OR Connection Volume 7 Issue 3

TheAligning practice with policy to improve patient care

Volume 7, Issue 3

VOLUME 7, ISSUE 3

THE OR CONN

ECTION

w

Startling SSI Statistics

2012 Pink Glove Dance Video

Competition Winners! Page 80

5 Tips for Reducing Perioperative

Pressure Ulcers

Escape FireU.S. Health Care in Crisis

Free CE!Page 29Atul Gawande:

Can Health Care BeRun Like a Restaurant?

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CoverIn this issue, general and endocrine surgeon, writer, public health researcher and professor Atul Gawande shares his article, Big Med, in which he compares health care to a restaurant chain. Dr. Gawande has been a staff writer for The New Yorker magazine since 1998. He has also written three New York Times bestselling books: Complications, Better and The Checklist Manifesto. He has won two National Magazine Awards, AcademyHealths Impact Award for highest research impact on health care, a MacArthur Award, and selection by Foreign Policy Magazine and Time magazine as one of the worlds top 100 influential thinkers.

Aligning practice with policy to improve patient care 3

About MedlineMedline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 800 dedicated sales representatives nationwide to support its broad product line and cost management services.

2012 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Contents

16

29

20

80

Escape Fire. This eye-opening new documentary reveals the sad state of health care in the United States and how it is linked to financial incentives.

Surgical Site Infections Following Orthopedic Surgery. Learn new ways to stop the staggering numbers of preventable SSIs and related death and disability.

Big Med. Restaurant chains have managed to combine quality control, cost control and innovation. Can health care?

2012 Pink Glove Dance Video Competition Winners! Lexington Medical Center takes first place, winning $10,000 for the Vera Bradley Foundation for Breast Cancer.

Editor

Sue MacInnes, RD

Senior Writer

Carla Esser Lake

Creative Director

Michael A. Gotti

Clinical Team

Jayne Barkman, BSN, RN, CNOR

Lorri Downs, BSN, MS, RN, CIC

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

Joan Ferrara, BA, RN, CNOR

Kimberly Haines, RN, Certified OR Nurse

Rebecca Huff, MSN, RN

Angel Trichak, BSN, RN, CNOR

Perioperative Advisory Board

Garry Crawford, MS, RN, CNORNorman Regional Health System, Oklahoma

Evangeline Dennis, RN, BSN, CNOR, CMLSOSpivey Station Surgery Center, Georgia

Linda Groah, MSN, RN, CNOR, NEA-BD, FAANAssociation of PeriOperative Registered Nurses, Colorado

Darvina L. Heichemer, BSN, CNORGwinnett Medical Center Duluth, Georgia

Vivienne P Kaplan, RNAnaheim Regional Medical Center, California

Colleen Mattioni, MBA, RN, CNORHospital of the University of Pennsylvania, Pennsylvania

Julieann McIntyre, MSN, RN, CNORSouth Shore Hospital, Massachusetts

Susan A Miller, MSN, RN, CNORSt. Lukes Hospital, Missouri

Susan S Phillips, MSH, RN, CNORUNC Hospitals, North Carolina

Jo Quetsch, MA, RN, NE-BCProvidence Sacred Heart Medical Center, Washington

Eleonora Shapiro, BSN, MHA, CNORMount Sinai Medical Center, New York

Pat Thornton, MS, RN, CNORSouthern Regional Medical Center, Georgia

Judith A. Townsley, MSN, RN, CPAN Christiana Care Health System, Delaware

Pat Thornton, MS, RN, CNORSouthern Regional Medical Center, Georgia

Judith A. Townsley, MSN, RN, CPAN Christiana Care Health System, Delaware

FREE CE!

4 The OR Connection

Page 8

Page 44

Page 55

Page 49

Page 104

Patient Safety

41 Five Ways to Avoid Perioperative Pressure Ulcers

44 Nine Sources of Danger with Patient Controlled

Analgesia Pumps

OR Issues

29 Surgical Site Infections Following

Orthopedic Surgery

42 Perioperative Process Change to Reduce

the Risk of Post-Operative Infection Following

Orthopedic Procedures

55 Scalpel Safety; Staying Safe While Working on

the Cutting Edge

Special Features

8 A New Year in Health Care: How Healthcare Re-form Will Affect You and Your Hospital in 2013

16 Escape Fire 20 Big Med 49 Whats Your Cleaning and Disinfection IQ? 69 Evidence for the Validity of the Medline Pressure

Ulcer Prevention Program 80 Pink Glove Dance Video Competition

2012 Winners

Caring for Yourself

78 New Study Identifies Four Subtypes

of Breast Cancer

84 Beat the Winter Blues

104 Healthy Eating: White Bean Chicken Chili

Forms & Tools

106 CMS FY 2014-2016 Measures for CMS

Payment Determination

108 Pros and Cons of Common Sterilization

Technologies

109 PCA Patient Safety Checklist

111 Now You See It, Now You Dont

112 Ambulatory Surgery Patient Safety Checklist

(Pre-Operative)

113 Ambulatory Surgery Patient Safety Checklist

(Post-Operative)

115 Sharps Safety Begins with You

Beat the Winter Blues, page 84


For the first time in a very long time I wrote an article for The OR Connection. The article is about healthcare reform and trends we are seeing for 2013. After I wrote it, I sent it to several people who would not necessarily know the ins and outs of the topicl wanted feedbackhow do you make a dry subject interesting. I got feedback all rightall of it helped, but the underlying mes-sage was that for many of us we just have a hard time with the details of legislation. Any legislation.

But I just couldnt help myself. I wanted to know more. I feel it is important to understand what is going on and how we fit. I want to tell you things I found out and discuss areas that are clearer to me now. It would be a lot more entertaining to read a good novel, but we need to know this stuffits our job, and how else can we make a difference if we dont know what is going on?

I went to dinner about a month ago with my friend Dale Bratzler. He had come to Chicago for a meeting so I decided to drive downtown to meet him for dinner before he had to leave for the airport. We went to Petterinos, a Chicago feeling restaurant in the Theater area. Usually, it is very crowded but it was 5pm and the place was pretty empty. Dale formerly was the CMO of the Oklahoma Foundation for Medical Quality (the national Quallity Improvement Organization (QIO) for hospitals). He led the SCIP project, he is a member of HICPAC. In short, he knows his stuff. Currently, he oversees the physicians at the Univer-sity of Oklahoma and teaches. We talked about physicians and medical schools and different areas working together.

It was when we were leaving the restaurant that he told me about a film that he showed his medical students. He was quite passionate about it and said, Sue you are going to really like this film. Oh boy, was he right. So, as part of our research you have to look at pages 16 and 17. Because after I give you the

healthcare reform story, you have got to see this movie. Start with the trailer, and you will get excited too. The movie is called Escape Fire. After seeing it, you will want to save the world. You will want to push innovation. You will see your role in health care differently I promise you.

Once again I cant help myselfI have included in this issue an article called Big Med by Atul Gawande. My staff thought it was too long, so they cut the 17-page article down to about 5 pages. As I was reviewing itIm thinking where is the good stuff in this article.what about the story about the Cheesecake Factory? And I made them put the whole article back in. I know, yikes. But I had to do it. It was that good. I just put most of it in the back so if you really dont want to read it, you dont have to, but its there.

Im giving you just a few of the things I learned in looking into health care reform, but there is so much more. We are fortunate to be a part of an evolving system. Yes right smack in the middle of change. We are going to be challenged with thinking smarter, of doing more with less, of being innovative, etc. because the way things have been done in the past arent going to work in the future. Arent you glad that you have a part in molding the future?

2013 is a year of change. Health care the way we have known it will begin to transform and have a new identity. And we are all lucky enough to be a part of it. Here is to the New Year!See you in San Diego in March at the Breast Cancer Breakfast during the AORN meeting!

Cheers!

Sue

The OR Connection Letter from the Editor

Dear Readers,Over the last month or so, Ive been on a mission to research and really understand healthcare reform and what it means to you and me and the organizations that we work for. Along the way, Ive had some Gidget moments where I think to myself, how did I get here? Im meeting people and having experiences I wouldnt have thought possible years ago. Ive been to The Forbes Healthcare Summit, Strategic Imperatives Beyond Healthcare Reform, National Center for Healthcare Leadership, The Joint Commission Advisory Board meeting .but I am on a mission and I want to get it.

6 The OR Connection

Contributing Writers

Wolf Rinke, RD, CSPKeynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletter Read and Grow Rich, available at www.easyCPEcredits.com. In addition he has authored numerous CDs, DVDs and books including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations. Reach him at [email protected].

Atul Gawande, MDAtul Gawande is a surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Womens Hospital in Boston. He is also Professor of Surgery at Harvard Medical School and Professor in the Department of Health Policy and Management at the Harvard School of Public Health. He has written several books, includ-ing The Checklist Manifesto and serves as lead advisor for the World Health Organizations Safe Surgery Saves Lives program, which developed the Safe Surgery Checklist.

Michelle DeMeoMichele DeMeo is an expert in the sterile processing field who is highly regarded for her management techniques, product development and contributions to various healthcare associations and professional publications. She is now tackling another important role learning to live well in the face of a terminal illness.

Beth Boynton, MS, RNBeth Boynton is an organizational development consultant specializing in issues that affect nurses and other healthcare professionals. She is a national speaker, coach, facilitator and trainer for topics related to communication, conflict management, teambuilding and leadership development and author of the book, Confident Voices: The Nurses Guide to Improving Communication & Creating Positive Workplaces.

Pat Iyer, MSN, RN, LNCCPat Iyer is president of www.avoidmedicalerrors.com. She is a legal nurse consutant with medical malpractice and pesonal injury cases. She has served as president of the AALNC and is the cheif editor of Legal Nurse Consulting: Principles and Practice (2nd ed.) and Business Principles for Legal Nurse.

Atul Gawande, MD

Daniel L. Young, PT, DPTDaniel L. Young is an assistant professor in the Department of Physical Therapy at the Uni-versity of Nevada, Las Vegas. A few of his many research interests include factors affecting use of physical therapists for inpatient wound care, prevalence and incidence of nosocomial wounds in various acute care populations and factors related to the success of programs to address the nosocomial wounds. He received his bachelor of science degree in biology from Southern Utah University and he was awarded his doctor of physical therapy (DPT) degree from Creighton University.


Surgical Safety News

period, hospital lengths of stay for the procedure declined while readmissions for certain complications following knee replacement revisions more than doubled.

According to the authors, findings from this and other recent studies suggest an inherent tradeoff between shorter hospital LOS, greater need for post-acute care and higher readmission rates. The Medicare Payment Advisory Commission has recommended that the Centers for Medicare & Medicaid Services publish readmission and complication information for knee replacement patients and incorporate such measures into payment programs.

References

1. McKinney M. Post-discharge complications common after surgery, study finds. Modern

Healthcare.com. Posted October 2, 2012. Available at: http://www.modernhealthcare.

com. Accessed November 16, 2012.

2. Wasek S. One in 7 surgeries results in complications. Outpatient Surgery E-Weekly.

October 9, 2012. Available at:

http://www.outpatientsurgery.net/newsletter/eweekly/2012/10/09#3.

Accessed November 16, 2012.

3. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Arthroplasty volume, utilization, and

outcomes among medicare beneficiaries, 1991-2010. JAMA. 2012;308(12):1227-1236.

One in 7 SurgerieS reSultS in COmpliCatiOnS1,2

About 15 percent of surgical procedures result in complications within 30 days post-op, leading to SIGNIfICANTLY HIGHER HEALTHCARE COSTS, more frequent emergency department visits and higher readmission rates, according to researchers at the University of Alabama Birmingham who presented their findings at the annual meeting of the American College of Surgeons in October.

One in seven cases of orthopedic, gastrointestinal, vascular or gynecological surgery resulted in a complication WITHIN 30 DAYS Of SURGERY. The authors of the study derived their results by analyzing data from nearly 60,000 surgical procedures performed at 112 VA hospitals from 2005 to 2009. The complications included surgical site infections, urinary-tract infections and respiratory problems. The researchers said their findings demonstrate hospitals need to boost patient education efforts and more effectively track complications following hospital stays.

Study examineS Knee replaCement trendS, readmiSSiOnS3

The number of Medicare enrollees receiving knee replace-ments more than doubled over the past 20 years, partly due to an aging population and increase in patients likely to benefit from the procedure, according to a new study in the Journal of the American Medical Association. Over the same

knee replacement patients and incorporate such measures into

8 The OR Connection

by Sue MacInnes


Are you up to speed on healthcare reform and the impact it will have on you as a consumer and as a healthcare worker?

2013 may be one of the most impactful years weve had in

healthcare since the 1960s when President Lyndon B. Johnson

signed Medicare and Medicaid into law. Few people want to

read the 906 pages of legislation that make up the Patient

Protection and Affordable Care Act (PPACA) more commonly

known as Obamacare, but many of us are curious about

what healthcare reform really means and how it affects us.

10 The OR Connection

The burning purpose of the PPACA was to provide healthcare coverage to the millions of Americans who do not have insurance (actually, 48.6 million or 15.7% of the U.S. population as of 2011).1 Now here is the irony. The United States is the only country that does not have universal health care, and the cost of health care is expensive. According to the Organisation for Economic Co-operation Development, in 2010 the cost of health care per capita in the United States was $8,233 far greater than other wealthy countries.2 In fact, the United States ranks first in expenditure per capita. Norway ranks second with a per capita healthcare spending rate of $5,388, or 65 percent of the average per capita cost for healthcare in the United States. Other wealthy countries in the world spend an average of $3,265 per capita on health care.2 And yet, much higher spending does not equal better healthcare quality in the United States. In the same 2010 report by the Organisation for Economic Co-operation Development, the United States ranked 32nd out of 34 countries on infant mortality and 27th in life expectancy.2 We spend more than any other country for health care but our outcomes are a poor reflection of the price we pay.

And, with over 48 million uninsured, many Americans cannot afford to get wellness care or go to the doctor when

they detect a problem. In many cases, people with serious illnesses are left either going to the Emergency Room for care or suffering with no resources. Can you imagine having a child that is ill and not being able to get them care because you have no insurance? Or what if it was you who had a lump or a pain or had diabetes or needed

dialysisand you couldnt afford it? There are women who have felt lumps in their breasts who are trapped and unable to get help because they cant pay for care. for some, no insurance is a death sentence. Under healthcare reform, 30 million currently uninsured Americans will have the opportunity to get insurance.

$8,233United States2

$3,265other wealthy countries2

COST OF HEALTHCARE PER CAPITA:

THE UNITED STATES IS:

#32 on infant mortality2 & #27 on life expectancy2 of 34 countries

HIGHER COSTS BETTEROUTCOMES

Maybe a little background is in order

$$$$$$$ $

$$ $


How will 30 million people now get insurance?

1 Beginning in 2014, a person who does not have insurance will be able to shop for their own policy, just like car insurance, but with government-sponsored plans, like Medicaid or an exchange plan. There are some rules.

Medicaidwillbeavailableforindividuals and families based on income.

Companieswithunder50employees are not required to provide health insurance coverage. Those who work for these companies will be able to participate in a new state-based competitive private health insurance plan known as an exchange plan. Exchange plans

will provide individuals and small businesses with a one-stop shop to find and compare affordable, private health insurance options.

Baseduponyourincome,thecost of health insurance could be capped at a certain percentage, earning you tax credits.

2 If a U.S. citizen does not get insurance, they will be penalized on their tax return.

3 Large companies must meet specific minimum requirements on the mandatory healthcare insurance they offer.

What does all this mean?In addition to more Americans having coverage, the consumer will also have more choice. Information about healthcare providers is becoming transparent. You can look up infection

rates, pressure ulcers, mortality rates, patient experience scores, and just like Consumer Reports, rate the hospital options you have in your geographic area. This could conceivably mean that the patient might be more willing to go to a high-scoring hospital for an acute MI, versus a hospital that is closer to home. The rise of consumerism is changing how hospital systems are strategizing. You will see hospitals marketing more and more to the patient. With this will come a rise of consumerism as consumers exercise choice due to considerations of transparency, plans and pricing, as well as transparency around outcomes. They will pay for value.

The big mystery will be how 30 million patients in exchange plans and Medicaid change the payor mix in the hospitals. Will hospitals be

The rise of consumerism is changing how hospital systems are strategizing.


required to do even more with less, as the exchanges and Medicaid will pay much lower than Medicare and private insurance?

And so, 2013 will bring a shift in how hospitals get paid. Hospitals are strategizing around the advantages and disadvantages of healthcare reform.

Pros and cons of healthcare reform from a financial point of view, as described by McKinsey3

Pros = Potential increases in revenue

Increaseinutilizationduetocoverage expansion in government-sponsored plans

Reductioninuninsuredbaddebtas the formerly uninsured join Medicaid and exchange plans

Ongoingdemographicagingmayalso increase utilization on a per capita basis

Cons = Corresponding decreases in revenue Replacementofmorehighly

reimbursed lives (commercial insurance) with less highly reimbursed (Medicare, Medicaid, exchange plans)

ReductioninMedicareandMedicaid reimbursement rates

- Lower Medicare growth rate

- Decreased DSH (Disproportionate Share Hospital) payments

- Reduced Medicaid reimbursement

So, there is an uncertainty about how healthcare reform will affect the revenue of your organization.

Value based purchasing Now, in addition to these financial and coverage changes, quality of care has never been more important. Value based purchasing is now in effect, and hospitals are competing against each other as well as themselves. Value based purchasing will be rated on how well core measures are met (which

include SCIP measures in the OR) and HCAHPS, or patient experience scores. Dollars that were available in previous years are now at risk, depending on how well your hospital scores. Patient experience scores not only affect payments. They also affect the image of the hospital in the community.

Hospital-acquired conditions and readmissionsOther financial incentives involve hospital-acquired conditions (HACS) effective fY 2015 and readmissions effective fY 2013.

The chart on the opposite page summarizes the quality initiatives that affect your hospital now and in the years to come. Percentages increase as the years go on. Each of these comes with incentives to increase reimbursement if your organization performs wellor penalties for lesser performance. In some cases, such as value based purchasing, the penalties could be significant.

+Pros =Potential increases

in revenue

Cons =Corresponding decreases in

revenue

HEALTHCARE REFORMFINANCIAL PROS

CONS3


Fiscal Year Value Based Purchasing

Hospital Aquired

Conditions

Excessive Readmissions

Penalty

2011 0% 0% 0%

2012 0% 0% 0%

2013 1% 0% 1%

2014 1.25% 0% 2%

2015 1.5% 1% 3%

2016 1.75% 1% 3%

2017 2% 1% 3%

2018 2% 1% 3%

2019 2% 1% 3%

But with all of these things, an important aspectmaybe the most importantis the reputation of your organization. As performance scores are made public, it will be critical to market and engage the people in your community so that your organization is looked upon as the healthcare leader. Loyalty of patients and families and the reputation of your hospital are critical considerations. In 2013, you will see some trends occurring:

1 Hospitals will be enacting broad-ranging cost control programs including lean operations, back office cost control and clinical transformations.3 Hospitals are looking to cut $5-10 million a year in costs each year for 5 years. Hospitals will be thinking big picture about costsincrease quality, increase patient satisfaction, outcomes versus costs, cost variation by docs, supply chain squeezed.

Areas of consideration:3

a. Hospital labor productivity

b. Clinical cost variation

c. Operational efficiency/lean methodology

d. Purchasing and supply chain management

PERCENTAGES OF REIMBuRSEMENT DOLLARS AFFECTED UNDER HEALTH CARE REFORM


2 Cost saving is not always just price. It can also include efficiencies, guarantees, waste reduction, and better outcomes. Has your OR engaged in a lean assessment? Has innovation and thinking out of the box been a more broadly accepted way for the future in your organization?

3 Markets are consolidating. Increased merger & acquisition activity to capture perceived scale and synergy benefits and support new business models.3 Has your hospital partnered with another recently, or been purchased or merged?

4 Given competitive pressures, hospitals must carefully decide which service lines to prioritize,3

e.g., orthopedics (one of the most attractive and fastest growing service lines of the future).

5 A hospitals brand identity has more value than ever. Some hospital systems are investing heavily in a new look, new branding guidelines, new signage. They want to communicate their strengths on billboards and TV ads to gain consumer loyalty and community leadership.

6 Social media is a real business strategy and another way to communicate and attract customers.

7 Accelerated strategy of hospitals employing physician groups to help hospitals lock up markets, to improve contracting margins, to control outcomes, etc.3

8 Provider groups are considering innovative incentive relationships3 (e.g., ACO-like or clinical integration), but they are cautious of appropriate strategic and business model rationale. Payors and providers are partnering to explore a variety of new reimbursement and risk-sharing models.

You are in a unique position because you will get to see how healthcare reform will unfold as both the consumer and the healthcare worker.Take notes because you are making history as the biggest changes in health care get underway.

References

1. Census: uninsured rate falls as young adults gain coverage and government programs grow. Huffington Post. Posted September 12, 2012. Available at: http://www.huffingtonpost.com/2012/09/12/census-uninsured-young-adults_n_1876862.html. Accessed December 12, 2012.

2. Health policies and data. Organisation for Economic Co-operation Development website. Available at: http://www.oecd.org/health/healthpoliciesanddata/oecdhealthdata2012-frequentlyrequesteddata.htm. Accessed December 12, 2012.

3. Strategic Imperatives Beyond Healthcare Reform. Objective Health: A McKinsey Solution for Healthcare Services. Executive Breakfast Seminar. Presented September 13, 2012.

WHAT HEALTHCARE PROVIDERS LIKE YOU WILL BE LOOKING FOR IN 2013

1 BETTER pricing

2 Cost reductions

3 Outcomes

4 Ways to improve the customer experience

5 Ways to improve market/consumer image

6 Ways to make their staff happy

2012 Medline Industries Inc. Isolex is a trademark and Medline and SensiCare are registered trademarks of Medline Industries, Inc.

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MoVIE SPARkS HoPE FoR DAMAGED U.S. HEALTH CARE

By Beth Boynton, MS, RN

ESCAPE FIRE FIREIRE

Escape Fire: The Fight to Rescue American Healthcare is an exciting and timely documentary revealing the brokenness of the healthcare system in the United States and how it is linked to financial incentives. With a powerful combination of patient stories, objective data, and viewpoints of respected healthcare leaders, such as Drs. Don Berwick, Andrew Weil, and Dean Ornish, the movie raises critical awareness for creating the tipping point! This is key for the paradigm shift we need in our complex healthcare systems!

Aligning practice with policy to improve patient care 17Aligning practice with policy to improve patient care 17

Hello.. our System Is Not Working!

Most of us who have close ties to U.S. health care will be more validated than shocked, as we see poor outcomes every day that can be tied to wasted treatments, unsafe staffing levels, insufficient time, and delayed care that are rooted in financial gain for a few and limited resources for many. But, they are tough to explain and not necessarily even safe or appropriate to talk about freely. This film is easy to follow, well-researched, and compelling. As such, it provides an effective tool for educating consumers about underlying problems in our system and making it safe to discuss. And, we are all consumers!

The term Escape Fire comes from the story of a quick thinking firefighter that did something different in a crisis and lived to tell about it, unlike his colleagues who all died. (The movie starts out with this story so I wont spoil it for you with more details.) But, it is a great analogy for us, because solutions are right in front of us!

Some of the heroes in the movie:

Steve Burd, CEO of Safeway: Created healthiness incentives for employees.

Wendell Potter, Former Head of Communications, CIGNA: Had an awakening about how he was contributing to suffering.

Shannon Brownlee, Medical Journalist (formerly of US News & World Report) through research became aware of harmful aspects aka dark matter of our medical system.

Sgt. Robert Yates, Infantry, U.S. Army, injured in Afghanistan and his courageous recovery both from his injuries and over medication.

I do take issue with two aspects of Escape Fire:

First, nurses, as usual, are under-represented. With at least ten physicians highlighted and only one nurse leader (briefly at that), it is a little hard to swallow. Especially since nurses have been championing prevention and healthcare education forever and nurse practitioners as family practice clinicians are examples of the solutions that indeed are right in front of us! In addition, many physical therapists, psychotherapists, chiropractors, and holistic health practitioners have been advocating for cost-effective, helpful solutions for ages. Diet, exercise, alignment and emotional support are all keys to health care!

Second, there are a couple of places that seemed to me to avoid accountability and blame.like comments about the system being bad, but people being good, or people having good intentions. For the most part, I am OK with this and dont believe that blaming people is an effective strategy, However, it is a fine line between blame and ownership and ownership is extremely important. In fact, Wendell Potter, one of the heroes noted above recognized his own contribution to the problem and stopped. Since this is so integral to the Escape Fire analogy, it is worth mentioning! I would challenge any high paid hospital, pharmaceutical, or medical device, or nurse executive, malpractice attorney, or physician specialist to examine the possibility of personal accountability!

Despite these two criticisms, please see the movie! Lets generate some buzz and get this movie in high schools, libraries, theatres, and living rooms across the country. There are lots of awesome talking points that will spark dynamic discussion and fuel a growing power of the people. That is the fire that will save our system from burning!


Misperceptions of Immediate Use Sterilization

by Michele DeMeo

Sterile Processing Corner

there is a relatively new term in use called immediate use sterilization. Its purpose is to better qualify and define what was once called flash sterilization, usually occurring in the operating room. It was created by a multi-disciplinary work team composed of experts from the Association of Medical Instrumentation (AAMI), the Association of perioperative nurses (Aorn), the International Association of Healthcare central Service Materiel Management (IAHcSMM), the Food and Drug Administration (FDA), the centers for Disease control and prevention (cDc), Association for professionals in Infection control and epidemiology (ApIc) and other key stakeholders including manufacturers and developers.

even with hundreds of articles written on the subject, there are still some misunderstandings and myths surrounding immediate use sterilization. there are several reasons for this. For one, nurses are not specifically trained as sterile processing experts in all of the nuances and complexities of sterilization. this is understandable. the nurses role is so diverse, the focus should be on just the patient and other issues occurring in the operating room not on tasks support staff should be performing.

Immediate use sterilization is just that, for immediate use not to be done half an hour or hour after the cycle finishes and not to be done because of poor planning, schedule changes or because an unsterile item might be remotely needed. Its function is to provide a means to process, once properly re-cleaned, sterilization for a critical item that may have been dropped or needed due to an emergency. It applies to a single item or two, never a full set or tray of instruments you know the ones I mean, the orthopedic trays just dropped off by the sales rep 20 minutes before the scheduled cut time or the sets that have wrapper holes on them. Immediate use sterilization was never meant to replace traditional processing by the sterile processing department. nor was it meant to mask the task of fixing internal operation/administrative issues with your surgical instrumentation processing system and flow.

This is second in a series of 8 columns written by Michele DeMeo, a sterile processing expert with more than 20 years of experience in this field.

Ifyouuseimmediateusesterilizationformerlyknownasflashing, as a routine practice because you have internal operational mismanagement, team up with SPD leadership to fix the issues. They should be included; it is their role to provide instrumentation for you, period.

Ifyoumustusethiscycle,useproperprotocol.Followmanufacturers instructions (not every item can be immediately sterilized or the settings are not limited to just a three- or 10-minute cycle. Some items require 10 or more minutes, etc.)

Justbecausetheintegratorshowssomeparametersweremet,it does not necessarily mean the item was properly sterilized. It simply indicates that the sterilizer functioned and the chamber was suitable for sterilization to have occurred not that it actually did. Using any item that has been sterilized is not a no-brainer. Use critical thinking when processing any instrument. Your staff will likely be in a hurry, and that is exactly when an item could be unknowingly compromised and rendered unsterile.

Ensureyouareproperlytestingyoursterilizer.Documentaccurately. Interpret not only the integrator, but the item, the diagnostic information on the printout from the sterilizer, etc., to determine whether the just processed item is actually safe and appropriate to use.

These are just a few of the key considerations when having to use immediate use sterilization. Enlist sterile processing to help fine tune your program or to take over this responsibility when necessary. Use it as intended for emergencies only. Strive for zero occurrences. Thats the best practice.

Some reminders:

Editors Note:

Program for Healthcare

2012 Medline Industries, Inc. greensmart is a trademark and Medline is a registered trademark of Medline Industries, Inc.

greensmart is not a third-party certification. The use of the greensmart trademark is determined by Medline Industries, Inc. through an internal review process of environmental claims.

Measure Your BaselineFrom calculations to benchmarking, your greensmart RoadMAP provides all the tools you need to green your OR, Housekeeping, Laundry, Food Services and Patient Rooms.

1

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3Identify Green Products and StrategiesWith the help of your Program Manager, you will identify products, services and education that are right for your facility.

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Francesca Olivier, Medlines corporate sustainability manager, is ready to work with you no matter where your facility is on your sustainability journey. Call her at (847) 643-3821 or email [email protected]


Restaurant chains have managed to combine quality control, cost control and innovation.

Can health care?by Atul Gawande, MD

BIG MED

Aligning practice with policy to improve patient care 21Aligning practice with policy to improve patient care 21

It was Saturday night, and I was at the local Cheesecake factory with my two teen-age daughters and three of their friends. You may know the chain: a hundred and sixty restaurants with a catalogue-like menu that, when I did a count, listed three hundred and eight dinner items (including the forty-nine on the Skinnyli-cious menu), plus a hundred and twenty-four choices of beverage. Its a linen-napkin-and-tablecloth sort of place, but with something for everyone. Theres wine and wasabi-crusted ahi tuna, but theres also buffalo wings and Bud Light. The kids ordered mostly comfort foodpot stickers, mini crab cakes, teriyaki chicken, Hawaiian pizza, pasta carbonara. I got a beet salad with goat cheese, white-bean hummus and warm flatbread, and the miso salmon.

The place is huge, but its invari-ably packed, and you can see why. The typical entre is under fifteen dollars. The dcor is fancy, in an accessible, Disney-cruise-ship sort of way: faux Egyptian columns, earth-tone murals, vaulted ceil-ings. The waiters are efficient and friendly. They wear all white (crisp white oxford shirt, pants, apron,

sneakers) and try to make you feel as if it were a special night out. As for the foodcan I say this with-out losing forever my chance of getting a reservation at Per Se?it was delicious.

The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheese-cake factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the on-

ions out of his Hawaiian pizza).I wondered how they pulled it off. I asked one of the Cheesecake factory line cooks how much of the food was premade. He told me that everythings pretty much

made from scratchexcept the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.Id come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Un-like the Cheesecake factory, we havent figured out how. Our costs are soaring, the ser-

vice is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.

Its easy to mock places like the Cheesecake factoryrestaurants that have brought chain produc-tion to complicated sit-down meals. But the casual dining sec-tor, as it is known, plays a central role in the ecosystem of eating, providing three-course, fork-and-

+Essentially, were moving from a Jeffersonian ideal of small

guilds and independent craftsmen to a Hamiltonian recognition of the advantages that size

and centralized control can bring.


knife restaurant meals that most people across the country couldnt previously find or afford. The ideas start out in lite, upscale restau-rants in major cities. You could think of them as research restau-rants, akin to research hospitals. Some of their enthusiasmsmiso salmon, Chianti-braised short ribs, flourless chocolate espresso cakespread to other high-end restaurants. Then the casual-dining chains rengineer them for afford-able delivery to millions. Does health care need something like this?

Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Walmart the most successful retailer on earth. Pizza Hut alone runs one in eight pizza restaurants in the country. The Cheesecake factorys major competitor, Darden, owns Olive Garden, LongHorn Steakhouse, Red Lobster, and the Capital Grille; it has more than two thou-sand restaurants across the country and employs more than a hundred and eighty thousand people. We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god. Then you spend a bad night in a quaint one of a kind bed-and-breakfast that turns

out to have a manic, halitoxic innkeeper who cant keep the hot water running, and its right back to the Hyatt.

Medicine, though, had held out against the trend. Physicians were always predominantly self-em-ployed, working alone or in small private-practice groups. American hospitals tended to be commu-nity-based. But thats changing. Hospitals and clinics have been forming into large conglomerates. And physiciansfacing escalat-ing demands to lower costs, adopt expensive information technology, and account for performancehave been flocking to join them. According to the Bureau of Labor Statistics, only a quarter of doctors are self-employedan extraordi-nary turnabout from a decade ago, when a majority were independent. Theyve decided to become em-ployees, and health systems have become chains.

Im no exception. I am an em-ployee of an academic, nonprofit health system called Partners HealthCare, which owns the Brigham and Womens Hospital and the Massachusetts General Hospital, along with seven other hospitals, and is affiliated with dozens of clinics around eastern Massachusetts. Partners has sixty thousand employees, including six thousand doctors. Our competitors include CareGroup, a system of five regional hospitals, and a new for-profit chain called the Steward Health Care System.

Steward was launched in late 2010, when Cerberusthe multi-

billion-dollar private-investment firmbought a group of six failing Catholic hospitals in the Boston area for nine hundred million dol-lars. Many people were shocked that the Catholic Church would allow a corporate takeover of its charity hospitals. But the hospitals, some of which were more than a century old, had been losing money and patients, and Cerberus is one of those firms which specialize in turning around distressed businesses.

Cerberus has owned controlling stakes in Chrysler and GMAC fi-nancing and currently has stakes in Albertsons grocery stories, one of Austrias largest retail bank chains, and the freedom Group, which it built into one of the biggest gun-and-ammunition manufacturers in the world. When it looked at the Catholic hospitals, it saw an-other opportunity to create profit through size and efficiency. In the past year, Steward bought four more Massachusetts hospitals and made an offer to buy six financially troubled hospitals in south florida.

continued on page 90

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account for 20%of all health care-associated infections in U.S. hospitals.2

estimated 8,205annual deaths caused by SSIs2

780,000 SSIs occur each year3

35,000 SSIs develop annually

after orthopedic surgery4

up to 20,000 knee and hip replacement patients contract an SSI4

Surgical Site Infections (SSI)Surgical Site Infections (SSI)Surgical Site Infections (SSI)Following Orthopedic Surgery

Taking a look back in time, before the

mid-1800s, surgical patients commonly

developed postoperative irritative fever,

followed by purulent drainage from their

incisions, overwhelming sepsis, and often

death. It was not until the late 1860s, after

Joseph Lister introduced the principles of

antisepsis, that postoperative infectious

morbidity decreased substantially.1

Fast forward more than 150 years to 2012.

We are doing surgery in modern ORs

with high-tech equipment and advanced

techniques, and yet

SSIs

CE ArtiClE Visit www.medlineuniversity.com and login or create an account. Choose your course and take the test to receive 1 FREE CE creidt. Course is approved for continuing education by

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Astronomical costs of added careIn addition to the burden of coping with the painful and disabling effects of an SSI, patients and providers face increased healthcare costs. According to the Institute of Medicine, hospital-acquired infections cost up to $5.7 billion per year.5

SSIs prolong a patients total hospital stay by an average of two weeks, double the chances of being re-hospitalized and increase the total cost of health care by more than 300 percent.6

Clearly, there is a great need for all members of the healthcare team, including OR nurses, to help reduce the risks of SSIs.

Types of surgical site infections and how they relate to orthopedic surgeryTwo types of SSIs typically occur: incisional and organ/space. Incisional SSIs are subcategorized as superficial (for example, skin, subcutaneous tissue) or deep (for example, deep soft tissues). Organ-space SSIs manifest in any body part other than the site of the incision.3

According to an orthopedic surgery specific executive summary of the Association for Professionals in Infection Control and Epidemiology (APIC) elimination guide,4 orthopedic surgery frequently involves the placement of a foreign body, such as a prosthetic joint, various joint components, or hardware used to stabilize bony structures or repair fractures. Unfortunately, placing these structures increases the risk of infection, either by introducing local contamination or by spreading microorganisms through the bloodstream.4 The APIC executive summary also states that locally introduced contamination can occur during the perioperative period. Spread of microorganisms occurs after the perioperative period and is associated with primary bacteremia or infection at a site distant from the surgery. Secondary bacteremia from this distant infection leads to microbial seeding of the prosthetic joint.4 In addition, biofilm from bacterial microorganisms that may be attached to a prosthetic implant can cause an SSI to develop.4

Common risk factors associated with SSIIt is important for OR nurses to know the types of factors related to both an individual patient and the hospital environment that can increase the risk of a patient developing an SSI. The World Health Organization (WHO)3 outlined the following characteristics of patients who may have an increased risk: advanced age, poor nutritional status, diabetes, cigarette smoking, obesity, colonization with microorganisms, coexisting infection at a remote body site, altered immune response, and preoperative hospitalization.3

Also, WHO listed characteristics of the surgical procedure that can increase the likelihood of developing an SSI.3 These include inadequate preoperative skin preparation, inappropriate preoperative shaving, inadequate surgical team preoperative hand and forearm antisepsis, contaminated operating room environment, inappropriately sterilized surgical attire and drapes, inadequate sterilization of instruments, excessive duration of

Layers of skin and deep space.

Skin

SubcutaneousTissue

Deep Soft Tissue(fascia & muscle)

Organ/Space

SupercialIncisional

SSI

Deep IncisionalSSI

Organ/SpaceSSI

Patient Risk Factors for Developing SSI3 Advanced age

Poor nutritional status

Diabetes

Cigarette smoking

Obesity

Colonization with microorganisms

Coexisting infection at a remote body site

Altered immune response

Preoperative hospitalization

operation, poor surgical technique, and inappropriate or untimely antimicrobial prophylaxis.

Most hospital infection prevention teams use National Healthcare Safety Network (NSHN) definitions for postoperative surveillance of patients at risk for SSIs. Because most cases of SSIs appear after the patient has left the hospital, the NHSN protocol states that healthcare practitioners should monitor patients for SSIs for up to 30 days after the surgical procedure.4 OR nurses should refer to the APIC guide for examples of how to monitor patients4,7 and for descriptions of a variety of factors that may be associated with increased rates of SSI following orthopedic surgery.7

Preventing SSIs in orthopedic surgery patientsEliminating modifiable risk factors can help prevent SSIs,4 and there are many proven strategies to achieve this goal. for example, OR nurses can ensure that clean and disinfected equipment are used and that the surgical environment is pristine; they can also ensure that the team

uses evidence-based practices for hand hygiene and surgical site preparation.4 Preoperative skin preparation for patients is important because microorganisms commonly associated with patients predominate in orthopedic SSIs.4 In particular, OR nurses can verify that patients have showered before having an orthopedic-related surgery to reduce bacterial colonization of the skin.4

for more specific interventions, OR nurses can refer to the previously mentioned APIC guidelines for eliminating SSIs. Published in 2010, these guidelines are easily accessible online at the APIC website (http://apic.

org/Professional-Practice/Scientific-guidelines).4 These guidelines offer comprehensive approaches for all healthcare professionals to consider as they develop the most effective orthopedic SSI prevention program for their specific hospital or ambulatory setting.4

Although no standardized clinical practice guidelines exist regarding which SSI prevention strategies can reliably reduce the risk of infection after a total hip arthroplasty (THA), Merollini and colleagues6 identified the following infection prevention measures to be critical based on a review of expert opinion and

Perioperative Conditions Often Related to SSI3 Inadequate preoperative skin preparation

Inappropriate preoperative shaving

Inadequate surgical team preoperative hand and forearm antisepsis

Contaminated operating room environment

Inappropriately sterilized surgical attire and drapes

Inadequate sterilization of instruments

Excessive duration of operation

Poor surgical technique

Inappropriate or untimely antimicrobial prophylaxis

SSIs following orthopedic surgery increase healthcare costs by more than 300%6


clinical guidelines: preoperative antibiotic prophlyaxis, antiseptic skin preparation of patients, hand and forearm antisepsis by surgical staff, intraoperative use of sterile gowns/surgical attire, ultraclean/laminar air operating room, antibiotic-impregnated cement, and postoperative surveillance. These investigators stressed that the degree to which these measures can be efficiently and effectively incorporated into practice depends on the cost-effectiveness and usefulness of each measure in any given healthcare setting.8

The experts whom Merollini and colleagues8 interviewed agreed primarily on the importance of the recommendation for appropriate antibiotic prophylaxis. They recognized this strategy as being highly effective in theory and in practice and as being established as a routine safety measure for patients undergoing THA.8 Merollini and colleagues8 also stressed that a comprehensive approach is necessary to successfully prevent SSIs after THA, and that nurses may need to use a combination of interventions.8

By identifying patients who are at high risk for developing an SSI

after having a THA or total knee arthroplasty (TKA), healthcare professionals, including OR nurses, can help improve the reporting of the incidence of SSIs and verify or set in motion appropriate prevention strategies before surgery occurs.9 Berbari and colleagues9 developed a risk assessment tool for prosthetic joint infection in use at Mayo Clinic in Rochester, Minn. Their results highlighted the usefulness of a risk assessment tool in terms of both patient care and for the prevention of costly complications that may or may not be reimbursed by insurance providers. Because more than four million THAs or TKAs are estimated to be performed by 2030, healthcare professionals should diligently assess patients risk status and conduct preventive strategies.9 Minimizing a patients risk of developing an SSI after orthopedic surgery is useful for both the patients well-being and for the healthcare facilitys bottom line.9

Using teamwork to address SSIsTeamwork is essential for addressing the problem of SSIs. It is evident that fostering a culture in the healthcare facility that leans toward teamwork is important in preventing SSIs that occur following orthopedic surgery.4

Antibiotic prophylaxis [antibiotic prophylaxis]

1 : The prevention of infection complications using antimicrobial therapy

continued on page 37

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The following real patients share how infection following orthopedic surgery has changed their lives. They went into surgery disabled by a broken bone or a failing joint, hoping to come out stronger than before. Unfortunately these patients contracted a hospital-acquired infection, which led to a lesser quality of life, often accompanied by further surgeries and years of pain and loss.

These stories and more are provided through the Safe Patient Project, a Consumers Union campaign focused on eliminating medical harm, improving FDA oversight of prescription drugs and promoting disclosure laws that give information to consumers about healthcare safety and quality. To learn more, visit http://safepatientproject.org/.

Real Stories from People Affected by SSIs

Alice BuehringGold Bar, WashingtonAfter taking a bad fall in January 1999, I required surgery to replace the humeral head in my right shoulder. Unfortunately, my recovery was painful and mostly unsuccessful. By May 1999, I discovered why. It turned out that I developed a Pseudomonas aeruginosa infection in the surgical site, which was fast becoming septic. I spent the next week in the hospital on IV antibiotics to treat the infection. I was discharged to continue my IV treatments at home for another six weeks followed by oral antibiotics for another six weeks.

By the end of these treatments, I hoped that the worst was behind me. But my recovery continued to be painful and difficult. For the next six years, I struggled to find relief. I began to work with some natural and alternative healthcare practitioners who believed my arm was still infected. Most of the time my arm hurt enough to require pain medication and was periodically hot. I would slowly gain range of motion in my arm, only to lose it again. Each year I would return to my surgeon when the pain became unbearable. And each time he would insist that the infection was no longer present and send me home with more pain medication.

In May 2004, my pain became impossible to endure. I returned to my doctor who took another X-ray of my arm and finally determined that the infection was still present. By then, the infection had eaten through my humerus bone and destroyed my rotator cuff. I underwent a second surgery to remove the prosthesis, spent three days in the hospital recuperating and then continued my IV antibiotic treatments at home for another six weeks. Once the infection cleared up, I had a third surgery to insert a new prosthesis and then began physical therapy. Finally, I was infection free.

My hospital infection experience has had a lasting impact. I now have only a 20 percent range of motion in my dominant arm, which has limited my abilities in my daily life and at work, and I still havent gotten my energy back. I am grateful to be alive, that I still have an arm, and that the damage was not more extensive, but angry that an infection I caught in the hospital turned my life upside down for so long. I continue to live my life upside down.

After taking a bad fall in January 1999, I required surgery to replace the humeral head in

Pseudomonas aeruginosa


Sandi SampsonBoaz, AlabamaWhen I had ankle replacement surgery in December 2003, I looked forward to finally recovering from a broken ankle bone I injured in my backyard. Unfortunately, I left the hospital not only with a new ankle, but also a staph infection from my surgery. In the weeks following the operation, I felt tired and always seemed to run a low grade fever, but I didnt think much of it. I was diagnosed with the infection after my cast was removed three months after my surgery, and it became clear during physical therapy that the ankle replacement had failed. Tests revealed that I had methicillin-resistant Staphylococcus aureus (MRSA), a difficult-to-treat infection.

As a result, the prosthesis was removed and an antibiotic spacer was installed in its place. I underwent 12 weeks of Vancomycin treatments administered through a PICC line at home. The infection seemed to improve, and I had another ankle replacement surgery. But the prosthesis never bonded to the bone, and I experienced another outbreak of MRSA. I was put on Vancomycin for another month to treat the infection. In June 2005, I had another surgery to install a concrete spacer in place of my ankle, but again it failed to adhere to my bone.

My doctor has told me that the MRSA, which is in my bone and blood, will never go away. It becomes dormant after it is treated, but trauma to my body like a spider bite I got in November 2005 can cause it to re-emerge. I underwent another surgery in May 2006 to address my ankle problem. I fought to save my life and leg for four years: 37 surgeries. Finally, the only way to save my life was to remove my leg. I had that done in February 2007.

Glenn Cartrette Castle Hayne, North CarolinaOn January 1, 2003, my husband, Glenn Cartrette had knee surgery. After three weeks he went back to work and found he had a new pain in his hip joint, which grew worse during his 17-hour work days. Glenn had a full hip replacement in October. After the two surgeries, pain began to be a daily part of Glenns life. Finally the pain was so intense that he no longer could go to rehab. Then problems started with his lungs. The orthopedic surgeon said there was nothing wrong with his surgery but during one of his many hospital admissions Glenn and I were told he had MRSA. He was placed in a private room where visitors were required to wash their hands, put on a gown, gloves and mask before entering the room. He spent weeks in the hospital and continued to take Vancomycin for the MRSA after he was released.

After returning home Glenn continued to have pain and difficulty breathing, which required visits to the emergency room often. I would beg for help because I could see the stress on him just to breathe. We also consulted with pain management doctors to monitor the pain medications needed in ever-increasing doses. Except for about 15 days in a nursing home, Glenn was in the hospital from July 2005 until January 2006. His lungs were infected with MRSA, and he was in a great deal of pain. He died on January 26, 2006, unaware of what was going on around him. Death was the only escape from the horrible things MRSA had done to him and his body.

outbreak of MRSA. I was put

like a spider bite I got in November 2005 can cause

husband, Glenn Cartrette

Glenn and Teri Cartrette

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Reference

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focusing on patient-centered care, communicating well with patients and healthcare colleagues in all positions, and having leaders who emphasize the need for all team members to understand the importance and the effects of SSIs in orthopedic surgery patients are useful strategies.6 Risk assessment tools and simple cleaning and presurgical checklists can be created or customized to fit each facility.4

Working together, one team (including infection control staff members, surgeons, nurses, and perioperative staff members) reduced the rate of SSIs in their orthopedic surgical setting by 60 percent; their results included not having a single patient develop a MRSA-related SSI over the course of one full year.7 Collaboration and a concerted effort to follow accepted preoperative prophylaxis protocols were critical components to their success.

Another way a team can use communication to reduce the risk of SSIs is by taking a time-out before making the initial surgical incision.6 The time-out provides needed time for team members to check whether appropriate and timely antibiotic prophylaxis procedures have been completed and to ensure that the sterilization level is optimal.4

Effective infection prevention and control programs can help reduce the risk of patients developing SSIs.7 OR nurses, along with other specialists, must understand the common characteristics of patients undergoing orthopedic surgery, be able to identify and address the risk factors, use accepted methods for case

finding, analyze data, communicate outcomes, and implement evidence-based strategies to improve outcomes.7 To achieve these goals, collaboration among team members is critical.7

Abdul-Jabbarandcolleagues10 analyzed a total of 6,628 patients who underwent spinal surgery. They found that 193 (2.9 percent) of all spinal surgery patients had an SSI, and that patients with SSIs exhibited many of the commonly known risk factors (for example, diabetes, revision surgery, extended operative time, and transfusion). Because they also noted risk factors for predicting whether a patient would develop an SSI that were unique to their own study participants (for example, diagnoses of neoplasm and coagulopathy and having had anterior or posterior surgery), they recommended that these factors be added to their facilitys preoperative risk assessment process.

Richards and colleagues11 evaluated a large sample of patients who underwent orthopedic surgery. Based on their results of patients who had developed SSIs 30 days

after surgery, they determined that recognizing that a relationship exists between hyperglycemia and infectious complications could influence positively the postoperative care of orthopedic patients.

Dancer and colleagues,12 in a study conducted in Scotland, linked a sharply increased rate of deep SSIs in orthopedic (and ophthalmic) patients with the contamination of sets containing surgical instruments that occurred after sterilization techniques had been done. They found that poor handling practices at the facilities participating in the study and at the sterilization plant were related to a sharp increase in SSIs. Their results highlighted the need for close cooperation and collaboration among sterile service providers, managers, and clinical staff members. They suggested a series of guidelines to lower the risk of sterile surgical instruments becoming contaminated before use that included using adequate cooling and drying procedures at the sterilization plant along with focusing their inspections on finding damp packs. Other key recommendations

Poor surgical instrument handling

practices have been found to

increase SSIs10

continued from page 32

38 The OR Connection 38 The OR Connection

included periodically visiting sterilization site locations; performing weekly audits of procedures and issuing reports to stay abreast of the results; regularly reviewing cleaning processes, inspection processes; and providing ongoing staff training and supervision related to these processes. As a result, infections rates among patients receiving clean surgical procedures returned to levels that were consistent with those noted before the sharp increase, which was the reason this study was conducted.

Gathering follow-up data to decrease patients likelihood of future SSIsKeeping track of the types and frequency of SSIs that occur in or as a result of a stay in a healthcare facility is important.11 Using guidelines for procedure categories described by the Centers for Disease Control and Prevention (CDC) as well as the NHSN guidelines is essential.13 Correct coding and other helpful details will ensure appropriate record keeping.

OR nurses play an integral role in assessing a facilitys risk of being a host for SSIs, which can lead to lowering the risk factors of patients developing SSIs in the future.

References1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis

WR. Guideline for Prevention of Surgical Site Infection, 1999. Infection Control and Hospital Epidemiology. 1999; 20(4): 251.

2. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1820440/. Accessed November 5, 2012.

3. World Health Organization. WHO Guidelines for Safe Surgery, 2009: Safe Surgery Saves Lives. Available at: www.who.int/patientsafety/safesurgery/tools_resources/9789241598552/en/index.html. Accessed Nov. 1, 2012.

4. Greene LR. Guide to the elimination of orthopedic surgery surgical site infections: an executive summary of the Association for Professionals in Infection Control and Epidemiology elimination guide (published online ahead of print Aug. 25, 2011). Am J Infect Control. 2012;40(4):384-386. doi:10.1016/j.ajic.2011.05.011.

5. Sydnor ERM & Perl TM. Hospital epidemiology and infection control in acute-care settings. Clin Microbiol Rev. 2011; 24(1): 141173. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021207. Accessed December 4, 2012.

6. Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost [abstract] Infect Control Hosp Epidemiol. 2002;23(4):183-189.

7. Green LR, Mills R, Moss R, Sposato K, Vignari M. Guide to the Elimination of Orthopedic Surgical Site Infections: An APIC Guide, 2010. Available at: http://apic.org/Professional-Practice/Implementation-guides. Accessed Nov. 1, 2012.

8. Merollini K, Zheng H, Graves N. Most relevant strategies for preventing surgical site infection after total hip arthroplasty: guideline recommendations and expert opinion (published online ahead of print Sept. 21, 2012). Am J Infect Control. 2012; doi:10.1016/j.ajic.2012.03.027.

9. Berbari EF, Osmon DR, Lahr B, et al. The Mayo prosthetic joint infection risk score: implication for surgical site infection reporting and risk stratification (published online ahead of print June 20, 2012). Infect Control Hosp Epidemiol. 2012;33(8):774-781.

10. Abdul-Jabbar A, Takemoto S, Weber MH, et al. Surgical site infection in spinal surgery: description of surgical and patient-based risk factors for postoperative infection using administrative claims data. Spine. 2012;37(15):1340-1345.

11. Richards JE, Kauffmann RM, Zuckerman SL, Obremskey WT, May AK. Relationship of hyperglycemia and surgical-site infection in orthopaedic surgery. J Bone Joint Surg Am. 2012;94(13):1181-1186.

12. Dancer SJ, Stewart M, Coulombe C, Gregori A, Virdi M. Surgical site infections linked to contaminated surgical instruments (published online ahead of print June 15, 2012). J Hosp Infect. 2012;81(4):231-238.

13. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN). Procedure-Associated (PA) Module [follow link to Protocol and Instructions: Surgical Site Infection (SSI) Event (pdf)]. Available at: www.cdc.gov/nhsn/psc_pa.html. Accessed Nov. 1, 2012.

In conclusion, all members of the healthcare team, particularly OR nurses, can help reduce the incidence of SSIs in patients who have had orthopedic surgery. Among the important steps to take are identifying patients who are at risk for developing SSIs and taking extra care to address these risk factors before, during and after surgery.

Also, familiarity with the appropriate clinical guidelines that outline risk factors in patients and understanding and implementing recommended sterilization practices in the preoperative and surgical environment are extremely important. Working collaboratively with all members of the healthcare team is a critical strategy that serves patients, the team and the facility in the common goal of avoiding SSIs.

OR nurses play an integral role in

assessing a facilitys risk of being a host for SSIs, which can

lead to lowering the risk factors of

patients developing SSIs in the future.

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Sterillium Rub is the only waterless, brushless surgical scrub with 80% (w/w) ethyl alcohol the highest alcohol concentration of any surgical rub available in the US. Its long-lasting, persistent effect exceeds FDA requirements for surgical hand antisepsis. Sterillium Rub provides a rapid and comprehensive kill of transient and resident skin flora, with a 6 log reduction within two minutes.2

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Specialized mattress overlays In a study of 446 patients undergoing elective major surgery, specialized foam mattress overlays on operating tables decreased the incidence of postoperative pressure ulcers.2

Positioning AORNs Recommended practices for positioning the patient in the perioperative setting suggests that a patient should be repositioned routinely to prevent continuous pressure on pressure points and assist in decreasing the risk of adverse physiological responses.1

Preoperative assessment The preoperative assessment should include details of the patients skin status (e.g., presence of a rash, maceration, infection, breakdown, dermatitis, incontinence, lymphedema) along with a risk assessment noting whether the patient is a high-risk candidate for pressure ulcers based on the proposed procedure and extrinsic factors (shear, friction, and moisture) and intrinsic factors (advanced age, nutritional deficiencies).1

1. Walton-Geer P. Prevention of pressure ulcers in the surgical patient. AORN Journal. 2009; 89(3): 538-552. Available at: http://www.aornjournal.org/article/ S0001-2092(08)00898-3/fulltext#section9. Accessed October 25, 2012.

2. Reddy M, Gill SS, Rochon, PA. Preventing pressure ulcers: a systematic review. Journal of the American Medical Association. 2006; 296(8):974-984. Available at: http://jama.jamanetwork.com/article.aspx?articleid=203227. Accessed October 25, 2012.

3. Institute for Clinical Systems Improvement (ICSI). Skin safety protocol: risk assessment and prevention of pressure ulcers. Available at: http://www.icsi.org/pressure_ulcer__ skin_safety_protocol__risk_and_assessment_of/pressure_ulcer__skin_safety_ protocol__risk_assessment_and_prevention_of__protocol_.html. Accessed October 25, 2012.

At risk for pressure ulcers All surgical patients should be considered at risk for pressure ulcer development because of the uncontrollable length of surgery and the effects of anesthesia, along with the use of vasoactive medications that affect blood pressure and heart rate during surgery.1

Ways to AVOID Perioperative Pressure Ulcers5

Medical devices Minimize/eliminate pressure from medical devices such as oxygen masks and tubing, catheters, cervical collars, casts, IV tubing and restraints.3

References



Peri-operative process change to reduce the risk of post-operative infection following orthopedic proceduresMelissa Lingle, RN, CNOR

INTRODUCTIONOf an estimated annual 500,000 hospital acquired infection events, from Centers for Disease Control and Prevention data, as many as 16% involved post-operative surgical site infections (SSI).1

Risk of post-operative surgical site infections following orthopedic surgery is increased for patients with body mass index (BMI) >25 and compounded for those with a co-morbidity of diabetes, both growing population segments. Post-operative infections involving multi-drug resistant organisms (i.e., MRSA) for at risk patients leads to increased morbidity-mortality, costly hospitalizations, corrective surgeries, long-term antibiotic therapy, extended recovery time, and delay in return to functional activities of daily living. Hip and knee arthroplasty procedures have a predicted occurrence rate of 1 to 2.4% and cost rom $60,000 to more than $100,000. The economic burden to U.S. hospitals from joint arthroplasty infections is projected to exceed $1.62 billion annually by 2020.2, 3, 4, 5, 6

The goal of this study was to assess the efficacy of interventions to reduce the risk of post-orthopedic procedure infections by using pre-operative chlorhexidine cleansing in tandem with post-operative silver-impregnated dressings.7, 8, 9

METHODOLOGYIn 2011, an orthopedic surgical site infection reduction task force was created, responding to an unacceptably high rate of infection events. Pre-intervention orthopedic procedure data was collected for a seven-month period of 2011, including hip, knee, and shoulder arthroplasty surgeries, as well as laminectomy and discectomy procedures. Four hundred eighty eight (488) procedures were performed during the base line period with 18 infections identified occurrence rate of 3.7%. Interventions were instituted in 2012 to reduce pre-operative resident and transient skin bacteria burden and post-operative incisional inoculation of bacteria. Surgical sites were cleansed daily for three days with 2% chlorhexidine wipes prior to surgery and on the day of surgery. Surgical incisions were then dressed for 10 days post-operatively with silver-impregnated, absorbent dressings*. The application of the wound dressings was initiated in the O.R. following incision closure and maintained during hospitalization.

Further wound coverage following discharge was accomplished with written instructions and replacement dressings sent with each patient. Data for the seven-month intervention period in 2012 were compiled to compare outcomes.

RESULTSOf 498 orthopedic procedures performed to date in 2012, following the interventions, only three infection events were identified an occurrence rate reduction from 3.7% to 0.6%. It is to be noted that the post-operative silver-impregnated absorbent dressing protocol was not used in one infection occurrences. By any estimate, the interventions instituted to reduce surgical site infections following orthopedic procedures have been successful. Unwanted negative outcomes for patients have been avoided, the overall quality of care improved, and significant cost savings realized.

CONCLUSIONThe results of our interventional study will continue to be monitored. Initial discussion of the results seen to-date are leading to strong consideration of applying the same peri-operative process and silver-impregnated dressing principles to additional surgical procedures. Our experience over seven months confirms the efficacy of these efforts, noted in prior clinical literature.

KEY STEPS TO SUCCESS1. SSI case data reporting confirmed

unacceptable post-operative surgical site infection rate (SSI) comparison of performance for orthopedic procedures to National Healthcare Safety Network (NHSN) data base.

2. Creation of surgical site infection reduction task force with physician champion to lead multi-discipline team covering full peri-operative process.

3. Review and discussion of pertinent literature for best case practices to reduce/prevent post-op. SSI events.

4. Follow the Action Plan to either improve or adopt as new processes.

Orthopedic Procedure Totals

498

488

484486

488490

492494

496

Orthopedic Surgical Site Infection Reduction

3

18

0

5

10

15

20

2011 SSI 2012 SSI2012 Procedures2011 Procedures

Ortho

OR Connection Volume 7 Issue 3

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Transcript of OR Connection Volume 7 Issue 3