OR Connection Magazine - Volume 5; Issue 4

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Principlesfor achievinginner peace

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WINNERPage 6

TheAligning practice with policy to improve patient care

FREE CE!

Meet checklistguru Dr. PeterPronovost

YES!Checklists

Work

Tips forTackling

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OR ConnectionThe

Aligning practice with policy to improve patient care

Subscribing to The OR Connection guarantees that you’llcontinue to receive this info-packed magazine and won’t missout on our industry updates and articles addressing on-the-job issues and tips on caring for yourself!

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Content KeyWe've coded the articles and information in this magazine to indicate which patient careinitiatives they pertain to. Throughout the publication, when you see these icons you'llknow immediately that the subject matter on that page relates to one or more of thefollowing national initiatives:• IHI's Improvement Map• Joint Commission 2009 National Patient Safety Goals• Surgical Care Improvement Project (SCIP)

We've tried to include content that clarifies the initiatives or gives you ideas and toolsfor implementing their recommendations. For a summary of each of the initiatives,see pages 10 and 11.

Aligning practice with policy to improve patient care 111

Bathing and ShoweringMost incisions should be kept dry for several days after surgery, except for incisions closedwith surgical glue. It is usually safe to allow glued incisions to get wet while showering orbathing. It is important, however, to dry the area around the incision carefully after washing.

Physical Activity and ExerciseAvoid any activity that pulls on the edges of the incision or puts pressure on it. Walking andother light activities are encouraged to restore normal energy levels and digestive functions.Do not, however, participate in sports, engage in sexual activity or lift heavy objects until afteryour postoperative checkup.

AspirinAvoid aspirin or over-the-counter medications containing aspirin for a week to 10 days aftersurgery. Aspirin interferes with blood clotting and makes it easier for bruises to form nearthe incision.

Sun ExposureAs an incision heals, the new skin that forms over the cut is very sensitive to sunlight andwill burn more easily than normal skin and lead to worse scarring. Keep the incision areacovered from direct sun exposure for three to nine months in order to prevent burning andsevere scarring.

General HygieneInfection is the most common complication of surgical procedures. It is important, therefore,to minimize the risk of an infection when caring for your incision at home.

Observe the following precautions:• Wash your hands carefully after using the toilet and after touching or handling trash;

pets and petequipment; dirty laundry and anything else that is dirty or has been used outdoors

• Ask family members, close friends, and others to wash their hands before contactwith you

• Avoid contact with family members and others who are sick or recovering from acontagious illness

• Stop smoking (smoking slows down the healing process)

Adapted from www.surgeryencyclopedia.com/Fi-La/Incision-Care.html

Patient Handout Forms & Tools

Caring for Your Surgical Incision at HomeThe following are general guidelines. Consult your surgical team for more specific instructions.


PATIENT SAFETY10 Three Important Initiatives for Improving Patient Care12 Patient Safety News20 Conversation with Dr. Peter J. Pronovost24 Checking it Twice: Yes! Checklists Do Save Lives39 Why the Universal Protocol Hasn’t Eradicated Patient Harm42 A New Guidebook for Patient Safety in the OR46 They’re Lurking in the Operating Room and Beyond74 5-Step Approach for Avoiding VAP

OR ISSUES36 Preventing Sharps Injury in the OR55 Medline Joins Greening the Operating Room Initiative60 Stuck Like Surgical Glue

SPECIAL FEATURES7 Pink Glove Survey Comments

14 Third Annual Prevention Above All Conference Highlights30 Patient, Heal Thyself56 3 Checklists on the Cleaning and Disinfection of

Endoscopic Equipment69 Product Spotlight: Medline Bioguard Barrier Dressings92 Pink Glove Dance: The Sequel

CARING FOR YOURSELF78 Get Set for Winter Illness Season84 8 Principles for Achieving Inner Peace96 Healthy Eating: Crock Pot Chili

FORMS & TOOLS99 AORN Surgical Time Out

100 SCOAP Surgical Safety Checklist – Ambulatory Surgery101 SCOAP Surgical Safety Checklist103 Wrong-Site Surgery Prevention Tool105 Medicare & the New Healthcare Law109 Tips for Safer Surgery111 Caring for Your Surgical Incision at Home

EditorSue MacInnes, RD, LD

Clinical EditorAlecia Cooper, BS, MBA, RN, CNOR

Senior WriterCarla Esser Lake

Creative DirectorMike Gotti

Clinical TeamJayne Barkman, BSN, RN, CNOR

Margaret Falconio-West, BSN, RN, APN/CNS,

CWOCN, DAPWCA

Rhonda J. Frick, RN, CNOR

Anita Gill, RN

Kimberly Haines, RN, Certified OR Nurse

Carla Nitz, BSN, RN

Claudia Sanders, RN, CFA

Megan Shramm, RN, CNOR, RNFA

Angel Trichak, RN, BSN, CNOR

Perioperative Advisory BoardLarry Creech, RN, MBA, CDT

Carilion Clinic, Virginia

Sharon Danielewicz, MSN, RN, RNFA

St. Luke’s The Woodlands, Texas

Tracy Diffenderfer, MSN, RN

Vanderbilt University Medical Center, Tennessee

Barb Fahey RN, CNOR

Cleveland Clinic, Ohio

Susan Garrett, RN

Hughston Hospital Inc., Georgia

Zaida I. Jacoby, MA, MEd, RN

NYU Medical Center, New York

Jackie Kraft, RN, CNOR

Huntsville Hospital, Alabama

Tom McLaren

Florida Hospital, Florida

Susan Phillips, RN, MSH, CNOR

University of North Carolina Hospitals

Donna A. Pritchard, BSN, MA, RN, CNOR, NE-BC

Kingsbrook Jewish Medical Center, New York

Debbie Reeves, MS, RN, CNOR

Hutcheson Medical Center, Georgia

Diane M. Strout, BSN, RN, CNOR

St. Joseph Medical Center, Washington

About MedlineMedline, headquartered in Mundelein, IL, manufactures and distributes more than100,000 products to hospitals, extended care facilities, surgery centers, home caredealers and agencies and other markets. Medline has more than 800 dedicatedsales representatives nationwide to support its broad product line and cost manage-ment services.

Meeting the highest level of national and international quality standards, Medline is FDAQSR compliant and ISO 13485 registered. Medline serves on major industry qualitycommittees to develop guidelines and standards for medical product use includingthe FDA Midwest Steering Committee, AAMI Sterilization and Packaging Committeeand various ASTM committees. For more information on Medline, visit our Web site,www.medline.com.

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©2010 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Page 74

You should recognize and celebrate your achievements.Those milestones are what will continue to inspire you andpush you to be your very best. And, when you are at yourbest and do your best, everyone wins…especially thepatients you are caring for. So, for 2011, I hope you willtake care of yourself. You are so important to your patients.Sometimes it takes being a patient or the family memberof a patient to really appreciate all that you do. I’ve beenthere, and so have many, many of the people I work with.We all thank you.

To set the tone for 2011, you might want to start reading onpage 84, “8 Principles for Achieving Inner Peace.” There isnothing better than an inspirational article like this one toget those New Year’s resolutions and goals flowing. High-light the article, take notes, think about the message…andthen figure out what YOU are going to do to make 2011 thebest ever!! Once you’ve put your plan together, look againat the pictures of the pink glove dancers. Take note of thehospitals involved, look at the people’s faces, feel their joy.Breathe in all those positive vibes. Then set the magazineaside and do something for yourself, something that makesyou feel good. Surprise a co-worker with a smile, ask themabout their holiday, get them a cup of coffee. Or, listen toyour child or your spouse talk about their day. Be there, inthe moment, and forget everything else that is distract-ing you and taking time away from living.

I know, I know, at some point you have to get back to workand deal with reality and everyday pressures. But it iseasier to do when you make time for yourself and yourfamily. I realize it’s hard to do everything, know every-thing, remember everything…that is why in this issue ofThe OR Connection, you are going to learn more than youprobably ever wanted to know about checklists. On thecover isn’t just another handsome face. It is Dr. PeterPronovost, a well-known advocate of patient safety,quality and the infamous checklist. On page 20, he tellshis own personal story about his father and how it hasinspired him to champion a culture of safety. Whether yourchecklist is healthcare-related or a checklist for travel or asocial event, it is easy to forget the simplest things whenour minds are buzzing. We should embrace and adoptchecklists and encourage others to do likewise. If onelife is saved or one error is avoided, it’s worth it, don’tyou think?

This edition is packed full of stories and ideas you can usein your profession as well as in your personal life. You arethe face of health care. Thank you for making a differencein so many people’s lives. And don’t forget. Step one ismaking sure you take care of YOU.

Sue MacInnes, RD, LDEditor

4 The OR Connection

The OR ConnectionLetter from the Editor

Another New Year is here! It’s a great time to reminisce, to make our New Year’s resolu-tions and set our goals for 2011. Do you ever just stop and think about what was happeningthis time last year or even five years ago? Do you think about what you were doing then?Have you changed responsibilities, or maybe even careers? Did you get married, have a child,become a grandparent, move, have to deal with a tragic situation … And when you think back,do you ever say, “I can’t believe I’ve come this far.” Because if you haven’t, you should!

The results are in!We’ve tallied your votes and compiled your thoughts about Medline’s pink glovesand the Pink Glove Dance. Thank you for your heartfelt comments and participationin last issue’s survey.

Turn the page to find the winner!

And the winning pink glove ad is…

Precious. And Pink.

Soft and shimmery.Layered with organic aloe.

Fashioned from nitrile.

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Medline’s newest Generation Pink glove.Supporting the National Breast Cancer Foundation.

©2010 Medline Industries, Inc. Medline is a registered trademark and Pink Pearlis a trademark of Medline Industries, Inc.

only wear Pink Pearls.

Only Medline’s Pink Pearl™ gloves combinealoe, nitrile and breast cancer awareness.

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©2010 Medline Industries, Inc.Medline is a registered trademarkand Pink Pearl is a trademark ofMedline Industries, Inc.

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©2010 Medline Industries, Inc.Medline is a registered trademarkand Pink Pearl is a trademark ofMedline Industries, Inc.

6 The OR Connection

54% Voted for Pearls!


Q

A

What does thePink Glove Dance

mean to you?

What our readers said:

pink glove survey

It means unity, joy, excitement, a cause“on the go” for all involved.Shannon Sessoms, RN, BSN, CNORSoutheast Missouri HospitalCape Girardeau, MO

Awareness! Hope! While in the OR I toldco-workers and the patient about this.It raised our spirits. Big companythat CARES.Deb Cimino, RN, BSN, CPSN, CNORYardley Plastic & Reconstructive SurgeryYardley, PA

Celebrating the lives of two of our nurseswho died—and the two who are stillwith us.MJ BalunNaples Day SurgeryNaples, FL

It is a fun but touching video that showsthe true concern healthcare workers havefor people with breast cancer.Holly Creel, RNThe Kirklin ClinicWarrior, AL

8 The OR Connection

My mother had breast cancer, so itmeans everything.Tina HollisNortheast Alabama Regional Medical CenterHerflin, AL

Hope for patients with breast cancer.Beautiful women, strength, good fun.Patricia Nieszel, RNAlgonquin Surgery CenterCrystal Lake, IL

It shows how caring healthcare workersof ALL types are towards supportingthe cause!Helen Aylward, RN, BSN, L.Ac.Maine Medical CenterPortland, ME

It made me cry to see the teamwork thatwent into making it. I’m a breast cancersurvivor.Carolyn Meyer, RN, BSN, CNORSt. John Medical CenterBartlesville, OK

As a breast cancer survivor it means somuch to know that many people care andwant to show it - keep it up!Ellen Whitehead, RN, CNORGeorgia SurgicalAcworth, GA

Those with cancer are not alone.We are out there standing besidethem and showing our support.Kathleen IngrahamFirstHealth Moore Regional HospitalPinehurst, NC

Shows how much healthcare workerswant to make a difference towardrecognition, education and care ofbreast cancer.Susan Karns, CST, CFAKettering Medical Center - SycamoreFranklin, OH

People from all different walks of lifecoming together for a common cause– fighting breast cancer.Sue Montgomery, RNFoothill Presbyterian HospitalGlendora, CA

Wonderful healthcare providers, notprofessional dancers, working hard tospread the word about breast cancerawareness.Mary Valley, RN, CNORFrisbie Memorial HospitalRochester, NH

Joy for cancer survivors and hopefor more.Carol Athey, RN, MSN, CNORWoodland Heights Medical CenterLufkin, TX

It makes me smile.Debra Ann Caise, RN, BSNProvena St. Mary’s HospitalSt. Anne, IL

Left to right:Tina Hollis, PatrickMontgomery andCindy Gibson.Co-workers in thesurgery departmentat NortheastAlabama RegionalMedical Center inHerflin, AL.

What does the Pink Glove Dance mean to you?


As a breast cancer survivor,every time I see the videos I crywith gratitude that so many peoplecare and did something so funand positive as a response. Thankyou to everyone who participated.And thank you to so-hip Portlandfor getting the ball rolling. And as alifetime rock and roller, dancer andsilly person, every time I see these

folks dance and carry on, I laugh and I am infused with love oflife and humanity. Boy do they get their groove on!

I was diagnosed with breast cancer in mid-2004. I had twolumpectomies and two months of radiation, and have beenfree and clear ever since (as of October 2010). I had verygood care in Marin County, CA.

I made some wonderful friends in my support group andbecame closer to many of the friends I already had. Besidesmy support group, I have about ten women friends whohave had breast cancer. I would never wish it on anyone asa life experience (I don’t believe that things like this happento teach us a lesson, but rather that we use what happensto us in a way that teaches us something), but I used it torecommit myself to the best health and the best appreciationof life and friendships that I can muster, which is pretty danggood. Every single day counts, as does every single person.

In the pink,Francine Falk-AllenSan Rafael, CA

The dance demonstrates the joy ofliving while increasing awarenessabout breast cancer.Paula Bishop, RN, MSN, CNORAultman HospitalCanal Fulton, OH

The closer we get to a cure! I lost asister and have a sister who is a survivorgoing on 10 years now! Very close tomy heart.Lynetta BaldwinAdvanced Surgical CareCreve Coeur, MO

A hospital works as a unified unit tocomplete its mission.Colleen Witt, RN BSNRoswell Park Cancer InstituteBuffalo, NY

A way to show support for breastcancer survivors.John Ratliff, BS, CST, FASTYork Technical CollegeRock Hill, SC

People getting involved to bringawareness to breast cancer.Darlene McCraney, RNSouth Central Regional Medical CenterLaurel, MS

It energizes you and makes you want tomove, especially when you see everyoneworking toward the same goals.Jerlene McClain, RN, BSN, MHR, CNORReynolds Army Community Hospital - Fort SillLawton, OK

10 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 January 2009Purpose: To help hospitals improve patient care by focusing on an essential set of processes needed to

achieve the highest levels of performance in areas that matter most to patients.

Hospitals sign up through IHI and can choose to implement some or all of the recommended interventions.IHI provides how-to guides and tools for all participating hospitals.

The IHI Improvement Map covers the entire landscape of outstanding hospital care to help hospitals make sense of countless requirementsand focus on high-leverage changes to transform care. There are 70 processes grouped into three domains: leadership and management,patient care and processes to support care.

Origin: Developed by Joint Commission staff and the Patient Safety Advisory Group(formerly the 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 Commission offersguidance to help organizations meet goal requirements.

Over the next year, the current National Patient Safety Goals (NPSGs) will undergo an extensive review process. As a result,no new NPSGs will be developed for 2011; however, revisions to the NPSGs will be effective in 2011.

Origin: Initiated in 2003 as a national partnership. Steering committee includes the followingorganizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and theJoint Commission

Purpose: To improve patient safety by reducing postoperative complicationsGoal: To reduce nationally by 25 percent the incidence of surgical complications by 2010

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

IHI Improvement Map1

Joint Commission 2011 National Patient Safety Goals2

Surgical Care Improvement Project (SCIP)3

IHI Improvement Map: 73 Processes to Transform Hospital Care

Surgical Care Improvement Project (SCIP): Target Areas

Joint Commission 2011 National Patient Safety Goals


Patient Safety

Effective January 1, 2011:• Improve the accuracy of patient identification.• Improve the effectiveness of communicationamong caregivers.

• Improve the safety of using medications.• Reduce the risk of healthcare-associatedinfections.

• Accurately and completely reconcile medicationsacross the continuum of care.

• The organization identifies safety risks inherent inits patient population.

• Universal Protocol for Preventing Wrong Site,Wrong Procedure, and Wrong Person Surgery.™

To learn more about National Patient Safety Goals, go to www.jointcommission.org.

The IHI Improvement Map is an online tool that distills the best knowledge available on the key processimprovements that lead to exceptional patient care.

To learn more about the IHI Improvement Map and the 73 processes to transform hospital care, go to www.ihi.org/imap/tool

1. Surgical infections• Antibiotics, blood sugar control, hair removal, perioperativetemperature management

• Remove urinary catheter on Post Operative Day (POD) 1 or 22. Perioperative cardiac events

• Use of perioperative beta-blockers3. Venous thromboembolism

• Use of appropriate prophylaxis

3 New Key Processes as of June 20101. Anticoagulation Management2. Essential Care for Frail Older Patients3. Glycemic Control in Non-Critically Ill Patients

Top 5 Key Processes Shared by Improvement Map Users1. Central Line Bundle2. CA-UTI3. Anti-Biotic Stewardship4. Falls Prevention5. Heart Failure Core Processes

Visit www.qualitynet.org

By the numbers:• 3,740 hospitals are submittingdata on SCIP measure #9, representing75 percent of all U.S. hospitals

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


APIC, CDC, Other Infection Control OrganizationsPledge to Eliminate HAIs1Action steps published in AJICA number of professional healthcare organizations,including the Association for Professionals in InfectionControl and Epidemiology (APIC), the Society for HealthcareEpidemiology of America (SHEA), the Infectious DiseasesSociety of America (IDSA), the Centers for Disease Controland Prevention (CDC) and others have joined together tomove toward the elimination of healthcare-associated infec-tions (HAIs). They announced their plan in a white paper,“Moving Toward Elimination of Healthcare-Associated Infec-tions: A Call to Action,” published in the November 2010 issueof the American Journal of Infection Control (AJIC).

The group proposes to eliminate healthcare-associatedinfections through a series of action steps, as outlined in thepaper:• Adherence to evidence-based practices• Aligning financial incentives• Innovation and research• Gathering data for action

New Hampshire Hospital Initiative Aims to EliminateHarm to Patients by 20152In a new effort to promote better and safer patient care, theNew Hampshire Hospital Association and Foundation forHealthy Communities recently began a new initiative to elim-inate harm to patients by 2015.

The definition of “harm,” according the New Hampshireinitiative, refers to an injury associated with medical care thatrequires or prolongs hospitalization and/or results in perma-nent disability or death.

A statewide steering committee will spearhead the NewHampshire Eliminate Harm Initiative and identify whichaspects of harm hospitals will target for elimination.

Death Rate Six Times Higher for Hospital Patientswith HAIs3Adults who developed health care-associated infections(HAIs) due to medical or surgical care while in the hospital in2007 had a death rate six times higher than patients withoutan HAI, according to the latest News and Numbers publishedby the Agency for Healthcare Research and Quality (AHRQ).

Patients with HAIs also had to stay in the hospital anaverage of 19 days longer. On average, the cost of a hospitalstay of an adult patient who developed an HAI was about$43,000 more expensive than the stay of a patient withoutan HAI. AHRQ also discovered that:• In 2007, about 45 percent of patients with HAIswere 65 or older, 33 percent were 45 to 64 and 22percent were 18 to 44.

• Patients in the 45 to 64 age group had the highestrate of HAIs.

• The top three diagnoses in hospitalized adult patientswho developed HAIs were septicemia (12 percent),adult respiratory failure (6 percent) and complicationsfrom surgical procedures or medical treatment(4 percent).

References1. Cardo D, Dennehy PH, Halverson P, Fishman N, Kohn M, Murphy CL, et al.Moving toward elimination of healthcare-associated infections: a call to action.American Journal of Infection Control. 2010;31(11):1101-1105. Available at:http://www.journals.uchicago.edu/doi/pdf/10.1086/656912. Accessed October25, 2010.

2. New Hampshire’s hospitals commit to eliminate harm [news release].Concord, NH: New Hampshire Hospital Association; September 27, 2010.www.nhha.org/WhatsNewFiles/EliminateHarm092710.pdf. Accessed October25, 2010.

3. Health care-associated infections greatly increase the length and cost ofhospital stays. Agency for Healthcare Research and Quality website. October2010 feature story. Available at: www.ahrq.gov/research/oct10/1010RA1.htm.Accessed October 25, 2010.

PATIENT SAFETY NEWSPATIENT SAFETY NEWS


Medline Industries, Inc. has signed an agreement with the JointCommission Center for Transforming Healthcare to contributefinancially to the Center’s Endowment Fund. The Center forTransforming Healthcare was developed to help solve health-care’s most critical safety and quality problems.

In this effort, Medline is joining other leading healthcareorganizations in their commitment to eliminate preventablecomplications and transform healthcare.

“Medline is proud to support and share in the mission of solvinghealthcare’s most critical safety and quality problems,” saidAndy Mills, president of Medline. “Medline’s approach is to‘Make it hard for the healthcare worker to do the wrong thing.’The Center is studying some of the most pressing issuesfacing providers, bringing together teams of experts to designand test practical solutions to healthcare’s everyday challenges.”

Issues the Center is working on include Hand Hygiene,Surgical Site Infections, Wrong Site Surgery and Hand-offCommunication.

Hospitals and Healthcare Systems Participating

in the Hand-Off Communication Project

• Exempla Lutheran Medical Center,

Wheat Ridge, Colorado

• Fairview Health Services, Minneapolis, Minnesota

• Intermountain Healthcare LDS Hospital,

Salt Lake City, Utah

• The Johns Hopkins Hospital, Baltimore, Maryland

• Kaiser Permanente Sunnyside Medical Center,

Clackamas, Oregon

• Mayo Clinic Saint Marys Hospital,

Rochester, Minnesota

• New York-Presbyterian Hospital, New York

• North Shore-LIJ Health System Steven and Alexandra

Cohen Children’s Medical Center, New Hyde Park,

New York

• Partners HealthCare, Massachusetts General

Hospital, Boston

• Stanford Hospital & Clinics, Palo Alto, California

Medline Partners with The JointCommission to Help SolveHealthcare Quality and Safety Issues

Ways to improve hand-off communicationHealthcare organizations have long struggled with errors andissues associated with passing along critical patient informationfrom one caregiver to the next, also known as hand-offcommunication.

The Center and participating hospitals set out to solve theseproblems and recently released some new solutions using theacronym SHARE.

Standardize critical content by providing details of the patient’shistory to the healthcare worker who will be taking over thepatient’s care, emphasizing key information about the patient.

Hardwire within your system, which includes developing stan-dardized forms, tools and methods, such as checklists to assistin making the hand-off successful.

Allow opportunity to ask questions and use critical thinkingskills when discussing a patient’s case as well as sharing andreceiving information as an interdisciplinary team.

Reinforce quality and measurement, which includes holdingstaff accountable, monitoring compliance with use of stan-dardized forms, and using data to determine a systematicapproach for improvement.

Educate and coach, which includes organizations teachingstaff what constitutes a successful hand-off and making suc-cessful hand-offs an organizational priority.


The heat is on in health care like never before. Error prevention,efficiency and cost containment have been top priorities for avery long time, but now, with the introduction of healthcare re-form, they are absolutely critical for survival, according to JointCommission President Mark Chassin, MD, MPP, MPH.

What to expect from healthcare reformDr. Chassin delivered the keynote address at Medline’s 3rdAnnual Prevention Above All Conference devoted to sharingnew strategies for delivering cost-effective, high-quality, evi-dence-based health care. An audience of more than 100 hos-pital CEOs, chief nursing officers and other executives attendedthe meeting August 16 and 17, 2010, in New York City.

“Today’s message is clear,” Dr. Chassin said. “Solve safety andquality problems. Don’t say you’re trying; just solve them. Takecare of 30-plus million more people in your organizations.Become or participate in an accountable care organization. Fig-ure out bundled payments. Adopt electronic medical recordsquickly. And one more thing. You can’t have any more money.”

Overall, Dr. Chassin explained, healthcare reform increasescoverage while experimenting with some new payment andcare delivery ideas. Reform will increase federal costs, and

there is only one vehicle for cost containment: limiting paymentto providers.

Dr. Chassin cautioned, “You will never be paid better than youare being paid now. This was true six months ago, it’s true now,and it will be true tomorrow and next week.”

So how do healthcare providers control costs and avoid majorpayment cuts and benefit reductions while also maintainingquality? Dr. Chassin outlined several keys to survival in today’sera of healthcare reform.

Employ a quality-driven strategy to eliminate overuse of healthservices. Examples include discontinuing wasteful practicessuch as prescribing antibiotics for colds and inducing laborearlier than 39 weeks.

“This is one part of health policy that has not received anyattention,” Dr. Chassin explained. “It’s been overlooked fordecades in the research community. We must come togetherto do this.” Two more keys to survival are eliminating the wasteinherent in needlessly complex care delivery processes andputting an end to preventable complications.

Strategies for Thriving in theNew Era of Healthcare Reform

Third Annual Prevention Above All Conference


Deborah Adler, Trent Haywood,Mark Chassin and Mikel Grayanswer questions from theaudience at the Third AnnualPrevention Above All Conferenceheld at the Hudson Theatre inNew York City.

Special Feature

A look into the futureSpeaking from his experience as CEO of New York City’s MountSinai Hospital, one of the nation’s largest and busiest hospitals,Wayne Keathley provided a firsthand look at what he predictswill be the norm for the average U.S. hospital amidst the newera of healthcare reform—having to do a lot more with a lot lessat average capacity levels of 95 percent.

“A fair number of you probably don’t recognize the kind of con-gestion, overcrowding and difficulties with flow that I’m aboutto describe,” Keathley said. “I would ask you to indulge in a lit-tle suspension of disbelief and assume for a minute that ashealth reform evolves, possibly because of a whole new groupof patients who will come to you for care … and more likelybecause the economics will require you to rethink capacity andthe way you manage it — that the situation I’m going todescribe for us, in fact has some meaning for you.”

Mount Sinai is operating at 95 percent capacity, and they arecurrently working with GE Healthcare to implement newsystems to accommodate this level of activity.

Keathley advocates improvement through fixing systems,not by adding more resources. For example, whereas hospi-tals often rely on intuition and personal judgment when man-aging patient flow and locating empty beds, Keathley suggeststhat studying capacity patterns and related data leads tomore efficient use of resources. He also encourages collabo-ration among departments, viewing the hospital as a wholerather than operating as individual silos.

“If money were no object, we would add more beds, add moreoperating rooms, hire more nurses, and we could driveoccupancy back down to the ideal 85 percent,” Keathleysaid. “But I am telling you, that fantasy doesn’t exist.”

Prevention Above AllAnother solution to meeting the challenges of healthcare reformlies in preventing costly medical errors and infections that areindeed preventable. Sue MacInnes, Medline’s Chief MarketingOfficer and host of the Prevention Above All Conference,reviewed Medline’s growing offering of preventive strategiesfor healthcare providers:

The Gold Standard Surgical Safety Program to help preventoperating room errors, the Hand Hygiene Compliance Pro-gram, the Pressure Ulcer Prevention Program, EducationalPackaging, the ClearCount Surgical System to help preventsponges from being left behind and the Catheter-Associated

Urinary Tract Infection (CAUTI) Foley Catheter ManagementSystem to help prevent CAUTIs.

These six strategies are targeted, focused and achievable evi-dence-based solutions that are also practical. They fit witheveryday processes and systems currently in place at mosthealthcare facilities.

MacInnes emphasized, “Sometimes the simplest solutionsmake the biggest difference.”

Left: Keynote speakerJoint Commission PresidentMark Chassin, MD, MPP, MPH.

Above (left to right): MedlinePresident Andy Mills, DeborahAdler, Medline Chief MarketingOfficer, Sue MacInnes, RD, LD,Atul Gawande, MD, MPH,Medline COO Jim Abrams.

Right: The Third AnnualPrevention Above All Conferencetook place at the historic HudsonTheatre in New York City.


Caroline Fife, MD and Kevin W. Yankowsky, JDLawsuits, Technology and Wound Care: How ElectronicHealth Records Change Your Legal Risks“Any time a lawsuit is filed, you and your facility and yourpractitioners lose. The only question is the questionof degree ... I would suggest and recommend that youtake a moment to focus on how, in addition to improvingyour clinical care, you can take steps to absolutely mini-mize your risk of ever being involved in the legal system; ofever being sued in the first place.” - Kevin W. Yankowsky

Trent T. Haywood, MD, JDSocial Practice: Observationfor Understanding and Improving“One of the key things people have taught us in anythingthat has to do with practice improvement is not really whatyou don’t know; it’s what you think you know that ain’t so.”

Dale Bratzler, DO, MPHHealthcare-Associated Infectionsand Public Accountability“Clearly, if there is a single practice that we can do betterthat will dramatically reduce healthcare-associated infec-tions, it would be hand hygiene.”

Mikel Gray, PhD, FNP, CUNP, CCCN, FAANP, FAANEvolution of Evidence: New Modelsfor Demonstrating Effectiveness“Insufficient evidence remains the primary challengeof evidence-based practice; demystification of theresearch process is urgently needed.”

Atul Gawande, MD, MPHAuthor, The Checklist Manifesto“What we have today, though, is a volume and complex-ity of medical discovery that has now exceeded our abilityas individual specialized artisans to be able to deliver thatcare to the right person, the right way, at the right timewithout waste of resources.”

For video clips of the speakers’ presentations fromthe 3rd Annual Prevention Above All Conference,visit www.medline.com/media-room. Or contactyour Medline representative for a free set of DVDs.

What the Experts Are Saying ...

Fife Yankowsky

Haywood Bratzler

Gray Gawande


Continued on page 19

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Practicing Advanced MedicineWithin Outdated Systems

Atul Gawande, MD, a Harvard professor and author of severalbooks, including his most recent, The Checklist Manifesto,addressed the challenges of delivering highly advanced medicalcare within outdated systems.

He pointed out that we’ve entered a complex medical world inwhich we have 13,600 different diagnoses, 6,000 prescriptionmedications and more than 4,000 medical and surgicalprocedures.

Compounding matters, we’ve inherited a structure from 50years ago that didn’t have nearly so many diagnoses, drugsand procedures. At that time, the doctor was considered anartisan, and all you really needed was the physician’s brain,along with an operating room, a few simple tools and someskills behind that.

“What we have today, though, is a volume and complexity ofmedical discovery that has now exceeded our ability asindividual specialized artisans to be able to deliver that care tothe right person, the right way, at the right time without wasteof resources,” Dr. Gawande said.

The Checklist Manifesto: How to Get Things RightAtul Gawande, MD, MPH

We live in a world of great andincreasing complexity, where eventhe most expert professionals strug-gle to master the tasks they face.Longer training, ever more advancedtechnologies— neither seems to pre-vent grievous errors. But in a hopefulturn, acclaimed surgeon and writerAtul Gawande finds a remedy in thehumblest and simplest of techniques:the checklist.

AORN: Spreading knowledge,preventing complications

AORN Executive Director LindaK. Groah, RN, MSN, CNOR,NEA-BC, FAAN, began her pres-entation with these statistics: theaverage department of surgery isresponsible for 40 to 60 percentof expenses, 70 percent of rev-enue and 50 percent of errors.

To help reduce surgical errors, the Association of peri-Operative Nurses (AORN) promotes safe surgical prac-tices and optimal patient outcomes by educatingperioperative nurses and partnering with other profes-sional and governmental healthcare organizations.

AORN collaborates on patient safety initiatives with anumber of major healthcare organizations, includingthe Centers for Medicare & Medicaid Services (CMS),the Surgical Care Improvement Project (SCIP), theWorld Health Organization (WHO), the Joint Commis-sion, IPPS, Blue Cross and others. In fact, AORNworked closely with the WHO and Dr. Atul Gawandeto ensure the perioperative nurse’s role was incorpo-rated into the Surgical Safety Checklist.

As a leader in the perioperative arena, AORN has alsodeveloped a number of its own initiatives for practicalapplication in the OR. Some of these include Periop-erative Standards and Recommended Practices, acomplete perioperative curriculum and various toolkits.

“The Perioperative Standards really are the core ofAORN,” Groah said. “They represent the intellectualproperty of AORN.” Groah also emphasized that hun-dreds of hospitals and surgery centers across thecountry look to the Perioperative Standards as thego-to guide for evidence-based surgical practices.New and revised standards go through up to threerounds of revisions based on input from surgical pro-fessionals and the general public.

To learn more about AORN, including group and indi-vidual membership, visit www.aorn.org.

Aligning practice with policy to improve patient care 19Aligning practice with policy to improve patient care 19

Conversation with Dr. Peter J. Pronovost

Doctor Leads Quest for SaferWays to Care for Patients

by Claudia Dreifus

Dr. Peter J. Pronovost, 45, is medical director of the Qualityand Safety Research Group at Johns Hopkins Hospital inBaltimore, which means he leads that institution’s quest forsafer ways to care for its patients. He also travels the country,advising hospitals on innovative safety measures. The HudsonStreet Press has just released his book, “Safe Patients, SmartHospitals: How One Doctor’s Checklist Can Help Us ChangeHealth Care from the Inside Out,” written with Eric Vohr. Anedited version of a two-hour conversation follows.

What got you started on your crusadefor hospital safety?My father died at age 50 of cancer. He had lymphoma. Buthe was diagnosed with leukemia. When I was a first-yearmedical student here at Johns Hopkins, I took him to oneof our experts for a second opinion. The specialist said, “Ifyou would have come earlier, you would have been eli-gible for a bone marrow transplant, but the cancer is tooadvanced now.” The word “error” was never spoken. But itwas crystal clear. I was devastated. I was angry at theclinicians and myself. I kept thinking, “Medicine has to dobetter than this.”

A few years later, when I was a physician and after I’d donean additional Ph.D. on hospital safety, I met Sorrel King,whose 18-month-old daughter, Josie, had died at Hopkinsfrom infection and dehydration after a catheter insertion.

The mother and the nurses had recognized that the littlegirl was in trouble. But some of the doctors charged withher care wouldn’t listen. So you had a child die of dehy-dration, a third world disease, at one of the best hospitalsin the world. Many people here were quite anguished aboutit. And the soul-searching that followed made it possiblefor me to do new safety research and push for changes.


Patient Safety


What exactly was wrong here?As at many hospitals, we had dysfunctional teamworkbecause of an exceedingly hierarchal culture. When con-frontations occurred, the problem was rarely framed interms of what was best for the patient. It was: “I’m right. I’mmore senior than you. Don’t tell me what to do.” With thething that Josie King died from — an infection after acatheter insertion, our rates were sky high: about 11 per1,000, which, at the time, put us in the worst 10 percent inthe country.

Catheters are inserted into the veins near the heart beforemajor surgery, in the I.C.U., for chemotherapy and for dial-ysis. The C.D.C. estimates that 31,000 people a year diefrom bloodstream infections contracted at hospitals thisway. So I thought, “This can be stopped. Hospital infec-tions aren’t like a disease there’s no cure for.” I thought,“Let’s try a checklist that standardizes what clinicians dobefore catheterization.” It seemed to me that if you lookedfor the most important safety measures and found someway to make them routine, it could change the picture. Thechecklist we developed was simple: wash your hands,clean your skin with chlorhexidine, try to avoid placingcatheters in the groin, if you can, cover the patient andyourself while inserting the catheter, keep a sterile field, andask yourself every day if the benefits of catheterizationexceed the risks.

Wash your hands? Don’t doctorsautomatically do that?National estimates are that we wash our hands 30 to 40percent of the time. Hospitals working on improving theirsafety records are up to 70 percent. Still, that means that30 percent of the time, people are not doing it.

At Hopkins, we tested the checklist idea in the surgicalintensive care unit. It helped, though you still needed to domore to lower the infection rate. You needed to make surethat supplies — disinfectant, drapery, catheters — werenear and handy. We observed that these items were storedin eight different places within the hospital, and that waswhy, in emergencies, people often skipped steps. So wegathered all the necessary materials and placed themtogether on an accessible cart. We assigned someone tobe in charge of the cart and to always make sure it wasstocked. We also instituted independent safeguards tomake certain that the checklist was followed.

We said: “Doctors, we know you’re busy and sometimesforget to wash your hands. So nurses, you are to makesure the doctors do it. And if they don’t, you are empow-ered to stop takeoff on a procedure.”

How did that fly?You would have thought I started World War III! The nursessaid it wasn’t their job to monitor doctors; the doctorssaid no nurse was going to stop takeoff. I said: “Doctors,we know we’re not perfect, and we can forget importantsafety measures. And nurses, how could you permit a doc-tor to start if they haven’t washed their hands?” I told thenurses they could page me day or night, and I’d supportthem. Well, in four years’ time, we’ve gotten infection ratesdown to almost zero in the I.C.U.

We then took this to 100 intensive care units at 70 hospitalsin Michigan. We measured their infection rates, imple-mented the checklist, worked to get a more cooperativeculture so that nurses could speak up. And again, we gotit down to a near zero. We’ve been encouraging hospitalsaround the country to set up similar checklist systems.


In your book, you maintain that hospitals canreduce their error rates by empowering theirnurses. Why?Because in every hospital in America, patients diebecause of hierarchy. The way doctors are trained, theexperiential domain is seen as threatening and unimportant.Yet, a nurse or a family member may be with a patient for12 hours in a day, while a doctor might only pop in for fiveminutes.

When I began working on this, I looked at the liability claimsof events that could have killed a patient or that did, at severalhospitals — including Hopkins. I asked, “In how many ofthese sentinel events did someone know something waswrong and didn’t speak up, or spoke up and wasn’t heard?”

Even I, a doctor, I’ve experienced this. Once, during a sur-gery, I was administering anesthesia and I could see thepatient was developing the classic signs of a life threateningallergic reaction. I said to the surgeon, “I think this is a latexallergy, please go change your gloves.” “It’s not!” heinsisted, refusing. So I said, “Help me understand howyou’re seeing this. If I’m wrong, all I am is wrong. But ifyou’re wrong, you’ll kill the patient.” All communicationbroke down. I couldn’t let the patient die because thesurgeon and I weren’t connecting.

So I asked the scrub nurse to phone the dean of the med-ical school, who I knew would back me up. As she wasabout to call, the surgeon cursed me and finally pulled offthe latex gloves.

What can consumers do to protectthemselves against hospital errors?I’d say that a patient should ask, “What is the hospital’s in-fection rate?” And if that number is high or the hospital saysthey don’t know it, you should run. In any case, you shouldalso ask if they use a checklist system.

Once you’re an in-patient, ask: “Do I really need thiscatheter? Am I getting enough benefit to exceed the risk?”With anyone who touches you, ask, “Did you wash yourhands?” It sounds silly. But you have to be your ownadvocate.

From The New York Times, © March 8, 2010 The New York Times.All rights reserved. Used by permission and protected by the CopyrightLaws of the United States. The printing, copying, redistribution, orretransmission of the Material without express written permissionis prohibited.

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Yes! Checklists do save lives

It’s been more than a decade since the Institute of Medicine (IOM) issued itsgroundbreaking report, To Err is Human, outlining the poor state of patient safety in the UnitedStates. And yet, progress toward reducing healthcare errors over the past ten years has been“frustratingly slow,” say the authors of the report.1 Patients continue to die at a rate of 99,000per year due to hospital-acquired infections alone, according to the latest estimate from theCenters for Disease Control and Prevention.1

Needless to say, healthcare professionals have a longway to go toward improving patient safety. There are,however, glimmers of hope, one of which comes in theform of a checklist.

A checklist for the ICUBuried on page 171 of the thick To Err is Human reportis one sentence recommending that healthcare organi-zations use checklists as a way to prevent errors byavoiding reliance on memory.2 But it was not until 2006,with the published results of a study headed by nowrenowned patient safety advocate Peter Pronovost, MD,PhD, that the healthcare checklist came to the forefrontas a proven way to prevent errors and save lives.3

Dr. Pronovost, a practicing anesthesiologist and criticalcare physician at Johns Hopkins in Baltimore, craftedhis first checklist by listing on paper the steps necessaryto avoid catheter-related bloodstream infections (CR-BSIs).4 The steps were nothing new; just things thatclinicians may not remember to do every time they placea new central line. He and fellow researchers thenrefined the list, making sure the steps corresponded withitems from the CDC guidelines for preventing CR-BSIs.5

Dr. Pronovost introduced the checklist at Johns Hop-kins Hospital, asking staff to run through it each timethey inserted a line. The central line infection rate soondecreased from 11 percent to zero.4

Next, Dr. Pronovost implemented the ICU checklist andother related safety interventions at 103 hospitals acrossMichigan, resulting in a 66 percent reduction in CR-BSIs.6 In the first 15 months of the study, known as theKeystone Initiative, the checklist is estimated to havesaved 1,500 lives and $175 million in costs.4

The ICU checklist is simple; as experts recommendhealthcare checklists should be. It requires clinicians toemploy the following evidence-based practices whenplacing central venous catheters: hand washing, usingfull-barrier precautions during the insertion of thecatheter, cleaning the patient’s skin with chlorhexidine,avoiding the femoral site, if possible, and removingunnecessary catheters.6 To download a sample copy ofDr. Pronovost’s ICU checklist, go to www.ihi.org/IHI/Pro-grams/IHIOpenSchool/OnCallPeterPronovostCheck-lists.htm.

Checking it Twice


Patient Safety

Reference1 Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces urinary catheterization in

hospitalized patients. Jt Comm J Quality Patient Saf. 2005; 31(8): 455-4622 Patient Safety Quality Measures for the Surgical Care Improvement Project (SCIP). Health Services Advisory Group.

Available at: http://qualitymeasures.ahrq.gov/content.aspx?f=rss&id=16275. Accessed December 7, 2010.3 Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. Centers for Disease Control and Prevention.

Available at: http://www.cdc.gov/hicpac/cauti/001_cauti.html. Accessed December 7, 2010.

©2010 Medline Industries, Inc. Medline is a registered trademark and InserTag is a trademark of Medline Industries, Inc.

Despite SCIP Measure #9 recommending removal ofurinary catheters in surgical patients by postoperative dayone or two,1 and CDC guidelines advising prompt removalof catheters,2 74 percent of hospitals do not keep track ofhow long patients have catheters in place.3

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Four Esfor implementing a healthcare checklist5

Patient safety advocate Peter Pronovost, MD PhD,offers the following four steps to remember whenimplementing a safety checklist at your own facility:

1. Engage staff and physicians with stories andbaseline performance.

2. Educate staff and physicians explicitly on whatneeds to be done to carry out the checklist; walk

through the checklist a few times to identify

any glitches

3. Execute the checklist, making sure everyone iscommitted to following it.

4. Evaluate how it’s working by analyzing

collected data.

He also recommends determining in advance the prod-ucts and equipment needed to carry out the items onthe checklist, making sure allsupplies are close at hand whenclinicians go to implement thechecklist.

For more tips, read Safe Patients,Smart Hospitals: How One Doc-tor’s Checklist Can Help UsChange Health Care from theInside Out by Peter Pronovostand Eric Vohr.

Checklists for safer surgeryNot long after the Keystone Initiative study came out,the World Health Organization (WHO) Surgical SafetyChecklist gained recognition in 2009 with a study pub-lished in the New England Journal of Medicine describ-ing how use of the checklist helped reduce patientmorbidity and complications.7

TheWHO Surgical Safety Checklist was used at hospitalsaround the world, resulting in a reduction in complicationrates from 11 percent to 7 percent. Death rates droppedfrom 1.5 percent to 0.8 percent.7

For a copy of the WHO Surgical Safety Checklist andtips on how to use it, visit www.safesurg.org.

Another study, just published in October 2010 in theJournal of the American Medical Association (JAMA),showed an 18 percent reduction in surgery deaths overthree years at 74 Veterans Affairs hospitals that used asurgery checklist.8,9

The Surgical Care and Outcomes Assessment Program(SCOAP), has developed a surgical safety checklist aswell, which is being used by most hospitals and somefreestanding surgery centers in the state of Washington.SCOAP links hospitals and surgeons with clinicians fromacross Washington to increase the use of best practicesin surgical care. The organization’s goal is to provide thekind of surveillance of procedures and response to neg-ative outcomes that exists in the world of aviation.10

To access a copy of the SCOAP Surgical Checklist,including a version specifically for ambulatory surgerycenters, go to www.scoap.org/checklist. Copies of theSCOAP Surgical Checklists are also included in theForms & Tools section of this issue.

Checklist success requires teamworkBoth Dr. Pronovost and Atul Gawande, MD, whoco-authored the paper on the WHO Surgical SafetyChecklist, agree that in order to work, checklists mustbe studied carefully in advance, and then implementedwisely.11 And, although checklists are helpful, they areonly one part of the equation for improving patientsafety. Before a checklist can be useful, healthcareteams must improve communication and change theway they work together.12

Dr. Pronovost wrote, “Until a junior nurse can correct asenior physician who forgot to use the checklist, untilthat conversation goes well, we will continue to harmpatients. In most U.S. hospitals, that conversation doesnot go well.”12 In fact, in the OR, the lowest perceptionsof teamwork are reported by nurses with surgeons.13

Have a serious discussion with physicians and nurses,Dr. Pronovost recommends. Instruct nurses to speak up


if a doctor misses a step on the checklist. Explain to thedoctor that it is not about hierarchy or second guess-ing. It’s about the obligation to make sure every patientall the time receives evidence-based interventions.5

Dr. Pronovost also remarked that if any link in the chainof accountability is not intact, the checklist will not beeffective. He said it is the hospital’s senior leadershipthat is ultimately responsible for getting and keepingstaff on board.14

According to Dr. Pronovost, “To reach our ultimate goal– making patients safer – we must engage teams toembrace the concepts behind checklists and becomefull partners in developing and improving this lifesavingtool. And, we must measure our results to make surethat every patient always gets the care they deserve.”12

References1. O’Reilly KB. Patient safety improving slightly, 10 years after IOM report on errors.

American Medical Association. amednews.com. December 28, 2009. Available atwww.ama-assn.org/amednews/2009/12/28/prsb1228.htm. Accessed November 1, 2010.

2. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Eds. To Err Is Human:Building a Safer Health System. Washington, DC: National Academy Press; 2000.Available at: www.nap.edu/openbook.php?isbn=0309068371. Accessed October29, 2010.

3. Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Affairs.2010;29(1). Available at: http://hospitalmedicine.ucsf.edu/downloads/patient_safety-_at_ten.pdf. Accessed November 1, 2010.

4. Laurance J. Peter Pronovost: champion of checklists in critical care. The Lancet.2009;374(9688).

5. Pronovost P. On Call: How a Simple Checklist Can Dramatically Reduce Medical Errors[audio]. Institute for Healthcare Improvement (IHI) website. Recorded November 3,2008. Available at: www.ihi.org/IHI/Programs/IHIOpenSchool/OnCallPeter-PronovostChecklists.htm. Accessed November 2, 2010.

6. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. Anintervention to decrease catheter-related bloodstream infections in the ICU. The NewEngland Journal of Medicine. 2006;355(26):2725-2732. Available at:www.nejm.org/doi/pdf/10.1056/NEJMoa061115. Accessed November 1, 2010.

7. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS, Delliner EP, et al. A surgicalsafety checklist to reduce morbidity and mortality in a global population. The NewEngland Journal of Medicine. 2009;360(5):491-499.

8. Tanner L. Big U.S. study shows surgery checklist saves lives. ABC-2 News Baltimorewebsite. Posted October 21, 2010. Available at: www.abc2news.com/dpp/news/health-/USMEDSurgery-Checklist_9727648034-wews1287662508003. Accessed November3, 2010.

9. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, et al. Association betweenimplementation of a medical team training program and surgical mortality. Journal of theAmerican Medical Association. 2010;304(15).

10. SCOAP Surgical Checklist Initiative. Surgical Care and Outcomes AssessmentProgram website. Available at http://www.scoap.org/checklist. Accessed October22, 2010.

11. Szalavitz M. Study: a simple surgery checklist saves lives. Time. January 14, 2009.Available at: http://www.time.com/time/health/article/0,8599,1871759,00.html.Accessed October 22, 2010.

12. Pronovost P. Checklists alone won’t change health care: the full story. Huffington Post.February 23, 2010. Available at: http://www.huffingtonpost.com/peter-pronovost-md-phd/checklists-alone-wont-cha_b_473396.html. Accessed November 1, 2010.

13. Carney BT, West P, Neily J, Mills PD, Bagian JP. Differences in nurse and surgeonperceptions of teamwork: implications for use of a briefing checklist in the OR.AORN Journal. 2010;91(6):722-729.

14. Aizenman NC. Hospital infection deaths caused by ignorance and neglect, surveyfinds. The Washington Post. July 13, 2010. Available at: www.washingtonpost.com-/wp-dyn/content/article/2010/07/12/AR2010071204893.html. Accessed October21, 2010.

1. Assess your organization’s safety culture. A widelyused survey developed by the Agency for Healthcare Research and Quality (AHRQ) is available atwww.ahrq.gov/qual/patientsafetyculture.

2. Understand the science of improvement andreliability. Strive to be a high reliability organization.

3. Foster transparency.4. Create a formal, written leadership promise that

outlines the steps you personally will take to attainand maintain patient safety at your facility.

5. Engage physicians in your organization’ssafety efforts.

6. Develop hiring and credentialing processesgrounded in selecting candidates with a desire toserve, good communication skills, an eagernessto work in teams, a commitment to excellence andan appreciation for feedback.

7. Involve board members in the safety journey.

+ 1 Another helpful tool for fostering a safety culture atyour organization is the Comprehensive Unit-BasedSafety Program (CUSP) developed at Johns HopkinsHospital by Dr. Pronovost and his team. For details, visitwww.patientsafetygroup.org/program/index.cfm.

Adapted from Rupp W, Bonacum D, Frush K, Balik B, Haraden C. The role ofleadership. In: Frankel A, Leonard M, Simmonds T, Haraden C, Vega KB, eds.The Essential Guide for Patient Safety Officers. Oakbrook Terrace, IL: JointCommission Resources; 2009:1-10.

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Patient,HealThyselfAfter shorter hospital stays,doctors raise demandsand time for recovery

By Laura Landro


Special Feature


But recovery was another matter. He needed the crutchesfor three weeks, had 12 weeks of physical therapy threetimes a week, then six weeks of exercises at home. Herented a strap-on ice compression device to reduceswelling, and wore a brace for about five weeks. Thoughfully healed now, being responsible for so much of his ownrehabilitation, he says, “was like taking a new baby homefor the first time—you don’t really feel like you’re licensedto do it.”

Surgery is easier and faster than ever before: Nearly 65%of all surgeries don’t require an overnight hospital stay,compared to 16% in 1980. Hospitals that once keptpatients for three weeks after some major operations nowdischarge them within a matter of days. But the body stillheals at its own pace, and reduced time in hospital caremeans patients are assuming more responsibility for theirown recovery—and more risks. Patients not only have toperform rehabilitation regimens at home, but they are moreoften caring for their own incision wounds and dressingsand having to watch for signs of infections and blood clots.They also may be managing drains, implanted IV ports andpumps, all of which can be difficult and stressful.

The move to speedier surgeries is largely the result of newminimally invasive techniques, improvements in anesthesiaand cost-cutting by insurance companies and hospitals.Surgical procedures now often use smaller incisions, cutless muscle, and result in less blood loss. Newer anes-thetics allow patients to regain consciousness quickly ornot go to sleep at all. Pain medications are more effective.

At the same time, concern about rising health care costshas led to changes in Medicare and insurance plans thathave encouraged the development of outpatient surgicalcenters and created financial incentives for hospitals toshift less complex surgery to their own outpatient facilities.So, many types of surgeries previously performed in hos-pitals with overnight stays are now being done on an out-patient basis: The number of freestanding surgery centersgrew from about 240 in 1983 to more than 5,000 now.

The mean charge for outpatient surgery was $6,100 ver-sus $39,000 for inpatient surgery in 2007, according tothe most recent report on surgical costs from the federalgovernment. Insurance companies are also less likely topay for stays at rehabilitation centers, places where surgi-cal patients were often sent after hospital discharge torecuperate.

With patients going home so quickly, more are having tograpple with complications on their own. Of all the com-plications that occur in the 30 days after surgery, such asinfection and blood clots, almost half will surface after apatient leaves the hospital, according to data from one mil-lion patients in a surgical quality improvement programsponsored by the American College of Surgeons.

“The onus is really on patients to recognize if something isa problem,” says Clifford Ko, a colorectal surgeon at theUniversity of California, Los Angeles, and director ofresearch and optimal patient care for the American Collegeof Surgeons. “The recovery period is often as important asthe procedure itself, and patients who don’t follow theirdischarge instructions could have longer recovery times,greater risk of a complication, and potentially more pain.”

The Long Road to RecoveryWhile most surgeries now require much shorter hospitalstays than in years past, patients often face weeks ormonths of recovery on their own. The picture for somecommon procedures: Knee surgery patients, for example,are counseled to maintain their weight after surgery. But arecent study shows that most patients gain weight, whichcan jeopardize the health of the other knee. Depression,

For Michael Noonan, knee surgery in April was practically a breeze —an outpatient procedure that had the 41-year-old investment banker hobblinghome on crutches in a matter of hours after surgeon David Altchek replacedhis anterior cruciate ligament using small incisions.


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another common after-surgery occurrence, also caninhibit healing, if patients don’t seek treatment.

Efforts are underway to improve follow-up for patients, par-ticularly those who have surgery in doctor’s offices, whichdon’t have the same regulation as outpatient surgery cen-ters. The Institute for Safety in Office-Based Surgery hasdeveloped a checklist that includes assuring that dischargeinstructions are provided and a plan for follow-up care isclear. “Patients need to be asked things like if there is red-ness at the incision site, do you know what to do?” saysFred Shapiro, a Harvard anesthesiologist and president ofthe group. (Redness at an incision site can be a sign ofinfection.)

Infections that can occur after any surgery can lead to asevere bloodstream infection that can be fatal. A studypublished in July in the Journal of Hospital Infection of84,000 patients who developed a surgical site infectionfound that more than half occurred after discharge,increasing the risks of an emergency room visit, readmis-sion to the hospital, and another surgery.

For months after a procedure, surgical patients are also athigh risk of developing blood clots which can travel to thelung and cause death from a pulmonary embolism. Afterjoint replacement, for example, though the risk is greatestwithin two to five days, a second peak development periodoccurs about 10 days after surgery when most patientshave been discharged from the hospital. In knee surgerypatients, a clot can form in the calf if the patient fails to

elevate the leg and perform specific movement exercises.Blood clots and subsequent pulmonary embolisms remainthe most common cause for emergency readmission anddeath following joint replacement, according to the Ameri-can Academy of Orthopaedic Surgeons.

The American Academy of Orthopaedic Surgeons spon-sors workshops to teach its members better communica-tions skills to help patients understand procedures and tostress the importance of follow-up care, such as providingclear written instructions and monitoring patients after sur-gery. “We can have a perfect total knee replacement butthen have a poor outcome if we don’t convince surgeonsthat explaining the post-operative care is in everyone’s bestinterest,” says John Tongue, a Portland, Ore.-area ortho-pedic surgeon and clinical associate professor at OregonHealth & Science University who teaches the workshops.Insurers have become stricter about paying for inpatientrehabilitation programs where surgical patients were oncetransferred to recover. The move has been spurred partlyby studies that show that cheaper at-home visits from ther-apists are effective.

But Nina Reznick, a 63-year old patient who had both hipsreplaced last July, says the home therapist her insurancepaid for did not have the equipment or time to really help,so she did extra exercises on her own. She believes thateffort enabled her to walk a week after surgery. “You arereally on your own, and you have to be very motivated,”she says.

84,000 patients who developed a surgical site infection found that more than half occurred after discharge


Blood clots and subsequent pulmonary embolismsremain the most common cause for emergency readmission and death following joint replacement.

Some doctors say that the changing demographics of theirpatients also can contribute to bumpy recoveries. Dr.Altchek, who performs knee and rotator cuff surgery at theHospital for Special Surgery in New York, says that moreyounger patients are opting to replace troublesome kneesand hips so they can resume athletic activities such as ten-nis and skiing; close to 42% of all knee replacements in2008 were for patients aged 45 to 65, compared to lessthan 35% in 2002, and studies show that waiting too longonce a joint starts to deteriorate before having surgery canmake recovery more difficult.

But younger patients may also be impatient and assumethey are healed, and then quit rehabilitation too early, Dr.Altchek says.

Andrew Minko, a 41-year-old patient of Dr. Altchek’s whoplays tennis and surfs, has had two surgeries to repairjoints on his left shoulder and now needs surgery on hisright shoulder. Though he healed well, he admits he wassomewhat lax about doing his exercises at home and mayhave rushed into some activities too quickly after theprevious procedures. For the upcoming surgery, he says,“I will be more diligent about the recovery.”

Write to Laura Landro at [email protected]

Reprinted by permission of The Wall Street Journal, Copyright © 2010 Dow Jones & Company, Inc. All Rights Reserved Worldwide. License number 2537291131129

To download a new guide to help patients take care of themselves at home, visit www.ahrq.gov/qual/goinghomeguide.htm. “Taking Care of Myself: A Guide for When I Leave the Hospital” is published by the Agency for Healthcare Research and Quality (AHRQ).

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THE NEW SHAPE OF SURGERY

DASH® in use gently retracting the small intestine while absorbing fluid


Preventing sharps injury in the OR

by Mary Ann Alexander-Magalee, MSN, RN, CNOR-BC

Nearly 30% of the estimated 385,000 needle sticks andother sharps-related injuries that occur each year happenin the OR.1 The CDC’s recommended work practices thatcan help ensure safety can be simplified into three points:Be prepared, be aware, and dispose with care.1 This arti-cle describes what you can do to protect yourself fromsharps injury.

Studies indicate that 6% to 16% of all percutaneousinjuries for scrubbed personnel are self-inflicted duringhand-to-hand passing of suture needles, with the non-dominant hand being the most injured body part.2 Thisoften occurs during the loading or repositioning of sutureneedles, loading or removing scalpel blades, suturing, tyingsutures with the needle attached, and immediately beforeor after the sharp has been used and remains unattendedon the operative field.2

For nonscrubbed personnel, the greatest risk of injury isduring hand-off of used sharps or disposal of sharps.

Healthcare organizations and their employees are respon-sible for actively participating in strategies to reduce per-cutaneous injuries. Wear personal protective equipmentwhen indicated. Use needless systems or sharps with

injury protection devices, and use a one-handed recap-ping technique, if no other alternatives exist.

The Occupational Safety and Health Administrationrequires healthcare organizations to protect their workersand have a written exposure control plan.3 Facilities mustalso observe local, state, and federal regulations on injuryprevention.

Common strategies for sharps injury prevention during aprocedure include:• Double gloving and monitoring gloves for punctures.2

• Encouraging neutral or hands-free technique for passing sharp items.2

• Giving verbal notification when passing a sharp item.• Loading suture needles using the suture packet to help mount the needle in the needle holder.

• Using the appropriate instrument to help adjust or unload the needle.

• Removing the needle before tying the suture, or usingcontrol-release sutures.

• Activating the safety feature of a safety-engineered device immediately after use.2

• Using another available instrument or a magnet to pickup a sharp item that’s fallen on the floor. Discard thesharp immediately.

Preventing sharps injury in the OR


Aligning practice with policy to improve patient care 37After the procedure, follow these strategies:• Transport sharps in a closed, secure container and place them in an approved, puncture-resistant container large enough to accommodate the entire device.

• Don’t put your hands or fingers into the container to dispose of a device.1

• Keep your hands behind the sharp tip when disposing of the device.

In addition to common strategies, using safety scalpels isrecommended, as scalpels are the second most frequentmechanism of percutaneous injuries (suture needlesare first).2

If you experience a needle-stick injury, follow your facility’spolicy for postexposure management and report the injuryimmediately. Maintaining a sharps-injury log is anotherintervention that identifies the number of employees injuredas well as the products and circumstances of the injury.4

About the authorMary Ann Alexander-Magalee, MSN, RN, CNOR-BC, is aprofessor of nursing at Valencia Community College in Orlando,Fla., and a board-certified nurse informatist.

References1.CDC Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program. 2008. http://www.cdc.gov/sharpsafety/resources.html.

2.AORN. Guidance statement: Sharps injury prevention in the perioperative setting. Perioperative Standards and Recommended Practices. Denver, CO: AORN; 2010:697-702.

3.OSHA. Regulations (Standards-29 CFR) Bloodborne pathogens 1910.1030. http://wwwloshalgov/pls/oshaweb/owadisp.show_document?p_table=STAN-DARDS&p_id=10051.

4.Taylor DL. Bloodborne pathogen exposure in the OR—what research has taught us and where we need to go. AORN J. 2006;83(4):834-848.

Printed with permission. Mary Alexander-Magalee, Preventing sharps injury in the OR,OR Nurse 2010, September 2010, p. 56.

Be prepared. Be aware. Dispose with care.Points of Sharps Safety3

OR Issues

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• Legal Implications of Pressure Ulcers

• Safe Medication Practices in the Perioperative Practice Setting

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WHY THE UNIVERSALPROTOCOL HASN’T ERADICATED PATIENT

HARM

...AND THE THREETHINGS YOU MUST DO ABOUT IT

By Steve Harden

According to a recent report in the Archives of Surgery, patientsundergoing surgery still risk being victims of stunning medical mis-takes including procedures done on the wrong surgical site andundergoing surgery intended for another patient.

To try to curb the rate of surgical errors, the Joint Commission in2004 introduced a Universal Protocol for all hospitals, ambulatorycare facilities, and office-based surgical facilities to follow. How-ever, even though these steps have largely been adopted, errorscontinue to happen.

The study’s author, Dr. Philip F. Stahel, a visiting associate profes-sor at the University of Colorado School of Medicine in Denver, hadthis to say about the research: “What is shocking about the datais that each and every one of those wrong-site, wrong-patienterrors is really an event that should never happen. These happenmuch more frequently than we think.”

“This is just the tip of the iceberg,” he said, “introducing the Uni-versal Protocol has not reduced the frequency of these events.”

During the research done in Colorado, doctors reported 27,370adverse events that happened between January 2002 and June2008. Among these, the researchers identified 25 wrong-patientand 107 wrong-site operations. The report cites the reasons forthese mistakes.

Patient Safety


Not surprisingly, 100 percent had poor communication as aroot cause.

And 72 percent were due to not performing a “Time Out” asrequired by the Universal Protocol.

At LifeWings, we’ve helped almost 100 organizations create andimplement a successful Time Out process that really does elim-inate patient harm. From that experience, here are three thingsyou can do to fix these problems with your Universal Protocol.

1. Make sure your physicians lead the Time Out. In aviation, the captain of the aircraft always “calls” for the checklist at the appropriate time. The captain has the responsibility to start the checklist and to make sure that it is accomplishedcorrectly and in its entirety. Once the checklist is started, he can delegate portions of the checklist to others, but the captain has the ultimate and final responsibility to lead the checklist process.

2. To cure communication failures during the Universal Protocol,give as many folks as possible a “speaking part” in your TimeOut process. Knowing that they have a speaking part and will have to verbally respond to a checklist item creates mindfulness, focus on the process and participation. No one wants to be the person not prepared and gumming up the works.

3. Make sure your Time Out is a true “challenge and response”checklist, requiring a real cross check with two or more setsof eyeballs confirming critical items—and not just a “ticksheet” where one staff member independently puts a checkin the box when they think an item has been completed. A “tick sheet” mentality is the number one reason we see for failing to complete the Time Out as required.

As Dr. Stahel, the author of the report notes, “... Now we hidebehind a safety system that should cover the problem. The TimeOut is performed, but people are not mentally involved—thesystem alone cannot protect you from wrong-site surgery.”

Dr. Stahel is absolutely spot on. The Universal Protocol is notgoing to protect your patients if your teams are not going touse the safety system correctly.

About the author

Steve Harden is Chairman of the Board andCEO of LifeWings Partners LLC and co-founderof Crew Training International, Inc. (CTI). He hashelped over 80 healthcare organizations in 28states implement the best safety practices fromaviation and other high reliability industries. Heis the author of Never Go to the Hospital Alone,published by BPS Books, and co-author of

CRM: The Flight Plan for Lasting Change in Patient Safety, thedefinitive how-to text on implementing aviation-based safety tools inhealth care, published by HCPro. LifeWings Partners is the industryleader in using aviation safety, leadership, team building and humanfactors tools to reduce patient-harming medical errors and improvesafety and quality.


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A New Guidebook for Patient Safety in the OR

by Connie Yuska, RN, MS, CORLN


Over the last decade, manyorganizations have focused onprinciples of surgical safety,such as ensuring accuratesponge counts, adhering tohand hygiene standards andlabeling medications on thesurgical field. These practices,however, have been appliedinconsistently across the country.1

Building a culture of safety con-tinues to be a priority for hospi-tal administrators since thepublication of the Institute ofMedicine’s groundbreakingreport, To Err is Human in 1999.Awareness of patient safety

has been heightened, but the progress has been slow.Improvements in safety have grown by only one percentannually between 2000 and 2009.1 Over the past decade,standards that specifically address safety have beenadded to the work done by regulatory and accreditingbodies. For example, The Joint Commission addedNational Patient Safety Goals with the purpose of pro-moting specific improvements in patient safety.

There are many rules and regulations that address safetyand guide healthcare practitioners, but unless a culture ofsafety is strong and supported by senior leaders in theorganization, significant progress will continue to be slow,and patients will continue to be harmed.

The Safe Surgery Guide, released in November 2010 byThe Joint Commission, is specifically designed to provide

More than 50 million

surgical procedures

are performed in the

United States each

year.1 And while the

number of procedures

is rising, so are the

risks. The risk of

death from a surgical

procedure is 10-100

times greater than

the risk of having

a baby.1 Surgical

errors are second

only to medication

errors as the most

frequent cause of

error-related death.1

organizations with direction on how to improve safety inthe surgical suite. The book focuses not only on improvingsafety in procedural and operative areas, but alsoaddresses the patient’s surgical experience across thecontinuum of care.

The book begins with a foreword by patient safety expertPeter Pronovost, MD, PhD, in which he emphasizes theneed to remove barriers to complying with patient safetypractices and measure performance. He also recognizesthat overcoming the hurdles to patient safety requires cul-ture change. And so, Chapter 1 discusses effective com-munication techniques, emphasizing the importance ofsenior leadership support in establishing those techniques.

Chapter 2 focuses on hand hygiene, a practice that oftenremains difficult for organizations to consistently practiceand enforce. The chapter offers suggestions for improvinghand hygiene compliance in the surgical suite andthroughout the organization.

Chapter 3 outlines all of the preparation that occurs beforethe patient enters the surgical suite. These activitiesinclude managing the operating room schedule, cleaningthe room, preparation of the sterile field, ensuring theproper instruments are available, ensuring proper air qualityand ventilation and controlling traffic in the room andsurrounding areas.

Chapter 4 contains information for a review of everythingthat must be ready for the procedure when the patientarrives in the surgical suite. Information focuses onassessing the patient for risk, documentation of medica-tions the patient is currently taking and preparation of thesurgical site.

Patient Safety

to the same goal of providing safe surgical care. The teammust be fiercely dedicated to supporting each other in theirindividual roles and keenly aware of all steps needed toensure the procedure goes safely from beginning to end.There are many resources available to assist with estab-lishing a culture of safety in your hospital. Reading the SafeSurgery Guide is an excellent place to start.

Reference1. Schuldt LM, ed. Safe Surgery Guide, Oakbrook Terrace, IL: Joint Commission Resources; 2010. Available at: http:// www.jcrinc.com/e-books/EBSSW10/2177.Accessed November 12, 2010.

About the author

Connie Yuska, RN, MS, CORLN, began her nursing career inthe specialty of otolaryngology. Her clinical experience includesboth inpatient and outpatient care of head and neck oncologypatients, and she is certified in otolaryngology and head and necknursing. She has held clinical manager and director of nursingpositions in a large academic medical center and also has expe-rience in the home care setting as vice president of operations fora large home care agency in the Chicago area. Connie laterjoined the executive suite as the chief nursing officer of a largecommunity hospital in Chicago, and she is currently a vice pres-ident of clinical services for Medline.

Now available from Joint Commission Resources!

Safe Surgery Guide Price: $75 (PDF version); $85 (hard copy)ISBN: 978-1-59940-638-1198 pages


Key points to ensure the readiness of the surgical team areoutlined in Chapter 5. The discussion not only includesobvious preparation, such as appropriate surgical attire,but also addresses the attitudes and behaviors of the per-sonnel involved, a key component to ensuring safety in ahigh stress environment such as an OR suite.

Chapter 6 discusses the Joint Commission’s ongoingefforts to reduce the incidence of surgical errors through itsUniversal Protocol for Preventing Wrong Site, Wrong Pro-cedure, and Wrong Person Surgery. The chapter alsodescribes the World Health Organization’s Surgical SafetyChecklist.

Monitoring the patient through all aspects of the surgicalprocedure is critical to ensuring safety. Chapter 7describes the activities of monitoring anesthesia andsedation levels, medications, body temperature, bloodglucose levels and blood administration.

Chapter 8 discusses some of the problems that can occurduring the surgical procedure and offers suggestions forhandling those issues. Some of the problems discussedinclude objects that are inadvertently left in the patient’sbody, fire breaking out and distractions during the proce-dure that may divert the staff’s attention away from thepatient.

Chapter 9 reviews all of the activities that occur after theprocedure, including disposal of medical waste, trans-portation of contaminated materials such as sheets andinstruments, and clean-up of the operating suite.

Chapter 10 outlines the care the patient receives followingthe procedure, including assessment of the patient’s phys-iological and mental status, medications ordered post-operatively and care of the surgical site, includingmeasures to prevent postoperative infection.

Finally, Chapter 11 is a review of the activities that promotethe patient’s discharge and appropriate care after thepatient leaves the organization.

Attaining a successful, safe surgical outcome is the resultof a TEAM of healthcare professionals who are committed

To orderCall 877-223-6866 (M-F, 8am to 8 pm Eastern time), or visit www.jcrinc.com/e-books/EBSSW10/2177

Promote Correct-Site Surgery Our Surgical Time Out Procedure (S.T.O.P.™) safety products alert the surgical team to perform a time-out verification and help reduce the risk of wrong-site surgery.

Support Sharps Safety PracticesTransfer trays, scalpel holders and needle counters with blade guards promote sharps safety and help make you OSHA compliant.1

Improve Fluid Disposal SafetyThe Safety-Splash™ fluid management system converts biohazardous fluids into a solid, minimizing the risk of exposure.

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Safety-Splash and S.T.O.P are trademarks of Medline Industries, Inc.

References: 1. Occupational Safety and Health Standards, Toxic and Hazardous Substances, Bloodborne pathogens. Regulations (Standards - 29 CFR). Available at: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051#1910.1030(d)(2)(i). Accessed October 13, 2010.

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Remember the old riddle, “Where do most pressure ulcers occur?” The answer is — in the ambulance!

Well, the truth is pressure ulcers do occur in the ambulance — and lots of other places youmight not even think about, including the operating room (OR). In fact, the pressure ulcerincidence rate as a result of surgery may be as high as 66 percent1 and 42 percent of allhospital-acquired pressure ulcers are occurring in surgical patients.2

Here are some more daunting facts:• 37 percent of patients undergoing head or neck surgery develop sacral ulcers3

• Cardiac, general vascular and open heart surgeries have a high incidence of occiput and heel ulcers

• 72 percent of perioperative pressure ulcers occur on heels4

The following types of surgical patients are at greater risk for pressure ulcers:• Neonates• Elderly• Malnourished• Morbidly obese• Patients with chronic diseases• Patients with existing pressure ulcers

by Cynthia A. Fleck, RN, BSN, MBA, ET/WOCN, CWS, DWC, CFCN

Patient Safety


Perioperative risk factors for pressure ulcer developmentCertain conditions specific to the surgical experience canalso contribute to the risk of pressure ulcers. Some ofthese conditions include blood volume loss, temperature,time and moisture.

Blood volume loss. Blood volume loss and shunting canincrease the hazard of pressure ulcers and lack of bloodflow to the lower extremities.5,6

Temperature. Another consideration is the cold OR envi-ronment. The body will likely shunt blood away from theskin into the trunk of the body to protect the vital organs,which can be dangerous to the skin. The use of warmingblankets tends to occur in lengthy procedures. These canbe helpful to prevent cooling of the body, which can con-tribute to pressure ulcers, however, the blanket should becovered with a sheet. In addition, the thermostat on theunit should be set at a maximum temperature of 42 de-grees Celsius.

Time. Increased time in the OR is associated withincreased pressure ulcer development as well.7 Surgerieslasting between three and four hours had pressure ulcerincidence rates of 5.8 percent; seven or more hours hadincident rates of 13.3 percent,8 and there is a significantincrease in pressure ulcer incidence for operations lastinglonger than eight hours.9

Moisture. We all know moisture can wreak havoc on theskin and predispose individuals to pressure ulcers, so it isrecommended that pooling of any fluid or blood be moni-tored intraoperatively. It is suggested that the OR surfacehave minimal linens or layering. There are also novel ORproducts available (modern-day “chux” that are superabsorbent) that can actually absorb large volumes of fluidand remain dry to the touch, thus protecting the patient’s skin.

Evaluating surgical surfaces Always remember that no matter where a patient’s bodyresides, pressure ulcers can develop rapidly. OR surfacesshould be evaluated before each case, and the Associationof Perioperative Registered Nurses (AORN) guidelinesrecommend using pressure redistribution surfaces forsurgeries lasting longer than two-and-a-half hours.

In fact, I recently had foot surgery, and my surgeon origi-nally thought it would last only a couple of hours. Lo andbehold, it lasted three hours and 45 minutes, and althoughI am a fairly young, well-nourished and healthy individual,I succumbed to a Stage II perioperative pressure ulcer. Thelesson to be learned: because there is no guarantee how

Perioperative tips for avoiding pressure ulcers• Assure that the OR table or surface is of sufficient size to support the patient –especially important for obese patients whose bodies may be larger than the average size OR surface

• Lift – do not drag – the patient from surface to surface.

• Monitor pressure points when possible during “time outs”

Post-operative considerations for avoiding pressure ulcers• Be aware of a possible delay in visualization due to bandages and other monitoringequipment

• Prolonged immobility or confinement to a bed or chair increases pressure ulcer risk10


HEELMEDIX™ Heel Protector Pressure relief and skin protection all in one

The heels are the most common site for facility-acquired pressureulcers in long-term care, and the second most common site over-all.1 According to clinical experts, the most effective aspect ofpressure ulcer prevention for heels is pressure relief, also knownas offloading.1,2 Offloading is achieved with the use of pillows orheel protection devices that relieve pressure by elevating the heel.

The HEELMEDIX Heel Protector is designed to help eliminatepressure, friction and shear on the skin by elevating the heel.Made of soft, suede-like material on the inside and easy-to-cleannylon on the outside. Adjustable straps are soft against vulnerableskin. Includes a mesh laundry bag with patient ID label to simplifywashing and sorting.

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Relieve Pressure on Vulnerable Heels


1Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10):42:48.

2Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure ulcers: stand guard. Advances in Skin & Wound Care. 2008;21(6):282-292.

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long a surgery will take, a pressure redistribution surfaceshould be available in every operating room.

There are high-quality surfaces that self-adjust (Figure 1),provide a stable environment for the surgeon and OR staffto work and conform to the patient’s body. Some of thesesurfaces contain the same type of visco or viscoelasticmemory foam many of us sleep on in our own bedrooms.When evaluating various surfaces, ask the vendor aboutthe warranty, weight limits, cleaning instructions and com-parative data such as pressure mapping. This will help youmake an educated decision regarding your purchase.

Important steps to take after surgeryAt the hand-off to the post-anesthesia care unit (PACU) itis advisable to:• Clean and dry the patient’s skin• Conduct a post-op skin assessment, noting:- Skin irritation- Discoloration- Bruising- Swelling

• Provide a thorough report including: - Results of pre-surgery risk factors and potentialnew risks that developed during surgery

- Results of threats and skin assessment performedbefore, during and after surgery

- How long the surgery lasted (e.g., my own surgerywas scheduled for two hours and lasted almostdouble that time)

Pressure ulcer risk in ancillary servicesThere is also high risk for pressure ulcers in ancillaryservices:• Radiology• Renal dialysis• Cardiac and vascular procedure laboratories such as cath labs

The problem is that until awareness is increased, we willcontinue doing what we always did, and patients will con-tinue to develop pressure ulcers.

Patients undergoing lengthy radiology procedures have a53.8 percent incidence of pressure ulcers. Emergency de-partments are another area of risk, with 40 percent of pa-tients admitted through the emergency department at riskfor pressure ulcer development.11

The average emergency department patient waits six toeight hours lying on a stretcher that usually consists of twoto three inches of open-celled foam and an uncomfortablenon-conformable cover that can contribute to the devel-opment of pressure ulcers.

This is especially important now that acute care facilitiesare financially responsible for acquired pressure ulcers –which can be quite costly. Many hospitals have instituteda comprehensive program to prevent pressure ulcersacross the continuum, including the OR, ED and ancillaryareas. Introducing a tool kit on average can reduce a facility’s

Figure 1

AORN guidelines recommend using pressure redistribution surfaces for surgeries lasting longer than 21/2 hours.


Medline Named One of Becker’s

100 Best Places to Work in HealthcareBecker’s recognizes company for “Excellence in Promoting Teamwork, Professional Development”

Medline Industries, Inc. has been named one of the “100 BestPlaces to Work in Healthcare” for 2010 by Becker's ASC Reviewand Becker's Hospital Review, well respected industry publications.

According to Becker’s, the list was developed “through nomina-tions, recommendations and research, and the organizations wereselected for their demonstrated excellence in creating a work envi-ronment promoting teamwork, professional development and qual-ity patient care.”

Benefits Of A GreatWork Environment

Businesses can improve retention and make their organizationthe good place to work by following the five-step PRIDE model:

P – Provide a positive working environment

R – Recognize, reinforce, and reward individual efforts

I – Involve and engage everyone

D – Develop the potential of your workforce

E – Evaluate and hold managers accountable

Source: workz.com

By Greg Smith

Join us for this webcast presentation as twoindustry experts bring you critical infor-mation on how the utilization of the nursingprocess and proper documentation are vitalcomponents in maintaining the standard ofcare and avoiding litigation.

Presented by attorney Kevin W. Yankowsky,JD, a partner in the health law litigationgroup of Fulbright & Jaworski, LLP, Hous-ton, Texas, and physician Caroline Fife, MD,the Chief Medical Officer of Intellicure, Inc.and an associate professor at the UniversityTexas Medical School at Houston.

LEGAL IMPLICATIONS OF PRESSURE ULCERS

1 Contact Hour

Courses approved for continuing education by the Florida Boardof Nursing and the California Board of Reigistered Nursing.

To view this webcast, visitwww.medlineuniversity.com


pressure ulcers by 70 percent while substantially increas-ing the knowledge of licensed staff and nurse assistants.12

Take your knowledge and pass it onConsider sharing this article with the emergency depart-ment, ancillary areas such as the cath lab, dialysis andother high-risk area personnel, and of course with theambulance companies where your patients could be atrisk. If you are on a skin care committee, get the othermembers involved, as these care areas present jeopardy thatcan be easily mitigated.

When we ask ourselves the age-old question of whereall the pressure ulcers are occurring, now we have moreammunition to fight the battle. And yes, the ambulance,with its tiny vinyl-covered two-inch, foam mattress maybe part of the problem. The good news is that we haveanswers and products that can make positive changehappen.

About the author

Cynthia Ann Fleck, RN, BSN, MBA,CWS, DNC, CFCN is a certified wound spe-cialist, dermatology advanced practicenurse, certified foot and nail care nurse,writer, speaker, a past president and chair-man of the board for the American Acad-emy of Wound Management (AAWM), pastdirector for the Association for the Ad-

vancement of Wound Care (AAWC), and Vice President, ClinicalMarketing for Medline Industries, Inc. Cynthia can be reached [email protected].

References1. Recommended practices for positioning the patient in the perioperative

practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010.

2. Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparison of costs in medical vs. surgical patients. Nursing Economics. 1999; 17(5):263-271

3. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010.

4. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010.

5. Keller C. The obese patient as a surgical risk. Seminars in Perioperative Nursing. 1999; 8(3):109-117.

6. McEwen DR. Intraoperative positioning of surgical patients. AORN Journal. 1996; 63(6):1058-1063, 1066-1075, 1077-1082.

7. Papantonio C, Wallop J, Koldner K. Sacral ulcers following cardiac surgery: incidence and risks. Adv in Wound Care. 1994;7(2):24-36.

8. Aronovitch S. Intraoperatively acquired pressure ulcer prevalence: a national study. J Wound Ostomy Continence Nursing. 1999;26(3):130-136.

9. Ratliff C, Rodeheaver G. Prospective study of the incidence of OR-induced pressure ulcers in elderly patients undergoing lengthy surgical procedures. Adv Skin Wound Care. 1998;11(suppl 3):10.

10. Allman RM, Goode PS, Burst N, Bartolluci AA, Thomas DR. Pressure ulcer hospital complications and disease severity: impact on hospital costs and length of stay. Advances in Skin & Wound Care, 1999;12(1):22-30.

11. Tarpey A, Gould D, Fox C, Davies P, Cocking M. Evaluating support surfaces for patients in transit through the accident and emergency department. J Clin Nurs. 2000;9(2):189-198.

12. Armstrong DG, Ayello EA, Capitulo KL, Fowler E, Krasner DL, Levine JM, et al. New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission (POA) indicators/hospital-acquired conditions policy. J Wound Ostomy Continence Nurs. 2008. 35(5):485-492.

©2010 Medline Industries, Inc. Medline, QuickSuite and Sahara are registered trademarks of Medline Industries, Inc.

References1Braden Scale for Predicting Pressure Sore Risk. Available at:www.bradenscale.com/braden.PDF. Accessed November 6, 2008. 2Recommended practices for positioning the patient in the perioperative practice setting. In:Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008.

KEEP YOUR SURGICAL PATIENTS DESERT DRY.

Medline’s Sahara® Super Absorbent OR table sheets are designed with your patients’ skin integrity in mind. QuickSuite®

OR Clean Up Kit

The Braden Scale tells us that moisture is one of the major risk factors for developing a pressure ulcer.1 We alsoknow that as many as 66 percent of all hospital-acquiredpressure ulcers come out of the operating room.2

That’s why we developed the Sahara Super AbsorbentOR table sheet. The Sahara’s super-absorbent polymertechnology rapidly wicks moisture from the skin andlocks it away to help keep your patients dry.

Sahara OR table sheets are available on their own or as a component in our QuickSuite® OR Clean Up Kits, which were designed to help you dramatically improveyour OR turnover time and help reduce cross contamina-tion risk through a combination of disposable products. To sign up for a FREE webinar on perioperative

pressure ulcer prevention, go towww.medline.com/pupp-webinar.

Medline’s new patent-pending EcoDrape is the onlyeco-friendly surgical drape available today. Made ofmore than 96% wood pulp, EcoDrape will biodegrade in only two to five months in a landfill – polypropylenedrapes take hundreds of years to break down. EcoDrapehas all the same great features as other Medlinedrapes, including hook-and-loop line holders, largereinforcement zones, and premium tape and incise film flush to the fenestration.

Try the new EcoDrape and take your OR to the nextlevel of green!

For a quick online video demonstration,visit www.medline.com/ecodrape

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.EcoDrape and greensmart are trademarks of Medline Industries, Inc.

–– the only TTRRUULLYY eco-friendly surgical drape

The OR Goes Green

Composition Comparison

EcoDrape SMS

Fibers More than 96% No wood wood pulp pulp

Petrochemical 0% 100% PPingredients (plastics)

Additives Bio-based Fluorine

Medline has joined a group of corporate sponsors to sup-port Practice Greenhealth’s Greening the Operating Room(GOR) initiative. This initiative to green the nation’s oper-ating rooms was launched earlier in 2010 to reduce theenvironmental footprint of operating rooms in U.S. hospi-tals. Hospital operating rooms contribute between 20 and30 percent of the hospital’s total waste.1

Medline will join the collaborative effort of hospitals, man-ufacturers and related stakeholders to develop guidancedocuments for helping reduce the environmental impact ofthe nation’s operating rooms and potentially reduce cost,increase quality and improve worker or patient safety. Thefollowing are the GOR areas for “green” interventions in theoperating room:• Single-Use Device (SUD) Reprocessing• Reusables v. Disposables: Gowns, Surgical Drapes, Basins and Other Reusables

• OR Kit Formulation• Waste Anesthetic Gas Scavenging Systems• Fluid Waste Management Systems• Energy Use/Lighting & Thermal Comfort• Regulated Medical Waste (RMW) Minimization/Segregation

• Substitution of Reusable Hard Cases for Blue Sterile Wrap

• Recycling of Medical Plastics• Laser Safety/Smoke Evacuation• Green Cleaning/Proper Disinfection in a Surgical Setting

• Medical Equipment and Supplies Donation

To learn more about Practice Greenhealth’s Greening theOR initiative visit www.greeningtheor.org.

Medline Joins Greening the Operating Room Initiative

Reference1. Esaki RK & Macario A. Wastage of supplies and drugs in the operating room. Medscape Anesthesiology. Posted October 21, 2009.Available at. http://www.medscape.com/viewarticle/710513. Accessed October 22, 2010.

OR Issues

3 Checklistson the Cleaning & Disinfection of Endoscopic Equipment

by Lorri A. Downs RN, BSN, MS, CIC

According to the Association for Professionals in Infec-tion Control (APIC), many factors contribute toendoscopy-associated infection, including numerousreports of outbreaks associated with equipment cleaningand disinfection. Infection prevention related to the useof endoscopy equipment begins with educating andtraining practitioners and strict adherence to reprocess-ing protocols.1

We know that in busy healthcare environments, check-lists can help reduce errors and improve adherence tocritical steps. Below you will find three checklists to help

staff quickly and efficiently adhere to infection controlguidelines for reprocessing endoscopic equipment inthe central sterile processing department, same-daysurgery arena and freestanding endoscopy clinics.

The following checklists for the cleaning and disinfec-tion of endoscopes were adapted from the Society ofGastroenterology Nurses and Associates (SGNA) Stan-dards of Infection Control in Reprocessing of FlexibleGastrointestinal Endoscopes.2 To see the guidelines intheir entirety, go to www.sgna.org.


Reprocessing of soiled endoscopy equipment begins at the patient’s bedside immediatelyupon removal of the endoscope from the patient and prior to disconnecting the endoscopefrom the power source.

Have the following equipment available immediately after the procedure:• Personal protective equipment: gloves, eye protection, impervious gown, face shield or surgical mask that will not trap vapors.

• Container with detergent solution• A sponge and a soft, lint-free cloth• Air and water channel cleaning adapters per manufacturer’s instructions• Protective video caps if using video endoscopes

Use the following checklist after you have gathered the supplies listed above and put on your

personal protective equipment.

� Immediately wipe the insertion tube with a wet cloth or sponge soaked in freshlyprepared detergent solution. (Note: Do not reuse cloths or sponges between cases.)

� Place distal end of the endoscope in the detergent solution and suction the solution through the channel. Alternate suctioning, detergent solution and air several times until the solution is visibly clean. Finish with suctioning air.

� Flush or blow out air and water channels in accordance with the endoscope manufacturer’s instructions.

� Flush the auxiliary water channel.� Detach the endoscope from the light source and suction pump.� Attach the protective video cap if using a video endoscope.� Transport the endoscope to the reprocessing area in an enclosed container.

1 Checklist 1:Cleaning the Endoscope Immediately Afterthe Endoscopy Procedure


Special Feature


Have the following equipment available in the reprocessing area:• Personal protective equipment: gloves, eye protection, impervious gown, face shield or surgical mask that will not trap vapors

• Leak-testing equipment• Channel cleaning adapters (per manufacturer’s instructions)• Large basin of endoscope detergent prepared per manufacturer’s instructions• Channel cleaning brushes• Sponge and lint-free cloth

Use the following checklist after you have gathered the supplies listed above and put on your

personal protective equipment.

� Leak test the endoscope either manually or via computer testing following the manufacturer’s instructions. If a leak is detected, follow the manufacturer’s instructions.

� Fill the sink or a basin with a freshly prepared solution (for each endoscope) of water and a medical grade, low-foaming, neutral pH detergent formulated for endoscopes that may or may not contain enzymes.

� Immerse the endoscope.� Wash all debris from the exterior of the endoscope by brushing and wiping the instrument

while submerged in the detergent solution.� Keep the scope submerged to prevent splashing of contaminated fluid and aerosolization

of bioburden.� Use a small soft brush to clean all removable parts, including inside and under the suction

valve, air/water valve, and biopsy port cover and openings. Brush all accessible channels,the scope body, insertion tube and the umbilicus of the endoscope.

� After each passage of the brush, rinse the brush in the detergent solution, removing any visible debris before retracting and reinserting it. Continue brushing until there isno visible debris on the brush.

� Clean and high-level disinfect reusable brushes between cases.� Attach manufacturer’s cleaning adapters for special endoscopic channels. Flush all

channels with detergent solution to remove debris. (Note: Automated pumps are availablefor flushing endoscopes. Refer to the manufacturer’s instructions.)

� Soak the endoscope and its internal channels for the period of time specified on the label of the detergent.

� Thoroughly rinse the endoscope and all removable parts with clean water to remove residual debris and detergent.

� Purge water from all channels using forced air and dry the exterior of the scope with a soft, lint-free cloth.

2 Checklist 2:Cleaning the Endoscope in the Reprocessing Area


• Once the endoscope has been cleaned, it is ready for disinfectants and sterilants. • Be sure to follow the manufacturer’s instructions for proper use of these chemicals.• Test the chemical for the minimum effective concentration (MEC) according to the label on the test strip container.

• Never use the MEC value to extend the “reuse” life claim on the product and never use beyond the date specified on activation.

• Use product-specific test strips to check for the MEC and keep a log of the test results.

� Completely immerse the endoscope and all removable parts in a basin of high level disinfectant/sterilant.

� Inject disinfectant into all channels of the endoscope until it can be seen exiting theopposite end of each channel. Make sure no air pockets remain within the channels

� Do not coil the scope tightly and cover the basin to contain chemical vapors.� Soak the endoscope in the high-level disinfectant/sterilant for the appropriate time and

temperature.� Required to achieve high-level disinfection. Use a timer to verify soaking time.� Purge all channels completely with air before removing the endoscope from the high-

level disinfectant/sterilant.� Thoroughly rinse all surfaces and removable parts and flush all channels of the endoscope

and its removable parts with clean water and disinfectant per the manufacturer’srecommendations.

� Purge all channels with air until dry and follow with 70% isopropyl alcohol (even if sterile water is used to flush) to assist in drying the interior channel surfaces.

� Thoroughly rinse and dry all removable parts and do not store removable parts attached to the endoscope when not in use.

� Dry the exterior of the endoscope with a soft, lint-free cloth.� Thoroughly rinse the endoscope and all removable parts with clean water to remove

residual debris and detergent.� Hang the endoscope vertically with the distal tip hanging freely in a clean, well-vented,

dust-free area.

3 Checklist 3:High Level Disinfection/Sterilization for Endoscopesin the Reprocessing Area

References1. Stricof RL. Endoscopy. In: Carrico R, ed. APIC Text of Infection Control and Epidemiology. 3rd ed. Washington, DC: Association for Professionals

in Infection Control and Epidemiology, Inc.; 2009.2. Society of Gastroenterology Nurses and Associates, Inc. The Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes.

10-19. Available at: http://infectioncontrol.sgna.org/SGNAResources/tabid/55/Default.aspx#standards. Accessed November 10, 2010.

About the authorLorri Downs, RN, BSN, MS, CIC is a board-certified infection preventionist and vice president of infec-tion prevention for Medline Industries, Inc. She has a diverse portfolio of more than 25 years in the nursingprofessions. Her expertise focuses on infection prevention surveillance at large acute care organizations,plus ambulatory and public health settings. Lorri has developed hospital infection control programs andlocal emergency preparedness plans, and she ahs lectured on various infection prevention topics.


Continuing Education Article OR Issues

Stuck Like GlueNEW USES AND IMPROVED OUTCOMES

Surgical^

Are your surgeons increasingly requesting surgical glue? If theyaren’t asking for it yet, all indications are that surgical glue willbe a mainstay in operating rooms in the near future. Let’sexplore why use of surgical glue is becoming so prominentamong surgeons.

Current Market SnapshotCurrent research on the success of surgical sealants and gluesin clinical practice was published in October 2010 by Med-Market Diligence, a provider of data and insight on advancedmedical technologies. The report states that the advance-ments in surgical sealants and glue technology are enablingthese products to increasingly penetrate the existing marketsfor sutures and staples, in addition to capturing a caseload ofnew applications.1 A wide array of wound closure products isnow in use by both general surgeons and surgeons special-izing in gynecologic, orthopedic, gastrointestinal, neurology,cosmetic, vascular and nearly all other surgical areas.

Many aspects of prevailing surgical methods (from as recentlyas 10 years ago) have undergone major changes. Theincreased use of surgical sealants and glue is one suchchange and is primarily attributable to both new technological

advancements and the expanding caseloads for which thesetechnologies apply. While traditional wound closure products,including sutures and staples, still command a sizable portionof the overall market, their rate of use compared to alternativeproducts is relatively flat, and in some cases declining, incertain geographic regions. In contrast, the use of surgicalsealants and glues is growing at an estimated 10 to 15 percentper year.1

In August 2010, Outpatient Surgery conducted a poll askingreaders about their use of surgical glue and the results were asfollows:

By Alecia Cooper, RN, BS, MBA, CNORand Debashish Chakravarthy, PhD

OUTPATIENT SURGERY MAGAZINE READER POLL2

“In which types of cases do you use surgicalglue instead of sutures?”

ARTHROSCOPY . . . . . . . . . . . . . . . . . . .28%

ENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1%

GENERAL SURGERY . . . . . . . . . . .34%

GYNECOLOGY . . . . . . . . . . . .11%

PLASTICS . . . . . . . . . . . . .26%


Importance of Surgical Glue Knowledge Whereas surgeons select and evaluate the effectiveness ofclosure devices, including surgical glues, it is the responsibilityof nurses, physician assistants, residents, interns and studentsto routinely assist or close the procedure under the surgeon’sdirection. Therefore, it is imperative to have thorough knowl-edge of these materials and their appropriate application anduse in order to achieve the best performance and results.

Focusing on CyanoacrylatesCyanoacrylates were first used in 1949 after being discoveredaccidentally while researchers were studying refracting indexesof coatings on glass.3 Cyanoacrylates became popular duringthe Vietnam War as a hemostat for soldiers wounded in fieldcombat. These compounds entered the clinical market duringthe 1980s and 1990s in dental products, bandages andwound closure adhesives. Today, several cyanoacrylates havebeen cleared and/or approved as medical devices by the FDA.

TYPES OF SURGICAL TISSUE ADHESIVESSurgical glues, also referred to as surgical tissue adhesives orsealants, are used after a surgery or traumatic injury to bindtogether both deep as well as superficial tissue. These gluesprovide a chemical bond to hold tissue together for healingand serve as a barrier to stop the flow of bodily fluids. Certainphysicians use surgical glues in conjunction with, or as andalternative to, sutures and staples.

Including surgical closure glues, there are several main typesof surgical glues approved for various surgical applications:

Fibrin sealants. Fibrin sealants are a type of surgicaladhesive derived from both human and animal blood prod-ucts. Ingredients in the fibrin sealant interact during appli-cation to form a clot. Fibrin sealants are effective for use incardiovascular surgery, lung surgery, the closure of dura,and to seal spleen and liver lacerations. Fibrin sealants arenot suitable for external or topical use.

Glutaraldehyde-based glues. Glutaraldehyde glues areprotein-based compounds that are crosslinked byglutaraldehyde, in situ, to make a strong and bioabsorbableinternal seal. These glues are not suitable for external ortopical use.

Collagen-based products. Collagen-based adhesivesmay be combined with other hemostatic proteins such asthrombin to make an effective internal adhesive.

Hydrogels. Hydrogels are synthetic polyethylene glycol(PEG) polymers commonly used in lung and thoracic surgeryfor their ability to seal air leaks. Due to their physical prop-erties, they are unsuitable as an incision site closure or glue.

Cyanoacrylates. Cyanoacrylates are compounds ideallysuited—because of their physical properties when “setup”—to close topical incisions, minor lacerations or an inci-sion site. The subcutaneous tissue is closed with suturesand the glue is used only to close the dermal and epidermalincisional defects. These compounds are very commonlyused on laparoscopic incisions and are much stronger thanall the internal glues discussed above. Cyanoacrylates arealso able to withstand the external environment while theincision heals naturally underneath the glue line. In general,cyanoacrylates are waterproof, flexible and requireno secondary dressing. Cyanoacrylates are not bio-absorbable and must be restricted to external and tem-porary applications.

1

4

5

3

2


©2010 Medline Industries, Inc. Medline is a registered trademark and OctylSeal is a trademark of Medline Industries, Inc.

Introducing Medline’s OctylSeal high viscosity tissue adhesive for closure of simple wounds

• Flexible structure moves with the skin, minimizing the chance of cracking

• Acts as a barrier to microbial penetration as long as the adhesive film remains intact

• 40 percent more glue per container than most other tissue adhesives (0.7 grams versus 0.5 grams)

• Easy, versatile application – interchangeable tips (swab and nozzle) included in every package; violet color for easier identification on skin

• Metal tube instead of glass ampule means no risk of broken glass entering the wound

Indications for useTopical application only to hold closed easily approximatededges of wounds from surgical incisions, including punc-tures from minimally invasive surgery and simple, thoroughlycleansed trauma-induced lacerations. OctylSeal may beused in conjunction with, but not in place of deep dermalsutures. Available by prescription only.

Stick with OctylSeal™Flexible wound closure that’s easy on your budget

To learn more about OctylSeal,call 847-643-4526.


Two main types: octyls and butyls. There are, in essence,two main types of cyanoacrylates approved as medical tissueadhesives. One type is N-butyl-2-cyanoacrylate (simply calledbutyl in most cases) and the second type is 2-octyl-cyanoacrylate (Simply called octyl).4

The difference between the two types is in the nature of thechemical chains present in the ester groups of the molecules.The molecules are sometimes referred to as monomers. Incontrast, the adhesive that is “set up” on skin post applicationis the polymer. A butyl cyanoacrylate contains a short chain(4 carbon length) portion in its structure. An octyl cyanoacry-late contains a longer chain (8 carbon length) portion.

The polymer film resulting from the use of a butyl glue is con-sidered to be more rigid than the film resulting from the set upof an octyl glue on skin, and far less flexible. Thus, butyls aremore prone to cracking and splitting under tension and flex-ure of the skin, limbs and joints during normal movement. Insummary, a butyl film provides only strength, but very little flex-ibility, while the octyl film seems to balance both tensilestrength and flexibility without fissures or cracks appearing inthe film.

Since both types of cyanoacrylate adhesives have FDAapproval,4 how does a surgeon select the preferred product?Many factors can play into the surgeon’s decision, though top-ping the list seem to be the features and benefits of each typeof adhesive that appeals to the surgeon, the product type thesurgeon trained on, and the product brand that the hospitalstocks. Table 1 compares octyl and butyl cyanoacrylates andshows the factors that may play into the clinicians preferencein product choice.

Determining How to Close the WoundIn determining the appropriate type of product to close anysurgical procedure, surgeons take into account many factorsbased upon the desired goals.

1. Reason for the surgery2. Location of where and how the injury occurred

(if applicable)3. Location of the wound4. Length of the surgical procedure

Surgical wound closure using a cyanoacylate is best suited forwounds that are not subject to significant stress or flexion.Many surgeons follow this rule of thumb: if the skin requiresmore than simple pulling together with forceps or fingers to

Potential benefits of surgical wound closure with cyanoacrylates6

1. Quicker wound closure

2. Comparable/better scar cosmesis than sutures or staples

3. Occlusive microbial barrier

4. Non-invasive – less tissue trauma and reduced inflammatory reaction

5. No secondary dressings required

6. Easy-to-use/quick learning curve

7. Ease of wound visualization

8. Reduced risk of needle-stick injury associated with suturing

9. Cost-effective

Table 1. Octyl versus butyl cyanoacrylates

Octyl Butyl

No need to refrigerateCures or polymerizes as a smooth surface and an even filmSets up with a flexible “glue” line at the application site.

Needs refrigerationCures or polymerizes as a rough surface Sets up with a brittle “glue” line at the application site.


achieve approximation of the wound, then deeper suturesand/or subcutaneous sutures should be used before the glueis applied.5 Octyl cyanoacylates appear to work better onareas of flexion as compared to butyl cyanoacylates, becausethey set up with a flexible “glue line” and maintain their micro-bial barrier.

The best results are obtained when the wound incision is cleanand dry with total hemostasis prior to the application of theskin adhesive. Cyanoacrylate adhesives close the skin byforming a polymerized layer across the top of the skin, creat-ing a a bridge between the skin edges. Therefore, it is impor-tant for best results to obtain edge-to-edge apposition whilethe glue sets over the wound.

If the procedure is a routine, elective surgery and not causedby a trauma, surgical glue should be considered. If an injurytook place outdoors or on a playground, for example, wherethere are potential contaminants, it is best not to consider sur-gical glue. The duration of surgery may affect the potential forinfection, and surgical glue should be used with caution.

Benefits of Using Surgical Tissue AdhesivesMany surgeons prefer coverage of the suture line with acyanoacrylate surgical glue as opposed to a dressing becausethe glue allows the incision line to be easily visible.6 Once com-fortable with the technique, most surgeons find that surgicalglues offer a fast, simple and effective means of surgicalwound closure, particularly for smaller surgical incisions. Inaddition, cosmetic results are superior. Patients are pleasedwith the waterproof and microbial barrier nature of glue,especially octyl glues, which are resistant to cracking andallow patients to shower soon after the procedure. Additionalbenefits of using a surgical glue are the lack of visible dress-ings or sutures and the absence of procedures to removesutures or staples.5

Trauma

Most surgeons find that surgical glues offer a fast,simple and effective means of surgical wound closure

SKIN GLUE – TOP TIPS6

• Make sure the wound is clean and dry

• Stop bleeding prior to application

• Apply glue over tightly and correctly approximated wound edges

• Hold until glue/tissue adhesive is dry

• No further dressings required, although secondary dressing will not harm incision site and may provide additional microbial barrier protection

• Ensure patient/post-op staff know glue was used and know wound site care

• Provide patient information/instructions at discharge

Microbes and Surgical Tissue AdhesivesRecent in vitro studies have shown that 2-octyl-cyanoacrylate is an effective microbial barrier for the first 72 hours afterapplication.3

A key aspect of using surgical glues is that the skin formedwith 2-octyl-cyanoacrylate is effective against gram-positive


and gram-negative bacteria including Staphylococcus epi-dermis, S. aureus, Escherichia coli, Pseudomonas aeruginosa,and Enterococcus faecium. The adhesive creates a protectivelayer for the wound and keeps the area moist, resulting infaster epithelialization. In this way, the system of closure andprotection of the wound using surgical glue can result inreduced costs and better management in the postoperativephase.3

Cyanoacrylate skin adhesives may potentially reduce the riskof surgical site infections (SSIs) by:7

1. Forming an occlusive, impermeable, waterproof barrier2. Prevention of translocation of local skin flora3. Reducing post-operative wound dressing changes4. Improving hygiene by allowing patients to shower

Wound Site CareTo allow proper care and management of the incision siteclosed with surgical glue, it is imperative to communicateeffectively regarding glue use at handoff in the immediatepost-operative period. Incisions closed with glue typically donot produce drainage because in general, the use of glue isrestricted to non-draining wounds.

If the incision appears to be opening, the edges should bepushed together, and then butterfly-type bandages may beapplied to hold the edges together. The surgeon may applyadditional surgical glue to the wound as needed prior to dis-charge from the hospital. Surgical glues will slough off naturallyas normal skin grows to heal the incision site.

Best practice requires providing education and training onsurgical wound care to the patient and family prior todischarge so that proper care is extended at home. Postop-erative evaluation has shown good patient satisfaction whenusing surgical glues.3

Perioperative personnel need to know how to care for inci-sions closed with glue and should be able to communicate topatients and their families the methods to properly care for andmaintain the incision site at home.

New Uses and Improved OutcomesThe key to the successful use of surgical glue is that surgeonsshould precisely apply the products to the appropriate surgi-cal wounds. Both surgeons and other clinicians will need toperfect their technique for applying and using surgical glues.

Proper application of surgical glue can be learned quickly andeasily; the method is not particularly challenging.

As the process for the surgical glue to ”set up” and protectthe incision site happens in about a minute, the use of surgi-cal glue can save valuable time and improve both patient out-comes and patient satisfaction. Patients report morepostoperative comfort, appreciate the ability to see the inci-sion and like being able to bathe immediately following theprocedure.

Surgical glues are relatively inexpensive, comprising onlya small fraction of the overall costs associated with most sur-geries. There is no need for a secondary dressing or dressingchanges, which adds to costs of treatment. Use of glue alsomay eliminate follow-up visits related to post op care andsuture removal. Based upon these myriad factors, the use ofsurgical glues is likely to continue growing, and new innova-tions in the technology will continue to emerge.

References1. Surgical Sealant and Glue New Uses and Penetration of Traditional Wound Closure,

Hemostasis. MedMarket Diligence, LLC. October 11, 2010. Available at: http://www.prlog.org/10991463-surgical-sealant-and-glue-new-uses-and-penetration-of-traditional-wound-closure-hemostasis.html. Accessed November 8, 2010.

2. InstaPoll. In which types of cases do you use surgical glue instead of sutures? Outpatient Surgery E-Weekly, August 17, 2010. Available at: www.outpatientsurgery.net. Accessed November 9, 2010.

3. Silvestri A, Brandi C, Grimaldi L, Nisi G, Brafa A, Calabro M, et. al. Octyl-2-cyanoacrylate adhesive for skin closure and prevention of infection in plastic surgery. Aesthetic Plastic Surgery. 2006;30(6):695-699.

4. Petrie EM. High strength surgical adhesives. Available at: http://www.specialchem4adhe-sives.com/home/editorial.aspx?id=3043. Accessed November 18, 2010.

5. Liversedge NH. Get stuck in! Hands on experiences with surgical skin glue. Obs & Gynae News. 2007;14(1):24-28.

6. Malangoni MA, Cheadle WG, Dodson TF, Dohmen PM, Jones D, Kushagra K, et al. Roundtable discussion. New opportunities for reducing risk of surgical site infections. Surgical Infections. 2006;7 Suppl 1:S23-39.

7. Non-invasive closure of laparoscopic surgical incisions. Available at: http://www.admed-sol.com/Doc/LBL%20Clinical%20Update.pdf. Accessed November 18, 2010.

Linear


CE TestTrue/False1. The use of surgical sealants and glues is growing at a rate of 10 to 15 percent per year. T F

2. Recent in vitro studies have shown that 2-octyl-cyanoacrylate is an effective microbial barrier for the first 72 hours after application. T F

3. Butyl cyanoacrylates cure or polymerize as a smoothsurface. T F

4. Octyl cyanoacrylates require refrigeration. T F

5. Cyanoacrylate adhesives first entered the clinical market in the 1960s. T F

Multiple Choice6. Which of the following is one of the factors surgeonstake into account when determining the appropriate type of product to close a surgical incision?a. Patient’s age b. Skin temperaturec. Ability to approximate wound edgesd. None of the above

7. Which type of surgical glue is commonly used in lungand thoracic surgery?a. Cyanoacrylates b. Glutaraldehyde glues c. Hydrogelsd. Fibrin sealants

CE Test Questions

Stuck Like Surgical Glue: NEW USES AND IMPROVED OUTCOMES

Submit your answers at www.medlineuniversity.com

and receive 1 FREE CE credit

8. Patients tend to prefer surgical glue over sutures or staples because __________________. a. It allows them to lightly wash or shower right after surgery

b. There is no need for required follow up for removalc. They provide more postoperative comfortd. All of the above

9. Glutaraldehyde glues are used in the repair of _________________.a. Simple skin lacerationsb. Aortic dissectionsc. Massive head woundsd. Laparoscopic surgical incisions

10. Surgical adhesives derived from both human and animal blood products are called _____________________.a. Fibrin sealants b. Collagen-based compoundsc. Cyanoacrylates d. None of the above

Courses approved for continuing education by the Florida Board of Nursing and the California Board of Reigistered Nursing.

A new product for your infection control program Medline BIOGUARD® barrier dressings are specificallydesigned to help protect wounds from more than 12types of bacteria, including methicillin-resistant Staphy-lococcus aureus (MRSA). The active component is acationic polymer called Poly (diallyl dimethyl ammoniumchloride) (pDADMAC).

No leachingUnlike similar cationic biocides (such as PHMB – the active component in the competitor’s dressings),pDADMAC is permanently bound to the barrier dressing. It keeps working at the same rate for the life of the dressing – without leaching.

No resistanceLack of leaching helps prevent the potential for resistant strain formation.

No toxicityMedline BIOGUARD® barrier dressings are non-toxic,allowing them to be used safely on all wounds.

Medline BIOGUARD® barrier products act as a physicalbarrier to outside contaminants and do not act on thesurface or the interior of the wound nor do they containantimicrobial agents that act on the body. These dressingsare not intended as a treatment for clinical infection. If signs of clinical infection are present, consult a physician.Available by prescription only.

To request a sample of BIOGUARD®

contact your Medline salesrepresentative or e-mail [email protected]

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. BIOGUARD is a registeredtrademark of Derma Sciences, Inc. US Patent No. 7,045,673 and 7,709,694 and 7,790,217 and foreign counterparts.NIMBUS technology is licensed by Quick-Med Technologies, Inc. NIMBUS is a registered trademark of Quick-MedTechnologies, Inc. Covidien is a registered trademark of Covidien.

PROVEN 99.999% BACTERIAL REDUCTION

Medline BIOGUARD® Barrier Dressings

product spotlightINTRODUCING MEDLINE BIOGUARD® BARRIER DRESSINGS

Proven 99.999% bacterial reduction for your infection control program

Medline BIOGUARD is a new line of gauze-based dressings with a >5-log(99.999%) average reduction of more than 12 common pathogens,including MRSA, vancomycin-resistant Enterococcus faecium andPseudomonas aeruginosa. The active component is a non-toxic, highmolecular weight cationic polymer called Poly (diallyl dimethyl ammoniumchloride) or p-DADMAC contained within the dressings.

Unlike PHMB, the active ingredient in the competitor’s barrier dressing,p-DADMAC is permanently bound to the dressing. So it keeps working atthe same rate for the life of the dressing. Lack of leaching helps preventbacteria from growing and spreading in the dressing, reducing the potentialfor resistant strain formation.

Timemagazine Innovation Leader Dr. Greg Schultz developed the patentedtechnique for bonding p-DADMAC to the gauze dressings.1 A biochemistwith an interest in wound care, Dr. Schultz serves on the board of direc-


Special Feature


Efficacy of Medline BIOGUARD® and Covidien AMD After 24 and 48 Hours*

6

5

4

3

2

1

0Methicillin-resistant

Staphyloccus aureus (MRSA)

Ant

ibac

teria

l Act

ivity

(Log

Red

uctio

n)

Pseudomonas aeruginosa (PA) Vancomycin-resistant Enterococcus faecium (VRE)

Medline Bulkee II BIOGUARD®

Gauze Bandage RollCovidien® Kerlix AMD™ Antimicrobial Large Roll

*Tested at an Independent third party laboratory

tors for the National Pressure Ulcer Advisory Panel (NPUAP)2 and on theeditorial boards of several journals in the areas of ocular and skin woundhealing.3

Medline BIOGUARD® dressings are intended for use with:• Exuding wounds• First and second degree burns• Surgical wounds• Securing and preventing movement of a primary dressing• Wound packing

The dressings are available in many sizes and types, including rolls,sponges, packing strips, non-adherent pads and conforming bandages.Contact your Medline representative for further details.

Medline BIOGUARD barrier products act as a physical barrier to outsidecontaminants and do not act on the surface or the interior of the woundnor do they contain antimicrobial agents that act on the body. These dress-ings are not intended as a treatment for clinical infection. If signs of clinicalinfection are present, consult a physician. Available by prescription only.

Medline BIOGUARD Comparative Efficacy StudyLaboratory testing4 comparing the effectiveness of Medline BIOGUARDdressing versus Covidien AMD dressing showed the same log reductionagainst MRSA, Pseudomonas aeruginosa (PA) and VRE. The efficacyremains the same at 24 and even after 48 hours. All results indicate >5-logreduction of broad spectrum microbes.

Reference1. S Morrissey. Epidemiology: forging the future: microbe-busting bandages. Time. 2006; 167(12). Posted March 12, 2006. Available at: www.time.com/time/maga-zine/article/0,9171,1172215,00.html. Accessed November 9, 2010.

2. National Pressure Ulcer Advisory Panel Board of Directors 2010. Available at: www.npuap.org/about.htm. Accessed November 9, 2010.

3. University of Florida website. Biochemistry and Molecular Biology. Gregory Schultz, PhD. Available at: www.med.ufl.edu/IDP/BMB/bmbfacultypages/gschultz.html.Accessed November 9, 2010.

4. Data on file.

Bioguard is a registered trademark of Derma Sciences, Inc.

product spotlight

BioCon™- 500 Bladder Scanner Safely Measures Bladder VolumeMinimize unnecessary catheterizationResearch has shown that 80 percent of urinary tract

infections acquired at healthcare facilities are associated

with an indwelling urethral catheter.1 This type of infection

is known as CAUTI, or catheter-associated urinary tract

infection. What’s more, Medicare no longer reimburses

for treatment of CAUTI if it happens while a patient is

hospitalized, giving hospitals a major incentive to prevent it.

But how?

Avoiding unnecessary catheter use is a primary strategy

for preventing CAUTI, and clinical guidelines recommend

the consideration of alternatives to catheterization.2

Bladder scanners can be used in place of a urinary

catheter to assess bladder volumes, and many

catheterizations can be avoided.3

1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50.

2. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009.

3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Med/Surg Nursing. 2005; 14(4):249-253.

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.BioCon-500 is a trademark of Mcube Technology Co., Ltd.

To learn more about CAUTI prevention and the BioCon-500, visitwww.erasecauti.com/alternatives.aspor contact your Medline sales representative.

What did we do after designing a revolutionary new catheter tray system?

We found THREE more ways to make it even better.

We’re obsessed with engineering new and bettertechnology for healthcare workers. So after we revolutionized the outdated Foley catheter tray with a unique, one-layer system design, we immediatelyturned our attention to addressing how we couldmake it even easier to use. We studied how the tray was being used in the field. The result was three more great improvements.

Combined with the previous innovative tray redesignand comprehensive ERASE education, these threenew features help to improve patient safety and quality,while reducing avoidable costs associated with wasteand urinary tract infections.

To learn about the ERASE CAUTI system, as well asother strategies for minimizing the risk of CAUTI, signup for a free Innovation in the Prevention of CAUTI webinar at www.medline.com/erase/webinar.


A revised checklist for the medical recordThe reformatted checklist is smaller, making it easier to place in the paper chartor attach to the electronic medical record.

Education you’ll want to present to your patientThere’s nothing like the new Patient Education Care Card. Designed to lookand feel like a “Get Well Soon” card, ittells patients about catheterization sothey know you are providing them thebest care possible.

1

2

3

Real photography on the outside – so you know exactly what’s insideA photo on the package helps identify thecontents of the kit, serves as an educationaltool for the clinician and can be used todiscuss the procedure with the patient.Also, the label opens up to a booklet with step-by-step instructions and helpful tipsfor the clinician.


Ventilator-associated pneumonia (VAP)is a hospital-acquired infection that occurs in upto 27 percent of all mechanically ventilatedpatients.1 It is specifically defined as an airwayinfection that develops more than 48 hours after apatient is intubated.2

Among ICU patients, nearly 90 percent of episodesof hospital-acquired pneumonia occur duringmechanical ventilation.1 Because half of all episodesof VAP occur within the first four days of mechani-cal ventilation, it is especially critical to prevent thecondition all together.1 Reducing mortality due toventilator-associated pneumonia requires anorganized process that guarantees early recognitionof pneumonia and consistent application ofevidence-based practices.2

The Institute for Healthcare Improvement (IHI)advocates use of a bundle approach to help fightVAP. The ventilator bundle is a series of interventionsrelated to ventilator care that, when implementedtogether, achieves significantly better outcomes.2

The five components of the (IHI) Ventilator Bundle are:2

1. Elevating the head of the bed 30 degrees2. Daily “sedation vacations” and assessmentof readiness to extubate

3. Peptic ulcer disease prophylaxis4. Deep vein thrombosis prophylaxis5. Daily oral care with chlorhexidine

References1. Kollef MH. What is ventilator-associated pneumonia and why is it

important? Respiratory Care. 2005;50(6):714-724. Available at: www.rcjournal.com/contents/06.05/06.05.0714.pdf. Accessed November 4, 2010.

2. Implement the Ventilator Bundle. Institute for Healthcare Improvement (IHI) website. Available at: www.ihi.org/IHI/Topics/Criti-calCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm. Accessed November 4, 2010.

Five Step Approach for Avoiding

VAP


Patient Safety

1. Elevating the Head of the Bed 30 Degrees• Implement a mechanism to ensure head-of-the-bed elevation, such as including this intervention on nursing flow sheets and as a topic at multidisciplinary rounds.

• Create an environment where respiratory therapists work collaboratively with nursing to maintain head-of-the-bed elevation.

• Involve families in the process by educating them about the importance of head-of-the-bed elevation and encourage them to notify clinical personnel when the bed does not appear to be in the proper position.

• Use visual cues to easily identify when the bed is in the proper position.

• Include this intervention on order sets for initiation and weaning of mechanical ventilation, delivery of tube feedings, and provision of oral care.

2. Daily “Sedation Vacations” and Assessment of Readiness to Extubate • Implement a protocol to lighten sedation daily at an appropriate time to assess for neurological readiness to extubate. Include precautions to prevent self-extubation such as increased monitoring and vigilance during the trial.

• Include a “sedation vacation” strategy in your overallplan to wean the patient from the ventilator; if you have a weaning protocol, add “sedation vacation” to that strategy.

• Assess that compliance daily during multidisciplinary rounds.

• Consider implementation of a sedation scale (e.g., the Riker Scale) to avoid oversedation.

3. Peptic Ulcer Disease Prophylaxis • Include peptic ulcer disease prophylaxis as part of your ICU order admission set and ventilator order set. Make application of prophylaxis the default value on the form.

• Include peptic ulcer disease prophylaxis as an itemfor discussion on daily multidisciplinary rounds.

• Empower pharmacy to review orders for ICU patients to ensure that some form of peptic ulcer disease prophylaxis is in place at all times.

4. Deep Venous Thrombosis Prophylaxis • Include deep venous prophylaxis as part of your ICU order admission set and ventilator order set. Make application of prophylaxis the default value on the form.

• Include deep venous prophylaxis as an item for discussion on daily multidisciplinary rounds.

• Empower pharmacy to review orders for ICU patients to ensure that some form of deep venous prophylaxis is in place at all times.

5. Daily Oral Care with Chlorhexidine• Educate registered nurses (RNs) about the rationalesupporting good oral hygiene and its potential benefit in reducing ventilator-associated pneumonia.

• Develop a comprehensive oral care process that includes the use of 0.12% chlorhexidine oral rinse.

• Schedule chlorhexidine as a medication, which then provides a reminder for the RN and triggers oral care process delivery.

Source: www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/Implement-

theVentilatorBundle.htm

Tips for Complying with the VAP Prevention Bundle

VAPREVENT SYSTEM: Making it easier to avoid Ventilator-Associated PneumoniaEvidence-based innovation in oral care

Easy to identifywhich mouthwash the kit contains

IHI Checklist of activitiesto helpreduce VAP

Strongbuilt-in IV pole hanger

Compliance at a glance –clearly labeledand sequencedin the order they should be used

Thumb grip for easydispensing

To schedule your evaluation of the VAPrevent System, contact your Medline representative or call1-800-MEDLINE (633-5463).

Easy identificationof oral carefrequency

Clear visualidentificationof kit components

Recordstart time, date and patientinformation

VAPrevent is a comprehensive oral care system modeled after the guidelines ofthe Institute for Healthcare Improvement (IHI) Ventilator Bundle. It’s designed to address ventilator-associated pneumonia (VAP)—the second most common healthcare-associated infection1, affecting up to 40 percent of ventilator patients.2

The VAPrevent System brings you the three Ps to better oral care: the right productscombined with a comprehensive educational program at a value-added price.

ProductOnly Medline features these three options for oral care: IHI-recommendedchlorhexidine gluconate (CHG), the alcohol-free moisturizing of Biotene®, or the proven antisepsis of hydrogen peroxide. Color-coded packaging allows for quick identification, thorough caregiver education and simplecompliance. The system is designed to dispense each kit one-at-a-time in the right order at the right time.

ProgramProducts are only as beneficial as knowing how to use them appropriately.That’s why we also developed the Medline VAP Program, which helps buildyour staff’s knowledge and clinical skills with educational modules for noviceand experienced clinicians, as well as an online interactive competency for oralcare. We help you implement the program, and then provide you with 90-day reports to help you track your incidence of VAP.

PriceAll this – and a lower price! The cost of the VAPrevent System is five to 10 percent lower than competitors, who offer less comprehensive systems.

References1 Bingham M, Ashley J, De Jong M, Swift C. Implementing a unit-level intervention to reduce the probability of ventilator-associated pneumonia. Nursing Research. 2010; 59(1): S40-S47.

2 Trouillet J, Chastre J, Vuagnat A, Joly-Guillou M, Combaux D, Dombret M, et al. Ventilator-associated pneumonia cased by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998. 157(2):531-539.


Suction Toothbrush & Catheter Kit


Get Set for

WINTER ILLNESSSEASON

In much of the Northern Hemisphere, this is prime timefor colds, influenza (flu), and other respiratory illnesses.

While contagious viruses are active year-round, fall and winterare when we’re all most vulnerable to them. This is due in largepart to people spending more time indoors with others whenthe weather gets cold. The Food and Drug Administration(FDA) regulates medicines and vaccines that help fightwinter illnesses.

Colds and FluMost respiratory bugs come and go within a few days, with nolasting effects. However, some cause serious health problems.Although symptoms of colds and flu can be similar, the twoare different.

Colds are usually distinguished by a stuffy or runny nose andsneezing. Other symptoms include coughing, a scratchythroat, and watery eyes. No vaccine against colds existsbecause they can be caused by many types of viruses. Oftenspread through contact with mucus, colds come on gradually.

Flu comes on suddenly, is more serious, and lasts longer thancolds. The good news is that yearly vaccination can help pro-tect you from getting the flu. Flu season in the United Statesgenerally runs from November to April.

Flu symptoms include fever, headache, chills, dry cough, bodyaches, fatigue, and general misery. Like colds, flu can cause astuffy or runny nose, sneezing, and watery eyes. Young childrenmay also experience nausea and vomiting with flu.

Caring for Yourself


Prevention TipsGet vaccinated against flu. According to the Centers forDisease Control and Prevention (CDC):• More than 200,000 people in the United States are hospitalized from flu-related complications each year,including 20,000 children younger than age 5.

• Flu-associated deaths number in the thousands each year. Between 1976 and 2006, the estimated number offlu-related deaths every year ranged from about 3,000 to about 49,000.

Flu vaccine, available as a shot or a nasal spray, remains thebest way to prevent and control influenza. The best time to geta flu vaccination is from October through November, althoughgetting it in December and January is not too late. A new flushot is needed every year because the predominant flu viruseschange every year.

All people 6 months of age and older should be vaccinated.However, you should talk to your health care professionalbefore getting vaccinated if you• have certain allergies, especially to eggs• have an illness, such as pneumonia• have a high fever• are pregnant

Flu vaccination for health care workers is urged becauseunvaccinated workers can be a primary cause of outbreaks inhealth care settings. Certain people are more at risk for devel-oping complications from flu; they should be immunized assoon as vaccine is available. These groups include:• people 65 and older• residents of nursing homes or other places that house people with chronic medical conditions such as diabetes,asthma, and heart disease

• adults and children with heart or lung disorders,including asthma

• adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes),kidney dysfunction, a weakened immune system, or disorders caused by abnormalities of hemoglobin (a protein in red blood cells that carries oxygen)

• young people ages 6 months to 18 years receiving long-termaspirin therapy, and who as a result might be at risk for developing Reye’s syndrome after being infected with influenza (See aspirin information in the section “Taking OTC Products.”) Note that only one vaccine is neededfor the 2010-2011 influenza season.

During last flu season, two different vaccines were needed; oneto prevent seasonal influenza and another to protect againstthe 2009 H1N1 flu virus. This year’s seasonal flu vaccine pro-tects against three strains of influenza, including the 2009H1N1 flu virus.

Also, a vaccine specifically for people 65 years and older isavailable this year. Called Fluzone High-Dose, this vaccineinduces a stronger immune response and is intended to betterprotect the elderly against seasonal influenza.

This vaccine—which was approved by FDA in 2009—wasdeveloped because the immune system typically becomesweaker with age, leaving people at increased risk of seasonalflu-related complications which may lead to hospitalizationand death.

Wash your hands often. Teach children to do the same. Bothcolds and flu can be passed through coughing, sneezing, andcontaminated surfaces, including the hands.

CDC recommends regular washing of your hands with warm,soapy water for about 15 seconds.

Tips for Avoiding

WINTER BUGS:• Get vaccinated against flu

• Wash your hands often

• Limit exposure to infected people

• Keep stress in check

• Eat right

• Sleep right

• Exercise


FDA says that while soap and water are undoubtedly the firstchoice for hand hygiene, alcohol-based hand rubs may beused if soap and water are not available. However, the agencycautions against using the alcohol-based rubs when hands arevisibly dirty. This is because organic material such as dirtor blood can inactivate the alcohol, rendering it unable tokill bacteria.

Try to limit exposure to infected people. Keep infants awayfrom crowds for the first few months of life. This is especiallyimportant for premature babies who may have underlyingabnormalities such as lung or heart disease.

Practice healthy habits.• Eat a balanced diet.• Get enough sleep.• Exercise. It can help the immune system better fight off the germs that cause illness.

• Do your best to keep stress in check.

Also, people who use tobacco or who are exposed tosecondhand smoke are more prone to respiratory illnesses andmore severe complications than nonsmokers.

Already Sick? Usually, colds and flu simply have to be allowed to run theircourse. You can try to relieve symptoms without taking medi-cine. Gargling with salt water may relieve a sore throat. And acool-mist humidifier may help relieve stuffy noses.

Here are other steps to consider: • First, call your doctor. This will ensure that the best course of treatment can be started early.

• If you are sick, try not to make others sick too. Limit your exposure to other people. Also, cover your mouth with a tissue when you cough or sneeze, and throw used tissuesinto the trash immediately.

• Stay hydrated and rested. Fluids can help loosen mucus and make you feel better, especially if you have a fever. Avoid alcohol and caffeinated products. These may dehydrate you.

• Know your medicine options. If you choose to use medicine, there are over-the-counter (OTC) options that can help relieve the symptoms of colds and flu.

If you want to unclog a stuffy nose, then nasal decongestantsmay help. Cough suppressants quiet coughs; expectorantsloosen mucus so you can cough it up; antihistamines help stopa runny nose and sneezing; and pain relievers can ease fever,headaches, and minor aches.

In addition, there are prescription antiviral medicationsapproved by FDA that are indicated for treating the flu. Talk toyour health care professional to find out what will work bestfor you.

Taking OTC Products Be wary of unproven treatments. It’s best to use treatmentsthat have been approved by FDA. Many people believe thatproducts with certain ingredients—vitamin C or Echinacea, forexample—can treat winter illnesses.

3Things You Can Do:

1. Wash your hands often with soapand warm water.

2. Get vaccinated against the flu. 3. Choose over-the-counter medicinesthat treat only your specific symptoms.


©2010 Medline Industries, Inc. Medline is a registered trademarkand Remedy is a trademark of Medline Industries, Inc

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Unless FDA has approved a product for treatment of specificsymptoms, you cannot assume that the product will treat thosesymptoms. Tell your health care professionals about anysupplements or herbal remedies you use.

Read medicine labels carefully and follow directions. Peoplewith certain health conditions, such as high blood pressure,should check with a health care professional before taking acough and cold medicine. Some medicines can worsenunderlying health problems.

Choose appropriate OTC medicines. Choose OTC medi-cines specifically for your symptoms. If all you have is a runnynose, only use a medicine that treats a runny nose. This cankeep you from unnecessarily doubling up on ingredients, apractice that can prove harmful.

Check the medicine’s side effects. Certain medications suchas antihistamines can cause drowsiness. Medications caninteract with food, alcohol, dietary supplements, and each other.

The safest strategy is to make sure your health care profes-sional knows about every product you are taking, includingnonprescription drugs and any dietary supplements such asvitamins, minerals, and herbals.

Check with a doctor before giving medicine to children.Get medical advice before treating children suffering from coldand flu symptoms. Do not give children medication that islabeled only for adults.

Don’t give aspirin or aspirin-containing medicines to chil-dren and teenagers. Children and teenagers suffering fromflu-like symptoms, chickenpox, and other viral illnessesshouldn’t take aspirin.

Reye’s syndrome, a rare and potentially fatal disease foundmainly in children, has been associated with using aspirin totreat flu or chickenpox in kids. Reye’s syndrome can affect theblood, liver, and brain.

Some medicine labels may refer to aspirin as salicylate orsalicylic acid. Be sure to educate teenagers, who may takeOTC medicines without their parents’ knowledge.

When to See a Doctor See a health care professional if you aren’t getting any better orif your symptoms worsen. Mucus buildup from a viral infectioncan lead to a bacterial infection.

With children, be alert for high fevers and for abnormal behaviorsuch as unusual drowsiness, refusal to eat, crying a lot, holdingthe ears or stomach, and wheezing. Signs of trouble for all people can include • a cough that disrupts sleep • a fever that won’t go down • increased shortness of breath • face pain caused by a sinus infection • worsening of symptoms, high fever, chest pain, or a difference in the mucus you’re producing, all after feeling better for a short time

Cold and flu complications may include bacterial infections(e.g., bronchitis, sinusitis, ear infections, and pneumonia) thatcould require antibiotics.

Remember: While antibiotics are effective against bacterialinfections, they don’t help against viral infections such as thecold or flu.

Find this and other Consumer Updates at www.fda.gov/ForConsumers/ConsumerUpdates

Sign up for free e-mail subscriptions at www.fda.gov/con

Article courtesy of the Food and Drug Administration (FDA).

©2010 Medline Industries, Inc. Medline is a registered trademark and Liqui-Loc is a trademark of Medline Industries, Inc.

Introducing a fluid management system that saves time, adds convenience and reduces waste.

Medline Suction Canister with patent

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• FREE accessory program! Eligible customers may receive free suction canister carriers and holders.

Medline advanced Liqui-Loc solidifiers Dissolvable PVA packs are:• Safer - Add solidifier before the procedure, maintaining a closed system

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To request a sample of the advanced Liqui-Loc Solidifier in the PVA pack, send an e-mail to [email protected].


by Wolf J. Rinke, PhD, RD, CSP

Travel alerts, seemingly never ending natural and manmadedisasters, cranky patients bugging you…stress accelerat-ing at logarithmic speed! We certainly live in a very unsettlingand stressful time. A time where achieving inner pieceseems totally out of reach. And yet I have found that youcan attain it by relentlessly practicing the eight principlesthat follow.

1. Be honestBP, politicians, clergy … do I need tosay more? But before you get too smug,better look at the face in the mirror.Study after study has shown that mostpeople lie. We inflate our resumes,fudge our accomplishments and exag-gerate even inconsequential events.And when we lie there is no trust, and

without trust you can’t have solid relationships, withoutrelationships there is no love, and without love you won’thave inner peace. Call me old-fashioned; I believe there isno excuse for lying … none. There is not even a good rea-son for exaggerating. Because if you do, you will have totalk from the head, always checking your memory to makesure you are consistent. And who can keep track of that,when most of us have trouble remembering where we putour car keys. Only by getting in the habit of always tellingthe truth—especially if it is at your own expense—will you beable to talk form the heart and that will set you free. This inturn will enhance your leadership skills because peoplefollow people they can trust. And it will put you on the fasttrack in any endeavor. It will also enrich your personal rela-tionships and, most importantly, will get you to like andrespect yourself—the foundation for achieving inner peace.

2. Think empowering thoughtsAs a man thinkest, so he becomes, saysthe Bible. And yet most of the time weare totally inattentive to our thoughts.It’s almost like they run amok—totallyout of control—doing their own thing. Toachieve inner peace requires us to firstbecome aware of our thoughts—insteadof just letting them ruminate at the sub-

conscious level. Second we must ask ourselves: is this athought that empowers me and makes me stronger, or doesit make me feel mad, bad or sad? And third we must be-come aware that at any one nanosecond our minds canhold only one thought. It can be a positive thought that givesus inner peace and improves our quality of life, or it can bea negative thought that does just the opposite. It’s so sim-ple, yet difficult, to develop this powerful new awarenessand transform it into a habit.

3. Take advantage of the abundance all around youWhen we are struggling and having trou-ble making ends meet, it is really difficultto see the abundance. What we seeinstead—almost oppressively—is scarcity.I know firsthand. Having been born rightafter World War II in Germany, with myparents losing all their earthly posses-

sions—yes, everything—we had less than scarcity, we haddesperation. Finding enough food and shelter to keep usalive is what consumed my parents. Then some 17 yearslater—when I immigrated to the United States—scarcity,although not as extreme, reared its ugly head again. Basi-

8PrinciplesFor Achieving Inner Peace

Caring for Yourself


cally I only spoke a few words of English, had $20 in my pocketand the proverbial shirt on my back. And I certainly had troublefinding all “the milk and honey” that supposedly was just wait-ing for me. However, it was all around me, and over timeI learned to find it by internalizing a powerful concept that Ilearned from several different mentors: If you want more ofsomething, you have to give it first. I know it sounds counterin-tuitive. (By the way, lots of things are…otherwise men wouldride sidesaddle. If that didn’t at least make you smile, you’retaking this much too seriously.) Here is how it works: If you wantmore love in your life, give more love. If you want to be happier,make others happy. If you want people to trust you, giveunconditional trust. Of course the only way you can takeadvantage of this principle is to internalize the next one.

4. Take really great care of #1 firstGotcha! Especially if you are a cynic. Thosewho are cynics immediately translate thisinto selfishness, conceit and greed. Nothing;however, could be further from the truth.(Why do you suppose that in an emergency,you are told to put your oxygen mask onfirst, before you help anyone else, even yourown child?)

It’s also important to remember that you can’t give away whatyou don’t own. Going back to the previous paragraph. If youwant to love someone you must first love yourself, if you wantto be happier you must choose to be happy. It you want to trustsomeone…I’m sure by now you’re catching on.

Achieving inner peace requires you to begin to love who youare, not who you ought to be…by someone else’s standard,whether that’s your parents, spouse or friend. The unvarnishedfact is that at this very nanosecond you are who you are. Andno wishing, hoping or praying is going to change that one iota.Now, who you will become in the future will be determined byyour thoughts (see Principle #2), which in turn will drive theactions you take.

So begin right now to become your own best friend, because ifit is not you, who is it going to be? In addition to taking reallygreat care of your thoughts, also take extraordinary care of yourbody. And if you want to avoid psychosomatic illnesses—which,as you probably know, account for the majority of illnesses inthis country—then you must eat right—which means you learnto stop when it tastes the best. Get adequate rest—seven toeight hours of sleep is a great start—and do 25-30 minutes ofaerobic exercise three times per week, alternating with strengthtraining for the other three days. (Go ahead and take Sundayoff.) It also means that you don’t put stuff into your body thatdoes not belong there—read drugs and nicotine. (Please don’tyawn. This is important. You only will be given one body—a theone you’ve got is it. So treat it accordingly.)

5. Become your own creatorMovie directors, such as JamesCameron of Avatar, are geniuses at cre-ating exciting “realities.” You can be yourown “creator” once you realize that there isno reality. There is only perception. (No, Ihaven’t lost it.) Let me explain with a won-derful story: A young man was interviewingfor his dream job. He had done his home-

work. He spent hours on the Internet learning all he could aboutthe hospital of his choice and the people he was going to beinterviewing with. He had read the last three annual reports andknew the hospital’s mission, vision and core values by heart.In short he was ready to ace this interview. On the big day, heentered the impressive lobby of the hospital and had to checkin with the security guard to get his visitor badge. Wanting toleave no stone unturned he said to the elderly gentleman behindthe desk, “Sir, I’m interviewing for my dream job today. Tell meabout the people at this hospital. What are they like?”The elderly man replied with a question. “Tell me young man,what were the people like at the last hospital you worked for?”“Oh, they were deceitful, unsupportive and mean. There simplywas no vestige of teamwork or joy. In fact that’s why I left.”“Well,” the security guard answered, “I believe you will find thesame kind of people here.”

8 Principles For Achieving Inner Peace


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Just about an hour later the scene repeated itself all over again.Except this time it was a young lady who was also interviewingfor the same job. She, too, had done her homework andwanted to make a great impression. She also asked the secu-rity guard, “What are the people like around here?”In turn, he asked, “What were they like where you came from?”The vivacious young lady answered, “Oh, I just loved the peopleat my former hospital. They were kind, supportive and hard-working. Everyone worked together as a team. We cared somuch for each other that I developed some of the best friend-ships. It’s really a shame that my husband is relocating to thisarea. I just hate to leave all those wonderful people behind.”“Well,” the wise elderly man answered, “I believe you will findthe same kind of people here.”

6. Let go of the pastIt’s amazing how much we mental energywe spend in a place over which we haveabsolutely no control—the past. It was Dr.Wayne Dyer who likened our past to a bagof manure that we carry around with us. Wekeep putting more and more manure intothe bag. Once in a while we put the bagdown, reach in and smear manure all over

us. And then, we wonder why our life stinks. Part of what wecarry around in our bag is resentment, hate and blame. All ofthese emotions will attack our souls and diminish the quality ofour spirit and our physiology.

Instead, go ahead pay tribute to your past. Visit it. And thentoss it in the trash. You can make that happen by taking own-ership of all that is going on in your life. Your life is not a func-tion of what other people have done to you; it is today what itis because of the choices you have made in the past. And ifyour feelings of resentment, hate and blame are attributed tothe actions of others, then you have to wait for those people tochange—which may never happen. And don’t even try tochange them! Think about how many of us have difficultychanging ourselves, let alone others. Instead live by the axiom:If it is to be it is up to me. Once you’ve done that, you are readyto take it to the next level by substituting the emotions of love,empathy and kindness for resentment, hate and blame, whichwill put you on the fast track to inner peace.

And while you are at it, force yourself to get off your case, quitliving in the past, and become future-oriented by learning fromevery action. If an action gives you the results you desired, keepdoing it. If the action did not accomplish the intended result,


review what happened; make a commitment to do it differentlyin the future, then quit doing it and let it go. No wait, I meanreally let it go. Get on with your life by refocusing your thoughtson the only moment you and I have any control over, the now.

7. Kill your egoEgo, right along with greed and envy, is oneof the most powerful destroyers of innerpeace. A look at history confirms that theseemotions are responsible for more evil.Think Napoleon, Stalin and Hitler—and morecorporate catastrophes. Think Toyota’s andeven venerable Johnson & Johnson’s recentrecalls—as well as relationship killers. Andyet we can get rid of our ego with just five

powerful phrases expressed liberally and from the heart:• You are right about that. Any time you get into a conflict,use this phrase and you will have no more conflict—guaranteed!

• I’ve made a mistake. This phrase helps you get off your high horse gracefully. All human beings make mistakes—and since you are a…I think you get it. There is only one omnipotent force in the universe—and it is not you. So quit defining unrealistic expectations for yourself.

• I changed my mind. You are an evolving human being, one who is like red wine and gets better all the time. That means you have to let go of your past beliefs. (Remember that the only person who can change his/her mind is the one who has one.)

• I don’t know. Admit it. You don’t know everything. It lets other people know that you have high levels of self-esteem.(Only people who are OK inside of their own skin can admit they don’t know everything.)

• Let’s agree to disagree. The phrase to use if all else fails. By the way, do try all five of these at home; the positive results will astound you.

8. Never give up on your dreamsThe purpose of life is not to make it safely tothe grave. Pursue your dreams no matterhow late or how “weird.” Let me share anexample. Doris Haddock had a passion. Shefelt that Congress needed to get off theirduff and change the campaign financelaws! Unlike most of us; however, Doris didnot sit around and complain and whine.Instead, Doris started to walk from

Pasadena, Calif.; walking 10 miles a day, every day. Fourteenmonths and 3,200 miles later she arrived in Washington, DC.Now, here comes the startling part of the story. Doris, betterknown as Granny D, had a severe case of arthritis, wore a braceand turned 90 years “young” while on the trail. And for an addedmeasure, she was arrested twice demonstrating for her beliefs.Why? Because she had a dream and a passion. So whateveryou do, don’t ever give up on your dreams, it’ll make youcranky. Instead, get off your butt and act on your dreams today,and you, too, will be on the road to achieving the most covetedof all possessions—inner peace.

© 2010 Wolf J. Rinke

Dr. Wolf J. Rinke, RD, CSP is a keynotespeaker, seminar leader, management con-sultant, executive coach and editor of the freeelectronic newsletter Read and Grow Rich,available at www.easyCPEcredits.com. Inaddition he has authored numerous CDs,DVDs and books including Make It a WinningLife: Success Strategies for Life, Love andBusiness, Winning Management: 6 Fail-Safe

Strategies for Building High-Performance Organizations and Don’tOil the Squeaky Wheel and 19 Other Contrarian Ways to ImproveYour Leadership Effectiveness; available at www.WolfRinke.com.His company also produces a wide variety of quality pre-approvedcontinuing professional education (CPE) self-study courses, avail-able at www.easyCPEcredits.com, including his Beat the Blues:How to Manage Stress and Balance Your Life, approved for 28CPEUs, from which this article was extracted. Reach him [email protected].

At home, at work or on the go…earn free CE credits It’s even easier to maintain licensure and certificationand validate competencies! All Medline Universitycourses are now available as free iPhone® and iPodtouch® apps that can be downloaded from TheApple® Store.

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Pink Glove Dance: The SequelPGD2

From Halifax, Novia Scotia to San Francisco, Califor-nia, Medline traveled across North America in 2010showcasing the spirit of breast cancer survivors andcaregivers who performed in the Pink Glove Dance:The Sequel. To see videos of Pink Glove Dancers inaction visit www.pinkglovedance.com.

Pink Gloves for a CauseOur goal is to create a Pink Glove Nation – that is, getas many people as possible talking about breast can-cer and to raise awareness for early detection. To thatend, partial proceeds from our pink gloves and otherpink ribbon products are donated to the NationalBreast Cancer Foundation (NBCF) to help fund mam-mograms for women who cannot afford them.

Medline presents a donation check to the NBCFeach year during the Breast Cancer Awareness Break-fast at the Association of periOperative Nurses(AORN) Congress.

Thank you, Pink Glove Dancers, for welcoming us toyour city!• New York, NY• Chicago, IL• San Francisco, CA• Indianapolis, IN• Minneapolis, MN• Richmond, VA• Tallahassee, FL• Newark, NJ

• La Jolla, CA• Portland, OR• New Orleans, LA• Denver, CO• Halifax, Novia Scotia• Plano, TX• Baltimore, MD

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Providence St. Vincent Medical Center. Portland, OR

New York City Survivors at Times Square. New York, NY

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San Francisco Survivors at the Golden Gate Bridge. San Francisco, CA

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Healthy Eating

1 lb. lean ground beef1 lb. lean ground turkey4 teaspoons chili powder1 teaspoon ground cumin1 large onion, chopped2 jalapeno peppers, chopped

1 green pepper, chopped4 teaspoons minced garlic1 16-ounce can tomato sauce1 16-ounce can diced tomatoes1 15-ounce can chili with beans1 6-ounce can tomato paste

1 15-ounce can kidney beans1 15-ounce can spicy chili beans1 bottle beer1 teaspoon black pepper (or to taste)Hot sauce to taste

Directions:Place ground beef and ground turkey in a large skillet, along with1 teaspoon chili powder and 1 tsp. ground cumin. Cook untilcrumbled and brown. Drain and place in crock pot.

Spray empty skillet with cooking spray. Saute onion, garlic,jalapenos and green pepper until tender. Place in crock pot. Addtomato sauce, diced tomatoes, beer, chili with beans andtomato paste. Simmer 20 minutes on high setting.

Add kidney beans, chili beans, 3 teaspoons chili powder, pepperand hot sauce and simmer at least 30 minutes.

“I find the longer it simmers, the better thetaste, so after the last round of ingredientsare added, I let it simmer on low for 6 to 8hours,” Jennifer said.

Senior Product Specialist JenniferSutschek, who has worked Medline’scorporate headquarters in Mundelein, Ill.since 1998, won second place for this

recipe in Medline’s 2010 Chili Cookoff. She offers productexpertise for Medline customers, sales representatives and cus-tomer service reps in the areas of diabetic testing, diagnostics,sharps containers, over-the-counter medications, enterals, oralcare, ReadyBath and wet wipes.

Jennifer originally found her chili recipe in one of her husband’sfitness magazines, and they have tweaked it a little over theyears to get it just right.

“It’s a healthier chili recipe, made with lean meat,” she said. You’llalso notice that the onions and peppers are sautéed with cookingspray rather than oil.

Jennifer has always enjoyed cooking, having learned by watchingher mother from the age of six. Her favorite meals includeseafood with lots of butter and garlic.

In addition to cooking, Jennifer, who lives on Illinois’ ChainO’Lakes with her husband and two children, enjoys watersports, such as boating, and in the winter months, sheenjoys snowmobiling and skiing.

Crock Pot Chili

Nutrition Information

Servings: 6Calories: 749Fat: 19.5 gSodium: 1427 mgFiber: 21.8 g


Forms & Tools

The following pages contain practical tools for implementing patient-focused care practices

at your facility.

Surgical SafetyAORN Surgical Time Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99SCOAP Surgical Safety Checklist - Ambulatory Surgery . . . . . . .100SCOAP Surgical Safety Checklist . . . . . . . . . . . . . . . . . . . . . . . .101Wrong-Site Surgery Prevention Tool . . . . . . . . . . . . . . . . . . . . . .103

Patient EducationMedicare & the New Healthcare Law . . . . . . . . . . . . . . . . . . . . .105Tips for Safer Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109Caring for Your Surgical Incision at Home . . . . . . . . . . . . . . . . . .111

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TIME OUT

I COMMIT TO SUPPORT

FOR EVERY PATIENT, EVERY TIME

NAME: _______________________________________

DATE: ________________________________________

The use of Time Out is recommended by the Association of periOperative Registered Nurses (AORN),the Joint Commission Universal Protocol, and the World Health Organization (WHO). For more information on Time Out and how it can save patient lives, visit aorn.org.

Surgical Time Out Forms & Tools


Ambulatory Surgery Version 1.1

Adapted from the WHO "Safe Surgery Saves Lives" campaign and the WASCA/Proliance Surgeons Surgical Checklist SCOAP is a program of the Foundation for Health Care Quality

www.scoapchecklist.org rev 1/19/2010

Step 1: Prior to Incision ALL TEAM MEMBERS STOP ACTIVITY AND BEGIN CHECKLIST

Team Members introduce themselves (when personnel have changed)

Introduce patient, verify consent, procedure

Confirm site marked and if there is a single or multiple operative field

Anesthesia Team Reviews

Airway issues or other patient-specific concerns (special meds, health conditions affecting recovery, etc.)

Patient allergies reviewed N/A

Antibiotics given within 60 mins before incision N/A

Surgeon Reviews

Brief description of procedure and anticipated difficulties

Describe implants needed, unusual instruments OR supplies N/A

Confirm that essential imaging is displayed and correctly oriented N/A

Nursing Team Reviews

Confirm that supplies and implants are available N/A

If using an implant, confirm expiration dates N/A

Step 2: Process Control IF PROCEDURE IS EXPECTED TO BE LONGER THAN ONE HOUR:

Active warming in place N/A

Glucose checked for diabetic patients N/A

VTE prophylaxis N/A

Step 3: Debriefing—At Completion of Case (Surgeon and Nursing) Before closure: Confirm that instrument, sponge, and needle counts correct

If counts incorrect, confirm x-ray negative

(Surgeon and Nursing) Confirm specimen, label & instructions to pathologist N/A

(All) Confirm name of procedure

(All) Equipment issues to be addressed? No Yes, and response plan formulated (Who/When)

(All) What could have been better? Nothing Something, with plan to address (Who/ When)

(Surgeon and Anesthesia) Key concerns for recovery (e.g., plan for pain management, nausea/vomiting)

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Forms & Tools Surgical Checklist


SCOAP Surgical Checklist Version 3.7 (July 2010)

Before Skin Incision: Briefing

All Team Members (Attending Surgeon Leads) :

Each person introduces self by name and role

Surgeon, Anesthesia team and Nurse confirm patient (at least 2 identifiers), site, procedure

Personnel exchanges: timing, plan for announcing changes

Description of procedure and anticipated difficulties

Expected duration of procedure Expected blood loss & blood availability Need for instruments/supplies/IV access beyond those normally used for the procedure

Questions/issues from any team member and Invitation to speak up at any time in the procedure

Nursing/Tech reviews: Equipment issues (instruments ready, trained on, requested implants available, gas tanks full)

Sharps management plan Other patient concerns

Anesthesia reviews: Airway or other concerns Special meds (beta blockers, etc.)

Allergies Conditions affecting recovery

Process Control

All cases:

Surgeon reviews (as applicable): Essential imaging displayed; right and left confirmed

Antibiotic prophylaxis given in last 60 minutes

Active warming in place Special instruments and/or implants

If case expected to be 1 hour, add:

Surgeon reviews: Glucose checked for diabetics

Insulin protocol initiated if needed DVT/PE chemoprophylaxis and/or mechanical prophylaxis plan in place

If patient on beta blocker, post-op plan formulated

Re-dosing plan for antibiotics Specialty-specific checklist

Just Before Closure of Operative Field No Retained Objects

Attending Surgeon : Perform methodical visual and physical sweep of the wound

Nursing/Tech : All music, conversation, and distractions halted Perform preliminary count of needles/sponges/instruments

Show Surgeon and Anesthesia all sponges and laps in holders (“Show Me Ten”)

After Skin Closure Complete: No Retained Objects, Debriefing, Care Transition

All Team Members (Attending Surgeon Leads) : Confirm final needles/sponges/ instruments count correct Nursing/Tech show Surgeon and Anesthesia all sponges and laps in holders (“Show Me Ten”)

Confirm name of procedure If specimen, confirm label and instructions (e.g., orientation of specimen, 12 lymph nodes for colon CA)

Equipment issues to be addressed? Response planned (who/when)

What could have been better? Improvement planned (who/when)

Surgeon and Anesthesia : Key concerns for patient recovery

What is the plan for pain management? What is the plan for prevention of PONV? Does patient need special monitoring (time in RR, ICU, tele?)

If patient has elevated blood glucose, plan for insulin drip formulated

If patient on beta blocker, post-op continuation plan formulated

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Surgical Checklist Forms & Tools

Arglaes provides:

• Antimicrobial protection for up to 7 days• Moist wound healing• Fewer dressing changes• Non-attaining assay• Transparency for wound monitoring

The Arglaes family of products has something for every incision:

• Arglaes Film is ideal for managing bacterial penetration on post-op incision and line sites.

• Arglaes Island features a calcium alginate pad for fluid management in addition to controlled-release silver.

ARGLAES® IN THE ORAANNTTIIMMIICCRROOBBIIAALL SSIILLVVEERR TTEECCHHNNOOLLOOGGYY

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.Arglaes is a registered trademark of Giltech Limited Corporation.

Use silver to fight bacteria and surgical site infections

To schedule a FREE demonstration of Arglaesin your OR, contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com.

2010

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Wrong-Site Surgery Forms & Tools

2010

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Forms & Tools Wrong-Site Surgery

MAY 2010

C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S

Medicare and the New Health Care Law — What it Means for You

A Message from Kathleen Sebelius, Secretary of Health & Human Services

� e A� ordable Care Act passed by Congress and signed by President Obama this year will provide you and your family greater savings and

increased quality health care. It will also ensure accountability throughout the health care system so that you, your family, and your doctor—not insurance companies—have greater control over your care. � ese are needed improvements that will keep Medicare strong and solvent. Your guaranteed Medicare bene� ts won’t change—whether you get them through Original Medicare or a Medicare Advantage plan. Instead, you will see new bene� ts and cost savings, and an increased focus on quality to ensure that you get the care you need. � is brochure provides you with accurate information about the new services and bene� ts to help you and your family now and in the future. � e Centers for Medicare & Medicaid Services (the federal

agency that runs the Medicare, Medicaid, and Children’s Health Insurance Program) will continue to provide you with up-to-date information about these new bene� ts and will ensure that your personal information is safe. Remember—rely on your trusted sources of information when it comes to accurate information about Medicare, and don’t hesitate to call 1-800-MEDICARE or go on-line at Medicare.gov if you have questions or concerns. Don’t give your personal Medicare information to anyone who isn’t a trusted source.


Patient Handout - Medicare Forms & Tools

2

HEALTH CARE LAW

What Stays the Same

The guaranteed Medicare benefits you currently receive will remain the same. During open enrollment this fall, you will continue to have a choice between Original Medicare and a Medicare Advantage plan. Medicare will continue to cover your health costs the way it always has, and there are no changes in eligibility. But, there are some important benefits that you and your family can take advantage of starting this year. Look for more details in your Medicare and You Handbook coming this fall.

Improvements in Medicare You Will See Right Away

More Affordable Prescription Drugs• If you enter the Part D “donut hole” this year, you will receive a one-time, $250 rebate check if you

are not already receiving Medicare Extra Help. These checks will begin mailing in mid-June, and will continue monthly throughout the year as beneficiaries enter the coverage gap.

• Next year, if you reach the coverage gap, you will receive a 50% discount when buying Part D-covered brand-name prescription drugs.

• Over the next ten years, you will receive additional savings until the coverage gap is closed in 2020.

Important New Benefits to Help you Stay Healthy • Next year you can get free preventive care services like colorectal

cancer screening and mammograms. You can also get a free annual physical to develop and update your personal prevention plan based on current health needs.

Improvements to Medicare Advantage • Today, Medicare pays Medicare Advantage insurance companies over

$1,000 more per person on average than Original Medicare. These additional payments are paid for in part by increased premiums by all Medicare beneficiaries—including the 77% of seniors not enrolled in a Medicare Advantage plan.

• The new law levels the playing field by gradually eliminating Medicare Advantage overpayments to insurance companies.

• If you are in a Medicare Advantage plan, you will still receive guaranteed Medicare benefits.

• Beginning in 2014, the new law protects Medicare Advantage members by taking strong steps to ensure that at least 85% of every dollar these plans receive is spent on health care, rather than administrative costs and insurance company profits.


Forms & Tools Patient Handout - Medicare


HEALTH CARE LAW

Improvements in Medicare You Will See Soon

Better Access to Care • Your choice of doctor will be preserved.• The law increases the number of primary care doctors, nurses, and physician assistants to provide better

access to care through expanded training opportunities, student loan forgiveness, and bonus payments.• Support for community health centers will increase, allowing them to serve some 20 million new patients.

Better Chronic Care • Community health teams will provide patient-centered care so you won’t have to see multiple

doctors who don’t work together. • If you’re hospitalized, the new law also helps you return home successfully—and avoid going back—by

helping to coordinate your care and connecting you to services and supports in your community.

3

Improvements Beyond Medicare That You and Your Family Can Count On

Improves Long-Term Care Choices • New tools and resources in the Elder Justice Act, which was included in

the new law, will help prevent and combat elder abuse and neglect, and improve nursing home quality.

• The new law creates a new voluntary insurance program called CLASS to help pay for long-term care and support at home.

• Individuals on Medicaid will receive improved home- and community-based care options, and spouses of people receiving home- and community-based services through Medicaid will no longer be forced into poverty.

Helps Early Retirees • To help offset the cost of employer-based retiree health plans, the new law creates a program to preserve

those plans and help people who retire before age 65 get the affordable care they need.

Helps People with Pre-existing Conditions • The new law provides affordable health insurance through a transitional high-risk pool program for

people without insurance due to a pre-existing condition. • Insurance companies will be prohibited from denying coverage due to a pre-existing condition for

children starting in September, and for adults in 2014.• Insurance companies will be banned from establishing lifetime limits on your coverage, and use of

annual limits will be limited starting in September.

Expands Health Coverage for Young People • Young people up to age 26 can remain on their parents’ health insurance policy starting in September.


Patient Handout - Medicare Forms & Tools

HEALTH CARE LAW

For More Information

4

CMS Product No. 11467

The New Law Preserves and Strengthens Medicare

New Tools to Fight Fraud and Protect Your Medicare Benefits • The new law contains important new tools to help

crack down on criminals seeking to scam seniors and steal taxpayer dollars.

• It reduces payment errors, waste, fraud, and abuse to make Medicare more efficient and return savings to the Trust Fund to strengthen Medicare for years to come.

• You are an important resource in the fight against fraud. Be vigilant and rely only on your trusted sources of information about your Medicare benefits.

• Call 1-800-MEDICARE if you have any questions or want to report something that seems like fraud.

Keeps Medicare Strong and Solvent • Over the next 20 years, Medicare spending will

continue to grow, but at a slightly slower rate as a result of reductions in waste, fraud, and abuse. This will extend the life of the Medicare Trust Fund by 12 years and provide cost savings to those on Medicare.

• In 2018, seniors can expect to save on average almost $200 per year in premiums and over $200 per year in co-insurance compared to what they would have paid without the new law.

• Upper-income beneficiaries ($85,000 of annual income for individuals or $170,000 for married couples filing jointly) will pay higher premiums. This will impact about 2% of Medicare beneficiaries.

For more information about the new health care law now, visit www.medicare.gov. If you have any questions, call 1-800-MEDICARE (1-800-633-4227) or your State Health Insurance Assistance Program (SHIP). Visit www.medicare.gov or call 1-800-MEDICARE to get their telephone

number. TTY users should call 1-877-486-2048. If you need help in a language other than English or Spanish, say “Agent” at any time to talk to a customer service representative. Visit the Eldercare Locator at www.eldercare.gov to find out how to access home- and community-based services and benefits counseling, transportation, meals, home care, and caregiver support services. You can also call 1-800-677-1116. The Eldercare Locator, a public service of the U.S. Administration on Aging, is your first step for finding local agencies in every U.S. community.


Forms & Tools Patient Handout - Medicare

s

.

s

.


Forms & Tools Patient Handout

OR ConnectionThe

Aligning practice with policy to improve patient care

Subscribing to The OR Connection guarantees that you’llcontinue to receive this info-packed magazine and won’t missout on our industry updates and articles addressing on-the-job issues and tips on caring for yourself!

To subscribe, simply go to www.medline.com/orconnection.You will need to provide:Your nameFacility and positionMailing addressE-mail address

Never miss an issue of The OR Connection!Subscriptions are free and signing up is a snap!

We also welcome any suggestions you might have on how we can continue to improveThe OR Connection! Love the content? Want to see something new? Just let us know!

Content KeyWe've coded the articles and information in this magazine to indicate which patient careinitiatives they pertain to. Throughout the publication, when you see these icons you'llknow immediately that the subject matter on that page relates to one or more of thefollowing national initiatives:• IHI's Improvement Map• Joint Commission 2009 National Patient Safety Goals• Surgical Care Improvement Project (SCIP)

We've tried to include content that clarifies the initiatives or gives you ideas and toolsfor implementing their recommendations. For a summary of each of the initiatives,see pages 10 and 11.


Bathing and ShoweringMost incisions should be kept dry for several days after surgery, except for incisions closedwith surgical glue. It is usually safe to allow glued incisions to get wet while showering orbathing. It is important, however, to dry the area around the incision carefully after washing.

Physical Activity and ExerciseAvoid any activity that pulls on the edges of the incision or puts pressure on it. Walking andother light activities are encouraged to restore normal energy levels and digestive functions.Do not, however, participate in sports, engage in sexual activity or lift heavy objects until afteryour postoperative checkup.

AspirinAvoid aspirin or over-the-counter medications containing aspirin for a week to 10 days aftersurgery. Aspirin interferes with blood clotting and makes it easier for bruises to form nearthe incision.

Sun ExposureAs an incision heals, the new skin that forms over the cut is very sensitive to sunlight andwill burn more easily than normal skin and lead to worse scarring. Keep the incision areacovered from direct sun exposure for three to nine months in order to prevent burning andsevere scarring.

General HygieneInfection is the most common complication of surgical procedures. It is important, therefore,to minimize the risk of an infection when caring for your incision at home.

Observe the following precautions:• Wash your hands carefully after using the toilet and after touching or handling trash;

pets and petequipment; dirty laundry and anything else that is dirty or has been used outdoors

• Ask family members, close friends, and others to wash their hands before contactwith you

• Avoid contact with family members and others who are sick or recovering from acontagious illness

• Stop smoking (smoking slows down the healing process)

Adapted from www.surgeryencyclopedia.com/Fi-La/Incision-Care.html


Caring for Your Surgical Incision at HomeThe following are general guidelines. Consult your surgical team for more specific instructions.

©2010 Medline Industries, Inc. Medline andRemedy are registered trademarks of MedlineIndustries, Inc.

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OR Connection Magazine - Volume 5; Issue 4

Documents

Transcript of OR Connection Magazine - Volume 5; Issue 4