment of dry skin associated with occupational exposure.AmericanJournal of Infection Control. 2003;31:40-42.

4 McCormick R, BuchmanT, Maki D. Double-blind randomized trial of scheduled use of a novel barrier cream and an oil-containinglotion for protecting the hands of health care workers.American Journal of Infection Control. 2000;28:302-10.

5 Larson EL, 1992, 1993, and 1994 Association for Professionals in Infection Control and Epidemiology Guidelines Committee.APICguideline for hand washing and hand antisepsis in health care settings.American Journal of Infection Control. 1995;23:251-69.

Isolex is a registered trademark of Baxter International, Inc.Sensicare®


• Gloves provide an added level of protec-tion and help reduce the transmission ofinfectious organisms.

• Skin care plays a decisive role in ensuringthe safety of personnel. Proper skinmoisturization and care helps improvepatient safety.

To assist you in knowing when to use handantisepsis versus handwashing, as well aswhen to wear gloves and when to use skin-care lotions, a chart has been included inthe Forms & Tools section on Page 102.This chart can be easily displayed in yourwork areas as a reference and reminder forall caregivers.

About the authorLillian Burns, MPH, CIC is currently theepidemiology/infection control coordinatorfor Greenwich Hospital in Greenwich, Conn. Lillianserves on the Centers for Disease Control andPrevention’s Healthcare Infection Control PracticesAdvisory Committee (HICPAC) and is a facultymember for the Institute of Healthcare Improve-ment’s Reducing Hospital-Acquired InfectionsLearning and Innovation Community.

References1 Kramer A, Schwebke I, Kampf G. How long do

nosocomial pathogens persist on inanimate sur-faces?A systematic review. BMC Infect. Dis. 2006;6:130.

2 McGinley KJ, Larson EL, Leyden JJ. Composition anddensity of microflora in the subungual space of thehand. J Clin Microbiol.1988;26:950-953.

3 Hedderwick SA, McNeil SA, Lyons MJ, Kauffman CA.Pathogenic organisms associated with artificial finger-nails worn by healthcare workers. Infect Control HospEpidemiol. 2000;21:505-509.

4 Gross A, Cutright DE, D’Allessandro SM. Effect ofsurgical scrub on microbial population under thefingernails. Am J Surg. 1979;138:463-467.

5 Pottinger J, Burns S, Manske C. Bacterial carriage byartificial versus natural nails. Am J Infect Control.1989;17:340-344.

6 McNeil SA, Foster CL, Hedderwick SA, Kauffman CA.Effect of hand cleansing with antimicrobial soap oralcohol-based gel on microbial colonization of artifi-cial fingernails worn by health care workers. ClinInfect Dis. 2001;32:367-372.

7 Kownatzki E. Hand hygiene and skin health. J HospInfect. 2003;55:239-245.

8 Brooks T. Preventing Occupational Contact Dermati-tis. EndoNurse 2003. Available at: http://www.en-donurse.com/articles/341feat2.html. Accessed June12, 2007.

9 Rubin DM. Prosthetic fingernails in the OR. AORN J.1988;47:944-945, 948.

10 Lowbury EJL. Aseptic methods in the operatingsuite. Lancet. 1968;1:705-709.

11 Hoffman PN, Cooke EM, McCarville MR, EmmersonAM. Microorganisms isolated from skin under weddingrings worn by hospital staff. Br Med J. 1985;290:

206-207.12 Jacobson G, Thiele JE, McCune JH, Farrell LD.

Handwashing: ringwearing and number of microor-ganisms. Nurs Res. 1985;34:186-188.

13 Trick WE, Vernon MO, Hayes RA et al. Impact of ringwearing on hand contamination and comparison ofhand hygiene agents in a hospital. Clin Infect Dis.2003;36:1383-1390.

14 Boyce JM, Pittet D. Centers for Disease Control andPrevention, Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the HealthcareInfection Control Practices Advisory Committee andthe HICPAC/SHEA/APIC/IDSA Hand Hygiene TaskForce. MMWR. 2002;51:1-45.

15 Larson EL, APIC Guidelines Committee. APIC guide-line for handwashing and hand antisepsis in healthcare settings. Am J Infect Control. 1995;23;251-269.

16 World Alliance for Patient Safety. WHO Guidelines inHand Hygiene in Health Care (Advanced Draft),Global Patient Safety Challenge 2005-2006: “CleanCare is Safer Care.” April 2006.

17 Institute for Healthcare Improvement. How-to Guide:Improving Hand Hygiene. Available at:http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/HowtoGuideImprovingHandHygiene.htm. Accessed June 12, 2007.

18 Commission for Hospital Hygiene and Infectious Dis-ease Prevention of the Robert Koch Institute. Handhygiene. Bundesgesundheitsbl – Gesundheitforsch –Gesundheitsschutz. 2000;43:230-233.

19 Kampf G, Loeffler H. Dermatological aspects of asuccessful introduction and continuation of alcohol-based hand rubs for hygienic hand disinfection. JHosp Infect. 2003;55:1-7.


Back to

BASICS

PerioperativePatient

Positioning

Sixth in a Series

”“


cary as they sound, all of the above are examples of real outcomes that occurred followingroutine surgical procedures. We cannot say that every one of these injuries was caused dueto improper positioning, nor can we say that each injury could have been prevented. Whatwe can say is that improper positioning and lack of prevention and safety measures canresult in patient injury and lead to debilitating consequences, even death.

Intraoperative positioning injuries are devastating for both patients and surgical team members.

Potential positioning injuries include:1 Pressure ulcers2 Alopecia3 Nerve injuries4 Physiologic compromises

Injury mechanisms that contribute to positioning include pressure (i.e., gravity), friction andshear forces.¹

Pressure ulcer injuriesThe operating room is a high-risk environment for the development of pressure ulcers.Preoperative identification of this risk is imperative if measures can be developed thatmeet evidence-based criteria and demonstrate prevention.²

Pressure sores have been thought of as slothful chronic wounds that form slowly and occuras a result of poor nursing care. In fact, they are acute injuries that develop rapidly whencompression of tissues causes ischemia and necrosis during serious illness and trauma,including surgery.2

Pressure ulcers that originate during surgical procedures may appear within a few hourspostoperatively, but the majority usually present one to three days after surgery. Tissuedamage resulting from prolonged, intense pressure created during surgical proceduresoften results from a “burn” or bruises in early stages and can be misdiagnosed. Theseso-called “closed” pressure ulcers deteriorate fairly rapidly to Stages III or IV.

By Alecia Cooper, RN, BS, MBA, CNORPatient Safety

“Vulval injury due to perineal post on fracture table.”

“Brachial plexus injury related to patient positioning.”

“Well leg compartment syndrome during prolongedsurgery in the lithotomy position.”

“Ophthalmologic complications associated withprone positioning in spine surgery procedure.”

“Erectile dysfunction after perineal compression in a youngman undergoing internal fixation of a femur fracture.”

“Lower limb acute compartment syndrome aftercolorectal surgery in prolonged lithotomy position.”

Intraoperativeskin injury is thefunction of unre-lieved pressure,duration of thepressure andthe location ofthe pressure onthe body surface.

The risk of pressureulcers occurring asa result of surgerymay be as highas 66 percent.

Procedures lastinglonger than twoand one-half tothree hours signifi-cantly increasethe patient’s riskfor pressureulcer formation.

S


As part of their 5 Million Lives campaign, IHIstates that because surgical patients who areunder anesthesia for extended periods of timeoften have an increased risk of developingpressure ulcers, all surgical patients (pre-operative,intraoperative, post-anesthesia) should re-ceive a skin assessment and risk assessment.Caregivers should then implement preventionstrategies such as ensuring repositioning andplacing patients on appropriate redistributionsurfaces for all surgical patients who are iden-tified as being at risk.3 CMS has declared thatas of October 1, 2008, hospitals will no longerbe reimbursed for eight preventable “hospital-acquired conditions,” several of which areassociated with surgical procedures. Oneof the eight is pressure ulcers.4

AlopeciaAn 11-year-old boy underwent vitreoretinalsurgery for left retinal detachment. One weekpostoperatively, his parents noticed a patchof alopecia where his head may have been incontact with the wrist-rest assembly placedaround the head during the surgical procedure.The result was diagnosed as pressure alopeciaon the parieto-occipital region of the scalp.Hair re-growth occurred during thefollow-up visits.5

Pressure alopecia is an under-recognized andrare complication of lengthy surgery. Precautionsshould be taken to avoid this preventablecomplication. Even though in most instancesthe results are minimal and cosmetic in nature,alopecia has been documented as a precursorfor pressure ulcer development when occurringafter sustained immobility and pressure to theocciput. Alopecia associated with pressureulcers usually develops within three days of a

surgical procedure and is preceded by pain,swelling and exudates.1

Ulnar nerve injuriesA patient undergoing abdominal surgery wasplaced on the operating table with his armsextended at 45 degrees on the arm boards.The surgeon stood at the patient’s right sidethroughout the hour-and-20-minute procedure.Postoperatively, the patient reported numbnessand tingling in his right hand that persistedwell after his discharge from the hospital.Eventually, the patient was diagnosed withan ulnar nerve injury, with numbness and painthat did not respond to physical therapy. Thepatient alleged a lawsuit and the jury foundfor the plaintiff.6

In surgery, arms on arm boards are not extendedmore than 45 degrees, which increases thelikelihood that a surgeon or other caregivercould inadvertently lean on the arm whilecarrying out the surgical procedure. This canlead to ulnar nerve injury. The standard ofcare when arm boards are used is to havethe arms positioned with palms up, with plentyof padding under them and with extensionsof 45 degrees or less. Elbow protection isoften recommended.7

Physiologic compromiseThe most common example of physiologiccompromise is effects to the respiratory systemdue to positioning interfering with the patient’sventilatory system. All of the most commonpatient positions (i.e., supine, prone, lateral,sitting, lithotomy) have proven to causeventilatory impedance when patients arenot positioned appropriately. Patients aremost vulnerable in the prone position.1

The cardiovascular system can also be atrisk. The cardiovascular system is influencedby anesthetic agents, inhibition of normalcompensatory mechanisms, cardiac reserve,venous return and vascular resistance. Bloodmay pool in a patient’s extremities, causinghypotension, and cerebral perfusion may bealtered by head positions.8

The Joint Commission collects sentinel eventdata for all operative injuries. Category 488,operative/post-op complications, excludeswrong-site surgery, medication errors, unintendedretention of foreign bodies, infection-related

Nerve and muscletrauma result fromstretching orcompression whenupper extremities areabducted at greaterthan 90 degrees tothe body, hips areplaced in excessiverotation and/or thehead and neck ishyperflexed orhyperextended.

Respiratory functioncan be decreased bymechanical restrictionof the rib cage, whichcan occur with certainpositions (e.g., prone,lateral, lithotomy)...

Circulatory functionis influenced byanesthetic agentsand surgicalprocedures thatmay result invasodilatation,hypertension,decreased cardiacoutput andinhabitationof normalcompensatorymechanisms.

n Advanced agen Malnutritionn Alcohol abusen Diabetesn Advanced cancern Terminal illnessn Sepsisn Vascular diseasen Neurological disease

Endogenous factors predisposingpressure ulcer development

events, anesthesia-related events, medicalequipment-related events and fire. As of June30, 2007, there have been 534 op/post-opcomplications, comprising 11.9 percent of allreported sentinel events – third only to wrongsite surgery and suicide. The op/post-op cate-gory includes injuries from patient positioning,but only if the injury resulted in death. Also,this category includes all unexpected patientdeaths as a result of all surgical complications.9Therefore, there is not a reporting system thatcaptures the total number of patient injuriesdue to surgical positioning.

Prevention of positioning injuriesThe first step in preventing positioning errorsis the development of a zero-tolerance atti-tude toward preventable patient injury amongall perioperative healthcare providers. This at-titude then lends itself very easily to imple-mentation of the necessary steps to preventand protect patients from injury. A comprehen-sive positioning safety initiative must includebest practice, education and best products –and it all begins with the basics of care.10

AssessmentBefore the patient ever enters the operatingtheater, assessment for positioning needsshould be made.11

Appropriate positioning devicesPositioning devices should be provided foreach surgical position and its variations.These devices include padding and pressure-relief devices. Firm and stable devices help


Assessment for both the patientand intraoperative factors includes:

n Agen Height and weightn Skin conditionn Nutritional statusn Preexisting conditions (e.g., vascular,

respiratory, circulatory, neurologic,immunocompromise)

n Physical/mobility limits (e.g., prostheses,implants, range of motion)

n Type of anesthesian Length of surgeryn Position required

Ask these very important questionsbefore each patient procedure:

1. How many people will be needed to transfer the patient tothe operating table and to safely position the patient?

Tip: Never transport or begin movement of the patientuntil the appropriate number of personnel is available.

2. What positioning devices will be needed to adequately andcompletely support the patient in the necessary position toperform the operation?

Tip: Have all necessary positioning devices andpadding materials in the operating room prior totransporting the patient.

3. Will the plan for positioning provide for airway management,ventilation and monitoring access for the anesthesiacare provider?

Tip: If the answer is no, change the positioning planof care.

4. Have plans been developed and supplies been addressedto maintain the patients’ dignity by controlling unnecessaryexposure during the positioning procedure?

Tip: Ensure applicable transfer devices and blanketsare available to allow for minimal patient exposureduring the transfer and positioning procedure.

5. Do I know the pressure points for the position that mypatient may be prone to due to patient positioning?

Tip: Refer to the pressure points labeling exercise onPage 98 to identify specific pressure points for varioussurgical positions.

External pressureexceeding normalcapillary interfacepressure (i.e., 23to 32 mm Hg) cancause occlusionthat will restrictor block blood flow.


distribute pressure evenly and decrease thepotential for injury. Studies suggest thatpositioning devices should maintain normalcapillary interface pressure of 32 mm Hgor less.11

When selecting positioning devices, keep thefollowing in mind:

n Be sure to have a variety of devices in theappropriate size and shape to cover all ofthe procedures performed in youroperating room.

n Select positioning and pressure-relievingdevices that are made of durable materialand design.

n Assure that the positioning device hasbeen tested to maintain normal capillaryinterface pressure (not applicable forpadding materials).

n Additional traits to look for:• Resistant to moisture and

microorganisms• Radiolucent• Fire resistant• Nonallergenic• Ease of use• Easily cleaned/disinfected if

not disposable• Easily stored, handled and retrieved

The use of gel pads or similar devices overthe OR table decreases pressure at any givenpoint by redistributing overall pressuresacross a larger surface area.11 Typical foammattress pads are not effective in reducingcapillary interface pressure because theyquickly compress under heavy body areas.For years, pillows, blankets and molded foamdevices have been used to not only pad bonyprominences but to position patients on surgi-cal tables. These devices typically produceonly a minimum amount of pressure reductionand are not adequate for patient positioning.11

Foam and gel pads provide better support forpadding of bony prominences. They are alsoexcellent adjuncts when used to protect patients’skin from injury. Do not forget to adequatelypad positioning devices in critical areas whereskin will be in contact with the device.

DocumentationDocumentation should include but not belimited to the following:

n Preoperative assessmentn Type and location of positioning

and/or padding devicesn Names and titles of persons

positioning the patientn Postoperative outcome evaluation

At the end of every surgical procedure andbefore the patient is transferred from theoperating table to the post-anesthesia careunit, a thorough visual assessment should beperformed and documented in the patient’srecord. Any areas that are reddened, showsigns of bruising or tissue damage, skin irritationsor any variation from the preoperative skincondition should be discussed with the surgeonand documented in the patient record as wellas provided in the patient hand-off reportgiven in the post-anesthesia care unit.

Policies and proceduresPolicies and procedures related to positioningshould be developed and reviewed annually,revised as necessary and readily available inthe practice setting.12 A sample policy andprocedure developed at the University ofNorth Carolina Hospitals has been includedon Page 98 for your consideration.

Comprehensive staff trainingand educationThere are several books and educationalprograms available to those seeking to provideadditional training and education on patientpositioning. A few include:

Textbooksn Alexander’s Care of the Patient inSurgery, 13th Edition by Jane C.Rothrock (Published by Mosby)

n Berry & Kohn’s Operating RoomTechnique, 11th Edition by NancymariePhillips (Published by Mosby)

Online coursesn ENST06-0905: Positioning:

Patient Safety InitiativeAvailable at: www.endonurseinstitute.com


Programs for purchasen Periop 101: A Core Curriculum

Available at: www.aorn.orgn Safely Positioning the Surgical Patient

AORN Video LibraryAvailable at: www.cine-med.com

The perioperative nurse’s rolein patient positioningAt many facilities, the anesthesia providerassumes the responsibility for patient positioning.In no way does this practice obliterate theresponsibility of the RN circulator to ensureproper patient care alignment and tissue integrityfor each patient. For specific injury risks andsafety considerations to be followed whenpositioning the patient, we have provided acopy of AORN’s Injury Risks and SafetyConsiderations when Positioning Patientson Page 94. This tool is designed to assistcaregivers in making sure patient injury doesnot occur.

After positioning, the perioperative nurseshould evaluate the patient’s body alignmentand tissue integrity.11 This evaluation shouldinclude, but not be limited to, thefollowing systems:

n Respiratoryn Circulatoryn Neurologicn Musculoskeletaln Integumentary

After repositioning or any movement of thepatient, procedure bed or devices that attachto the procedure bed, the patient should bere-assessed for body alignment.11

Bringing it all togetherA positioning safety program begins with zerotolerance for errors and includes best practicesfor patient assessment, selection of the bestproducts for appropriate positioning and pressurerelieving devices, comprehensive staff trainingand education and collaboration among theperioperative team members. Best practicesinclude policies that identify the requirementsfor each surgical position, identifying theanatomy at the highest risk for damage,identifying patient risk factors that predisposepatients to adverse outcomes and providingclear instructions for protecting the patient

adequately.10 Education ensures that all prac-titioners have the knowledge and skill to applythe policies, education and training effectively.Best products ensure that the items we useto protect our patients provide the protectionwe expect.10

The “Back to Basics” series was developeddue to our belief that perioperative profession-als should adhere to basics of practice andincorporate new technologies with evidence-based strategies to improve patient outcomes.Our readership is requesting “Back to Basics”topics in order to provide in-service, educationand training in their facilities. The OR Connec-tion is dedicated to continuing this service andwants to hear from you regarding future “Backto Basics” topics. Email your requests forfuture “Back to Basics” topics [email protected].

References1. McEwen DR. Intraoperative positioning of surgical patients. AORN Journal. 1996 Jun;63(6):

1059-63, 1066-79; quiz 1080-6.2. Schultz A, Bien M, Drummond K, Brown K, Myers A. The etiology and incidence of pressure

ulcers in surgical patients. AORN Journal. 1999 Sep;70(3):434, 437-40, 443-9.3. Institute for Healthcare Improvement. Getting Started Kit: Prevent Pressure Ulcers:

How-to Guide. 2006:13.4. Brandon GE. Rule denying payments for ‘never events’ will force a close look at current

practice. Available at: www.aorn.org/Managers/October2007Issue/. Accessed November14, 2007.

5. Bhatt HK, Charma MS, Blair NP. Pressure alopecia following vitreoretinal surgery.American Journal of Opthalmology. 2004 Jan;137(1):191.

6. Millsaps C. Pay attention to patient positioning! Available at: www.mediwire.skyscape.com.Accessed November 14, 2007.

7. Legal Eagle Eye Newsletter for the Nursing Profession. Operating room nurses share faultfor improper positioning of patient. Available at: www.nursinglaw.com.Accessed November 14, 2007.

8. Sewchuk D, Padula C, Osborne E. Prevention and early detection of pressure ulcers inpatients undergoing cardiac surgery. AORN Journal. 2006 Jul;84(1):78.

9. The Joint Commission. Sentinel Event Statistics: As of June 30, 2007.Available at: www.JointCommission.org. Accessed November 14, 2007.

10. EndoNurse Institute. Positioning: Patient Safety Initiative.Available at: www.endonurseinstitute.com/positioning. Accessed November 14, 2007.

11. Association of periOperative Registered Nurses. Standards, Recommended Practicesand Guidelines. Denver, Colo: AORN Publications; 2007.

12. Positioning the Surgical Patient. University of North Carolina Hospitals: Nursing ProcedureManual. January 2005.

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Crossword Puzzle – Back To Basics

Perioperative Patient Positioning

To receive one hour of

CE credit, enter your

answers online at

www.medlineuniversity.com

Across3 Best practices include _____ that identify

the requirements for each surgical position.5 The most common cause of _____ nerve

injury in surgery is arms on arm boards notbeing extended more than 45 degrees.

7 Intraoperative skin _____ is the function ofunrelieved pressure, duration of thepressure and the location of the pressureon the body surface.

9 The operating room is a high-riskenvironment for the development of _____.(2 words)

12 The most common example of physiologiccompromise is effects to the respiratorysystem due to positioning interfering withthe patient’s _____ system.

18 Potential positioning injuries includepressure ulcers, _____, nerve injuries,and physiologic compromises.

19 The result of pressure ulcers occurring asa result of _____ is thought to be as highas 66 percent.

21 Before the patient is transferred from theoperating table, a thorough visualassessment should be performed and_____ in the patient’s record.

23 Pressure alopecia is an under-recognizedand rare complication of _____ surgery.

24 Pressure ulcers are _____ injuries thatdevelop rapidly.

25 The Joint Commission collects _____ eventdata for all operative injuries.

26 Preoperative identification of _____ forpressure ulcers is imperative.

27 Positioning _____ should be provided foreach surgical position and its variations.

28 Procedures lasting longer than two andone-half to three hours significantly _____the patient’s risk for pressure ulcerformation.

29 After positioning, the perioperative nurseshould _____ the patient’s body alignmentand tissue integrity.

Down1 Injury mechanisms that contribute to

positioning include pressure, _____ andshear forces.

2 The standard of care when arm boards areused is to have arms positioned with palmsup and to ensure adequate _____.

3 Patients are most vulnerable to respiratorycompromise in the _____ position.

4 ____ ensures that all practitioners have theknowledge and skill to apply the policies,education and training effectively.

6 Pressure ulcers originating during surgicalprocedures may appear within a few hours,but the majority present one to three_____ after surgery.

8 Positions such as lithotomy andTrendelenburg’s can cause redistributionand congestion of the _____ supply.

10 Beginning October 1, 2008, hospitals willno longer be _____ for eight preventable“hospital-acquired conditions.”

11 After repositioning or any movement of thepatient, procedure bed or devices thatattach to the procedure bed, the patientshould be ______ for body alignment.

13 Category 488, operative/post-opcomplications, currently ranks _____overall in the number of sentinel eventsreported.

14 Alopecia has been documented as aprecursor for pressure ulcer developmentwhen occurring after sustained immobilityand pressure to the _____.

15 The first step in _____ positioning errors isthe development of zero tolerance towardpreventable patient injury among allperioperative healthcare providers.

16 Best _____ ensure that the items we use toprotect our patients provide the protectionwe expect.

17 Patients under anesthesia for extendedperiods can have an increased risk ofdeveloping pressure ulcers, so all surgicalpatients should receive a skin _____ andrisk assessment.

20 Before the patient _____ the operatingtheater, assessment for positioning needsshould be made.

22 Firm and stable positioning devices helpdistribute pressure evenly and _____ thepotential for injury.


www.medlineuniversity.com1. Register (free) or log in2. Click Free Courses tab3. Locate the puzzle and click Learn More,

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Patient Safety

Though they were on call, Sandy and Joehad decided to attend Dr. Michael’s annualemployee appreciation party and crosstheir fingers that they wouldn’t be called in.The party was held at Andy and Charlie’sLakeside Restaurant and was looked for-ward to by staff and physicians alike. Thisyear, the entertainment was provided by theCutups, a band composed of generalsurgery residents Tom, Mike, Kurt andSydney. Kurt’s wife Jackie was the leadsinger, and the band was quite good. Asthe set ended, Sandy’s cell phone rang.“It’s the hospital,” she mouthed to Joe asshe flipped her phone open.

A few minutes later, Sandy and Joe wereon their way to the hospital. They werecalled in for a leg exploration on a postoper-ative coronary artery bypass patient. On theshort drive to the hospital, they wondered ifthis was possibly another postop woundinfection. The surgical site infection rateat their facility was well below the nationalaverage; however, earlier in the year therehad been a sharp increase in surgical siteinfections. To make matters worse, several

Sandy and Joe sat onthe deck enjoying thecrisp fall evening, sippingtheir soft drinks andlistening to the band.

By Jayne Barkman, RN, CNOR

CCOOUUNNTTIINNGG AACCCCOOUUNNTTAABBIILLIITTYY


of the wounds were infected with MRSA.Strict adherence to aseptic and sterile tech-nique was the norm in the operating room,but additional measures were advocatedafter the outbreak of infection. Alcohol-basedhand rub delivered via touchless dispenserswas implemented and all scrubbed personnelinvolved in draping the patient were requiredto change their outer gloves prior to theincision being made.

At the last monthly in-service, Infection Controlhad presented updates on surgical siteinfection rates as well as information on theCenters for Medicare & Medicaid Services’new pay-for-performance guidelines regarding“never event” reimbursement for surgicalsite infections and retained objects. Accord-ing to Infection Control’s data, the surgicalsite infection rate had decreased and wasagain below the national average.

When Sandy and Joe arrived at the hospital,Jane, the weekend in-house RN, was open-ing their case. The patient arrived from theER and was in the OR shortly thereafter.The surgeon arrived in the OR and initiatedthe time out as he exposed the operative leftleg. Sandy placed the safety strap acrossthe non-operative leg and could feel heatresonating from the left leg. While she ap-plied the one-step prep, Sandy noted the leftleg looked as though it had been burned andwas nearly twice the size of the right leg.There was exudate seeping from one of theendoscopic saphenous vein-harvesting stabwounds. The patient was draped, the skinincision made and a Weitlaner retractorplaced to gain exposure. Joe grabbed anemesis basin off the back table as the surgeonpulled a handful of hemorrhagic tissue out ofthe patient’s leg. Sandy watched Joe probethe emesis basin with a tissue forceps. Hereached into the basin and unrolled a four-inchsquare X-ray detectable swab. The surgeonlooked up at the swab and muttered some-thing unintelligible. Joe tossed the black-ened swab into the kick bucket while thesurgeon continued to explore the wound.The leg wound was debrided, irrigated andclosed. After the patient was extubated,

Sandy and the CRNA transported the patientto PACU, where Sandy finished her chartingand filled out an incident report. Joe arrivedin PACU as Sandy was pulling up the patient’s old chart on the computer. Together,they scanned the previous perioperativerecord and were surprised to see thesponge count documented as correct.

Joe and Sandy decided to go home ratherthan back to the party. On the drive toSandy’s house, they discussed the need toreview and possibly revise the hospital’s policy and procedure on sponge counts.With coronary artery bypass, the PA harvestedvein as the surgeon worked simultaneouslyon the chest. Typically a sponge count wasnot performed when the PA closed theminute incisions made for the endoscopicharvests. This was despite the fact that X-raydetectable swabs were occasionally tuckedinto the endoscopic tunnels or cavities in the leg to apply pressure.

Working with a SafetyNetIn 2004, AORN began a voluntary reportingsystem as part of the Patient Safety First initiative. The system, known as SafetyNet,encourages perioperative nurses to reportnear misses or close calls in the perioperativesetting. The anonymous information provided



to SafetyNet is analyzed to look for patientsafety trends and assists AORN in developingeducational programs, recommended practicesand position statements to assist perioperativenurses in providing safe patient care. According to SafetyNet data, several factorscontribute to variable sponge counts. Thesefactors include distraction, such as the circulating nurse leaving the room to obtain additional supplies during the countingprocess; excessive talking when counts areperformed; sponges packed into cavities andcounts not being performed but documentedas having been done.1

To reduce the likelihood of a retained foreignobject, AORN and the American College ofSurgeons recommend that sponge countsbe performed in a systematic order, such assmallest to largest, and according to nationalstandards and facility policy. Other recom-mendations by the agencies include providingadequate personnel to support safe practices;using only X-ray detectable sponges, towelsand instruments in surgical sites; developingand reviewing policy and procedures relatedto counting to promote consistent practicesand utilizing technology such as radio frequency detection to ensure that allsponges, towels and instruments are removed from the patient.1

To learn more about SafetyNet and the Patient Safety First initiative, visit ww.patientsafetyfirst.org.

About the authorJayne Barkman, RN, BSN, CNOR, has 29years of perioperative experience in variousroles, including surgical technologist, staffnurse and clinical educator. She currentlyworks as a nurse consultant.

Retained sponge costs $2.4 millionA first-grade teacher in Pembroke Pines, Fla. wasawarded $2.4 million in damages after a foot-longsponge was left inside her abdomen during a routine cesarean section.1

Karlene Chambers gave birth to her first child on September 11, 2001. She began to experience excruciating pains in her abdomen shortly after the birth and returned to the hospital to find out what was wrong.

She was initially prescribed antibiotics for what she was told was an infection. When the antibiotics did not alleviate her pain, the same physician who had performed her C-section, ordered an X-ray of her abdomen. The X-ray revealed that a one-foot surgicalsponge had been left in her uterus after she gave birth.

An X-ray alone would not have revealed the sponge if the manufacturer had not attached a blue thread to it to make it X-ray detectable.

ReferenceMSNBC.com. Woman awarded $2.4 million after surgical spongeleft in abdomen. Available at:http://www.msnbc.msn.com/id/21128136/. Accessed October 15, 2007.

ReferenceBest practices for preventing a retained foreign body. AORN Journal. 2006;84(1) Supplement 1:S30-S36.

HYPOTHERMIAWe hear it every day from patients presentingfor surgery: “Why do you keep it so cold inhere?” No matter what part of the countryyou are practicing in or what kind of surgicalprocedures are being performed, the patientwill complain about being cold. Not only that,but there is a large population of operatingroom personnel who also complain about the“frigid” conditions. This is a real situation inthat we request patients to strip their clothesoff and place a paper or flimsy cloth gown on,get onto an uncomfortable stretcher and thenbe placed in a rather sterile holding area. Thisby itself is a chilling experience, let alone beingconcerned about their upcoming surgery!This sets the stage for hypothermia. Hypothermia, by definition, is “a reduction ofcore body temperature to 35 degrees C or lower, usually due either to coldness of theenvironment or artificial inducement.”1 Hypothermia develops when thermoregulationfails to control the balance of metabolic heat production and heat loss. There are certainfactors of the environment that we cannot control, such as the temperature in thepreoperative holding area and the continuous exchange of air in the operating rooms.To maintain a clean operating room environment, the total volume of air is exchanged15 times per hour.2 Many times we explain to the patient that being cool in the OR isgood for them because the cool environment deters the growth of bacteria.


By Gary Nitz, CRNA

Heat loss in a patient in the operating room can be from conduction, convection,radiation and/or evaporation.3 Conduction heat loss begins in the preoperative holdingarea lying a on cool stretcher and continues in the OR while lying on the table. Militarypersonnel doing nighttime tactical operations where concealment is essential canlose a significant amount of heat by being in close contact with rocks or outside wallsover a prolonged period. Heat loss by convection involves the ambient air movingover the body, decreasing the body’s core temperature. Because air is technically afluid, the analysis of heat transport from the patient involves convection. When a bodyis submerged in water, heat loss from convection is 32 times greater than when it isexposed to air. Heat loss from radiation is the process where a person’s body radiatesheat away from the body and into the room. Evaporation is the loss of heat viaperspiration, open wounds and natural secretions.

General anesthesia takes away the body’s natural responses to increase heat pro-duction. Heat loss is common because anesthetics alter thermoregulation, preventshivering and produce peripheral vasodilatation. All perioperative and anesthesiapersonnel should always keep in mind that once the core temperature of a patientbegins dropping, it will continue to drift unless actions are taken to help preventworsening hypothermia. Postoperative warming should not be a routine substitutefor maintaining intraoperative normothermia.

Through simple actions, we can disrupt the cascade effect of hypothermia. Active“prewarming” for 30 to 60 minutes usually minimizes hypothermia. Having the patientundress in a warm environment and covering them with warm blankets preoperativelyaids in the prewarming. Commercial gown heaters are on the market and act as a niceadjunct to the warm blankets. Warming of the OR table with forced warm air and/orwarm blankets reduces the convection heat loss aspect. Intraoperative use of forced-airblankets, with the recommended associated blankets, and warmed intravenous solutionsall aid in the heat retention of the patient. Airway heating and humidification areineffective4; however, I have found that certain airway filters and single-limb anesthesiacircuits help preserve normothermia.

Measuring of the patient’s temperature is vital and continuous intraoperative coretemperature can be obtained from the pulmonary artery, distal esophagus, tympanicmembrane and nasopharynx. The rectum, mouth, axilla and bladder can be used exceptin cardiopulmonary bypass. If there is any vital discrepancy between intraoperative andimmediate postoperative temperatures, a core temperature should be sought to verifythe patient’s temperature status.

With the number of warming adjuncts at our disposal, all perioperative and anesthesiapersonnel should be cognizant of our patients’ physiological need to stay warm, andhelp deter the “worst part of surgery.”

References1 Dorland. Dorland’s IllustratedMedical Dictionary, 31st Edition.Philadelphia, Pa.: Saunders; 2007.2 Spry C. Essentials of Periopera-tive Nursing, Third Edition. Boston,Mass.: Jones and Bartlett Publish-ers; 1997.3 Barash PG, Cullen BF, StoeltingRK, eds. Clinical Anesthesia, 2ndEdition. Philadelphia, Pa: JB Lippin-cott; 1992.4. Roizen MF, Fleisher, LA.Essence of Anesthesia Practice,Second Edition. Philadelphia, Pa.:Saunders; 2002.

About the authorGary Nitz, CRNA, is a staff anesthetist for Washington University School of Medicine in St. Louis, Mo. and is a Captain in the U.S Navy Reserves, servingwith the 4th Medical Battalion as the Senior Nurse Executive.

Consequences of hypothermia in surgical patients• Adverse myocardial outcomes

— 1.5° C core temperature decrease triples the risk of morbid myocardial events

• Coagulopathy— Impairs platelet function and coagulation cascade

• Reduces drug metabolism• Thermal discomfort (patient satisfaction)• Surgical wound infection

— Thermoregulatory vasoconstriction

How hypothermia developsHypothermia develops during general anesthesia in three phases:

1. Initial rapid reduction in coretemp after anesthesia inductionresulting from internal redistribu-tion of body heat2. Core temp decreases at a ratedetermined by the difference between heat loss and production3. When sufficiently hypothermic,thermoregulatory vasoconstrictionis triggered and core-to-peripheralflow of heat is restricted


OR Issues

The extent to which airborne contaminants contribute to surgical site infec-tion (SSI) is unknown but has long been a shared concern of perioperativeand infection control professionals. There is mounting evidence that they are underrecognized and might play a larger role than previously believed.

Adding to the complexity of this risk for the patient are the emerging airborneinfectious diseases, which can make their way into the operating room (OR).A case in point involves the emergence of drug-resistant strains of tuberculosis(TB), particularly XDR-TB (strains which are extensively drug resistant). Inaddition to XDR-TB, the potential for emergence of pandemic influenza, possiblyfrom strains causing avian influenza, and recent experience with worldwideSARS pandemic are other unwelcome visitors to the OR.

The alarming number of airborne pathogens that pose a serious threat topublic health has prompted new awareness of pandemic preparedness withinthe healthcare community. Our response to appropriately understand howthese diseases impact healthcare delivery, however, has been unsatisfactoryto date and few studies on this matter have been conducted.

Airborne Disease and Surgical Site Infection

By Russell N. Olmsted

The floating danger


OR Issues

Surgical site infection background Over the last decade, surgical site infection has had the dubiousdistinction of moving from the third to the second most commonhealthcare-associated infection (HAI). In America alone, SSIrepresents 22 percentof an estimated 1.7 million HAIs and contributes to the more than 99,000deaths associated with this complication of hospitalization.1,2 The preventablepain, suffering and loss this represents is not only staggeringin terms of patient well-being but also generates a huge financial burden. A recent study placed the average additionalincremental direct cost of patients with an HAI at $8,8324,which puts the total burden of managing this situation at more than a staggering $15 billion without consideration of indirect costs.

This financial burden has and will have a dire negative impacton the financial health of both healthcare and the insuranceinstitutions. The Centers for Medicare & Medicaid Services(CMS) recent decision not to cover “conditions that could rea-sonably have been prevented” beginning in 2008 is intendedto put financial pressure behind the movement to reduceHAI.6 The potential impact of these “no-pay” procedures onhospitals has already generated much debate. Regardless ofthe outcome, CMS is representative of a growing industryand social unwillingness to tolerate current HAI levels.

Contact vs. airborne transmissionBecause most endemic infections are transmitted by director indirect contact, hand hygiene has been identified as thenumber one way to reduce HAIs.3 This underlines a widebody of research that has been able to directly and clearlytest the dangers and potential solutions associated with directcontact or breaks in aseptic technique that can in turn lead tocontamination of the surgical site. The role of airborne trans-mission in SSI is much less well understood and only nowgaining wider attention.

There is mounting evidence that airborne transmission of mi-crobial populations may play a greater role in postoperativeinfections than previously thought. Edmiston and others,using sophisticated genetic fingerprinting, demonstrated thatmany microorganisms recovered from air samples taken nearthe surgical site matched the strains colonizing members ofthe surgical team.9 Testing is difficult, however, because par-ticulates of different sizes may or may not follow the rules ofBrownian motion and are difficult to conclusively track.10 It isalso very challenging to demonstrate that microbes presentduring a procedure are genetically identical to pathogens thatmay subsequently cause a SSI. Advances in equipment andcomputer modeling have given us a better understanding ofairborne particulate circulation.

Understanding airborne transmissionThe CDC represents the risk of SSI with the following relationship:12

In terms of airborne transmission, it follows that reducingoverall levels of airborne contaminants and establishing airflow patterns that move potentially contaminated air awayfrom the surgical site will minimize the potential for surgicalsite contamination and subsequent SSI.

Patients with airborne or droplet nuclei transmitted infectiousdiseases pose a special category of risk. All patients are apotential source of OR air contamination,7 but in the case ofpatients with these classes of infectious diseases the dangerof self-contamination is that much more salient. The illness itself may also reduce host resistance. Thus, the risk of SSI is increased on two fronts. These patients pose an additionalrisk for caregiver occupational exposure10 that must also beconsidered when establishing OR airflows.

Keeping OR air cleanUsing Mycobacterium tuberculosis as the prototype of an airborne infectious pathogen, the CDC recommends that theventilation of the OR remain in positive pressure if needed for apatient with active TB disease but also include an anteroom just

Dose of bacterial contamination × virulence Resistance of the host patient = Risk of surgical site infection



References:1 Klevens RM, Edwards JR, Richards CL Jr., et al. Estimating health care-associated

infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007 Mar-Apr;122(2):160-6.

2 Centers for Disease Control & Prevention (CDC). Data & Statistics for Surgical SiteInfections. Available at: www.cdc.gov/ncidod/dhqp/dpac_ssi_data.html. Accessed November 14, 2007.

3 Murphy DM, et. al. Dispelling the Myths: The True Cost of Healthcare-Associated Infections. Available at: www.apic.org/Content/NavigationMenu/PracticeGuidance/Reports/hai_whitepaper.pdf. Accessed November14, 2007.

4 Centers for Medicare & Medicaid Services (CMS). Medicare Program; Changes to theHospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates. 42CFR Parts 411, 412, 413, and 489. Available at: www.cms.hhs.gov/AcuteInpa-tientPPS/downloads/CMS-1533-FC.pdf. Accessed November 14, 2007.

5 Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advi-sory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.MMWR. 2002;51(No. RR-16):1-56.

6 Edmiston CE et al. Molecular epidemiology of microbial contamination in the opera-tion room environment: Is there a risk for infection? Surgery. 2005;138:573-82.

7 Memarzadeh F, Manning A. Reducing risks of surgery. ASHRAE Journal. Feb.2003:28-33.

8 Mangram AJ et. al. Guideline for Prevention of Surgical Site Infection, 1999. Centersfor Disease Control and Prevention (CDC) Hospital Infection Control Practices Advi-sory Committee. Am J Infect Control. 1999 Apr;27(2):97-132.

9 Hutton MD, et al. Nosocomial transmission of tuberculosis associated with a drainingabscess. J Infect Dis. 1990 Feb;161(2):286-95.

10 Centers for Disease Control and Prevention. Guidelines for Preventing the Trans-mission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR.2005;54(No. RR-17):1-147.

11 Edmiston C et al. Molecular epidemiology of microbial contamination in the operationroom environment: Is there a risk for infection? Department of Surgery, Medical Col-lege of Wisconsin. 2005.

12 ASHRAE. 1999 ASHRAE Handbook: HVAC Applications. Atlanta: ASHRAE; 1999.13 Scaltriti S et al. Risk factors for particulate and microbial contamination of air in oper-

ating theaters. J Hosp Infect. 2007;66:320-6.

outside the main OR door.11 The anteroom safeguards againstthe release of airborne contaminants into other occupied areas.It also helps maintain proper airflow within the OR, which is important to protect the patient’s surgical site. The Associationof periOperative Registered Nurses (AORN) has also recently released new recommended practices with consideration forpreventing both airborne and contact infectious disease transmission which reinforce prior CDC Guidelines.15

General OR recommendations for reducing contaminants include supply air being delivered from the ceiling, with top-downdirection to perimeter exhaust outlets on walls nearer to thefloor.12 The theory is that clean air should be pulled down andaway from the patient as it is potentially contaminated. By activelypulling air away from the OR table and toward the door, theanteroom helps establish this airflow pattern.

The availability of ORs with permanent anterooms is likely rarein most surgery suites in the U.S. Therefore, one alternative isto use temporary anterooms that are equipped with portableHEPA filters. This offers an effective, flexible solution for useover the entrance to any standard operating room and can notonly capture airborne microbes but also facilitate removal ofparticulates from the OR. An alternative option is to place free-standing portable HEPA devices in the OR; however, these must be turned off during the surgery as they may disrupt patterns of ventilation in the OR. In addition to surgery,temporary anterooms can be used whenever there is concern over aerosol generation, such as during special pulmonary procedures.

As highlighted, there might be additional benefit from use oftemporary anterooms for removal of contaminants in the criticalenvironment of the OR for cases where air quality is of particularconcern, e.g., orthopedic implants. Of note, a recent investiga-tion highlighted that opening of doors during procedures withoutan anteroom is positively correlated with increased microbialcounts at the surgical site.13 While further study is needed, atemporary anteroom may provide assistance with mitigatingairflow disruption caused by entry and exit from the OR andenhance removal of contaminants.

SummaryAirborne contaminants are a known cause of infection. Studiesestablishing specific SSI rates have not yet been conducted,in part because of the difficulty of conclusively identifying themovement of airborne particulates and causality. The ability ofvarious products and procedures to reduce airborne particulates,however, is demonstrable. The implied connection is clear:fewer contaminants near the surgical site can be expected toresult in fewer SSI. It is also worth noting that while infectiousdisease patients have more specific containment requirements,the benefits of contaminant reduction apply to the broader baseof surgery patients as well.

About the authorRussell N. Olmsted, MPH, CIC has more than24 years of experience in the field of infectioncontrol/applied epidemiology. He is an epidemi-ologist with Infection Control Services at SaintJoseph Mercy Health System, headquarteredin Ann Arbor, Mich., and President of AppliedEpidemiology Solutions, Inc., a private consulting

business that covers the field of infection prevention/control andhealthcare epidemiology.

Circuits

Masks

Filtration products

Breathing bags

Anesthesia accessories

Laryngeal masks

Endotracheal tubes

Oral airways

Laryngoscopes

Oxygen therapy

For more information, contact us at 1-800-MEDLINE | www.medline.com


PREVENTING

M EDIASTINITIS

By Denice Summerlin, RN

Mediastinitis, inflammation

of the area between

the lungs (the mediastinum),

can be one of the most devastating

complications of cardiac surgery.11

OR Issues

It occurs, on average, in 1 to 2 percent of surgicalpatients, but certain subsets of patients such asheart transplants, obesity and diabetes are at amuch higher risk.2 COPD, smoking, renal failureand advanced age can also be contributors.Certain procedures and conditions increase therisk of postoperative mediastinitis. Other riskfactors include: 1,2,3,4

• Use of bilateral internal mammary grafts• Emergency surgery• Cardiopulmonary resuscitation• Prolonged bypass and operating time• Postoperative shock• Obesity greater than 20 percent of ideal

body weight• Re-exploration following initial surgery• Sternal wound dehiscence• Surgical technique, including excessive use

of electrocautery and bone wax, paramedian sternotomy and pacing wires

Staphylococcus aureus and Staphylococcus epidermis are the causative organisms in 70 to 80percent of infected patients. The rise in methicillin-resistant Staphylococcus aureus (MRSA) infectionsis impacting prevalence of this condition andaccounts for 25 to 30 percent of all cases ofmediastinitis following coronary bypass surgery.1

When mediastinitis occurs, re-operation, prolongedventilation, additional time in critical care units andincreased therapy and treatment compound thecost of recovery and increase the risk of death.2

We have never wanted mediastinal infections tooccur, but now we have even stronger incentivesfor prevention. In the current system for reim-bursement for healthcare-associated complications,including infections, a trigger occurs that results in higher payments. The more severe the compli-cating condition, the higher the payment assigned.CMS (Centers for Medicare & Medicaid Services)believes there is a significant public health interestin focusing on serious preventable events. In August2007, CMS announced eight healthcare-associatedconditions that they believe could be prevented.One of the eight conditions is Surgical Site Infection– Mediastinitis after Coronary Artery Bypass Graft(CABG) Surgery and includes codes 519.2 MCCand 36.10-.19. Beginning October 1, 2008, CMScannot assign a case to a higher DRG based onthe occurrence of one of the selected conditionsif that condition was acquired during hospitalization.5

Although there have been mixed opinions on thisdecision among providers and caregivers, therehas been strong public support for CMS to payless for conditions that are acquired during a hospitalstay. Considerable national press coverage hasprompted dialogue of how to further eliminatehealthcare-associated infections and conditions.Prevention strategies now take on even moremeaning because preventable complications willnot be paid for and hospitals will be left holdingthe bill.

Perioperative professionals are on the front linewhen it comes to making a difference in patientoutcomes. By knowing the risk factors and thesigns and symptoms of mediastinitis, we canimplement prevention measures that not onlyreduce the risk but also promote prevention. This is the future of holistic nursing healthcare.

About the authorDenice Summerlin, RN, BSN, is the Cardiac ProductLine Nurse Manager at Centennial Medical Center inNashville, Tenn. She has worked as a CVOR Nurse for the past 22 years. Denice is currently working on her MSN.

References:1 Lavoie-Vaughn N. Recognizing Mediastinitis. Available at:

www2.nurseweek.com/articles/print.html?AID=14478. Accessed November 9, 2007.

2 Mueller D. Mediastinitis. Available at: www.emedicine.com/med/topic2798.htm. Accessed November 9, 2007.

3 King R, Barnes A. Mediastinitis. Curr TreatmentOptions Infect Dis. 2003:5:377-386.

4 El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thoracic Surgery. 1996:61(3):1030-1036

5 Valuck TB. CMS Progress Toward Implementing Value-BasedPurchasing. Presentation at 10/18/07 meeting.

6 Huber S, Bergmann P, Schweiger S, Machler H, Oberwalder P, Rigler B. Endoscopic vein harvesting in coronary artery bypass surgery. European Surgery. 2007; 39(2), 96-104.


Step 1: Assess all cardiac patients prior to surgery for common clinical risk factors, i.e., diabetes, immune deficiency, malnutrition, hepaticdysfunction, alcohol or drug abuse, COPD, smoking and obesity.

Step 2: For scheduled procedures, assess pa-tients prior to admission for signs and symptomsof secondary infection. One example would beNare cultures preoperatively for MRSA as part of the pre-admission protocol.

Step 3: Instruct use of chlorhexidine showersthe night before surgery and the morning of surgery.

Step 4:Warm patients for a minimum of 30 minutes prior to the surgical procedure.

Step 5: Implement preoperative, individualized insulin protocol for diabetic patients before and after surgery.

Step 6: Utilize alcohol-based hand antisepticproducts prior to patient contact and for the surgical scrub prior to donning surgical gloves.

Step 7: Assure that all supplies, personnel andequipment are ready and available prior to bring-ing the patient into the OR and beginning the surgical procedure to prevent any unnecessary intraoperative delays.

Step 8: Do not shave the surgical site. Clip only the hair necessary for operative preparation immediately before the surgical procedure.

Step 9: Use a surgical prep solution containingCHG (chlorhexidine) to provide maximum residual kill.

Step 10: Administer prophylactic antibioticswithin one hour of the surgical incision and postoperatively for a minimum of 48 hours.

Step 11: Utilize maximal barrier precautions(AAMI Level 4) for surgical gowns and surgicaldrapes around all fenestrations.

Step 12: Segregate surgical instruments between the graft harvest site (leg) and the chestcavity instruments.

Step 13: Closely monitor and document blood loss intraoperatively.

Step 14: Consider using endoscopic vein har-vesting (EVH) technology for vein graft harvest.The advantages of EVH are the reduced traumato the leg and the painless and faster mobilizationof the patients.6

Step 15: Consider silver antimicrobial dressings postoperatively.

Step 16: Assure that all pertinent information regarding the surgical procedure and patient tolerance is documented and communicated at the time of hand-off in the critical care unit.

Infection prevention measuresfor cardiac patients:



Tips for “Going Green”

in the Operating Room

Healthcare facilities are faced with limited abilities to channel the stream ofwaste due to government regulations, restrictions on incinerators and the decreasing numberof landfills that will accept medical waste.1 Couple this with escalating environmental concernsfor our planet and layer on top of that the call for “zero tolerance” in strategies to stop thespread healthcare-associated infections.

All of this is leading to more product introductions, more chemicals and more single-use products.What’s an operating room to do? After giving this some thought, I started making a list of howwe could possibly initiate a “Go Green” strategy in the OR and remarkably came up with anentire list of ways to begin!

We’ve also provided a list of 20 tips for effective recycling and waste segregation in your facility.Read through the list and see how many of these practices you’re already using – and howmany you can add to your routine!

See if you can add to the list and take this as a challenge to “Go Green” in your practice setting!

Special Feature

By Ann Shimek


1. Implement paperless systems2. Use office paper with at least 30 percent recycled contents3. Receive supplies in reusable shipping containers4. Reprocess disposable products according to FDA and manufacturer guidelines5. Turn off the water at scrub sinks when not in use6. Turn off lights in rooms that are not is use7. Look for alternatives to polyvinyl chloride (PVC) and di(2-ethylhexyl)phthalate (DEHP)8. Turn off radios and stereos when rooms are down9. Turn off all equipment when not in use

10. Purchase sterile supplies in procedure packs to limit packaging waste11. Purchase nontoxic/less toxic alternatives for janitorial chemicals12. Provide alcohol-based hand gels and rubs to control water consumption13. Replace ethylene oxide sterilization14. Only open products that are not used in surgical procedures an average of

90 percent of the time at the point of use in non-emergency procedures15. Provide recycling bins in frequent, convenient locations16. Go latex-free throughout the department17. Do not purchase equipment containing mercury 18. Ensure that disposable products are biodegradable19. Limit the use of formaldehyde20. Limit the use of glutaraldehyde21. Limit the use of products that contains DEHP22. Choose products with minimal packaging23. Choose products that are fragrance free24. Recycle toner cartridges25. Recycle lead aprons26. Recycle computers27. Recycle batteries28. Do not dispose of caustic materials through drains29. Integrate sharp-free systems where applicable 30. Standardize as many product categories as feasible

“Go Green”Tips for the OR1

About the authorAnn Shimek, RN, BSN, CASCis the director of materials manage-ment at United Surgical Partners International. She has 15 years of perioperative experience in variousroles, including clinical director, private scrub nurse and staff nurse at a number of acute care facilitiesand ambulatory surgery centers.

Reference:1. Illinois Environmental ProtectionAgency. Thinking “Green” Saving IllinoisHospitals Dollars. Available at: www.epa.state.il.us/environmental-progress/v24/n1/green-hospitals.html Accessed November 8, 2007.

50 THE OR CONNECTION50 THE OR CONNECTION

and Prosthetics


and ProstheticsSSIs

Surgical site infections (SSIs) are themost common healthcare-associatedinfection in surgical patients. Current datatell us that SSIs occur in 2.6 percent of alloperations and lead to increased costand increased length of stay (LOS).1The Centers for Disease Control andPrevention (CDC) define SSIs as thoseinfections occurring within 30 days of anoperation, and within one year if an implant was placed surgically.

Developing an infection in any orthopedicprocedure with or without implants canbe devastating, but when an implant isinfected you have major trouble. Studiesshow that the incidence of SSIs is greaterin total joint arthroplasties than otherorthopedic procedures (see Table 1).

As long as the world’s population livesto be older, the incidence of degenerativejoint disease and consequently theneed for prosthetic joint replacementwill continue to grow. Inevitably, some ofthese patients will acquire an infection oftheir prosthesis. Although the rates aredown, postoperative infections in totaljoint arthroplasties are still a seriousconcern.3

Who is at risk?Even though the infection rate hasdecreased considerably over the yearsthere are still factors that will put somepatients at a higher risk than others.4

Other risks that might put the total jointreplacement candidate at a greaterrisk include psoriasis (especially at theincision site), previous prosthetic jointinfections and a lengthy operative time,especially if that time is longer than 2.5hours.3

What to look forThere are two major categories of post-operative join infections: early and late.Early (or Type I) infections occur at thetime of surgery and symptoms are notedwithin one month.4 Early infectionspresent as painful red, swollen wounds.Purulent drainage is common and thereare usually complaints of continuous pain.Systemic symptoms, such as an elevatedtemperature, occur as well.3 These infec-tions are usually caused by hematomasthat act as bacterial culture mediums.

A“joint”concern

Table 1: Participation in mandatory surveillance of SSI in orthopedics22

Total no. Total no.Trusts Procedures no. SSI % infected

Total Procedures 146 4242 593 1.44Total hip prosthesis 109 16809 208 1.24Hip hemiarthroplasty 71 5364 217 4.05Knee prosthesis 96 15792 102 0.65Open reduction long 26 3277 66 2.01bone fracture

Health concerns such as diabetes, obesity, history ofsmoking, rheumatoid arthritis,periodontal disease, HIV, hemophilia, malnourishment,advanced age and immune suppressive therapy increase a patient’s chances of acquiringan infection and should be takeninto consideration.5

OR Issues

52 THE OR CONNECTION52 THE OR CONNECTION

They can also be triggered by super-ficial wound infections spreading tothe periprosthetic space.4

Late (or Type II) infections are alsothought to originate at the time ofsurgery, but the onset of symptomsis delayed. These patients presentbetween six months to two yearsafter an operation. Delay in onsetoccurs because the bacteria are ableto adhere to the prosthesis and surviveundetected beneath a coating of“slime” that the organism formed.3The patient will begin to note painand inflammation at the operativesite. These symptoms, as well asfindings on examination, are oftennon-specific and akin to thoseseen with aseptic loosening of the prosthesis.3

DiagnosisThe diagnosis of a prosthesis infectionis not easy because the results are so similar to those of aseptic jointloosening. Additionally, in the postop-erative period, signs and symptomsoften noted with infection (swelling,redness and drainage) are seen asnormal postoperative changes.4

Images produced by CT scans andMRIs are often distorted by artifactcaused when metallic images arefilmed in this way.4 Bone scans can-not differentiate between infection

and prosthetic loosening.5 An X-ray ofthe area will show destruction of bonearound the prosthesis. Most surgeonswill suspect infection when this isseen, but there is no way to definitivelydiagnose it. Direct microscopic exami-nation and bacteriological cultures oftissue samples obtained during therevision procedure are the mostcommon ways to obtain a definitivediagnosis.3

Prevention is the best treatment1. Preoperative IV antibiotic

administration is considered to be the most successful way to reduce infection rates.

2. The number of personnel in the surgical room should be kept to a minimum and traffic in and out of the room should be limited to essential tasks.

3. Copious amounts of irrigation, both plain saline and antibiotic-infused, are often utilized before insertion of prosthetic components.6

Two major carriers of bacteria in anoperating room are the staff and thepatient. Thousands of bacteria arefound on our body surfaces and travelthrough the air on tiny scales of skin.Even healthy people produce aboutone thousand of these bacteria-carrying scales each minute. Properhandwashing techniques and appro-priate preoperative patient skin

scrubs can greatly reduce thechances of these bacteria infectingthe surgical site.3

Clothing that can act as a barrierbetween these bacteria scales andthe patient is also necessary. Overthe years, different kinds of occlusivesurgical gowns have been producedthat are as effective, less costly tomake and more comfortable to wear.These materials are impermeableto bacteria, yet permeable to air.3

Operating rooms must be ventilated insuch a way to keep bacteria removed.One such system is called laminarair flow. These systems produce largeamounts of clean air that is continu-ously pumped into the room, changingthe entire room air volume up tofive hundred times an hour.3

“Two major carriers of bacteria inan operating room are the staffand the patient.”


TreatmentWhen faced with an infection, thesurgeon considers individual patientcharacteristics, timing of the diagnosisand the organism causing the infection.Although there are a few treatmentoptions, surgical removal of theprosthesis is almost always necessary.7

Antibiotic therapy is used in con-junction with other treatments. Alone,antibiotics are ineffective becausebacteria attach themselves to theprosthesis and form a protectivebarrier of slime that antibiotics are unable to penetrate. Once the revisionhas been performed, patients areusually on antibiotics for six weeks.The dose and type of antibioticused depends on the specific bacteria found.4

Some patients might not be able totolerate or refuse to have revisionsurgery. These patients are often puton suppressive antibiotic therapy forthe rest of their lives. It has beendemonstrated that in these patients,infection was suppressed for fouryears in about 60 percent of all cases.4

Arthroscopies are often performed on infected total knees in order to irrigate and debride the area as well as taketissue samples for culturing.

Spotlight on silver dressingsAn additional prevention strategy with increasing interest is the useof silver dressings, which can provide localized broad-spectrum antimicrobial properties and an additional line of defense.8

Silver does not promote bacterial resistance and is effective in treating resistant bacterial species. The antimicrobial efficacy of silverdressings depends on the silver content, the dressing formulationand the way the dressing is made. A 1 percent silver sulphadi-azine cream has historically been used for burn wounds, and thereare now silver dressings emerging on the market that are less toxicthan silver sulphadiazine.9 Several dressings on the market are impregnated with sustained-release ionic silver. Most of these dressings absorb fluid from the wound bed and have antimicrobial protection.9

Studies are currently being proposed to measure the impact of applying silver directly into the surgical wound prior to closure.

SILVASORB®®

PERFORATED SHEET

“


Revision surgeryIn most cases, it is necessary toremove the infected prosthesis andinsert a new one. There are two typesof revisions: first stage and secondstage reimplantation.6

In a first stage reimplantation,everything is done at the same time.In order for reimplantation to besuccessful, all foreign material mustbe removed and the area fully debrided. Bone cement mixed with antibiotics is used to affix the newprosthesis. This procedure is frequentlynot an option because of proximalbone loss due to the infection.5

Second stage revisions are consid-ered to be the gold standard in thetreatment of joint prosthesisinfections.7 After the infected prosthesisis removed, cultures are obtained andthe operative area has been fully irrigated and debrided, an antibioticspacer is made and inserted intothe wound. Antibiotic spacers aremade from bone cement, usually twoto three packs, with 1000 mg van-comycin and 2.4 g tobramycin mixedinto each pack. This spacer will thenmaintain soft tissue length and integrityacross the joint until it is time to implant the new prosthesis. The newprosthesis is usually inserted soon

after this, as waiting more than six totwelve weeks can lead to excessivejoint stiffness. Unlike a first-stage revi-sion, this procedure has the benefit ofantibiotic therapy from the spacer as well as allowing the surgeon topress-fit the prosthesis without ce-ment.6 The success rate of secondstage revisions is between 80 and 95 percent.6

About the AuthorMegan Giovinco, RN, CNOR, RNFA,currently a clinical nurse consultant, hasbeen an RN for more than 10 years. Previously, she worked as a nurse at a number of acute care facilities andtrauma centers.

References:1 Feature: surgical site infections: epidemiology,prevention, and emerging treatment guidelines. Podiatry Today. 2006;A(12A):8-10.2 Health Protection Agency. Mandatory surveil-lance of surgical site infection in orthopaedicsurgery: April 2004 to March 2005. London:Health Protection Agency, October 2005.3 Larikka M. Diagnosis of orthopedic prosthe-sis infections with radionucleotide techniques;clinical application of various imaging methods[thesis]. Oulu, Finland: University of Oulu; 2003. 4 Valdemar HB. Total Hip Infections. Availableat: www.totaljoints.info/totalhip_infection.htm. Accessed October 15, 2007.5 Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospec-tive review of 6489 total knee replacements. Clin Orthop Relat Res. 2001 Nov;(392):15-23.6 Orozco F, Haas S. Diagnosis and Treatment of an Infected Total Knee. Available atwww.medscape.com/viewarticle/412898. Accessed October 15, 2007.7 Medhaven et al. Deterioration of theater discipline during total joint replacement. Ann RColl Surg Engl. 1999;81:262-658 Streeter NB, McCain J. Surgical site infectionsin patients with diabetes. In: US Nursing Lead-ership 2006. 9 Tomaselli N. Prevention and treatment of surgical-site infections. Infection Control Resource. 2(2):5.

Proper handwashing techniquesand appropriate preoperativepatient skin scrubs can greatlyreduce the chances of bacteriainfecting the surgical site.”


Improving patient safety and lowering the risk of potentialsurgical complications are very real concerns in our worldtoday. Imagine if there was a way we could simplify ourcomplex world. One way to move toward simplification is to develop a standardized approach to sterile procedurepacks. Through standardization, risks are reduced andprocesses are improved.

Now don't get scared! This does not mean you cannothave custom packs or that you must always work with astandard stock pack. It is possible to standardize using

custom packs and complete delivery systems.

Current realityPulling suppliesand equipment for a total joint replacement, lum-bar laminectomyor an open-heartprocedure is both complex and timeconsuming. Timespent can be any-where from 30 to45 minutes pullingsupplies, not tomention the number of trips

in and out of the room. What if you forget something or dropa necessary supply item while setting up? Yet another trip in and out of the room.

Most ORs allow for a wide variation of customization, in partdue to physician preference. But consider if something assimple as standardization of sterile procedure packs andtheir many components could help to eliminate just one ortwo medical errors while reducing overall costs, saving timeand improving efficiency.

A consolidated system for procedure packs not only savesyou time and improves efficiency, it also improves accu-racy, eliminates waste and helps the entire surgical teambecome adept at procedures more quickly.

Standardization can work in all surgical specialitiesThe standardization concept not only holds true for themore complex procedures, it can also be beneficial forthose quick procedures that require clinicians to be efficientand proficient. Room turnover becomes smoother in betweenquick procedures. With increased speed, you can ensuregreater a ccuracy in necessary supplies.

National support for standardization in health careAccording to the World Health Organization (WHO), adverse events may result from problems in practice, products,procedures or systems.1 The Institute of Medicine’s reporton medical errors and patient safety, To Err is Human,called for a comprehensive and strong response to thismost urgent issue facing the American people.2 This wasfollowed by a report to President Clinton, Doing WhatCounts for Patient Safety: Federal Action to Reduce MedicalErrors and Their Impact, which outlined a road map for ac-tion including more than 100 activities. This plan addressedissues such as national focus and leadership, identifyingand learning from errors, setting performance standardsand expectations for safety, building public and purchaserawareness, working with providers, using decision-supportsystems and information technologies, using standardizedprocedures and addressing and strengthening standardsand integrating data for reporting and analysis.3

When supplies are not readily availableduring surgical procedures, delays increase patient risks for complications, including infection, hypothermia andbleeding, to name a few.

Imagine ensuring patient safety with standardized

Sterile Procedure PacksBy Claudia Sanders, RN, CFA


QWhat is meant by a standardized sterile procedure pack program?Take a quick survey of the following items included in your current procedure packs and also stocked on your shelves:

Needle counters: How many variations do you currently have in your packs?

Surgical gowns: Are they the appropriate level of protection for the procedure to be performed? Are they thecorrect size?

Which components contain latex and which ones are latex-free?

Are safety blades, needles and syringes immediately available?

Are sterile skin markers at your fingertips?

How many specialty drapes are stocked in your facility and included in your packs?

Where are the medication labels? Are they the appropriate size and do they stick well?

The standardization process is simpleand only requires a few strategies:

• A team approach (attitude) to work on standardization

• Ability to communicate

• A willingness to work with your pack manufacturer

In most cases, your pack manufacturer willcome in and do most of the work for you!The work is in analyzing the componentsused in each procedure, determining likeitems and agreeing to standardize on theone best component that will meet theneeds of 90 percent of the end users. It really is that simple and can be performedon-site by qualified clinicians.

Imagine having your sterile pack containeverything you need, from basins togowns, from blades and labels to drapes.

You could have most everything that you need in one sterile pack or kit and have it immediately available, ready to openand be used.

Circulator supplies can also be included,such as grounding pads, bag-a-jets,Foley kits and syringes. You could eveninclude turnover kit supplies, i.e. bedsheet and draw sheet, trash bags andlinen bags as well as cleaning cloths.Anesthesia items can be added as well.And best of all – the products look, feeland work the same from procedure toprocedure. Only the procedure specialtyitems would deviate from case to case.

It is not just a dream. Standardization canbecome a reality. We invite you to join usand try it. Then we can live in a worldwhere OR supplies can be as one....

Please refer to the Form & Tool on Page 103 for Tips for Building a Safe Pack.

Top 10 benefits of a standardized procedure pack system1. Less OR traffic2. Standardization of commonly used items, i.e.,

needle counters, medication labels, skin markers,electrocautery pencils, etc.

3. Appropriate levels of protection for surgical gowns according to the procedure being performed

4. Increased space in supply areas5. Improved staff productivity6. Streamlined orientation process7. Less risk for error8. Fewer SKUs to order and inventory9. Reduction in waste

10. Overall cost savings to the system

References1 World Health Organization,

Fifty-Fifth Word Health Assem-bly, Provisional agenda item13.9, A55/13, March 23, 2002.

2 Kohn LT, Corrigan JM, Donald-son MS, eds. To Err Is Human:Building a Safer HealthSystem. Washington, DC: National Academies Press; 1999.

3 Quality Interagency Coordina-tion Task Force. Doing WhatCounts for Patient Safety: Fed-eral Actions to Reduce MedicalErrors and Their Impact. Avail-able at: www.quic.gov/report/mederr2.htm. Accessed November 14, 2007.

About the authorClaudia Sanders, RN, CFA, iscurrently a clinical nurse specialist.She has practiced in the medicalfield for more than 30 years as a surgery technologist and perioperative nurse.


Competency-based learning is a very powerfulfoundation for the construction of any e-basedor closed loop systems training modules. CBLtargets the crucial skills and practices that directlycontribute to the overall organizational goals.The reason that it works so well with e-learning,i.e., learning through electronic media, is becauseit enables organizations to deliver content orlearning objects to individuals. Proponents of CBLtypically choose this learning method becauseit leads most directly to learning opportunitiesthat are intensely focused and are populated bylearners and employers who are chiefly inter-ested in the shortest route to results.1

HHOOWW DDOOEESS CCBBLL FFIITT IINNTTOO PPEERRIIOOPPEERRAATTIIVVEE NNUURRSSIINNGG??According to Sharron Abramson, RN, clinicalnurse practice leader of operating rooms atHumber River Regional Hospital (HRRH) inWeston, Ontario, CBL is a method of learningthat addresses the requirements necessary toperform a skill, but it also communicates clearexpectations and enhances critical thinking skills.It utilizes electronic media as well as preceptorsand many forms and tools to assess andmeasure skills and competency. Abramsonsays it not only works in perioperative services,but CBL has improved the orientation processand resulted in greater longevity and satisfactionamong employees at her facility.

CBL addressesthe requirementsnecessary toperform a skill,but it also com-municates clearexpectations andenhances criticalthinking skills.

To fully understand the impact of CBL at Humber,you need to know a little about the facility.HRRH has 600 beds on three campuses. Theyemploy more than 3,000 staff and have morethan 700 credentialed physicians and two oper-ating room sites with 15 operating rooms andthree cysto rooms. Personnel at the facilityperform more than 23,000 day surgeries and8,000 inpatient surgeries per year.

HRRH is a regional pediatric center and amember of the Child Health Network in Canada,as well as a regional dialysis center. They arelocated in an ethnically diverse community in theNorth-West region of Metropolitan Toronto. Patientscome from more than 140 countries and togetherspeak more than 80 different languages.

CCBBLL AATT HHRRRRHHHumber’s perioperative staff is as diverse as itspatients. This became apparent to Abramsonfour years ago when she took the position ofclinical practice leader, responsible for clinicaleducation, orientation and advancing clinicalpractice throughout the organization.The currentprogram was not meeting their departmentalneeds. The orientation program then consistedof a six-inch binder and a one-week class.Following the class, the trainee was assigned towork with a staff member to apply the knowledgelearned in the class and from reading the manual.Not only was the manual overwhelming, but the

OR Issues


interpretation of data varied to a great extentamong new employees based upon their diversecultural backgrounds.

AA CCOOMMMMOONN LLAANNGGUUAAGGEEWhen dealing with learning outcomes, a commonlanguage set is critical.2 The need for a commonlanguage was well established at HRRH. Forexample, aseptic technique as well as handlingof sharps had differing interpretations amongdiverse cultures and countries where many of thecaregivers had previously trained and practiced.This diverse perioperative staff needed a stan-dard set of definitions to be established. Ac-cording to Abramson, not everyone had thesame frame of reference. Therefore, conceptsand practices varied greatly. Learning throughreading a manual and attending one week ofclass was not providing the necessary results.

AASSSSEESSSSMMEENNTTThe next step following the establishment of acommon language is to determine the caregivers’current skills and competencies. This is accom-plished through multiple assessment strategies.Abramson believes in both a self-assessmentand an assessment by preceptors who areassigned to help train the caregivers in theclinical area. A generic tool for tasks is providedand each individual is expected to perform eachtask according to the established competency.Each procedure has been broken down step by

Through performance gap analysis,

individual results are

addressed oneby one until the

competency skillis mastered.

step according to the task and protocol and eachstep is assessed for accuracy and completeness.The caregiver also performs the self-assessmenton the same set of competencies and in thesame manner.

Results provide a measurement of individualizedperformance gaps that can be addressed one onone by either the clinical educator or the preceptorassigned to the orientee. Performance gapanalysis is a simple method to gather informationabout the competency skills and knowledgethat exists in an organization.2 Through per-formance gap analysis, individual results areaddressed one by one until the competencyskill is mastered.

TTRRAAIINNIINNGG MMEETTHHOODDOOLLOOGGYYOnce performance gaps are identified, CBLgoes to work to train the individual according toHumber’s standards of care in perioperativeservices. The cornerstone of this program is theCD that houses all of the information containedin the six-inch binder (which still exists and isstill provided) as well as the many forms andtraining tools and support materials. The CDmaterials are offered online at Humber and area convenient way to access information thatmight have become foggy over time. Abramsonmakes it her responsibility to keep the learningCD and online data up to date and current.

The typical training course takes approximately12 weeks, start to finish, but the CD remainsavailable to all as a resource. The originalprogram also included videos, which have allbeen updated and incorporated into the CDand online program.

When asked where she came up with the pro-gram’s contents, Abramson responded that shepulled data from three primary sources: Associa-tion of periOperative Registered Nurses (AORN),Operating Room Nurses Association of Canada(ORNAC) and the Australian College of Operat-ing Room Nurses (ACORN).

“I used the best from all three organizations todevelop this program that has significantlyevolved over the last five years,” Abramsonsaid. She added that AORN does an excellentjob with identifying the theory and rationale behind its recommended practices and standards,while ORNAC is, in her opinion, more proce-dure-driven. ACORN has included evidenced-based underpinning to their standards.Abramson maintains that blending materialsfrom the three sources provides a standardmethod of training and sets both clear and common expectations for each caregiver.

Feedback is continuous

through a teamapproach,

consisting of the educator,

resource nurse,a buddy

system and self-assessment.

Nurses at Humber learn to both circulate andscrub surgical procedures. Typically, the trainingbegins in the general surgical specialty. Thenthe caregiver progresses to plastics and basicorthopedics. At this point in the program, it is established whether the individual is going to be able to master perioperative nursing. Whilemost are successful, there have been thosewho have not found that the operating room is the best fit for them.

FFEEEEDDBBAACCKK LLOOOOPPSSAs a new employee goes through the program,the ongoing assessment pinpoints any specificproblem areas and one-on-one guidance is pro-vided. Feedback is continuous through a teamapproach, consisting of the educator, resourcenurse, a buddy system and self-assessment. Individual learning plans are communicated to the caregiver as needed via Humber’s email system.

Expectations are clearly defined, instructionsare provided and the caregiver is provided resources that they can refer to as needed. The clinical educator spends time observingand assures that basic skills are solid beforecaregivers move on to more advanced skills.When questions arise, evidence-based criteriaare relied upon to support standards and proto-cols. Abramson provided an example of whenthis strategy came in handy. Some employeeshad become accustomed to wearing surgicalmasks inappropriately – or not wearing them atall – at their former places of employment. Byproviding evidenced-based criteria, a standardfor Humber was established.

OOBBSSTTAACCLLEESS TTOO CCBBLLWhen about the biggest challenges she has experienced during the development and imple-mentation of CBL, Abramson said the numberone challenge was gaining the support of seniornurses. She said she heard comments such as“Why are you babying them?” and “We had tolearn by trial and error!” Next, when new care-givers were placed with senior nurses as resourcenurses or preceptors, the senior nurses had dif-ficulty in “letting go” and letting the new caregiversperform tasks on their own.



To address these challenges, Abramson decidedthat the entire department needed to takeownership in this program and responsibility forthe new employees’ success. That’s when shedecided to put the CD and training tools onlineand provide access to all caregivers. She encour-aged them to make suggestions and updates tothe entire CBL training program.

Abramson’s experience is similar to that ofothers. According to experts, innovations fosterresistance.2 Competency-based learning modelsare certainly no exception. Some have said theyare too restrictive. Most complaints stem fromrequiring others to perform and document ongoingassessments that are viewed as time-consuming.Despite these criticisms, results show universalbenefits through growth and maturity.

WWHHAATT’’SS TTHHEE DDIIFFFFEERREENNCCEE?? A side-by-side comparison of U.S. and Canadian healthcare11

They’re often compared, but just how do Canada and the United States measure up against eachother in terms of health systems and other health-related issues? We’ve assembled this chart foryour reference. Take a look – do any of the figures surprise you?

Canada United StatesDEMOGRAPHIC STATISTICS

Population 32,268 298,213Life expectancy at birth (male) 78 75Life expectancy at birth (female) 83 80

HEALTH SYSTEMSNumber of physicians 66,583 730,801Physicians per 1K population 2.14 3.65Number of nurses 309,576 2,669,603Nurses per 1K population 9.95 9.37Total % of GDP spent on health 9.8% 15.4%Total % of GDP spent on health by gov’t 69.8% 44.7%Private expenditure on health as % of total expenditure on health 30.2% 55.3% Total % of gov’t expenditure spent on health 17.1% 18.9%Social security expenditure on health as % of general gov’t 2.1% 28%expenditure on healthOut-of-pocket expenditure as % of private expenditure on health 49.4% 23.8%Private prepaid plans as % of private expenditure on health 42.3% 66.4%

RISK FACTORSObese adults* as % (male) 15.9% 31.1%Obese adults* as % (female) 13.9% 33.2%Prevalence of adult* tobacco use (%) (male) 22% 24.1%Prevalence of adult* tobacco use (%) (female) 18% 19.2%

* Adult = ≥15 yrs

Reference:1 World Health Organization. World Health Statistics 2007. Available at: http://www.who.int/whosis/whostat2007/en/index.html.Accessed November 13, 2007.


TTHHEE BBIIGGGGEESSTT BBEENNEEFFIITTSSCompetency-based models ultimately rely onmeasurable assessment. If a proposed compe-tency cannot be described and measured inways that are comprehended by all, learnerscan go back and repeat only the areas ofdeficiency versus repeating an entire program.

Abramson listed the following as the top benefits of a CBL program:• It allows everyone to understand

expectations.

• It can make a big difference in the interpretation of feedback.

• It can be adapted to any operating room in any location and in any setting.

References1 Squires P. ConceptPaper on SupportingCompetency-BasedLearning, Applied Skills& Knowledge, LLC.

2 Voorhees RA. Competency-basedlearning models: A necessary future. In: Voorhees RA, ed.Measuring What Matters:Competency-BasedLearning Models inHigher Education: NewDirections for Institu-tional Research, No.110. New York, N.Y.:John Wiley & Sons, Inc.;2001.

To learn more about the CBL program at Humberand how it could benefit your own facility, or torequest a copy of the CBL CD, you are invitedto contact Abramson via the information below.

The OR Connection thanks Sharron Abramsonand Humber River Regional Hospital forsharing this information and their successwith our readers!

To contact Sharron Abramson:Sharron Abramson, RNHumber River Regional Hospital Clinical Practice Leader, Operating Rooms Office: 416-744-2500 ext. 2640Pager: [email protected]

Continue your CE coursework at

Medline UniversityCourses you can attend at any time, from anywhere you have Internet access.Medline University offers more than 50 self-study nursing CE-credit courses.An affordable online resource. Visit www.medlineuniversity.com


”When healthcare facilities need partners…look to your vendors.

By Wayne Malone

“How I got

into thismess in the first place.

Special Feature


But Deby started calling “just to ask a coupleof questions” and then to invite me to “cometake a look at the new hospital.” After a while,like a trout that keeps seeing a fly in front ofhis nose, I bit. I became the first (and so far,only) Director, Perioperative Services in thehistory of Patients Medical Center, a brand-new hospital in Pasadena, Texas. It took Debyso long to convince me to take the job that wehad a running joke: “By the time you actuallyget down here and start, you won’t haveanything to do.” Right.

Needs assessments and status reportsMy first day at Patients Medical Center startedwith a meeting of my entire staff. The four ofus sat at the front desk and got to know eachother. My first assignment was a status report.“Bring me up to speed on what’s been done,and what remains,” I instructed. The responsescaused me to go in search of a white flag andthe job listings section of the classified ads.

“Well, we need to order instruments,” saidBryan. “Which ones?” I inquired. “All of them.” Gulp.

“We also need to order supplies,” addedMarko. Let me guess…yep, all of them.“We need more staff to help us get ready to open,” added Claudia, my OR manager. We were on a roll now….

The conversation went on, but you get theidea: no instruments, no sutures, no supplies,no staff and precious little time. We werescheduled to open in six weeks. I paid a visitto my mentor and friend (you remember, theone who said I’d have nothing to do) to giveher a status report. I assured her that eventhough we were six months behind schedule,we would open on time. Her obvious question– “How?” – was met with a simple “I don’tknow, but we will.” What I lack in judgment, I more than make up for in confidence.

After several very long days on the phonespent trying to track down vendors, sales repsand distributors, I caught a break. Our admin-istrative team had contracted with a medicalsupply company to handle the bulk of our supplyneeds, and they wanted to bring the salesrepresentative in to meet me. Our “new” repwas an old acquaintance. I breathed animmediate sigh of relief that at least oursupplies would get here on time. Assumingwe could figure out which ones to order….

I know what you’re thinking – he’s worked inthe OR most of his adult life, and now hedoesn’t know what supplies he needs? Trythis: While sitting at home some evening, takeout a notepad and pen and write down everysupply on your shelves at work. All of them.Every single one. Take that list to work thenext day and see how well you did. I’m bettingthat the very best of you probably did a littlebetter than me. But more on that later.

The three CsFinding this company, this sales representa-tive and his colleagues, was a serendipitousaccident, but it was also vital to our initial and

An old friend recently lured me outof a life of relative comfort back to myroots in the OR. I had spent the previ-ous three years away from the OR asa manager and interim director of theperformance improvement departmentof a large hospital. In this department,I handled risk management and per-formance improvement duties. I reallyliked the nine-to-five, hour for lunch,no holidays/nights/weekends lifestyle.Really, I did.


”“I coined a phrase that is still joked about here: ‘You don’t know what you don’t have until you don’t have it.’

The pre-op holding room/PACU,stocked and ready for opening day.


ongoing success. This representative livedand breathed customer service and came inevery day for several weeks, from our initialconversation through opening day and continuinguntil we were confident that we had everythingwe needed to operate effectively. This guyearned our business. And he didn’t comealone. He brought in a variety of specialists,experts on a variety of topics, ranging fromgloves to sterile custom packs to (Eureka!)instruments. And this is really where this storybegins. I had allowed my enthusiasm and myconfidence to write checks that my team andI now had to cash. Fortunately, I was able todraw upon the bank of knowledge and expertiseof our supplier.

Learning about all the services, programs,support, and expertise that our vendor had tooffer gave me an idea for accomplishing theseemingly impossible task at hand. I developeda strategy that I have continued to live bysince the beginning of this process, and itis what I refer to as the “Three Cs”:1. Communicate2. Consolidate3. Concentrate. It is, like me, painfully simple, and is intendedto get as much accomplished as possible inas little time as possible.

First, communicate with your vendors. Findout everything you can about their productlines, the services they provide and their will-ingness to go above and beyond to help youmeet your goals. My litmus test for a vendoris, “Are you willing to hand deliver a singleitem at 3 a.m.? At no additional charge?”

Second, consolidate as many eggs as possi-ble into as few baskets as possible. If you canget supplies, instruments, cleaning solutionsand scrubs all from the same vendor, whywaste your time talking to four (or maybe 40) vendors?

I know, you think it’s more expensive if youdon’t shop around, buying everything piece-meal from the lowest bidder, right? Wrong.Discuss the idea of product line consolidationwith your vendors and you’ll find that most allof them are happy to negotiate better priceson their products if they can provide you witha larger array of products.

The final C is concentrate. Concentrate yourtime, energy and effort on getting as much aspossible accomplished with this cadre of first-line vendors. Get as much as you can fromthem in terms of both products and services.Then spend your remaining time gathering upthe stragglers and tying up the loose ends.Apply the time-tested 80/20 Rule: 80 percentof your work can be accomplished with 20percent of your vendors. Now that I’ve laid alittle groundwork, I’ll continue my explanationas to why this methodology is so important,particularly in busy surgery departments.

Give me a case of everythingMy first real, sit-down meeting with our vendorwas very short. He asked me what I needed inthe way of supplies, and I answered him withone word – everything. He asked me to elabo-rate, but I was really at a loss as to how toeven begin to list “everything.” This is when Ibegan to realize that this guy was more than asalesman. He acted like he wanted to becomemy partner and ease the pain by offering solu-tions. His response was typical for this guy,and for most of his company: He pulled inven-tory lists from other comparable clients andused them as jumping-off points. We wentthrough the lists, adding and deleting as wefelt necessary and appropriate for our facility.One thing we noticed immediately was that wehad overlooked a surprising number of “obvi-ous” supplies. We’d also missed a few not-so-obvious ones.

I began to get worried. I coined a phrase thatis still joked about here: “You don’t know whatyou don’t have until you don’t have it.” Yes, Istudied at the Yogi Berra School of Philoso-phy, but there is a nugget here for anyone at-tempting to build a hospital from scratch. Youmust plan ahead for everything, conduct Fail-ure Mode Effects Analyses (FMEAs) on your intended processes and always keep one eyeon the weeks ahead of your current schedule.

We developed a process where members ofour blossoming OR staff pulled schedulesmore than a week in advance, went throughthem case by case, and called physiciansdirectly to discuss their preferences. We foundthat “It’s all on my preference card” isn’t veryhelpful if the preference card is from another


facility and hasn’t been updated in severalyears. And this is where having a vendor thatacts like a partner paid dividends. We’d findout a week or less before a case that weneeded something but didn’t have it. Our part-ner worked miracles, and, lo and behold, theneeded item would show up at our doorstepthe day before we needed it. Sometimes twodays before.

One day, our vendor overheard a conversa-tion about instruments that I was having at thefront desk. He casually said, “You know, ifyou need help with instruments, we have aninventory of the most common ones. I canhave our instrument expert give you a call.”He did better than that. The product managerfor their instrument line actually flew downhere, made copies of our hand-written countsheets, and talked at length with our newsterile processing department and OR staffregarding physician preferences, wants,needs and obstacles. A few days later, I had aquote covering all our outstanding instrumentneeds as well as a list of alternate sources forthose instruments not already in their ratherlarge inventory. We not only solved our instru-ment problem, we also got a jump-start on ourcomputerized instrument inventory and countsheets. The vendor actually sent us all of ourcount sheets, in spreadsheet format, withall the instrument names, model numbersand quantities, ready to print.

After taking a look at our list of physiciansand specialties, we noted that we had twoneurosurgeons who would have privilegeshere on opening day. Our rep inquired as totheir preferences and made a suggestion.We could build a custom pack for our neuro-surgery cases and save substantial moneyover individually packaged items. We couldalso decrease our turnover time by decreas-ing the time it takes to open a room. He intro-duced us to a specialist in the sterile traydivision. She met with my new neuro team,reviewed the preference lists and built amock-up of the neuro pack for my team toreview. The pack was subsequently put intoproduction and now resides in our supplyroom, where it occupies far less shelf spacethan all the individual items it contains. Wehave also established an average turnovertime for neurosurgery of less than ten min-

”“I had allowed my

enthusiasm andmy confidence towrite checks thatmy team and I

now had to cash.

OR #1 on opening day


utes. This specialist isnow working on custompacks for cardiovascularand orthopedic services.She keeps asking meabout our basin packs,and that’s on my hit list as well.

I have also spent timewith a specialist from theorthopedics line (castingmaterials, postop shoes,slings, et cetera), onefrom wound care (ostomysupplies, wound careproducts, specialty dress-ings) and…well, you getthe idea. The benefit here

is that I didn’t have to make all those initialcontacts, nor do I have to dive into my officeto hide from a horde of reps out to steal mytime. All of these folks have provided valuable service and loads of information, but they’ve done so on my schedule, and all of the meetings have been coordinated by my primary sales rep, whom I now referto as our partner. I only have to remember one number.

I have also cultivated this type of relationshipwith a handful of other vendors. These com-panies have virtually no overlap in productlines. And that’s the beauty of the Three Cs.What they do have in common is a broadrange of service or product lines, outstandingcustomer service and a willingness to bundleproduct lines at a reduced cost per item. Isave a substantial amount of money, but thereal savings is in time, effort and aggravation.By putting my eggs in fewer baskets, I havereduced the effort required to keep our facility running.

I’ve also developed collegial and mutuallybeneficial relationships with my vendors andreps, rather than adversarial ones. It meansbetter and more successful negotiations,lower operating costs, and more time for whatI love – being in the OR, working side by sidewith possibly the best OR staff on the planet.

Epilogue: So, how did it turn out?We opened our doors in late April 2007with an intentionally small surgery sched-ule. We had three surgical techs and twonurses. We did 32 cases, using one ORsuite at a time. By October 2007, we weredoing more than 400 cases per month.I now have a perioperative services staffof 40, and we’re continuing to grow. Ouraverage room turnover time is an eye-popping 7.8 minutes, and we intend toimprove on that. My vendor partners arestill on board and although we’re downto a modest two to three visits per week,my needs are being addressed.

The moral of the story is that relationshipsare all the same. Whether you are in apersonal or business relationship, youmust share in the problems and be part of the solutions. When you find a truevendor partner, you have earned thebusiness for life.

Wayne Malone, RN, has held various positionsin Perioperative Services during his 15 years ofnursing experience. He also has experience inPerformance Improvement, Infection Control andRisk Management, and has been a healthcareconsultant. He is currently Director of Periopera-tive Services at Patients Medical Center, a newacute care hospital in Pasadena, Texas.

Dr. Glen Garner, general surgeon, givesPatients Medical Centera thumbs-up during hisfirst procedure at the new facility

2008

7

How to make

your BESTyear ever!

Seven strategies to help you thrive

By Wolf J. Rinke, PhD, RD, CSP


1

2

Health care is getting more competitive every day.The following seven strategies will help youthrive in tough times.

Get paid lessYes, you read right! I said less! Why? Because if you get paidmore than you are worth, you will be out of a job soon! It'selementary, Watson! In our capitalistic society, you must gener-ate more worth or value than you receive, otherwise the systemwill go kaput. Besides, “golden handcuffs” make you a slave.What you want to do is give your employer more than he or sheexpects. Start right now. In the long run, you will be compensatedaccording to the value you deliver. I have designed an elegantlapel pin to remind myself of this concept at all times. The 111%pin comes with a card that reads:

Here is a little exercise that will keep you on track. Computeyour weekly pay, add about a third for benefits, and divide byfive. Put the value you just computed on a 3 x 5 card or a stickynote and place it where it is clearly visible to you several times aday. At the end of each day, ask yourself, “Did I generate $x ofvalue today?” If your typical answer is “yes,” keep on keepingon. If the answer is “no” more than 50 percent of the time, it’stime for you to look around and figure out how you can add more value.

Value yourself Who is your most important patient, client or customer? If you answered “me!”you have the right answer. This is super important because I’ve found thatmost healthcare professionals are really great at taking care of others – however, they often forget themselves! Want proof? Ask anyone in sales what

it takes to be a sales superstar, and they will tell you that you'vegot to love what you sell. Notice I said love, not like! Even

though you are probably not in sales, even in healthcare you sell yourself all the time! You sell your-

self, your ideas, your proposals, your be-liefs etc. to your patients, boss, spouse,

children and even your pet. And for youto be able to do that successfully,

Give 100% and you'll survive. Give 110% and you'll thrive.Give 111% and you'll MAKE it a Winning Life!

Continued

Seven strategies to help you thrive

By Wolf J. Rinke, PhD, RD, CSP


Caring for Yourself


3

5

4

you've got to value, like and even loveyourself, because if you don't have it youcan't give it away! So start right now tolove yourself the way you are, not theway you ought to be. (Read that again –it’s a biggie. It took me about 35 years tomaster!) That means that you have beenable to turn off that internal negative voicethat keeps focusing on all your weak-nesses. Begin to recognize that of themore than 6 billion people on this earth,there is not one perfect person! All of usare a composite of strengths and weak-nesses. The trick is to value yourself foryour strengths and forget your weak-nesses. If you can’t forget them, thenteam up with someone who compen-sates for your weaknesses.

Chase your passionWhen your opportunity clock rings in themorning, are you anxious to get up andgo to work? (I believe that starting yourday alarmed is counterproductive.) Areyou excited to be in your profession? Doyou love what you do? Does work seemlike play to you? Do you actually look for-ward to work at least four out of five dayseach week? If the answer is yes to all ofthese, count yourself lucky because youare part of a very small minority. If youranswer is no, it's time to make a change.Don't have the skills or the education todo what you love to do? Keep your cur-rent job, and make time to get what youneed to be successful in your dream job.Watch less TV, go to fewer ballgames,pay any price, make any sacrifice, just doit! Then start working part time in yourdream job. Can't find someone to payyou for it? Volunteer. Once you are cer-tain that you have found your passion,give up your day job. Not getting paid asmuch as in your former job? Not to worry.Just stay with it. I've learned after morethan 40 years of employment thatovernight success takes a long time. But

I've also learned that once you chaseyour passion, not your pay, you will havemore fun and make more money, muchmore money than you have ever thoughtpossible. Why? Because if it is fun, it getsdone! Want proof? Look around you atthe people who have made it to the topin their professions. I bet you that virtu-ally all of them love what they do, havelots of fun and are compensated hand-somely.

Have goals It's been said that if you don't knowwhere you’re going, the last thing youwant to do is get there any faster. Andyet most people have absolutely no ideawhat they want to get out of life. Writedown three “fire-in-the-belly” lifetimegoals for yourself. Prioritize these, andthen put them on two 3 x 5 cards orsticky notes. Put one on your desk orplanner, and the other on your bathroommirror. Then get busy visualizing and internalizing these goals. (If they are run-ning inside your head like a perpetualmovie loop, you've got it.) Follow that upwith a detailed step-by-step action planthat will get you to where you want to go.Now work that plan!

Do what you don't feel like doing

One of the comics I like to show in myMake It a Winning Life seminars is fromMother Goose & Grimm. Grimmy – that'sthe dog – is standing in front of a full-length mirror. He says, “Sit!” In the nextframe, he sits down, wags his tail andsays to the mirror, “Good dog, good dog.”The next frame has Grimmy smiling atthe mirror saying, “I'm a self-motivator.”That's what this is all about – having thediscipline to do what you don't feel likedoing. Chances are, those are the thingsthat others don't feel like doing either!When you do those things, you will suc-


7

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If you don't know where you’regoing, the last thing you want to do is get there any faster. And yet most people have

absolutely no idea what they want to get out of life.

ceed faster. To help me with this, I've developed this axiom: If I don't feel likedoing something, I go do it. If I really feellike doing something, I think about ittwice. For example, I'm sitting in front ofmy computer and writing this article onan incredibly beautiful fall day. The awe-some colors of the leaves and thesparkling sunshine are beckoning me to go out and go hiking with my Super-woman — that's my sweetheart of almost40 years. Yet, after thinking about it, Idiscipline myself to sit here and do what Ireally don't want to do. Here is a bonusstrategy that will enable you to make it tothe top even faster, especially if you areemployed: Figure out what your bossdoes not like to do, and do more of it!

Invest in yourselfIt's been said that if you want to earnmore, you've got to learn more. And it'strue. Statistics tell us that if you have ahigh school diploma, you'll earn an aver-age of $750,000 in your lifetime. With abachelor’s degree, that figure jumps toapproximately $1.5 million. With a pro-fessional degree, such as an MD, JD orPhD, you'll earn about $3 million. Butdon't stop there! Take a look at howmuch of your disposable income youspent on your own development duringthe past 12 months. If it is less than 3percent, it is likely that you are becoming

obsolete. In this era of rapid change, theonly way you can maintain a competitiveadvantage is to invest in the most impor-tant resource you own – you! Read atleast half an hour every day. Reading atleast one nonfiction book every year putsyou ahead of about 45 percent of theU.S. population. If, however, you want tomake it into the top 3 percent of the pop-ulation, you'll have to devour 16 books ayear. Listen to motivational and educa-tional audio programs in your car. By lis-tening only half the time while in yourcar, you'll earn the equivalent of twothree-credit college courses every year.Attend seminars and courses. After all,learning from other peoples' experiences(OPE) is a shortcut to success. If you stillmake the same mistake I made for manyyears by saying, “Yeah, but my employerwon’t pay for continuing education!” thenit’s time to read this paragraph again tofigure out who the ultimate beneficiary is.

Maintain balanceAll my life I was materialistically motivated– until that fateful day in December 1997.Superwoman and I were on our way toParis, France. Both of us were very ex-cited. Marcela was going to one of her favorite cities, and I was on my way tospeak to more than 300 managers from19 different countries. We had an un-eventful trip until we got to France, when

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FOLLOW THE LEADER we noticed that we were in a holding pat-tern. After about 20 minutes, the pilotcalmly advised us that the indicator lightfor the landing gear was not working, andthat the cockpit crew was trying to diag-nose the problem. About 30 minuteslater, the pilot told us that there wasnothing wrong with the indicator light,which meant that either the landing gearswere not extended or they were notlocked in. “We will now,” he continued,“fly over the tower so that they can makea visual inspection.” After doing thattwice, the pilot advised us that “the land-ing gears appear to be extended, so wemust assume that the gears are notlocked in.” After what seemed like aneternity, the captain got on the intercomagain and said, “Ladies and gentlemen,the flight attendants will provide you withemergency landing instructions. Now Iknow that you've heard these manytimes before, but this time I need you topay very close attention because we aregoing to be making an emergency landingat Charles de Gaulle International Airport.”He also told us that the airport had beenclosed and that emergency equipmentwas standing by. The flight attendantsvery calmly and professionally instructedus to get rid of all sharp objects, clear allaisles and put everything in the overheadbins. They also had us practice theemergency landing position – putting ourheads between our arms, leaning for-ward and bracing ourselves against theseat in front of us. After more than twohours, the captain finally began his de-scent and everyone quietly assumed the

emergency landing position upon his com-mand. What occurred to me during thoseeternal two hours is that at no time did Isay to myself, “Wish I had workedharder, wish I had made more money,wish I had bought a bigger house, wish Ihad bought more stuff.” Instead I thoughtabout relationships – my relationship withmy wife and if I had told her how much Ilove her often enough; my relationshipwith my daughters, and how they wouldcope without us; my relationship withmy parents and whether I had givenample credit where credit is due; my rela-tionship with my friends and if I had toldthem how much I value them and my rela-tionship with my team members and if Ihad expressed my deep appreciation forall they had done for me.

What I learned from all this is what is really important in our lives. Not money, not things, not stuff, but relationships.

Of course, being a professional speaker,I also thought, “If you make it out of thisalive, you'll have one heck of a story totell.” After the captain gave the commandto assume the emergency position, helanded the plane so softly that we did noteven know we had landed, right betweenrows of fire engines. By the way, that tripconcluded with the loudest round of ap-plause, cheers and joy I have ever heardon any flight. So whatever you do, keepyour life in balance and don't forget tospend quality time on the really importantstuff, your relationships.© 2008 Wolf J. Rinke

Who is your most importantpatient, client or customer?If you answered “me!” youhave the right answer.

About the authorDr. Wolf J. Rinke, RD, CSP is akeynote speaker, seminar leader,management consultant, executivecoach and editor of the freeelectronic newsletters Make It aWinning Life and The WinningManager. To subscribe, go towww.WolfRinke.com. He is theauthor of numerous books, CDsand DVDs, including Make It aWinning Life: Success Strategiesfor Life, Love and Business, avail-able at www.WolfRinke.com. Hiscompany also produces a widevariety of quality pre-approvedcontinuing professional education(CPE) self-study courses, availableat www.easyCPEcredits.com.Reach him at [email protected].



Determine your riskOne way to determine whether you have an increasedchance of developing heart disease, certain cancersand diabetes is to compare your body's shape to afruit. Apple-shaped people are at greater dangerthan pear-shaped people.

• An apple-shaped body is wider around the middle than on the hips.

• A pear-shaped body is wider on the bottom than in the waist.

To further determine your risk, measure the size ofyour waist.

• Wrap a tape measure snugly around the narrowestpart of your waist, usually near your belly button.

For women, if your waist measures more than 35inches, you're at greater risk; for men, it's 40 inches.However, even people who are moderately overweightmay have an increased chance for certain healthconditions, even if their waist size doesn't exceedthese measurements.

Get the factsCarrying excess fat around your middle — specificallythe abdomen — increases your risk of developingcertain health problems. These can include:

• High blood pressure• Type 2 diabetes• High levels of LDL, or "bad" cholesterol• Heart disease• Colon and breast cancer

Howdoesyour

body's shape influenceyour

health?

By Miriam Nelson, Ph.D.

About the authorDr. Miriam Nelson is the director of the JohnHancock Center for Physical Activity and Nutritionat Tufts University. She's also the author of theinternational best-selling Strong Women bookseries. A fellow of the American College ofSports Medicine, Dr. Nelson's research hasrevolutionized how people understand nutrition,strength training, aging and health.


Eat smart, move oftenThe good news is you can lose excess body fat nomatter where it's located. Combining a sensible eatingplan with a realistic exercise program is your best betfor success. Remember — you always should talkwith your doctor before beginning any diet or exer-cise program. Use these tips to get started:

Snack sensibly• Always keep sliced fruits and vegetables on hand.

Low-fat, low-calorie snacking between meals will help you avoid overeating.

• Focus on eliminating processed foods from your diet.

Add aerobicsActivities such as walking, biking, dancing or swimmingkeep your heart healthy and burn calories. Graduallywork your way from 30 to 60 minutes of aerobic exer-cise at least three times a week, if possible. Talk withyour doctor before beginning a new exercise routineor significantly increasing your activity level.

Start strength trainingResistance training helps build muscle and works offadditional calories. Slowly develop a routine of 10 to12 exercises that target your major muscle groups,and do them two times a week.

About the Book:In this accessible guide, trusted women'shealth author and exercise physiologistMiriam E. Nelson presents the informationevery woman needs to know to maintain ahealthy back. Complete with clear explanations,practical advice, and lively anecdotes fromwomen who have benefited from this simpleand effective program, the book reveals:

• the major causes of back pain in women;

• how stress and other emotional factors play a key role;

• a straightforward exercise program to improve flexibility, strength, and aerobic fitness-designed specifically for women;

• what you need to know to create a back-friendly home and office; and

• explanations of what medical optionsare available-and how to know whenthey might be necessary

Whether you've struggled with back problemsfor years or are hoping to prevent them in thefirst place, this is an essential guide to havea strong back for life.

To purchase this book for $25.95, go towww.strongwomen.com


“Dr. Marla”battles breast cancer

By Marla Shapiro, MD


“I felt like my identity wasbeing stripped away.”

It was a routine mammogram, but when the X-ray was done, the radiologist asked for a magnified view of my right breast. She needed to geta better look at something.

I wasn't anxious. I knew that this was fairly routine. If the breast tissue isdense, the X-ray film can be difficult to interpret.

But when she came back, the news wasn't good. She tried to be reassuring,but her eyes were fixed on the floor as she suggested that I undergo a biopsy.

I could feel the fear rising. I knew I was in trouble. After all, I was a doctor too.

But on that day, Friday, Aug. 13, 2004, without warning, I switched roles andbecame a patient. It was foreign territory for me, and now, having spent 14months there, I have to admit the journey has not been easy. The biopsy led to surgery that ultimately confirmed I was suffering from invasivebreast cancer.

In many ways, where Dr. Marla ended and just Marla began was poorly defined. My profession was inextricably woven into the very fabric of who I was – someone taught to be a clear thinker and problem solver whose decisions are based on evidence, even if it's just the best that science canoffer at the moment.

And when it comes to cancer, the evidence is staggering. According to theNational Breast Cancer Foundation, women in the United States developbreast cancer more than any other type of cancer, except skin cancer. Italso has the second highest rate of cancer death in females. An estimated200,000 women will be diagnosed with breast cancer this year and it will lead to the deaths of more than 40,000 of them.

However, this disease does not only affect women. The NBCF also notesthat approximately 1,700 men are diagnosed with breast cancer each year. It will kill roughly 450 of them.

As a doctor, you learn to respect those numbers and screen as effectively as you can, be it clinical examination, diagnostic tests or lifestyle counseling.As a patient, your life is changed forever. And mine has.

As well as the feelings everyone has when faced with a life-threatening diagnosis, I had to deal with the fact that, thanks to my appearances bothon [Canadian morning news show] “Canada AM” and on [health and lifestyleprogram] “Balance,” my own show, I am a public figure.

Caring for Yourself


Just what this meant was driven homethe day I went for my first oncologyappointment. As my husband, Bobby,and I stood at the reception desk inToronto's Sunnybrook Hospital, wecould see that “Balance” was playingon the television set in the waitingroom. People behind us began towonder out loud if "that woman stand-ing there" was Doctor Marla and if"she" had cancer.

I wanted to turn around and scream,"I may have cancer, but I'm not deaf."And yet I realized at the same timethat I'd have to say something aboutwhat I was going through. Keeping ita secret was the last thing I wanted.My goal was to deliver a message:Fight and hope. I wanted to supportmy family and friends with encour-aging words.

So, when I wrote the first of my weeklycolumns for The Globe and Mail'shealth page almost exactly a yearago, I introduced myself to readerswith the news of my recent diagnosis.

I also explained that I did not want thedisease to define me, but clearly ithas in many ways, some perceptibleand some not. I am not the samewoman who walked through the doorsof mammography that fateful day.

For one thing, the treatment meantthat I couldn't practice medicine. Idid not want to abandon this role Ifelt so comfortable with – I felt likemy identity was being stripped away.But chemotherapy wipes out yourwhite-blood-cell count and makesyou a sitting duck for any infection;to keep working in such a situationwould have been like doing the tangoin a minefield.

I forced myself to keep up with“Canada AM” and my other mediacommitments. I needed to hold on toa piece of me that was old and familiar. But most of my energy went intofighting the disease.

People ask if this fight has gone betterfor me because I'm an informed patient.I really don't know. In so many ways,it has been easier because I under-stand the language and the uncertainty.But in other ways, I know too muchand yet not enough. It is very hardever to feel reassured.

The treatment of breast cancer is tailored to the individual and based on where you are when you're diag-nosed. But even then, there are manyoptions and no black and white, noright answer. As I navigated throughthe maze of diagnosis and treatmentoptions, I realized that, despite myknowledge, I was totally unprepared.

It felt like I was running a race. Thereare so many decisions that have tobe made – and made quickly. Thevarious treatment options were out-lined, along with the potential benefitsand side effects, but ultimately I hadto make the choices that I hopedwere right for me.

And these choices hinged on thefact that my tests could not confirmwhether the areas where the cancerhad invaded my body were related toor independent of each other. As aresult, I was offered chemotherapy –although I could have refused that option.

After that, I had to decide betweenradiation and mastectomy, therapiesthat were considered equally effectiveeven if they are clearly so different.

So no one could tell me how to runthe race. It's something you have tofigure out yourself: what treatmentsare right for you, what your comfortlevel is, what risks you're willing totake. It's a race I had to run alone. Or so I thought.

When my husband and I told our twoolder children, daughters Jenna andAmanda, I minimized my concern.But when I was to start chemotherapy,I could not shield them from theobvious side effects I would have to endure.

We waited a while to tell nine-year-oldMatt, and thought we had done a goodjob of protecting him. But children areperceptive, and he soon sensed thatsomething was wrong. Which fright-ened him because our silencesuggested there was somethingthat he could not talk about.

Once told, he was obviously relieved,and being so young, he soon cameup with every conceivable question.He found it curious that I would losemy hair. (Actually, I did too.) Hewanted to know if cancer would just

Marla – with her hair starting to grow back – and her family.

“go away, like a cold does. When wetold him it was something that had tobe beaten, he walked around fordays, boxing imaginary demons inthe air.

Also, suddenly I was home a lot. Mychildren have grown up in a busyhousehold with a mother who leavesearly and often comes home late. Andwhile they knew that I was always"there for them," it wasn't always aphysical presence. Being there for carpools, events and homework often re-quired a juggling act.

My newfound free time allowed me torediscover my kitchen. I started bakingand cooking so much that, after awhile, the kids complained they weregaining weight even as I was graduallydisappearing into the side effects ofmy treatment.

Thanksgiving last year came right aftermy first round of chemotherapy, and I was unbelievably sick. Nothing hadprepared me for how ill I would be. Ifelt like a toxic waste dump. I couldn'tmove, I couldn't eat.

Home from school for the weekend,the girls were confronted with just howill I had become. The fear in their eyeshit me like a ton of bricks. Clearly thiswasn't just about me. This was theirfight too.

As I tried to suppress my darkthoughts about not being around tosee them marry, have children and move through life, I suddenly realizedthat they had the exact same fears.And while I felt I could force myself todeal with anything, I could barely copewith their pain and fear. Try as I might,I could not make it go away.

But as time went by, I found there werethings I could do.

The email and letters of support andconcern I received were overwhelming.I am eternally grateful to the women

who came forward to share their stories.I did not have to be alone.

Then one day my husband asked mewhy, if one in nine of us has breastcancer, does Canada not have morebald women running around?

The answer is that we are here butoften silent. We carry on. We wearour wigs. We move forward as bestwe can, considering so little is saidabout how nothing in life preparesyou to deal with a curve ball like this.

But when I was invited to go to Van-couver to appear on “Vicki Gabereau,”I wondered about leaving the wig athome. The truth was that I was wear-ing it only on “Canada AM.” In real life,I walked around bald. I gave speechesbald, went to dinner bald. But I knewthat this was different: national televi-sion without a wig.

I decided that this was who I was inreal life, and so I headed off to theWest Coast wearing just my littleblack hat to keep me warm.

As I sat in makeup and Vicki came into say hello, she stopped and, in hertypical way, said: "You look different,Mama." She smiled, I smiled and offwe went to do the interview.

She was frank and curious and askedtough questions. I was totally comfort-able in my own skin – and totallyunprepared for what happened next:Letters came from women saying theyhad taken off their wigs after seeingthe show.

Marla with Amanda, one of her two daughters...

and with her son, Matt.

I realized that, despite my knowledge, I was totally unprepared.”


I realized then that many people hadthought I was sailing through my fightwith cancer, that somehow I had theinside track. In reality, on many levels,it was exactly the opposite: I am nodifferent from anyone else in thesame situation.

It soon became apparent to me that Ihad a story to share – and it wasn'tas much about the medicine andscientific advances as it was aboutthe impact on my family, my life andall the things we don't talk about.

When I spoke to CTV about making adocumentary, the network was protec-tive of me and said it was my decision,but I felt strongly that I wanted to dothis. A crew more or less moved inand followed me around. My familyand friends and physicians were open and honest, and the result is calledRun Your Own Race.

Today, my chemotherapy is behindme. The surgeries I elected to haverather than radiation are over, and Ihave gone back to my office and acareer I love.

So how have I changed? In manyways, I am the same – juggling a zillionwork balls and loving the return. Butin so many other ways, I am different.The only word I can think of to de-scribe it is mindful. I am so much

more mindful of the decisions I make,my family, my children and how Ichoose to live my life.

My children would say that my valueshave changed, and perhaps they arewiser than their mother, who hasfinally learned to match her emotionaland her time commitments.

There are those who insist that Ihave inspired them with my so-calledcourage, when, in fact, they have in-spired me with their stories. It doesn'ttake courage to fight when there is noother option. I am not alone. You arenot alone. Together, we all make a difference.

Based on an article originally appearing in The Globe and Mail,October 2005.

About the authorFor years, well-known medical contributorDr. Marla Shapiro has waded through theconstant barrage of medical research andhas disseminated the most sensible med-ical information you need to make smarthealthcare decisions. She completedmedical school at McGill University andtrained at the University of Toronto for herMaster’s of Health Science in CommunityHealth and Epidemiology. She concludedher specialty training in Community Medi-cine receiving her Fellowship in Commu-nity Medicine from the Royal College of

Physicians and Surgeons of Canada.She is an Associate Professor in theDepartment of Family and CommunityMedicine at the University of Torontoand is in private practice.

In 1993 she joined City TV in Toronto,Ontario as the medical expert on thenationally syndicated show “Cityline.”Shortly thereafter she became the medicalexpert for “City Pulse” and CP24 News.In 2000, she left City to become thehealth and medical contributor for CTV's“Canada AM.” In addition to her weeklyappearances on “Canada AM,” she isseen on “Newsnet” and as the medicalconsultant on CTV’s “News with LloydRobertson.”

2003 saw the exciting addition of “Balance: Television for Living Well.” Dr.Shapiro hosted this exciting daily healthand lifestyle show. It is seen across NorthAmerica and has sold internationally.

Dr. Shapiro is the recipient of the 2005Media Award from the North AmericanMenopause Society for her work in ex-panding the understanding of menopause,and won the Society of Obstetricians andGynaecologists of Canada/CanadianFoundation for Women's Health Award forExcellence in Women's Health Journalismin 2006 for her documentary Run YourOwn Race.

Mark you calendar!Medline Industries will be hostingtheir annual AORN Breast CancerAwareness Breakfast, by invitation only,at the 2008 AORN Congress. The eventwill take place at the Marriott Anaheim on Monday, March 31, 2008 from 6:30 to7:30 a.m. We are honored to announcethat this year’s speaker will be Dr. MarlaShapiro and you will receive one CEcredit with your attendance. Contact yourMedline sales representative if you wouldlike more information about this event.

Laughing with chocolatebreasts before her bilateral mastectomy.


A Must-ReadLife in the Balance is Dr. MarlaShapiro’s inspirational account of herbattle with breast cancer from diagnosisto surgeries to chemotherapy and her agonizing decision to have both breastsremoved. It is also the personal story ofhow her family handled the news andcame together to achieve newfoundbalance in their lives. This is a book foranyone whose life has been touched by cancer or who knows someone who has.

Order your copy at one of these online retailers:Amazon.ca Chapters.Indigo.caMcNallyRobinson.com

Tips for Early DetectionThe most important thing any woman can do to fight breastcancer is to practice tips for early detection. Many womenare not familiar with the territory, so here are some early detection tips, signs and symptoms from the NationalBreast Cancer Foundation, included as reminders.

Three recommended screening methods• Breast Self-Exam

– Studies show that regular (monthly) breast self-exams, combined with an annual exam by a doctor, improve the chances of detecting cancer early.

• Breast Physical Exam (By a doctor) – This should be done on an annual basis and

in conjunction with breast self-exams.• Mammograms

– The National Cancer Institute, the American Cancer Society and the American College of Radiology now recommend annual mammogramsfor women over 40.

Symptoms and signs• A new or persistent lump or a thickening in or

near the breast or possibly in the underarm area• A change in the size or shape of your breast• Discharge from either of the nipples that has not

occurred before• Changes in the color or feel of your breast,

areola or nipples, which might consist of dimpling, puckering or a scaliness of the skin.

It’s critical to carry out regular breast self-examinations –this way, you will be able to detect any of these signs orsymptoms. If you find something that you feel is abnormal,arrange an appointment to see your doctor.

Referencebreastcancer.org. Symptoms and diagnosis. Available at: http://www.breastcancer.org/symptoms/. Accessed August 21, 2007.

Together w e can save lives through early detection

In 2005, Medline launched a year-round breast cancer awarenesscampaign with two critical goals: education and early detection. Wepartnered with the National Breast Cancer Foundation (NBCF) toprovide breast cancer education and help fund mammograms forunderserved women. Since the launch, Medline has donated morethan $250,000 to the NBCF and has distributed thousands of copiesof “Beyond the Shock,” a patient education DVD developed by morethan 70 leading oncologists in the United States. Medline is proud todonate to this cause. The statistics tell us that ten percent of thewomen who receive free mammograms will be diagnosed withbreast cancer -- this makes it clear that we can help save lives.


“Everyone has them, but often we do not take time to reflect and learn from whatever made the dayeither the best or the worst we’ve encountered. Many lessons could be learned from taking a fewminutes to sift through details and analyze data so that we can choose to either replicate or eliminate the factors that contributed to the success or demise of a given workday.

Below are some situational examples to stimulate your mind and help you start thinking about your own best and worst days!

After opening my room, I went to thepre-op area to interview the patientand review her chart. The patient wasundergoing a left thoracotomy andlower lobectomy. She was four yearspost-left mastectomy for breast can-cer. After interviewing the patientand answering her questions, I wasabout to excuse myself and return tothe room to finish some last-minutepreparations. The patient grabbed myhand and said, ‘Thank you. When Ilook into your eyes I see hope, and itis something I haven’t had since themass in my lung was discovered.’ Atthat moment, I realized the profoundeffect we as perioperative nurses haveon our patients in our brief interactionsbefore the patient is anesthetized.”

We want to hear from

Please email stories about yourbest and worst days at work to [email protected]. We will share many of the responses in future issues of The OR Connection!

YOU!

BEST day

”

“Ironically, the best day I ever spent in my eight years in hospital PR was also the worst. Our localhigh school had a shooting this past spring and the victim was brought to the hospital. The entireCommunications Department, save me, was out of the office at a seminar three hours away. Being apart-time writer, I had to step up and do interviews with national news agencies, over the phone withNPR, etc., which was a huge learning experience. And we were the heroes, because our staff savedthis kid’s life (he was shot four times, three in the torso). But not soon after, his mom is in the papertrashing the hospital for not covering his bills, etc. The good and the bad. That’s working in a hospital for me.”

“The phone rang at 2 a.m. It was the hospital calling to see if I would come in even though I wasn’t on call. Both call teams were on their way in and there was a third emergency that needed immediate surgery as well. Since I lived close to the hospital, it wasn’t uncommon for them to call me when they needed additional help. I agreed to cover the third emergency with the stipulation that I was relieved if either of the other two teams finishedbefore I did. The three emergencies were young men in their early twenties who were drag racing on their motor-cycles and collided. My patient was nearly severed in half and arrived in the OR with CSF running out of his nose. None of these young men were surgical candidates, but because of their young ages the surgeons decidedto try and save their lives. Needless to say, all three died on their respective OR tables. One poor decision changedthe lives of three families forever.


Caring for Yourself

WORST day


SDiana is no exception. Even at an early age,she knew she would go into health care. Shehas worn many hats. She began her careeras a candy striper and nursing home volunteer.She entered the world of perioperative servicesas a surgical scrub technician and then went onto become a registered nurse.

Diana is a natural leader and gets along witheveryone. She’s not only there for her patients,but her fellow staff as well. These characteristicsmade her the perfect person to run the board fora busy 13-room OR in Tampa, Fla. Like every-thing in her life, she met this challenge head onand was great at it – but she found she misseddirect patient care. While working full time, shewent back to school and became a family nursepractitioner. She then worked for a spinal/ortho-pedic surgeon and an orthopedic group. Bothwere invaluable learning experiences for Diana.

o many nurses say they got into nursing because they wanted to help people.

Conquering Cancer with a Nurse Hero

Clockwise from above:Diana crosses the finishline in Washington state;

Diana with her good friendJamie Morrow in San

Diego; Diana on her bike inChicago. All photos weretaken at races that were

part of the Women’sTriathlon Series Benefiting

the Ovarian Cancer Research Fund, Inc.


A cancer diagnosis, an outpouring of supportShortly thereafter, Diana was diag-nosed with stage IIIC ovarian cancer.She underwent two major surgeriesand a total of eight rounds ofchemotherapy, both IV and intraperi-toneal. Diana admits that this was avery frightening time for her. “I cried,but I just couldn’t let this get the bestof me,” she said. She attributes beinga nurse, athlete and generally positiveperson as the reasons she was ableto do this.

From the beginning, everyone aroundDiana pitched in with cards, phonecalls, parties, fundraisers and “justbelieving.” “I cannot begin to tell youabout the cards and money peoplegave us. The pictures sent and par-ties that were thrown were just whatI needed. All of these things helpedme get through the tough times,”Diana said.

Her friend Jamie kept everyone upto date on Diana’s progress. Friendscame out of the woodwork to cook,clean house and even mow the lawn!Her dad was with her for her chemoappointments and follow up. Familyflew in to visit and help. One of herbrothers is even a nurse with chemoexperience! He was able to helpher understand the side effects of

chemotherapy and the importanceof taking her meds.

Embracing the futureWe are happy to report that Diana’scancer is in remission and that she isback to work as the charge nurse forpediatric surgical services in the ORwhere she used to run the board.She is an excellent perioperativenurse and everyone is happy to haveher back on the team.

Diana has always loved the outdoorsand being active. While in school,she ran on the track team and nowfinds running is a great stress re-liever. She runs marathons and en-durance races. A physician friend gother started on triathlons and she en-joys the challenge. She and Jamie recently finished the last of a seriesof triathlons to raise money forovarian cancer.

Diana is a truly amazing nurse,athlete and person. She is a sourceof inspiration to many of her friendsand colleagues – not only because ofthe illness she beat, but the passionshe puts into everything she does.

In Diana’s own words: “You know, allof my life I was taught that the gift oflife was just that – a gift – so enjoyevery possible minute!”

“All of mylife I wastaught thatthe gift of lifewas just that– a gift – soenjoy everypossibleminute!”

Diana with her friendColleen Cannon at atriathlon in Fort Desoto, Fla.

By Laura KuhnThe OR Connection staff writer

t didn’t seem possible to Aurora, Angel, Ami and Anastasiathat the holidays were upon them once again – hadn’t theyjust finished the last of the turkey soup and turkey sand-wiches? And yet here they were, all four sisters at homeagain, just like it used to be when they were children.

Synchronizing days off from their busy nursing scheduleshad been a challenge!

Aurora had settled in for a nice, quiet evening in the family livingroom. She was sprawled on the floor in front of the fireplace,basking in the warmth and flipping through an old family photoalbum that she had found in the attic while helping her motherlocate holiday decorations.

She knew that her mother was not the first family member toenter the nursing profession, but Aurora was still surprised tosee woman after woman in the photo album dressed in variationson nursing attire.

Her mother walked into the room, arms filled with garland, andstopped to look over Aurora’s shoulder.

“Oh, that brings back memories,” she said. “My mother put thatalbum together for me when I couldn’t decide whether or not Iwanted to go into nursing. Those are the women in our familywho have been nurses. Funny to see how uniforms havechanged, isn’t it?

“You should have heard the stories my grandmother told meabout assisting with surgery in the early 1900s,” her mothercontinued as she wrestled with the garland. “Oftentimes, surgerieswere performed in private residences. When it came to sterili-zation, they just dusted down the walls and wiped the floor witha damp cloth!”

Aurora laughed, thinking of how much the profession hadevolved. One of the next pictures she saw was a woman whowas almost unrecognizable underneath her stark white gownand surgical mask.

“They thought white emphasized cleanliness,” Aurora remarkedto her mother. “I can’t imagine wearing a white gown in a brightoperating room – it would be blinding!”

“Not to mention how unpleasant it is to see red blood splashedon a white gown!” laughed her mother. “Thank goodness theystarted switching to green and other colors.”

Aurora flipped another page in the album and came face-to-facewith a black-and-white photo of a fair-haired nurse in a trimwhite uniform, a graduate nurse’s cap and a dark cape.

“Who’s this?” she asked her mother.

Her mother grinned. “That’s your great-aunt Alice,” she said.“Oh, the stories I could tell you about her!”

Just then, Angel, Ami and Anastasia burst into the room. “Mom,you promised us that this would be the year you would shareyour secret pecan pie recipe,” Ami said. “Let’s go!”

Their mother glanced back at the photo of Alice once more. “I guess we’ll have to talk about Alice another day,” she toldAurora. “But I promise her story is worth the wait.”

Stay tuned to future editions of The OR Connection tolearn more about the sisters and meet the next addition to their family!

I



Recipes for Strong,Healthy Living.From strongwomen.com

Champagne and Chocolate Covered Strawberries

Ingredients:Your favorite champagne or sparkling ciderFresh strawberries with the stems intactChocolate hazelnut spread (such as Nutella®)Several tbsp of heavy cream

Wash the strawberries and chill them. Place a cup of thechocolate hazelnut spread in a double boiler or fondue potand heat slowly. Add 1 to 2 tbsp of heavy cream and heatover low temperature until it is the consistency of heavycream.

To serve cold: Dip the strawberries in the warm chocolate,place on waxed paper and chill.

To serve warm: Sit around the table and dip the strawberriesin warm chocolate using a fondue pot. Eat immediately.

Either way, enjoy with your favorite champagne orsparkling cider!

Nutritional information: Strawberries are an excellentsource of vitamin C!

Mim’s MeltawaysMakes 45 to 60 cookies

Ingredients:¾ c ground unblanched hazelnuts or blanched almonds¼ c whole-wheat flour½ c all-purpose flour4 oz (1 stick) unsalted butter, at room temperature½ c confectioner’s sugar, plus more for siftingGrated zest of one orange1 tsp vanilla

Combine the hazelnuts and whole wheat and whiteflours and set aside. In a mixing bowl with an electricmixer, beat the butter until it is light. Add the confectioner’ssugar and orange zest and beat until fluffy. Beat in thevanilla. Add the dry ingredients and mix very well, scrap-ing down the sides of the bowl as necessary. Cover withwax paper and refrigerate for about 30 minutes or untilfirm enough to handle.

Preheat the oven to 350˚ F. Grease cookie sheets or linewith parchment paper (the paper is easier to handle andmakes for much easier cleanup). Shape the dough intoballs ¾-inch to one inch in diameter and place 1½ inchesapart on the cookie sheets. Bake in the middle of the ovenfor about 15 minutes, or until golden around the edges, rotating the pans halfway through baking. Cool the cook-ies for 2 to 3 minutes on the pans, then carefully slidethem off onto a sheet of waxed paper. Sift confectioner’ssugar over the cookies while they are still warm. The cook-ies are fragile while hot, so don’t handle until they are cool.

Nutritional information (per 2 to 3 cookies): 51 calories,3.9g fat (1.5g saturated), 3.8g carbohydrate, 0.6g protein,0.3g fiber


Forms &Tools

Perioperative Patient PositioningInjury Risk and Safety Assessment ............94

How Well Do You Know

Pressure Points? ..........................................96

Policy & Procedure ....................................98

Hand HygieneIndications for Hand Hygiene ................101

Surgical PacksSafety Checklist ........................................103

The following pages contain practicaltools for implementing patient-focusedcare practices at your facility.


INJURY RISKS AND SAFETY CONSIDERATIONS WHEN POSITIONING PATIENTS

Position Risk Safety Consideration

Supine

Prone

Lateral

Lithotomy

Pressure points, including occiput, scapulae,thoracic vertebrae, olecranon process,sacrum/coccyx, calcaneae, and knees.

Neural injuries of extremities, including brachialplexus and ulna, and pudendal nerves.

Head

Eyes

Nose

Chest compression, iliac crests

Breasts, male genitalia

Knees

Feet

Bony prominence and pressure points on de-pendent side

Spinal alignment

Hip and knee joint injury Lumbar and sacral pressure Vascular congestion

Neuropathy of obturator nerves, saphenousnerves, femoral nerves, common peronealnerves, and ulnar nerves.

Restricted diaphragmatic movement Pulmonary region

• Padding to heels, elbows, knees, spinal column, and occiput alignment with hips, legs parallel and uncrossed ankles.

• Arm boards at less than 90-degree angle and level with floor. • Head in neutral position. • Arm board pads level with table pads.

• Maintain cervical neck alignment.

• Protection for forehead, eyes, and chin.

• Padded headrest to provide airway access.

• Chest rolls (ie, clavicle to iliac crest) to allow chest movement and decrease abdominal pressure.

• Breasts and male genitalia free from torsion.

• Knees padded with pillow to feet.

• Padded footboard.

• Axillary role for dependent axilla. • Lower leg flexed at hip. • Upper leg straight with pillow between legs.

• Maintain spinal alignment during turning. • Padded support to prevent lateral neckflexion.

• Place stirrups at even height. • Elevate and lower legs slowly and simultane-ously from stirrups.

• Maintain minimal external rotation of hips. • Pad lateral or posterior knees and ankles toprevent pressure and contact with metal surface.

• Keep arms away from chest to facilitate respiration. • Arms on arm boards at less than 90-degreeangle or over abdomen.

Risk Assessment

18.

19. 21. 22. 23. 24. 25.20.

Lateral

Prone8. 16.9. 10. 11. 12. 13. 15. 17.

14.

Supine

3.

4. 5. 6. 7.

1.

2.


Forms & ToolsPATIENT POSITIONING

Choose from (some may be used more than once)

AnkleDorsal thoracic areaElbowFaceFootGreater trocanterHeelHipIschial tuberosityKneeLateral footLateral legNeckOcciputPosterior kneeSacrumShoulderThoracic areaToesUnder strap

How well do you know pressure points?

Answer key on Page 100

Lithotomy

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

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23.

24.

25.

26.

27.

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30.

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32.

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36.

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Trandelenburg

29.

33.

35. 36. 37. 38.

32.

34.

26. 27. 28. 30. 31.


Forms & ToolsPATIENT POSITIONING


PATIENT POSITIONING

Policy & Procedure

Excerpted from University of North Carolina Hospitals policy.

PURPOSE:To outline the nursing management of the surgical patient during the process of operative positioning.

LEVEL:Shall be performed by surgeon and RN with assistance from support staff (*required MD order).

SUPPORTIVE DATA:The patient’s position: (1) should provide optimum exposure and access to the operative site, whilesustaining body alignments, circulation and respiratory functions, and skin integrity; (2) must provide access to the patient for adminstration of intravenous fluids, drugs, and anesthetic agents,and (3) should afford as much comfort to the patient as possible.

Nurse needs to make the following assessments prior to starting the procedure.• Assess patient’s size and identify any existing respiratory, skeletal,

or neuromuscular limitations.• Determine position of choice by consulting surgeon’s preference card for the scheduled

procedure and/ or posting slip.

EQUIPMENT:• Foam rings• Eggcrate padding• Wilson Frame• Gel pads • Bean bags (Vac-Pack)• Laminectomy frame• Bolster • Horse shoe head rest

Positioning the Surgical Patient


Steps:

1. Do not allow instrument table, mayo stand, or other equipment to rest on or put pressure on patient.

2. Do not allow surgical team members to lean on patient.

3. Avoid unnecessary exposure of patient before, during, and after positioning.

4. Assure that all equipment/ supplies used are clean and in working order.

5. Assure that proper side is exposed if procedure is unilateral.

6. Move the patient only after the anesthesia care team gives approval; move gently and slowly.

7. Provide adequate numbers of personnel for the safe movement of the patient.

8. Do not abduct arms to greater that 90ˆ.

9. Place safety belt 2” above the knees and not so tight as to impeded circulation. This will provide optimum control of patient during induction and emergence from anesthesia.

10. Assure that legs and / or ankles are not crossed.

11. Avoid having body surfaces in contact with one another.

12. Assure that patient is not touching any exposed table parts or hanging over sides.

13. Check catheters, tubes, and drains for patency once patients is positioned.

14. Assure that kidney rest on OR bed is at lowest position.

15. Place padding under heels and head. If foam ring is used, do not remove foam from hole. Removing the center could diminish circulation.

16. Position arms on arm board or secure under draw sheet at patient’s side. Palms should either turnedtoward the patient or turned down. Pad elbows withtowel or foam.

17. Place a small pillow under calves supporting the full length of the lower legs.

a. Care must be taken not to put pressure on popliteal space.

b. This helps to minimize pain in patients with low back pain.

18. Apply Anti-embolism stockings.

19. Place small sandbag or blanket roll under right hip to relieve pressure on inferior vena cava in patients who are obese, have large abdominal masses or are pregnant.

Semi - Fowler’s Position:20. Assure that hand(s) and arm(s) that have been

secured under draw sheet are free of excess pressure created by flexing OR table.

Trendelenburg Position:21. Move patients into and out of Trendelenburg’s

position slowly to avoid sudden changes in blood pressure. Do not use Trendelenburg in patients with increased intracranial pressure or poorly controlled glaucoma.

Reverse Trendelenburg:22. Use a padded foot board to support patient.

Lithotomy Position: 23. Assure that patient’s buttocks do not extend

over the break in the bed. Pad sacrum with foam or other padding if necessary.

24. Raise and lower legs with knees together simultaneously, very slowly, and never abduct legs without first externallu rotating the hip.

25. Position thighs so they do not exert pressure on the abdomen or groin.

26. Secure arms on arm-board or across abdomen.

27. Adjust and secure safety belt as in #9 above before and after lithotomy position. The safety belt should be secured over the thighs during anesthesia induction and emergence. The safety belt may be used over the abdomen during the surgery if it does not get in the way of the procedure (e.g. gynecological laparoscopy).

PATIENT POSITIONING

Policy & Procedure

Excerpted from University of North Carolina Hospitals policy.

100THE OR CONNECTION

28. Pad legs at any points where they come in contact with stirrup. Use safety straps if applicable.

Prone Position:29. Provide chest rolls (bath blanket wrapped in

eggcrate foam) or laminectomy frame, a pillow for under the feet and padding for ear, eyelids, and cheeks.

30. Assure that there is no compression of female breast (place laterally if necessary) or male genitalia.

31. Position arms either at patient’s side with palms turned inward or upward or over the head on armboards. If positioned over the patient’s head, they should be slowly lowered toward the floor and brought up in an arc while the elbow is flexed.

Securely support the elbow and shoulder during this movement.

32. Secure safety belt 2” above knees.

Lateral Position:33. Turn shoulders and hips simultaneously. There should

be a minimum of four persons helping with this position.

34. Assure that the iliac crest is level with the break of the bed if the patient will be flexed.

35. Flex lower leg at hip and knee. Allow upper leg to remain straight.

36. Place pillow between knees and feet.

37. Place padding or foam under bony prominences: ankle, knee, hip.

38. Secure upper arm with Kerlix roll on overbed arm-board (“airplane”) with elbow slightly flexed and palm up.

39. Secure lower arm on arm-board with elbow slightly flexed and palm up.

40. Position lower shoulder slightly forward with axillary roll under axilla.

41. Check radial pulses after positioning is completed.

42. Stabilize patient using safety belt and/or 3” adhesive tape across hips and secured to OR Table. Assure that female breast and male genitalia are free from compression.

43. Elevate head on folded towels and/ or foam padding.

44. Do not allow kidney braces (if used) to come in direct contact with patients.

45. Refer to owner’s manual if Vac-Pak is used.

Frog-Leg Position:46. Provide four to six folded blankets to elevate

and support knees and legs.

47. Secure feet to OR bed with 3” adhesive tape. Protect feet from adhesive using folded towel.

Specialty Tables:48. Refer to reference materials supplied

by manufacturers.

Documentation:Document implementation of procedure. Document onPerioperative Standard Care Statement:

• Position of patient• Type and location of padding • Support used • Radial pulse assessment (from item #41 above)• Use of anti-embolitic devices and the

times(s) activated

PATIENT POSITIONING

Policy & Procedure

1. Heel2. Under strap 3. Occiput4. Dorsal thoracic area5. Elbow6. Posterior knee7. Ankle8. Occiput9. Face10. Shoulder11. Thoracic area12. Elbow13. Hip14. Under strap15. Knee16. Foot17. Toes18. Occiput19. Neck

20. Shoulder21. Hip22. Greater Trocanter23. Knee24. Lateral foot25. Ankle26. Occiput27. Dorsal thoracic area28. Elbow29. Under strap30. Posterior knee31. Heel32. Ankle33. Lateral leg34. Ischial tuberosity35. Sacrum36. Elbow37. Shoulder38. Occiput

PRESSURE POINT ANSWER KEY from pages 96-97.


Indication Hand

ant isepsis before

Hand ant isepsis

af ter

When hands are visibly dirty or contaminated with infectious material orare visibly soiled with blood/ other bodyfluids (incl. diarrhea)

Before eating

After using the restroom

Having direct contact with patients

Donning exam and sterile gloves

Inserting indwelling urinary catheters, peripheral vascular catheters or other invasive devices that do not require a surgical procedure

Moving to a clean body site during patient care when coming from a contaminated body site

Contact with body fluids or excretions,mucous membranes, non-intact skin and wound dressings if hands are not visibly soiled

Contact with patient’s intact skin

Removing gloves

Contact with inanimate objects (includingmedical equipment in the immediatevicinity of the patient

Before shift

After breaks

When required or desired

*Gloves should be worn for all types of contact if the patients is on isolation precautions.

After shift and in leisure time as needed

Recommended Practices

INDICATIONS FOR HAND HYGIENE

Use of glovesUse of a skincare

lotion

Handwash with soap

102THE OR CONNECTION

Indication Hand

ant isepsis before

Hand ant isepsis

af ter

When hands are visibly dirty or contaminated with infectious material orare visibly soiled with blood/ other bodyfluids (incl. diarrhea)

Before eating

After using the restroom

Having direct contact with patients

Donning exam and sterile gloves

Inserting indwelling urinary catheters, peripheral vascular catheters or other invasive devices that do not require a surgical procedure

Moving to a clean body site during patientcare when coming from a contaminatedbody site

Contact with body fluids or excretions,mucous membranes, non-intact skin and wound dressings if hands are not visibly soiled

Contact with patient’s intact skin

Removing gloves

Contact with inanimate objects (including medical equipment in the immediate vicinity of the patient

Before shift

After breaks

When required or desired

*Gloves should be worn for all types of contact if the patients is on isolation precautions.

After shift and in leisure time as needed

INDICATIONS FOR HAND HYGIENE

Recommended Practices

Answer Key Use of gloves

Use of a skincare

lotion

Handwash with soap

Change gloves

*

*

*


Safety Checklist

FORMS & TOOLS

MKT207354/LIT581/20M/WMP5

OR Connection Magazine - Volume 2; Issue 3

Documents

Transcript of OR Connection Magazine - Volume 2; Issue 3