OR Connection Magazine - Volume 4 Issue 3

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VOLUME 4, ISSUE 3
The
Aligning practice with policy to improve patient care
Volume 4, Issue 3
FREE CE!
THE OR CONNECTION
Positioning
YouTube to Prevent
Sensation! Injury
The Pink Glove
Dance
Page 70 9 Habits of Very
Happy People
Brand New
Fire Prevention
Guidelines
www.medline.com
Peggy Fleming Comes to Congress

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The
OR Connection
Aligning practice with policy to improve patient care
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Content Key
We've coded the articles and information in this magazine to indicate which patient
care initiatives they pertain to. Throughout the publication, when you see these icons
you'll know immediately that the subject matter on that page relates to one or more of
the following 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 tools
for implementing their recommendations. For a summary of each of the
initiatives, see pages 6 and 7.
PATIENT SAFETY
Editor
Sue MacInnes, RD, LD
6 Three Important National Initiatives for Improving Patient Care
8 New SCIP Measures for Normothermia, Urinary Catheters
Clinical Editor
Alecia Cooper, RN, BS, MBA, CNOR 9 Delaware Hospitals Standardize Wristband Colors
Senior Writer 11 CDC to Fund State Infection Control Efforts
Carla Esser Lake
12 State Reporting of Infections and Adverse Events
Page 11
Creative Director
20 Perioperative Positioning Injuries on the Rise: What to Do!
Mike Gotti
Clinical Team
Jayne Barkman, RN, BSN, CNOR
OR ISSUES
Rhonda J. Frick, RN, CNOR 13 Revised Universal Protocol for 2010

Anita Gill, RN 33 Can a Rigid Container System Be Greener and Safer
Megan Shramm, RN, CNOR, RNFA
Kimberly Haines, RN, Certified OR Nurse
at the Same Time?
Jeanne Jones, RNFA, LNC 39 O.R. Fires: New Recommendations for Prevention
Carla Nitz, RN, BSN Page 20
Connie Sackett, RN, Nurse Consultant
45 Scoring Fire Risk for Surgical Patients
Claudia Sanders, RN, CFA 48 Breaking Free From Our Cultural Chains
Angel Trichak, RN, BSN, CNOR
Perioperative Advisory Board SPECIAL FEATURES

Larry Creech, RN, MBA, CDT 43 Mark Bruley Talks About New Surgical Fire Prevention
Carilion Clinic, Virginia
Sharon Danielewicz, MSN, BSN, RN, RNFA
Guidelines
St. Lukeʼs The Woodlands, Texas 56 Changing the Catheter Culture at Your Facility
Tracy Diffenderfer, RN, MSN
Vanderbilt University Medical Center, Tennessee
69 Peggy Fleming to Speak at Medline’s AORN Breast Cancer Page 45
Barb Fahey RN, CNOR Awareness Breakfast

Cleveland Clinic, Ohio 70 Medline’s Pink Glove Dance: A YouTube Sensation
Susan Garrett, RN
Hughston Hospital Inc., Georgia
Zaida I. Jacoby, RN, MA, M.Ed
CARING FOR YOURSELF
NYU Medical Center, New York 65 9 Habits of Very Happy People
Jackie Kraft, RN, CNOR 77 Healthy Eating: Cheesy Potatoes Recipe
Huntsville Hospital, Alabama
Tom McLaren
Florida Hospital, Florida
Page 56
FORMS & TOOLS
Donna A. Pritchard, RN, BSN, MA, CNOR, NE-BC 79 FAQs About Catheter-Associated Urinary Tract Infection
Kingsbrook Jewish Medical Center, New York
80 Surgical Safety Team Communication
Debbie Reeves, RN, CNOR, MS
Hutcheson Medical Center, Georgia 81 Universal Protocol and Fire Risk Assessment
Diane M. Strout, RN, BSN, CNOR 84 Extinguishing a Surgical Fire
Chesapeake Regional Medical Center, Virginia
85 Preventing Surgical Fires
Margery Woll, RN, MSN, CNOR
North Shore Shore University Health System, Illinois 87 H1N1 Patient Handout: English
Page 70
89 H1N1 Patient Handout: Spanish
Medline, headquartered in Mundelein, IL, manufactures and distributes more than Meeting the highest level of national and international quality standards, Medline is
About Medline
100,000 products to hospitals, extended care facilities, surgery centers, home FDA QSR compliant and ISO 13485 registered. Medline serves on major industry
care dealers and agencies and other markets. Medline has more than 800 dedi- quality committees to develop guidelines and standards for medical product use in-
cated sales representatives nationwide to support its broad product line and cost cluding the FDA Midwest Steering Committee, AAMI Sterilization and Packaging
management services. Committee and various ASTM committees. For more information on Medline, visit
our Web site, www.medline.com.
©2010 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
Aligning practice with policy to improve patient care 3

THE OR CONNECTION I Letter from the Editor

Dear Reader,
2010 is going to be a great year … for you and for us. Check out this month’s cover. The photo was shot in
I believe this because we witnessed 2009 become the O.R. from the “now famous” YouTube video, the
one of the busiest and most productive years in the “Pink Glove Dance,” filmed at Providence St. Vincent’s
last two decades, and I am convinced that 2009 was Hospital in Portland, Ore. (To view the video, visit
just setting the momentum for what is coming in youtube.com and type “pink glove dance” in the
2010. As we move into the New Year and this excit- search bar.) Who would have believed that an off-the-
ing time, I want to thank a number of you for your con- cuff idea like this video would generate more than six
tinued support. million hits to date … and still counting.
First, thank you to our advisory board, for the time you
spent with us deliberating over details, testing ideas
and working with us to help make these ideas a
For the past five years Medline has been an active and
visible supporter of breast cancer awareness. Our first
Breast Cancer Awareness Breakfast was held at the
“
I am convinced that
2009 was just setting
the momentum for
reality. Your time is valuable, and we appreciate every AORN Congress in Washington, DC. I remember hop- what is coming in
”
minute you gave to us. ing you would show up for that event … and you did! 2010.
And every year since, many of you have joined us for
I’d also like to thank the Medline Grant Committee for our annual Breast Cancer Awareness Breakfast at
the many hours you spent reviewing and scoring grant Congress to support this important cause. The “Pink
applications. Because of your dedication, Medline Glove Dance” video is just our latest effort to engage
was able to award $685,000 in grant funding for you in this effort. Since the posting on YouTube,
healthcare research. Close to 25 percent of those you’ve sent us hundreds of congratulatory e-mails and
grants were specifically OR-related. While I’m at it, I’d letters. Thank you for your continued support.
like to thank all of you who are associated with peri-
operative activities in your facilities. You deserve a lot Take care. I look forward to an action-packed year
of credit for all you do. in 2010.
Thank you to the many, many healthcare workers who Here’s to you!
have contributed suggestions that have led to our
developing innovative product solutions, unique pro-
grams and state-of-the-art educational offerings. Here
Sue MacInnes, RD, LD
at Medline, we want to continue to lead the way in
Editor
developing cost-effective and practical solutions that
will make your jobs easier. That wouldn’t be possible
without your input.
On the cover:
Shelley Galvin (left) and Alana Ellerbroek (right) from the Car-
diac Surgery department at Providence St. Vincent Medical
Center in Portland, Ore. during the filming of the “Pink Glove
Dance” video. See page 70 for the full story.
4 The OR Connection
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Three Important National Initiatives

for Improving Patient Care
Achieving better outcomes starts with an understanding of current
patient-care initiatives. Here’s what you need to know about national
projects and policies that are driving changes in care.
1 IHI Improvement Map

Launched by the Institute for Healthcare Improvement (IHI) in January 2009
To help hospitals improve patient care by focusing on an essential set of processes needed to
Origin:
achieve the highest levels of performance in areas that matter most to patients.
Purpose:
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 requirements
and 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.
2 Joint Commission 2010 National Patient Safety Goals

Developed by Joint Commission staff and the Patient Safety Advisory Group
(formerly the Sentinel Event Advisory Group)
Origin:
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 offers
guidance 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 2010; however, revisions to the NPSGs will be effective in 2010.
3 Surgical Care Improvement Project (SCIP)

Initiated in 2003 as a national partnership. Steering committee includes the following
organizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the
Origin:
Joint Commission
To improve patient safety by reducing postoperative complications
To reduce nationally by 25 percent the incidence of surgical complications by 2010
Purpose:
Goal:
SCIP aims to reduce surgical complications in three target areas. Participating hospitals collect data on specific process and
outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgical
complications annually (just in Medicare patients) by getting performance up to benchmark levels.
6 The OR Connection
Patient Safety
IHI Improvement Map: 70 Processes to Transform Hospital Care

The IHI Improvement Map is an online tool that distills the best knowledge available on the key process
improvements that lead to exceptional patient care.
1. Acute Myocardial Infarction (AMI) Core Processes 1. Central Line Bundle

Top 5 Key Processes Viewed by Improvement Map Users Top 5 Key Processes Shared by Improvement Map Users
2. Set Direction: Aims 2. CA-UTI

3. CA-UTI 3. Anti-Biotic Stewardship
4. Communication and Teamwork 4. Falls Prevention
5. Central Line Bundle 5. Heart Failure Core Processes
To learn more about the IHI Improvement Map and the 70 processes to transform hospital care, go to www.ihi.org/imap/tool
Joint Commission 2010 National Patient Safety Goals

• Improve the accuracy of patient identification. • The organization identifies safety risks inherent in
• Improve the effectiveness of communication its patient population.
among caregivers. • Universal Protocol for Preventing Wrong Site,
• Improve the safety of using medications. Wrong Procedure, and Wrong Person Surgery.™
• Reduce the risk of healthcare-associated
infections.
• Accurately and completely reconcile medications No new NPSGs have been developed for 2010.
across the continuum of care. Effective January 1, 2010, organizations are expected
• Reduce the risk of patient harm resulting from falls. to have fully implemented the requirements related to
• Prevent healthcare-associated pressure ulcers healthcare-associated infections established in 2009.
(decubitus ulcers).
To learn more about National Patient Safety Goals, go to www.jointcommission.org.
Surgical Care Improvement Project (SCIP): Target Areas

1. Surgical infections
By the numbers:
* Antibiotics, blood sugar control, hair removal, perioperative • 3,740 hospitals are submitting
temperature management data on SCIP measures, representing
• Remove urinary catheter on POD 1 or 2 75 percent of all U.S. hospitals
2. Perioperative cardiac events • Currently, SCIP has more than 36
• Use of perioperative beta-blockers association and business partners
3. Venous thromboembolism
• Use of appropriate prophylaxis
Visit www.qualitynet.org

Patient Safety
KEY POINTS:
New SCIP Measures for Normothermia, Urinary Catheters
As reported in the last issue of The OR Con-

nection, the Surgical Care Improvement Project
(SCIP) introduced two new performance
measures effective October 1, 2009, in the
areas of normothermia and urinary catheters.
To clarify, here are the key points to

remember regarding each measure:
SCIP Infection Measure #9: Urinary catheter re- SCIP Infection Measure #10: Surgery patients for
moved on Postoperative Day 1 (POD 1) or Postopera- whom either active warming was used intraoperatively
tive Day 2 (POD 2) with day of surgery being day zero. for the purpose of maintaining normothermia or who
had at least one body temperature equal to or greater
Rationale: It is well-established that the risk of catheter- than 96.8 degrees F/36 degrees C recorded within
associated urinary tract infection (UTI) increases with the 30 minutes immediately prior to Anesthesia
increasing duration of indwelling urinary catheterization. End Time or the 15 minutes immediately after
Studies have shown the following: Anesthesia End time.
• Bacteriuria will develop in 26 percent of patients
after two to 10 days of catheterization; 24 percent Rationale: Core temperatures outside the normal range
of those patients will develop symptomatic pose a risk in all patients undergoing surgery. Studies
urinary tract infection and bacteremia will have shown the following:
develop in 3.6 percent. • Impaired wound healing, adverse cardiac events,
• Patients who had indwelling catheters for more altered drug metabolism and coagulopathies
than two days postoperatively were 21 percent are associated with unplanned perioperative
more likely to develop a urinary tract infection; hypothermia.
significantly less likely to be discharged to home • Incidence of surgical site infections among those
and had a significant increase in mortality at with mild perioperative hypothermia was three
30 days. times higher than with normothermic periopera-
tive patients.
• Hypothermia is associated with a significant
increase in adverse outcomes, an increased
chance of blood products administration,
Source: Specifications Manual for National Hospital Inpatient Quality
Measures. Available at http://www.qualitynet.org/dcs/ContentServer?c=
myocardial infarction and mechanical ventilation.
Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228695698425. • Adverse outcomes resulted in prolonged hospital
stays and increased healthcare expenditures.
8 The OR Connection
Patient Safety
Delaware Hospitals
Standardize Wristband Colors
In September 2009 Delaware joined the growing list of Movement toward a national standard of color-coded
states that have standardized the use of color-coded patient wristbands gained momentum in 2005 after a
hospital patient wristbands. In coordination with the hospital patient in Pennsylvania nearly died because a
Delaware Healthcare Association, all acute care general nurse incorrectly used a yellow wristband, which she
hospitals in the state have voluntarily agreed to adopt the thought meant “restricted extremity,” as it did at another
following colors and meanings to convey specific patient hospital where she worked. At this hospital, yellow meant
information to healthcare professionals.1 “do not resuscitate,” and the patient was nearly not
resuscitated.1
Red = patient allergies
References
Yellow = fall risk 1 Improving Patient Safety: Delaware Hospitals Adopt Common Color Wrist Bands.
Purple = do not resuscitate Delaware Healthcare Association. Press Release. September 14, 2009. Available at:
http://www.deha.org/news.htm. Accessed September 30, 2009.
2 State color-coded wristband standardization. Available at: http://www.patientidex-
In addition to these three colors, some states use a pink pert.com/material/us_colorcode_implementation.pdf. Accessed September 30, 2009.
3 American Hospital Association. Hospitals in Pursuit of Excellence website. Available at
wristband to identify a restricted extremity and green to http://www.hpoe.org/hpoe/wristband-colors.shtml.
symbolize a latex allergy.2
WA
VT ME
MT
ND
OR MN NH
MA
ID SD WI
NY
RI
WY MI
CT
IA PA NJ
NE
NV DE
IL IN OH MD
UT
CA WV
CO
KS MO VA DC
KY
TN NC
AZ NM OK
AR SC
MS AL GA
TX LA
AK
FL
States with
Standardized
Wristband Colors3
HI

ARGLAES IN THE OR
ANTIMICROBIAL SILVER TECHNOLOGY
Use silver to fight bacteria.
Medline Industries, Inc. first introduced Arglaes® silver features a calcium alginate pad for fluid management
dressings in 1997, and we’ve continued to be a leader in addition to controlled-release silver.
in silver antimicrobial technology ever since.
Arglaes Powder is perfect for difficult-to-dress wounds
Arglaes technology utilizes ionic silver to create an and can be easily combined with other dressings to
environment that is hostile to bacteria and fungi yet create a system for antimicrobial protection.
completely non-cytotoxic. Arglaes’ sustained-activity
ionic silver maintains full efficacy for up to seven days. To schedule a FREE demonstration of Arglaes
in your OR, contact your Medline representative,
The Arglaes family of products has something for every call 1-800-MEDLINE or visit www.medline.com.
wound: Arglaes Film is ideal for managing bacterial
penetration on post-op and line sites. Arglaes Island
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
CDC to Fund The Centers for Disease Control and Prevention (CDC)
is set to distribute $40 million in federal funds to state
State Infection health departments to help reduce healthcare-associ-
ated infections.
Control
The CDC’s funding focuses on controlling bloodstream
Efforts infections (BSI), surgical site infections (SSI) and catheter-
associated urinary tract infections (CAUTI). Specifically,
the agency wants state health departments to increase
investments in the U.S. Department of Health and Human
Services’ HAI Action Plan, which is designed to create wide-
spread infection prevention practices by coordinating the
efforts of local public and private partners.
The $40 million investment, funded by the American Recovery

and Reinvestment Act, marks the first time Congress has
allocated money to curb healthcare infection rates at the
state level. Part of the funding is earmarked to increase
healthcare facilities’ use of the CDC’s National Healthcare
Safety Network, a surveillance system that tracks, analyzes
and compares HAI data. Funds also will go toward hiring
and training local public health staff to implement and coor-
dinate national infection prevention efforts.
“We expect these programs to strengthen tracking and

prevention of healthcare-associated infections, enhance
facility accountability, provide data for informed policy, and
ultimately save lives,” said CDC Director Thomas R.
Frieden, MD, MPH. “Funding critical prevention efforts at
state and local levels represents a significant investment
toward elimination of HAIs and improved patient safety.”
Outpatient Surgery Magazine. September 8, 2009. Available at:

http://www.outpatientsurgery.net/newsletter/eweekly/2009/09/08.php

Patient Safety
State Reporting of Infections
and Adverse Events
WA
VT ME
MT
ND
OR MN NH
MA
ID SD WI
NY
RI
WY MI
CT
IA PA NJ
NE
NV DE
CA
UT
CO
** IL IN OH
WV
MD
KS MO VA DC
KY
TN NC
AZ NM OK
AR SC
** MS AL GA
TX LA
States with study laws
FL
Mandates public reporting
**
of infection rates
AK
Voluntary
HI
HAI Reporting Laws and Regulations Copyright 2008 – Association for Professionals in Infection Control and
Epidemiology, Inc.
Nearly 56 percent of states currently require pub- Please contact communications@apic.org for reprint permission and
lic reporting of hospital-acquired infections. update requests. Reprinted with permission.
WA
VT ME
MT
OR MN NH
MA
ID SD WI
NY
RI
WY MI
CT
IA PA NJ
NE
NV DE
IN OH MD
UT
WV
CO
KS VA DC
KY
TN NC
AZ NM OK
SC
MS AL GA
TX LA
Hospital-specific public data

FL
Statewide public data
AK
No public data
Voluntary reporting
HI
No reporting
System pending
State Reporting of Adverse Events

With no national mandatory event reporting system
in place, the United States is blanketed by a patch-
work of state reporting systems collecting a variety of
Reprinted with permission from Hearst Newspapers. Hearst research by
data in different ways. The amount of information
Olivia Andrzejczak. Graphic by Kyla Calvert. Template by Alberto Cuadra.
available to the public also differs from state to state. Available at http://www.chron.com/deadbymistake/hospitals.
12 The OR Connection
OR Issues
Joint Commission Update

Revised Universal Protocol for 2010:
What This Means for the OR Manager
by Connie Yuska, RN, MS
One of the most challenging management responsi- The highlights of the changes are summarized below:
bilities in every operating room or procedure area is
keeping patients safe. There are several ways to ensure Applicability: The Universal Protocol has been revised to
this happens, but one way is to make sure practices are apply to “all surgical and non-surgical invasive proce-
up-to-date and staff are fully aware of requirements dures.” In the past, the protocol applied to “all invasive
established by accrediting and regulatory bodies. procedures that put patients at more than minimal risk,
Recently, The Joint Commission revised the Universal regardless of the location within an organization.”
Protocol for Preventing Wrong Site, Wrong Procedure, and
Wrong Person Surgery. Pre-procedure verification (UP.01.01.01): As a man-
ager, you know patient safety in the OR begins with
Revisions were made in four areas to ensure that safe care ensuring that the right procedure is performed on the right
is provided to every patient having a surgical or non- patient. The Universal Protocol has been revised to
surgical invasive procedure. The changes apply to proce- remove references to the location (pre-procedure area)
dures performed in acute care and critical access and timing of the verification. In addition, the term checklist
hospitals, ambulatory care and office-based surgery has been replaced by reference to a standardized list that
programs. The intent of the changes is to continue to can be used in the verification process. The changes
address important patient safety issues while giving recognize that the pre-procedure verification is an ongoing
organizations the flexibility needed to apply the require- process of gathering and confirming information. The
ments in their own particular setting and also to be able to purpose of the pre-procedure verification is to ensure that
incorporate the changes into their unique work processes. all relevant documentation, information and equipment are
available prior to the start of the procedure. Staff also must
The purpose of this article is to summarize the changes ensure that all documents are correctly identified, labeled
so you can educate your staff and revise your practices and matched to the patient’s identifiers. Another
to meet the revised elements of performance (EP). important aspect of this process is making sure the
patient understands what procedure will be performed
and ensuring that all members of the operating or proce-
dure area correctly identify the patient and the procedure
to be performed.

Joint Commission Update
Site Marking (UP.01.02.01)
The changes recognize that the pre-procedure verification cedure site be marked by “a licensed independent practi-
process may occur at more than one time and place before tioner who is ultimately accountable for the procedure and
the procedure is performed. It is now up to the hospital to will be present when the procedure is performed.” However,
decide when this information is collected and who will collect The Joint Commission recognized the complexity of work
it. Some possibilities for when and where to collect this processes surrounding invasive procedures and changed the
information include: standard so that site marking can now be delegated to
• When the procedure is scheduled another individual in limited situations where the individual is
• At the time of preadmission testing and assessment familiar with the patient and involved in the procedure. They
• At the time of admission or entry into the facility for define those individuals as:
a procedure • Individuals who are permitted through a residency
• Before the patient leaves the pre-procedure area program to participate in the procedure
or enters the procedure room • A licensed individual who performs duties requiring
collaborative or supervisory agreements with a
What this means for you licensed independent practitioner. These individuals
Now you have the opportunity to work with your colleagues include advanced practice nurses (APRNs) and
who lead your pre-anesthesia and same-day surgery ambu- physician assistants (PAs.)2
latory areas to develop a staff protocol to ensure the pre- It is important to remember that the licensed independent
procedure verification process is completed in the area that practitioner remains fully accountable for all aspects of the
makes the most sense based on practices related to how procedure even when the marking of the site is delegated to
patients come into your institution. another practitioner.
Site Marking (UP.01.02.01): Surgery performed on the What this means for you
wrong site should never, never happen. One way to make Check the regulations in your state regarding the scope of
sure that everyone in the operating room or procedure area practice for your advanced practice nurses and your physi-
knows the correct location of the surgery or other procedure cian assistants to make sure this activity is consistent with
is to clearly mark the site. Patient safety is enhanced when the state’s practice act. Discuss this change with the mem-
a consistent process is used throughout the hospital to mark bers of your healthcare team who are doing surgery or per-
the site. The revised Universal Protocol requires that the pro- forming procedures. You’ll want to review your current
Continued on page 16
Setting
a new
standard
in patient
safety.
Medline’s Gold Standard Safety Program—a complete tool kit for surgical safety.
Designed to break down barriers to surgical safety

compliance by offering easy-to-use tools to help you
reach your safety goals, Medline’s Gold Standard
Safety Program offers four levels of safety options:
1. The Gold Standard Safety Bundle: Includes

six products to serve as visual safety reminders
to reduce needle sticks and wrong site surgery.
2. Innovative safety products: Surgical Time Out

Procedure (S.T.O.P.™) Drape and Dual Tip Marker
remind OR staff to take time to verify key information
Visit www.medline.com/goldstandard for a quick
before the first incision to reduce wrong site surgery.
video overview on how Medline’s Gold Standard
3. Med-Pack™: Electronic pack audit and a review Safety Program can help improve safety in your OR.
of safety components.
Time-out (UP.01.03.01)
among all members of the procedure team. Time-outs have

been found to be most effective when conducted consis-
tently across the hospital, so the OR manager often can take
a leadership role in helping to establish protocols for other
ambulatory procedure areas.
Keeping patients safe at all times when they are under our
care is the goal of every healthcare provider. Your role in
making your colleagues aware of these changes and inviting
them to actively participate in updating procedures at your
facility will ensure that you meet that goal.
procedure and discuss situations in which exceptions to site References

1. Approved: revised Universal Protocol for 2010. The Joint Commission Perspectives.
marking may be allowed. Develop an alternative process if 2009;29(10):3. Available at: http://www.jointcommission.org/NR/rdonlyres/DFBF9FFD-
AF97-4CA1-A9C8-8102C2D77AE0/0/JCP1009.pdf. Accessed October 28, 2009.
that meets your needs, but be sure to document the change
2. The Joint Commission. 2010 National Patient Safety Goals (NPSGs). Pre-publication
and educate all personnel who will interact with the patient. Version of the 2010 National Patient Safety Goals (NPSGs) outlines and chapters for
all applicable programs. Available at: http://www.jointcommission.org/patientsafety/
nationalpatientsafetygoals/. Accessed November 24, 2009.
Time-out (UP.01.03.01): The purpose of the time-out pro-
cedure is to conduct a final check that the correct patient, About the author
site and procedure are identified. This is the final safety check Connie Yuska, RN, MS began her ca-
that all systems are go! In the revised version of in the Uni- reer as a nurse in the specialty of otorhi-
versal Protocol, all references to conducting the time-out nolaryngology. Her clinical experience
before initiating anesthesia have been removed. The ration- includes both inpatient and outpatient care
of head and neck oncology patients, and she
ale states “a hospital may conduct the time-out before anes-
is certified in otorhinolaryngology and head-
thesia or may add another time-out at that time.”2 The list of neck nursing. She has held clinical manager
issues to be addressed during the time-out was shortened to and director of nursing positions in a large
enable healthcare team members to focus on the correct academic medical center and also has experience in the home
patient, procedure and site. care setting as the vice president of operations for a large aca-
demically affiliated home care agency in the Chicago area. Con-
nie later joined the executive suite as the chief nursing officer of a
What this means for you
large community hospital in Chicago, and she is currently a vice
You have the opportunity to meet with the surgeons and president of clinical services for Medline. In all of her leadership
other members of your team to decide how you want to roles, she has been responsible for ensuring the delivery of high
structure the time-out procedure. When is the best time for quality, safe and cost-effective nursing care.
you to perform the time-out? Think about all the steps you
take to keep your patient safe and ask yourself what the Connie is a 2003 graduate of the J&J/Wharton Nurse Executive
Program. She is member of the Board of the Illinois Organization
patient can contribute during the time-out. If you determine
of Nurse Leaders and a member of the American Organization of
that the patient can contribute to the safety aspect of their Nurse Executives. In 2005, she was inducted into the 100 Wise
care, then it would make sense to do the time-out prior to the Women Program sponsored by Deloitte & Touche. In addition, she
start of anesthesia. Remember to designate a member of the has published several articles and chapters in oncology journals
team to initiate the time-out and include active communication and textbooks.
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SPECIAL WEBCAST
BREAKING THROUGH HAND HYGIENE & SKIN CARE BARRIERS
“Effect of Lotions and Creams on Irritant Hand Dermatitis in Health Care Workers”
Featured in the American Journal of Infection Control
Join us for this exclusive webcast highlighting the latest hand care research as Dr. Marty
Visscher, PhD, discusses the conclusions of her recently published study showing
that frequent use of lotions and creams may mitigate the damaging effects of
repetitive hand hygiene. She also will discuss the need for intensive treatment of irritant
contact dermatitis in healthcare workers to counteract skin compromise and minimize
negative effects on infection control.
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development and use of sensory techniques to measure the
patient/consumer relevant skin effects of ingredients and products,
and is an expert on the effects of environment and skin treatment
products on the skin.
Shown on demand January 25-29, 2010, with one CE credit available through Medline University.
For more information and to register, please visit www.medlineuniversity.com
PERIOPERATIVE
PRESSURE ULCER EDUCATION
More important than ever before
Medline’s Pressure Ulcer Prevention Program now has a

component designed specifically for perioperative services.
The easy-to-use interactive CD addresses the following:
• Hospital-acquired conditions
• CMS reimbursement changes
• Best practices for pressure ulcer prevention
• Perioperative assessment tools
• Critical patient and equipment risk factors
“
I have seen an increase in the number of legal issues To learn more about Medline’s Pressure Ulcer
linking facility-acquired pressure ulcers to post-surgical Prevention Programs and FREE webinars for
acute care and perioperative services, call
patients. A pressure ulcer program for the OR is more
your Medline representative or visit
critical than ever.”
www.medline.com/pupp-webinar.
Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN
The AORN Seal of Recognition has been awarded to Pressure Ulcer Prevention for Perioperative Services
in June 2009 and does not imply that AORN approves or endorses any product or service mentioned in
any presentation, format or content. The AORN Recognition program is separate from the AORN, ANCC
Accredited Provider Unit and therefore does not include any CE credit for programs.
The AORN Seal of Recognition is a trademark of AORN, Inc., All rights reserved.
Patient Safety
Back to Basics Eleventh in a Series
Perioperative Positioning
Injuries on the Rise:
What to Do!
by Alecia Cooper, RN, BS, MBA, CNOR
Author’s note: In 2007, I wrote a “Back to Basics” article on Positioning for a surgical procedure depends on the sur-
the principles of proper positioning and prevention of posi- geon’s preference, the anesthesia provider’s needs, the pro-
tioning injuries. I listed many types of injuries that can occur cedure being performed and the need for exposure of the
as a result of improper positioning before, during and after surgical site. Overall, positioning is recognized as a balance
a surgical procedure. The content of that article still holds between the position a patient can physically assume and
true, but when I went back to the topic recently in prepara- what can be physiologically tolerated, based on the patient’s
tion for a live presentation, I was alarmed to learn that these age, height, weight and overall health. A patient’s body must
injuries were not on the decline, but rather on the rise. And be positioned adequately on an OR bed, and proper body
that’s what prompted me to write this article as a refresher alignment must be maintained to lessen the potential for
on positioning for perioperative professionals. injuries.3
The importance of proper patient positioning must not be Assessment

overlooked. More and more studies are attributing hospital- Proper patient positioning begins with an assessment before
acquired pressure ulcers to lack of proper positioning in the patient ever arrives in the operating room. Elements to
perioperative services. In fact, AORN’s 2009 Perioperative consider include the patient’s pre-existing conditions, the
Standards and Recommended Practices states that the type and duration of the procedure and individual patient
incidence of pressure ulcers occurring as a result of surgery characteristics such as height, weight, age, skin condition,
may be as high as 66 percent.1 In addition, more and more etc.1 Regardless of these factors, however, all surgical pa-
lawsuits are being filed due to positioning injuries, not only tients should be considered at risk for pressure ulcers be-
because of avoidable pressure ulcers, but also physiologic cause of the uncontrollable length of surgery and the effects
compromises and nerve damage. The incidence of nerve of anesthesia on the patient’s hemodynamic state, along
injuries is unknown, however in the United States, nerve with the use of vasoactive medications during surgery.3
damage accounts for 15 percent of postoperative litigation
claims.2

Risk factors identified during the assessment can determine Special considerations for avoiding eye injuries1
the degree of pressure the patient can tolerate. The following Patients are at increased risk of developing post-operative
factors affect the ability of the skin and supporting struc- vision loss if they:
tures to respond to pressure:3 • Are undergoing procedures lasting 6.5 hours or more
• Vasoactive medications and steroids • Have substantial blood loss
• Comorbid diseases, such as cancer, • Are in a prone position
cardiovascular and peripheral vascular
deficiencies, diabetes and neurological In general, direct pressure on the eye should be avoided to
or respiratory disease reduce the risk of central retinal artery occlusion and other
• Extracorporeal circulation ocular damage, including corneal abrasion. Assess eyes
• Impaired regulation in body temperature regularly, especially in long procedures and when the
• Existing fractures patient is in the prone position.
• Low hemoglobin and hematocrit levels
• Nutritional deficiencies The type of procedure dictates how the patient will
• Obesity be positioned on the operating table and the type
• Low serum protein (i.e., prealbumin of positioning equipment that will be required. The
or total albumin plus globulin) most common surgical positions are supine, prone, lateral
• Smoking and lithotomy. Each position carries its own risks and safety
• Low blood pressure considerations, as shown in Table 1 on page 29.
Maintaining optimal physiological conditions lessens the risk The length of the procedure is another consideration.
for complications both intraoperatively and postoperatively. Often, the longer a patient is on the operating table, the
When a patient has inadequate arterial blood flow, improper greater the risk for pressure ulcers. One study reported that
positioning can cause complications with blood pressure, intraoperative pressure ulcers increased when the proce-
decrease tissue perfusion and venous return and cause dure time extended beyond three hours. Cardiac, general,
blood clots. thoracic, orthopedic and vascular procedures were re-
ported to be the most common types of procedures
Pre-existing conditions are important to assess associated with pressure ulcer formation.1
because certain patients are especially vulnerable
to pressure ulcers and/or nerve damage. Patients with Specific factors such as age, weight and skin
vascular disease may have existing tissue ischemia and condition, among others, are also important to
often have additional risk factors such as age, nutritional assess prior to surgery.1 Patients who are 65 years of
deficits, obesity or diabetes.1 Interestingly, these are the age or older experience the highest incidence of pressure
same patients who often undergo cardiovascular surgery, ulcer development.3 These patients also have less flexibility
which already puts patients at higher risk for injury simply and poorer peripheral circulation, making them more prone
because the procedures typically last four hours or longer. to skin- and nerve-related injury. The same holds true for
In addition, patients who smoke often experience vaso- obese patients.4 Of course, every individual is different,
constriction, which contributes to pressure ulcer formation.1 and your assessment will reflect this. A fit, healthy 82-year-
Patients with respiratory, circulatory, neurologic or immune old may be less vulnerable than an overweight 35-year-old
conditions are also more vulnerable to injury, as are those with diabetes. Very young pediatric patients are also at
with physical limitations such as back problems and pros- greater risk for surgical injuries, as are frail, malnourished
theses or implants, such as an artificial hip or knee. individuals.
NO PRESSURE, JUST SUPPORT.

Gel positioners ease pressure in the OR
Recent studies have shown that pressure ulcers can start

to form in as little as 20 minutes in the operating room.1
When every second counts, the surfaces used for positioning
and transporting patients need to be chosen carefully.
Medline’s gel positioners are designed to help reduce

pressure while providing exceptional support during surgical
procedures. They’re latex- and silicone-free, antimicrobial,
antibacterial and radiolucent. They’re also reusable and can
easily be cleaned and disinfected with standard hospital
disinfectants. Available in a wide variety of shapes and sizes.
Gel positioners are one of several products recommended

as part of Medline's Pressure Ulcer Prevention Program.
This proven, systematic approach combines education,
best-in-class products and dedicated program management
to reduce pressure ulcer incidence.
To sign up for a FREE webinar on perioperative

pressure ulcer prevention, go to
References
1
Pressure ulcers hit a sore spot in the operating room. Healthcare Purchasing News. Available at:
http://www.hpnonline.com/inside/2007-08/0708-OR-pressure.html. Accessed November 17, 2008.
ment and support of joints when

an older adult patient is positioned
after undergoing sedation. If not
contraindicated, the circulating
nurse should also place a pillow
under the patient’s knees to avoid
postoperative stiffness that may
limit early mobility. Heels are an
often overlooked but vulnerable
area than can benefit from addi-
tional padding as well.6
Planning
After assessment, the next step is
planning. The nurse must anticipate
the proper positioning equipment
and supplies that will be needed
based on the knowledge acquired
during the assessment. The nurse
should review the surgery schedule
before the patient’s arrival – prefer-
ably before the day of surgery – to
Be sure to assess the patient’s skin before surgery, identify potential conflicts in the availability of positioning
looking for dryness, skin tears and existing wounds, equipment.1
including pressure ulcers, and document your findings
in the medical record. This information will be critical for The nurse should also confirm that the room is set up
comparing the condition of the patient’s skin after surgery to appropriately for the planned procedure before the patient
determine any damage that may have occurred in the oper- arrives. In addition, positioning and transporting equipment
ating room. Many pressure ulcers that originate during sur- should be periodically inspected and maintained. Properly
gery do not appear until one to four days after an operation, functioning equipment contributes to patient safety and
some are mislabeled as burns and some are unexplained assists in providing adequate exposure of the surgical site.1
because they appear and progress differently from the
pressure ulcers seen in nonsurgical patients. OR-acquired Even when you have a plan, observe the patient right before
pressure ulcers initially have a distinctive purple appearance.5 surgery to ensure that your positioning recommendations are
Shearing movement should be avoided when transferring still correct. Also double check that all necessary positioning
patients onto the OR table, especially the elderly, whose frag- devices and padding materials are in the operating room
ile skin can tear more easily than the skin of younger patients. prior to transporting the patient.
The overall goal of positioning elderly patients is to reduce
stress and pressure on the spine and skin. The circulating Tools for Proper Positioning
nurse should be particularly vigilant about optimal body align- The goal is to use equipment that is designed to redistribute
pressure and decrease the risk for positioning injuries. An
KEEP YOUR SURGICAL

PATIENTS DESERT DRY.
Medline’s Sahara® Super Absorbent OR table sheets QuickSuite®
OR Clean Up Kit
are designed with your patients’ skin integrity in mind.
The Braden Scale tells us that moisture is one of the

major risk factors for developing a pressure ulcer.1 We also
know that as many as 66 percent of all hospital-acquired
pressure ulcers come out of the operating room.2
That’s why we developed the Sahara Super Absorbent

OR table sheet. The Sahara’s super-absorbent polymer
technology rapidly wicks moisture from the skin and
locks 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 improve To sign up for a FREE webinar on perioperative
your OR turnover time and help reduce cross contamina- pressure ulcer prevention, go to
tion risk through a combination of disposable products.
References
1
Braden Scale for Predicting Pressure Sore Risk. Available at:
www.bradenscale.com/braden.PDF. Accessed November 6, 2008.
2
Recommended practices for positioning the patient in the perioperative practice setting. In:
Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008.
inverse relationship may exist between the duration and Special considerations for avoiding
intensity of pressure. Low-intensity pressure over a long nerve injuries1
period can initiate tissue breakdown, as can high-intensity Surgery-related nerve injuries most often are attributed to
pressure for a short period of time.3 careless positioning. The most common injury is to the
ulnar nerve, followed by the brachial plexus. To minimize
During the positioning procedure, it is the nurse’s respon- the risk of nerve injury, safety measures should include:
sibility to:1 • Padded arm boards attached at less than a
• Restrict access to the operating room 90-degree angle for the supine position
• Close all doors • Placing the patient’s hands palms up with
• Limit traffic within the operating room fingers extended
• Minimize exposure • Keeping shoulder abduction and lateral rotation
• Provide auditory privacy of the patient to a minimum
• Prohibit prejudicial behavior • Preventing the patient’s extremities from dropping
below the level of the procedure bed.
Positioning devices. Safety is the primary concern when • Placing the patient’s head in a neutral position,
determining the adequate number of personnel and type if not contraindicated by the surgical procedure
of devices to safely transfer and position the patient. Trans- or the patient’s physical limitations
ferring is accomplished with a lateral transfer device (e.g., • Adequate padding for the saphenous, sciatic and
slide boards, air-assisted transfer devices) that reduces peroneal nerves, especially for patients in the
friction and shear.3 lithotomy or lateral position
• Placing a well-padded perineal post against the
One study involving the review of 16 perioperative incident perineum between the genitalia and the uninjured
reports showed that in 63 percent of the cases, patients leg when a patient is positioned on a fracture table
were above the weight limit for the equipment. To avoid this
situation in your practice, ensure in advance that you will be
using a bed that is sufficiently sized for the patient, obtain
types of pressure redistribution support surfaces are avail-
pressure redistribution table pads and be sure that arm-
able. One type is an overlay, which is placed directly on the
boards are available.1
mattress or bed frame as a replacement for the standard
foam OR mattress.3
Use specific positioners for head and neck surgeries,
extremities procedures and procedures performed on
Foam, static-air and gel are common types of overlays.
the torso.
Static-air overlays allow air to exchange through multiple
chambers when a patient lies on the overlay. This type of
Support surfaces. Proper padding around the patient’s
overlay must be reinflated periodically. Gel overlays prevent
body helps prevent skin breakdown, especially on high-risk
shearing, support weight and prevent bottoming out. One
areas where soft tissue is compressed between a bony
study found that gel overlays helped prevent skin changes
prominence and a hard surface, such as the OR table. Use
and pressure ulcers in older adults, including those with
of too many pads or blankets, however, can cause the
chronic health comorbidities or vascular disease and those
capillary pressure to rise over 32 mmHg, which increases
experiencing extended surgical duration.3
the risk for poor tissue perfusion, causing the patient to be
at risk for developing pressure ulcers.3
Mackey reviewed three OR trials that indicated that the use
of air and gel pressure overlays might be beneficial in
Pressure redistribution devices should be used to promote
reducing the incidence of pressure ulcers for high-risk
reduction of interface tissue pressure for patients at high
surgical patients.3
risk of developing pressure ulcers or nerve injuries. Several
According to research published by Reddy et al, mattress Documentation

overlays on the OR bed may decrease the incidence of Here’s a question. Should nurses document specifically
postoperative pressure ulcers, along with adequate nutri- who does what when positioning a patient for a surgical
tion, moistening the skin and repositioning.3 procedure? According to legal experts, the nurse should
document exactly who did what to make it easier to deter-
Note: Rolled sheets and towels should not be used mine liability in case of a lawsuit. Remember that everyone
beneath the procedure bed mattress or overlay because in the OR is responsible for their own actions.7 If the anes-
they may negate the pressure-reducing effect of the thesia provider tucks the patient’s arm to the side, give that
mattress or overlay.1 person the credit on the operative record. If the surgeon
positions the patient’s legs in stirrups, document that fact.
Of course the nurse must always check to make sure all
pressure points are padded or that pedal pulses are intact
after the legs are positioned.
It may be time-consuming and cumbersome to chart all of

the specifics of positioning; however, it is advisable for the
nurse’s protection. To simplify the task, a checklist could
be developed, and the nurse could simply write the initials
of the responsible party next to each task performed.7
Documentation should include the following:1

Position to protect and support1
• A written preoperative assessment, including a
• Pad bony prominences
skin assessment on arrival and discharge
• Protect arms from nerve damage
• The type and location of positioning equipment
• Confirm finger locations
• Names and titles of persons participating
• Carefully apply safety restraints to avoid
in positioning
nerve damage
• Position patient is placed in and new position if
• Ensure no body parts touch metal equipment
repositioning occurs
• Elevate heels whenever possible
• Post-operative assessment for injury
• Align head and upper body with the hips
• Keep legs parallel (do not cross ankles)
• Position head in neutral position on a headrest
• A pillow may be placed under the back of the
patient’s knees to relieve pressure on the lower back
• If pregnant, insert a wedge under the right side
• Do not tuck arms at patient’s sides unless
absolutely necessary

Documentation Makes or Breaks the Case at Trial
If it’s not recorded, it didn’t happen5 Thorough nursing documentation wins the case8
A 60-year-old patient with multiple medical problems A patient sued her surgeon and the hospital over persist-
underwent 12-hour vascular reconstruction of the right leg. ent numbness in her right hand, which she first noticed
Sacral pressure ulcers were noted soon after, and despite after a total right hip replacement. Her lawsuit alleged the
treatment, severe necrosis developed. The patient’s leg numbness was an ulnar nerve injury from improper posi-
was amputated below the knee and the sacral ulcer tioning or the surgeon pressing against her arm or hand
required surgical debridement with grafting. The patient during surgery. All defendants were exonerated from blame
alleged negligence in positioning during surgery, which due to the effort made by the circulating nurse to docu-
resulted in severe sacral pressure ulcers that required pro- ment in precise detail how the patient had been positioned,
longed hospitalization and additional surgery. A review of stabilized and padded before surgery. Of special note was
the medical record revealed a lack of documentation by the the nurse’s documentation of the steps taken to extend the
surgeon, anesthesiologist and the OR nursing staff regard- patient’s arms out of harm’s way and to pad her arms and
ing the patient’s increased risk for skin breakdown. hands to avoid injury due to positioning or pressure.
Although serious skin breakdown may not have been pre-
ventable, documentation of heightened awareness by staff, The court record reiterated the circulating nurse’s docu-
as well as preventive measures, and a description of the mentation word-for-word: “6 table with safety strap in place
patient’s skin after surgery, may have made it easier for the 2 in. above knees – supine with bean bag underneath pa-
hospital to defend the case. The OR nursing documenta- tient post induction & catheter insertion into the left side,
tion lacked information on the condition of the patient’s with right side up, per __MD & __MD, - auxiliary roll in place
skin, and the padding used to position the patient on the (1000 cc bag IV fluid wrapped in muslin cover) – held in
OR table. The patient received a $100,000 indemnity pay- place per surgeons until bean bag deflated with suction –
ment and later sought additional compensation. pillow placed under right leg with left leg bent slightly – U
drape in place per surgeons pre-prep – left arm extended
on padded arm board - right arm placed on mayo tray that
is padded”
References
1. Recommended practices for positioning the patient in the perioperative practice 6. Doerflinger DMC. Older adult surgical patients: presentation and challenges. AORN
setting. In: Perioperative Standards and Recommended Practices. Journal. 2009;90(2):223-240.
Denver, Colo.:AORN, Inc. 2009. 7. For the nurse’s protection, it is advisable to document all specifics of positioning a
2. Prevention of injuries in the anaesthetised patient. Available at: http://www.surgical- patient for surgery. AORN Journal.1993;58(1):116.
tutor.org.uk/core/preop1/perioperative_injuries.htm. Accessed October 23, 2009. 8. Ulnar nerve injury alleged from surgery: hospital not liable – circulating nurse’s
3. Walton-Geer PS. Prevention of pressure ulcers in the surgical patient. AORN Journal. documentation of patient’s positioning carries the day. Legal Eagle Eye Newsletter
2009;89(3):538-548. for the Nursing Profession. 1997;5(1):3. Available at: http://www.nursinglaw.com/
4. Meltzer B. A guide to patient positioning. Outpatient Surgery. 2001;2(4). Available at: ulnar.pdf. Accessed December 4, 2009.
http://www.outpatientsurgery.net/issues/2001/04/a=guide-to-patient-positioning.
Accessed December 3, 2009.
5. ECRI Institute website. Executive summary. Pressure ulcers. HRC.2006;3(4). Available
at: http://www.ecri.org/documents/patient_safety_center/pressureulcers.pdf.
Accessed December 3, 2009.
Table 1
Injury Risks and Safety Considerations When Positioning Patients1
Position Risk Safety Consideration
Supine Pressure points, including occiput, scapulae, • Padding to heels, elbows, knees, spinal
thoracic vertebrae, olecranon process, column, and occiput alignment with hips,
sacrum/coccyx, calcaneae, and knees. legs parallel and uncrossed ankles.
Neural injuries of extremities, including brachial • Arm boards at less than 90-degree angle
plexus and ulna, and pudendal nerves. and level with floor.
• Head in neutral position.
• Arm board pads level with table pads.
Prone Head • Maintain cervical neck alignment.
Eyes • Protection for forehead, eyes, and chin.
Nose • Padded headrest to provide airway access.
• Chest rolls (ie, clavicle to iliac crest) to

Chest compression, iliac crests allow chest movement and decrease
abdominal pressure.
Breasts, male genitalia • Breasts and male genitalia free from torsion.
Knees • Knees padded with pillow to feet.
Feet • Padded footboard.
• Axillary role for dependent axilla.

Lateral Bony prominence and pressure points on • Lower leg flexed at hip.
dependent side • Upper leg straight with pillow between legs.
• Maintain spinal alignment during turning.

Spinal alignment • Padded support to prevent lateral neck
flexion.
Hip and knee joint injury • Place stirrups at even height.

Lithotomy Lumbar and sacral pressure • Elevate and lower legs slowly and
Vascular congestion simultaneously from stirrups.
• Maintain minimal external rotation of hips.

Neuropathy of obturator nerves, saphenous • Pad lateral or posterior knees and ankles to
nerves, femoral nerves, common peroneal prevent pressure and contact with metal
nerves, and ulnar nerves. surface.
• Keep arms away from chest to facilitate respiration.

Restricted diaphragmatic movement • Arms on arm boards at less than 90-degree
Pulmonary region angle or over abdomen.

Back to Basics CE Questions
Perioperative Positioning Injuries on the Rise: What to Do!
True or False (circle one)
1. In the United States, nerve damage accounts for 15 8. Which of the following is an often overlooked
percent of postoperative litigation claims. T F but vulnerable area that can benefit from
additional padding?
2. Patients who are 45 years of age and older a. Calves
experience the highest incidence of pressure b. Heels
ulcer development. T F c. Nose
d. None of the above
3. Surgical documentation should include a written
preoperative assessment, including a skin 9. Use of too many pads or blankets can cause the
assessment on arrival and discharge. T F capillary pressure to rise over
a. 19 mmHg
4. Patients are at increased risk of developing b. 32 mmHg
post-operative vision loss if they are in a prone c. 76 mmHg
position. T F d. 94 mmHg
5. OR-acquired pressure ulcers initially have a 10. The most common perioperative nerve injury is
distinctive greenish appearance. T F to the
a. Lingual nerve
Multiple Choice b. Ulnar nerve
c. Brachial plexus
6. The incidence of pressure ulcers occurring as a d. Sciatic nerve
result of surgery may be as high as
a. 10 percent
b. 82 percent
c. 66 percent
d. 38 percent
7. Which of the following affects the ability of the skin

and supporting structures to respond to pressure?
a. Obesity
b. History of sleep apnea
c. Nutritional deficiencies
d. Both a and c
Submit your answers at

www.medlineuniversity.com
and receive 1 FREE CE credit
TAKE THE PRESSURE OFF

YOUR SURGICAL PATIENTS
It’s estimated that up to 66 percent of pressure ulcers occur as a result of
surgery.1 What can you do to help prevent your patients from becoming statistics?
Medline’s pressure redistribution OR table and stretcher pads can help

redistribute the pressure that can occur before surgery while lying on
stretchers, on the table during surgery and while being transported
to the postoperative care unit.
All of our OR table and stretcher pads are designed

with state-of-the-art materials to offer an
advanced level of pressure redistribution.
Each pad offers a different level of pressure
redistribution and can be custom-made
to fit any OR table. Finally — product
solutions to help you meet your pressure Completely conforms
ulcer prevention goals! to the body
To sign up for a FREE webinar on perioperative pressure

ulcer prevention, go to www.medline.com/pupp-webinar.
Reference
1
AORN. Recommended practices for positioning the patient in the perioperative practice setting. Perioperative
Standards and Recommended Practices. 2008 Edition. Denver, Colo.: AORN Publications; 2008.
PROTECTION, PERFORMANCE & COMFORT.
WITHOUT COMPROMISE
SensiCare® surgical gloves address a rising concern in the OR — latex allergies.
The American Latex Allergy Association estimates that In fact, it is softer, more elastic and more comfortable.
between 8 and 17 percent of all healthcare workers are So never compromise again. Choose the SensiCare®
sensitized to natural rubber latex.1 Studies have suggested glove that best fits your needs.
that the costs of healthcare workers’ disability compensa- • SensiCare® with Aloe – standard thickness,
tion due to latex allergies justifies or significantly offsets smooth grip
the cost of conversion to a latex-free environment.2
• SensiCare® LT with Aloe – standard thickness,
Medline’s Sensicare® latex-free polyisoprene surgical
textured grip
gloves are made from Isolex™ (synthetic polyisoprene) that
has a molecular structure that is virtually identical to natu- • SensiCare® Green with Aloe – 10% thinner
ral rubber latex. for enhanced tactile sensitivity
• SensiCare® Ortho – 40% thicker for extra protection
Get a FREE one-day supply of SensiCare surgical

gloves to try for yourself. To learn more, contact
your Medline representative, call 1-800-MEDLINE or
e-mail glovedivision@medline.com.
References:
1
American Latex Allergy Association. Latex Allergy Statistics. Available at: www.latexallergyresources.org/topics/LatexAllergyStatistics.cfm. Accessed November 5, 2008
2
Phillips VL, Goodrich MA, Sullivan TJ. Health care worker disability due to latex allergy and asthma: a cost analysis. American Journal of Public Health. 1999:89(7):1024-28.
OR Issues
Can a Rigid Container System Be

Greener and Safer at the Same Time?
Unique rigid container benefits healthcare “greening” efforts
by Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT
Providing optimal safety for patients is a major responsibility

of any healthcare provider. One of the highest priorities should
be to promote patient safety by tackling problems and finding
solutions to known issues. In today’s healthcare environment,
infection prevention plays a huge role in national initiatives to
reduce healthcare-acquired infections (HAIs). This is particu-
larly important for perioperative professionals in regard to
surgical site infections (SSI).
One critical way to minimize risks to surgical patients is to

present items that are sterile (free of contamination) at the time
of use. It is imperative that sterilization packaging systems
ensure the integrity of the sterilized contents until opened for
use. The material or packaging device used for items to be
sterilized should provide a microbial barrier, protect package
integrity, provide adequate seal integrity, allow for aseptic
presentation and reduce the chance of contamination of the
contents once sterilized.1

Shelf life Sterile packages or trays must be handled several times

It has been proven that sterility does not change over time, when they are placed on and pulled off storage shelves,
but is compromised by events that harm the integrity of placed on and off case carts, and then again when in the
the package and/or the environmental conditions. We refer procedure area or operating room. Due to the fast-paced
to the time that an item may remain on the shelf and still environment of the operating room, packages are not
maintain sterility as shelf life.1,2,3 always handled with the greatest of care and are some-
times inadvertently subject to abuse (i.e., dropping). There-
The integrity of sterile packaging can be compromised by fore, we must place an increased importance on the
many things, such as poor package quality, improper stor- hygienic security of sterilization packaging.
age conditions and excessive and/or abusive handling.2
Package choices
Events that may lead to decreased package integrity and There are many available choices for sterilization packag-
therefore loss of sterility include:2 ing on the market today. A popular choice for numerous
• Multiple handling reasons is reusable rigid sterilization containers. These
• Moisture penetration containers serve as packaging for surgical instruments
• Exposure to environmental contaminants before, during and after sterilization. Sterilization container
• Uncontrolled/unclean storage conditions systems have been on the market for more than 25 years
• Improper type or configuration of packaging and vary in design, mechanics and construction materials.
materials used Reusable rigid sterilization containers require a barrier sys-
tem (i.e., filters or valves) to maintain package integrity.4
Handling sterile supplies
After surgical instruments are sterilized and cooled, it is Rigid container systems protect instruments, contain sets
extremely important that they are handled carefully to and help eliminate the chance of package compression,
maintain sterility. “Care should be taken to avoid dragging, tears or holes that may be associated with other types of
sliding, crushing, bending, compressing, or puncturing the packaging, resulting in compromised package integrity.
packaging or otherwise compromising the sterility of the
contents.”3 Reusable containers are an environmentally friendly alter-
native to disposable packaging. In the push for healthcare
1. Double Lid
Solid, double lid ensures
maximum protection and
complete hygienic security.
Also allows safe transportation
of soiled instruments after
a procedure.
2. Reusable Valve
Patented, automatic
valve eliminates the
need for disposable
filters. It assures
reliable, cost-effective,
maintenance-free
sterilization.
3. ThermoLoc
Patented locking
system eliminates
the need for
disposable,
tamper-evident
locks/arrows.
4. Condensate Drain
Temperature-activated
drain removes excess
condensation from
container.
facilities to become more “green,” reusable containers enter and exit based on the steam pressure during the
offer an opportunity to reduce the carbon footprint. sterilization cycle. The containers are also equipped with
reusable tamper-proof locks that are temperature-activated.5
A unique rigid container on the market is the Steriset con-
tainer system manufactured in Germany by Wagner and Environmentally responsible
distributed by Medline®. Steriset does not require any With the national initiatives to reduce HAIs, healthcare pro-
disposable filters or locks, which is an added benefit for fessionals’ major concern is patient safety. Perioperative
our healthcare greening efforts. professionals must do everything they can to help
decrease the chances of surgical site infections. Steriliza-
According to the Sterilization Container Overview & Tech- tion containers in themselves are much more environ-
nical Data sheet, Steriset containers are composed of mentally friendly than sterilization wrap; however,
a completely closed double lid protection system that is eliminating the use of disposable filters or locks as well
exceptionally tamper proof and hygienically secure. The makes Steriset containers the “greenest” container of
containers are designed with a permanent reusable stain- them all, thereby best meeting the need for both patient
less steel valve that opens and closes to allow steam to safety and environmental responsibility.

These environmentally friendly containers are a better filters were sprayed with distilled water. To obtain a thor-
alternative to those requiring disposable items, but do they ough set of qualitative data, this entire procedure was
offer any additional protection? replicated 10 times on each container. After each test,
photos of the filters and moistened facial tissue were taken
The container’s double lid is designed to provide complete for a visual comparison.7
hygienic security, therefore adding an additional shield
from any external contaminants once sterilized. Further, Study purpose
with its permanent filter and lock features, Steriset requires The purpose of this study was to compare the Steriset
much less assembly time and significantly reduces the container system with two other rigid container systems
possibility of user error during packaging – which can only that use disposable filters and locks. The principle idea
benefit patient safety. was to evaluate the ability of each container to protect the
contents from environmental contaminants.6
Does this design really help protect the con-
Table 1. Test Results
tents against external contaminants while in
Steriset
storage? To validate the complete hygienic se- Container 1 Container 2 Container
curity provided by Steriset against disposable With disposable With disposable No filters
filters, an independent lab study was con- filter filter
ducted by Q Laboratories Inc. in Cincinnati, Did the methylene blue strike through the filters?
Ohio. Trial No. 1 Yes Yes No
Trial No. 2 Yes Yes No
Study design and methodology Trial No. 3 Yes Yes No
A methylene blue strike-through test was Trial No. 4 Yes Yes No
employed to evaluate the rigid containers. In Trial No. 5 Yes Yes No
this analysis, tests were performed on empty Trial No. 6 Yes Yes No
containers. Two containers included the manu- Trial No. 7 Yes Yes No
facturer-recommended filter material assem- Trial No. 8 Yes Yes No
bled in the perforated lids and bottoms of the Trial No. 9 Yes Yes No
containers. The Steriset containers do not Trial No. 10 Yes Yes No
contain any filters. A single sheet of wet facial Total number of strike-throughs
tissue was placed over the bottom filters on 10 10 0
the inside of the two containers. A wet facial
tissue was placed on the bottom of the Steriset
Results of study
container. After the lids were closed and latched, one tea-
The study results indicate that none of the Wagner Steriset
spoon of methylene blue dust was sprinkled on top of each
containers had any methylene blue strike-through residue
of the three containers.7
present. The other two rigid sterilization containers had
strike-through residue present at the conclusion of all 10
Each container was dropped three times onto a hard table
trials tested. (See Table 1.)
surface from a height of 10 cm (3.9 inches). Following the
drop test, each container was placed into a closed cabinet,
Study conclusion
and the door was closed at normal force five times. Then
Wagner’s Steriset container is superior at eliminating the
the three types of container were again dropped three
possibility of external contaminants entering a closed con-
times onto a hard table surface from a height of 10 cm
tainer under storage and handling conditions. Steriset pro-
(3.9 inches). The lids were then carefully opened to
vides extra protection because it is a closed design
observe for any strike-through of the methylene blue on
container system with no pathway though the outer lid and
the wet facial tissue inside of each container. In order to
inner valve, therefore bacteria cannot reach contents
evaluate the degree of strike-through present, the lids and
unless opened.
Summary
As choices continue to expand, perioperative nurses, as
well as sterile processing professionals, have an essential
role in evaluating and selecting products that may affect
the quality of care and safety of the surgical patient while
being more ecologically responsible.8
When it comes to product selection, patient safety should

be the principal concern. In an effort to do all we can to
help decrease the chance of surgical site infections in our
patients, additional safety margins that help protect sterile
instruments from external contaminants are definitely
Other safety issues
worth considering.
Before being opened, sterile packages should be
inspected for package integrity. If the packaging is a rigid Steriset Sterilization Containers manufactured by Wagner are protected under United
States Patent No: US 6,620,390.
sterilization container system, the external latch, filters,
valves and tamper-evident devices should be inspected
Medline is a registered trademark of Medline Industries, Inc.
for integrity. The lid should be inspected for the integrity of Steriset is a registered trademark of Wagner GMBH Company
the filter or valve and the gasket.3 For disposable filters, References
this means the circulator must remove filter retention 1. Recommended practices for maintaining a sterile field. In: Standards,
Recommended Practices, & Guidelines. Denver, CO: AORN, Inc.;2009.
plate(s) in order to do a complete inspection of the filter 2. Recommended practices for selection and use of packaging systems for sterilization.
before the items are handled by the scrub person. In: Standards, Recommended Practices, & Guidelines. Denver, CO:AORN,
Inc.; 2009.
3. Comprehensive guide to steam sterilization and sterility assurance in health care
As mentioned earlier, Wagner’s Steriset container design facilities. ANSI/AAMI ST79:2006, A1:2008 and A1:2009. Arlington, VA: Association
for the Advancement of Medical Instrumentation; 2009.
helps significantly reduce user errors that surround 4. Containment devices for reusable medical device sterilization. ANSI/AAMI ST77:2006.
Arlington, VA: Association for the Advancement of Medical Instrumentation; 2006.
disposable filters and locks. Common errors include:
5. Medline Industries. Sterilization Container Overview & Technical Data page. Available
• Forgetting to replace disposable filters before every use at: http://www.medline.com/products/centralsterile/steriset-sterilization-containers.asp.
Accessed July 24, 2009.
• Forgetting to inspect disposable filters for pinholes 6. Proposal for the evaluation of the methylene blue test for sterilization of containers.
before every use Q Laboratories, Inc., Cincinnati, OH. Aug. 14, 2008.
7. Crowley, E. Final report: an evaluation of sterilization containers using the methylene
• Incorrectly replacing a disposable (i.e., not positioning blue test. Q Laboratories, Inc. Cincinnati, OH. September 2008.
it correctly) 8. Recommended practices for product selection in perioperative practice settings.
In: Standards, Recommended Practices, & Guidelines. Denver, CO: AORN, Inc.;2009.
• Forgetting to use disposable locks before sterilizing
the set
About the author
• Insufficiently securing disposable locks to ensure set
Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT,
it adequately sealed is president/CEO of Seavey Healthcare Consulting Inc., and
former director of the sterile processing department at The
All of the above insecurities are eliminated by the Steriset Children’s Hospital of Denver. Rose is an elected member of the
container design. 2008-2010 Association of periOperative Registered Nurses
(AORN) Board of Directors. She was honored with AORN’s
Event-related shelf life means dependence on the physical award for Outstanding Achievement in Clinical Nurse Education
integrity of the sterile packaging. However, if dust is able to in 2001. She has authored many articles on various topics
strike through disposable filters in rigid containers; will the relating to perioperative services and sterile processing.
particulates be visible to the naked eye?

JOIN THE PROGRAM TO

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pressure ulcers can be reduced.1 The main challenges were able to access it. I can’t imagine recreating
to having an effective pressure ulcer prevention program this wheel!”
are: lack of resources; lack of staff education; behavioral Katrina “Kitty” Strowbridge, RN
challenges; and lack of patient and family education.2 Quality Improvement Coordinator
St. Luke Community Healthcare Network
Medline’s comprehensive Pressure Ulcer Prevention
Ronan, Montana
Program offers solutions to these challenges.
The Pressure Ulcer Prevention Program from Medline

For more information on the Pressure Ulcer
will help you in your efforts to reduce pressure ulcers in
Prevention Program, contact your Medline
your facility. The program includes:
representative, call 1-800-MEDLINE or visit
• Education for RNs, LPNs, CNAs and MDs
www.medline.com/pupp-webinar to register
• Teaching materials for you to help train your staff
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• Practical tools to help reduce the incidence of
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• Innovative products supported by evidence-based
information that results in better patient care
References
1
Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.
2
CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.
OR Issues
O.R. FIRES
Although surgical fires are relatively rare, their effects The ECRI Institute released new surgical fire safety guidelines
are almost always tragic. Healthcare professionals were in October 2009, which are based on their own research and
reminded once again of this chilling fact when a 65-year-old investigations and collaboration with the Anesthesia Patient
woman died September 8, 2009, six days after being burned Safety Foundation (APSF) and the American Society of Anes-
in a flash fire during surgery at a Marion, Ill. hospital. Accord- thesiologists (ASA) surgical fire task force. The primary
ing to the medical examiner, the woman died from complica- change in the new guidelines is the recommendation to
tions of thermal burns. Further details have not been released discontinue the traditional practice of open delivery of 100
publicly.1 percent oxygen during surgery of the head, face, neck and
upper chest. The purpose for this recommendation is to
Virtually all operating room fires ignite on or in the patient, prevent the formation of oxygen-enriched atmospheres near
causing considerable injury or even death. The ECRI Institute, the surgical site, reducing the likelihood of fires.2
an independent not-for-profit organization that researches
approaches to improving patient care, estimates that 550 to The fire triangle4
650 surgical fires occur among the 65 million surgical cases Understanding the elements needed to create a fire is the first
performed in the United States each year. Of those fires, step toward learning how to prevent a fire. Three basic
about 20 to 30 are serious, resulting in disfiguring or disabling elements – known as the fire triangle – are necessary to
injuries. One or two result in patient deaths.2 The good news ignite a fire and keep it burning. The elements are oxidizers,
is that similar to many other healthcare-related errors, surgical ignition sources and fuel. In the operating room, oxidizers
fires are 100 percent preventable.3 include oxygen supplied for the patient, as well as nitrous
NEW
RECOMMENDATIONS
FOR PREVENTION
The Surgical Fire Triangle

Ignition sources
(Mainly controlled by surgeons)
Ign
- Electrosurgical devices
Oxidizers - Electrocautery devices
- Lasers
itio
rs
(Mainly controlled by
anesthesia providers) - Fiber optic light sources
ze
- Air - Defibrillator paddle or pads
ns
- Oxygen
idi
- Nitrous oxide
ou
Ox
rce
Fuel
Fuel (Mainly controlled by nurses)
- Prepping agents - Anesthesia components
- Linens - Patient’s hair
- Dressings - Tracheal tubes
- Ointments - Intestinal gases
oxide. Examples of ignition sources are electrosurgical and elec- Minimizing oxidizers. High oxygen concentration, including
trocautery devices, heated probes, defibrillators, lasers and the oxygen contributed by nitrous oxide, enhances the
fiberoptic light sources and cables. Fuel sources include certain ignitability of most fuels. Conversely, minimizing the percentage
prepping agents and ointments, linens, dressings, the patient’s of oxygen flowing around the patient will reduce the fire risk.
hair and anesthesia components.
According to new guidelines, except for certain cases, the
2
How to prevent surgical fires traditional practice of open delivery of 100 percent oxygen
The most obvious and easiest method of fighting fires is to should be discontinued. In the majority of cases, room air or a
prevent them from starting, primarily by making sure the three low concentration of oxygen balanced by an inert gas (e.g.,
elements of the fire triangle never combine in the operating room nitrogen, helium) may be adequate for ventilation and thus
(OR). This task is achieved by controlling ignition sources, man- reduce the fuel-ignition risk.
aging fuels and minimizing oxygen concentration.
If supplemental oxygen is needed during surgery, the patient’s
Similar to best practices for protecting patients from healthcare- airway should be sealed using a tracheal tube or laryngeal mask.
acquired injury in the OR, fire prevention must be a team effort.
For the most part, anesthesia professionals control oxidizers, Controlling ignition sources. Electrosurgical devices are the
surgeons control ignition sources and nurses control fuel most common ignition source in surgical fires. These devices
sources. Each team member should understand the fire haz- can produce a high-temperature electric arc or incandescence
ards associated with each side of the fire triangle and do their at the probe tip. Surgical fires also can start if electrosurgical
best to keep those elements apart. electrode cables spark. This problem usually occurs with
The primary change in the new guidelines is the recommendation to

discontinue the traditional practice of open delivery of 100 percent
oxygen during surgery of the head, face, neck and upper chest.
reusable monopolar cables that connect to an active electrode, Practice drills for fires on and in the patient are especially crucial
such as those used in laparoscopy. (Note: The ECRI Institute to ensure OR staff knows how to:
reports that to their knowledge, there has never been a report • keep minor fires from getting out of control
of a fire with bipolar electrosurgery; only monopolar.) • manage fires that do get out of control
• locate and properly use fire-fighting tools; medical
Sparking typically results from cable failure at the active gas valves; heating, ventilation, and air-conditioning
electrode connector or at its strain relief. The cable’s internal (HVAC) controls; and electrical supply switches
conductor strands become severed over time from use and • operate the fire alarm and communication system
handling during sterilization. A scheduled program of periodic
cable replacement is one way to avoid this problem. Although many facilities, in compliance with Joint Commission
requirements, conduct drills for evacuating the OR in the event
Managing fuels. Allotting sufficient time after patient prepping of a major fire, drills for the surgical team for fighting fires
and before draping allows vapors and gases to dissipate. Where involving the patient are rare—and should not be.
volatile liquid exists, so does the risk of fire. Volatile fuels, such
as alcohol, collodion and acetone, can take several minutes to Operating Room Fire Equipment and Supplies
fully vaporize, and a few minutes more to become diluted in to Keep Immediately Available5
room air. Care should be taken to avoid or minimize pooling of • Several containers of sterile saline
volatile liquids – particularly under the patient, where they may • A CO2 fire extinguisher
not be noticed. Taking the time to check that these volatile fuels • Replacement tracheal tubes,
have fully evaporated on and under the point of application will guides, face masks
prevent them from being ignited when electrosurgery or other • Rigid laryngoscope blades; this may
heat-producing devices are in use. include a rigid fiberoptic laryngoscope
• Replacement airway breathing circuits
Developing a fire plan that includes fire drills and lines
Being prepared for a fire will minimize the cost in dollars, lost • Replacement drapes, sponges
time, emotional shock and injury or death. Preparation involves
a number of steps—the most important of which is practicing Note: Your operating room may benefit from assembling a portable
fire drills that teach all staff about their responsibilities during a cart containing equipment and supplies to expedite immediate response
to an operating room fire. The contents of this cart will vary depending
fire. Having a predetermined method of fighting a surgical fire on your procedures and resources.
so that every team member knows what to do is critically
important.2
What to do if the patient is on fire2
A 2008 Practice Advisory published by the American Society of Most fires in the OR will be either on or in the patient. In either
Anesthesiologists notes that all team members should take a case, quick action will avert a disaster. Smoke, the smell of fire
joint and active role in agreeing on how a fire will be prevented or a flash of heat or flame should prompt a fast response. In
and managed. Each team member should be assigned a spe- 30 seconds or so, a small fire can progress to a life-threatening
cific fire management task to perform in case of a fire. If a team large fire. During any fire, protecting the patient is the primary
member completes a pre-assigned task, he or she should help responsibility of the staff; self-protection is a secondary
other team members perform their tasks.5 consideration.

All-new guidelines regarding open delivery

of oxygen in the operating room2
• Use only air (not oxygen) for open delivery to the face if
the patient can maintain a safe blood oxygen saturation
without supplemental oxygen.
• If the patient cannot maintain a safe blood oxygen saturation
without extra oxygen, secure the airway with a laryngeal
mask airway or tracheal tube.
To contain the flames, the fire triangle must be disrupted by
diminishing or removing one or all of its sides. For example,
Exceptions: The following recommendations are for surgery
a small area of burning drape or gown can be patted out
in which the patient’s verbal responses may be required – such
effectively and safely by hand; larger areas can be smothered
as carotid artery surgery, neurosurgery and pacemaker insertion
effectively with a fire blanket or towel. Fires inside the patient
– and where open oxygen delivery is required to keep the
are typically small, but can be deadly. Practicing for an airway
patient safe. At all times, deliver the minimum oxygen concen-
fire, such as from a burning tracheal tube, can develop the
tration necessary for adequate oxygenation (as monitored with
speed that will minimize injury in a real emergency.
a pulse oximeter).
• Begin with a 30 percent oxygen concentration and
Closing thoughts increase as necessary.
Stopping small fires before they become big fires – or
• For unavoidable delivery above 30 percent, deliver five
preventing them altogether – requires a team effort. Good
to 10 L/minute of air under drapes to wash out excess
communication among the surgical team can ensure fire-safe
oxygen.
practices.
• Stop supplemental oxygen at least one minute before
and during use of electrosurgery, electrocautery or laser,
If a surgical fire occurs, the anesthesia provider should stop
if possible. Surgical team communication is essential for
the flow of gas; the surgeon should remove the burning
this recommendation.
material and the nurses should extinguish the burning mate-
• Use an adherent incise drape, if possible, to help isolate
rial. Once the fire has been extinguished, attention must be
head, face, neck and upper-chest incisions from
turned to the patient, resuming ventilation but using only air
oxygen-enriched atmospheres and from flammable
until it’s certain the fire is totally out, then resuming use of
vapors beneath the drapes. The incise drape can help
oxygen appropriate to the patient’s needs; controlling bleeding;
prevent gas communication channels between the
evacuating the patient (if in danger from smoke or fire) and then
under-drape space and the surgical site.
examining the patient for injuries.
• Keep fenestration towel edges as far from the incision
as possible to prevent their ignition from electrosurgical
References flames or sparks.
1 Suhr J. Woman catches fire during surgery. Associated Press. September 17, 2009.
Available at: http://news.aol.com/article/woman-dies-after-catching-fire-during/675219? • Arrange drapes to minimize oxygen buildup underneath
Accessed September 27, 2009. (such as from an uncuffed tracheal tube or a laryngeal
2 New clinical guide to surgical fire prevention. Health Devices. 2009; 38(10):314-332.
3 AORN guidance statement: fire prevention in the operating room. In: Standards, mask airway) and to direct gases away from the
Recommended Practices & Guidelines. Denver, Colo.: AORN, Inc.; 2009:171-179.
operative site.
4 Mathias, JM. Scoring fire risk for surgical patients. OR Manager. 2006;22(1).
5 Practice advisory for the prevention and management of operating room fires. • Coat hair on head and face within the fenestration
Anesthesiology. 2008; 108(5):786-801. Available at: http://journals.lww.com/anesthesiol-
ogy/Fulltext/2008/05000/Practice_Advisory_for_the_Prevention_and.6.aspx. Accessed
with water-soluble surgical lubricating jelly to make it
September 28, 2009. non-flammable.
• For coagulation, use bipolar electrosurgery, not
monopolar electrosurgery.
Special Feature
Mark Bruley Talks About

New Surgical Fire
Prevention Guidelines
Vice President,
Accident and
Forensic
Investigation,
ECRI Institute
The OR Connection had the opportunity to interview surgical As a traditional course of practice, the majority of surgeries
fire safety expert Mark Bruley in October 2009, shortly after under monitored anesthesia care (MAC) of the head, face,
publication of the new ECRI Institute surgical fire safety guide- neck and upper chest have involved open delivery of 100 per-
lines, which he authored. As a forensic investigator for the ECRI cent oxygen, however, the ECRI Institute’s years of surgical fire
Institute for the past 30 years, Bruley has acquired a wealth of investigations have shown a strong correlation between surgical
knowledge and data through numerous on-site surgical fires and this practice. Therefore, they recommend avoiding
fire investigations and related research at the ECRI Institute the use of open delivery of oxygen whenever possible and
laboratories. delivering medical air instead. For patients who need extra
oxygen, they recommend securing the airway with a tracheal
Bruley said that in terms of well-researched, evidence-based tube or laryngeal mask airway. That recommendation is
recommendations, the newly published surgical fire safety endorsed by APSF.
guidelines are “at the pinnacle of recommendations. These
recommendations are supported by the physics of fire and the For the exceptional cases when open delivery is necessary, the
physics of anesthesia machinery.” anesthesia provider should blend air and oxygen to provide a
lower percentage of oxygen. But because open delivery of oxygen
The new ECRI Institute guidelines came about coincident with has been routine for so long, the prospect of changing this
Bruley and his colleagues being approached by the Anesthesia clinical practice led to considerable debate among anesthesia
Patient Safety Foundation (APSF) – an affiliate of the American providers and surgical fire prevention specialists.
Society of Anesthesiologists (ASA) – to create an updated
surgical fire safety educational video. In order to address these issues, the guidelines needed
to explain how to provide a blended air and oxygen mixture
“As we began working on the video,” Bruley said, “we came in those exceptional cases when open delivery of oxygen
upon pragmatic problems regarding the exceptional surgical was required.
cases that require open delivery of oxygen and the logistics of
how to provide blended air and oxygen in the operating room.” “The problem with open delivery of oxygen is that the oxygen
Exceptional cases are those where a patient may need to will exhaust at the patient’s head and neck, which presents a
flash fire hazard,” Bruley said. To minimize this effect, the ECRI

speak during the surgery.
“
Flash fires will occur during surgery only when oyxgen
levels are between approximately 40 and 100 percent
Institute’s new guidelines recommend a variety of techniques
to use in those exceptional cases when the patient requires
open delivery of oxygen, including:1
How to minimize risk
when a surgical fire occurs2
”
In spite of taking precautions to prevent surgical fires, they can
1. Delivery of the lowest percentage of oxygen possible
and do occur. If a fire or other serious incident ever takes place
to maintain patient safety
in your operating room, the ECRI Institute advises taking the
2. Beginning with 30 percent delivered oxygen
following steps immediately in order to minimize risk and pre-
concentration and increasing as necessary
serve evidence for later forensic investigation.
3. Delivery of 5 to 10 L/min of air under drapes to wash
• Take emergency measures to minimize and care for injury
out excess O2
to, discomfort of, and threat to life of patients and staff.
4. Stopping supplemental oxygen at least one minute
• Take appropriate action to minimize damage to equipment
before and during use of an ignition source such
and the environment.
as electrosurgery
• Notify the attending clinician who has legal responsibility
According to Bruley, with oxygen levels at 30 percent or below,
for the patient.
there is no flash fire hazard. ECRI Institute recommends
• Impound all equipment attached or contiguous to the
beginning with 30 percent oxygen, and titrating up only if nec-
injured party in the same room or areas.
essary to maintain the patient at a healthy oxygen level. “Flash
• Do not disconnect or change the relative physical
fires, which begin in an instant, will occur during surgery only
positions of equipment or connecting cables, except
when oxygen levels are between approximately 40 and 100
as absolutely necessary to avoid further injury or damage.
percent,” Bruley said.
• Retain and preserve any disposable products that may
have been involved (e.g., drapes, electrodes), as well
This new approach, however, of blending air and oxygen brings
as their packaging materials.
about a logistical dilemma. Not all anesthesia equipment is
designed to deliver blended air and oxygen. So how can the
Free educational posters on surgical fire prevention and extin-
blending be achieved?
guishment are available at ECRI Institute’s surgical fire website
at www.ecri.org/surgical_fires. See also pages 84 – 85.
According to the ECRI Institute’s 2009 guidelines, three
approaches are recommended for blending oxygen:1
• Use an oxygen-air blender. This is the preferred
and most reliable approach because it is the simplest.
• Use a three-gas (air, oxygen, N2O) anesthesia
machine that has a common gas outlet (CGO) Locations of Surgical Fires1
and take the blended gas from the CGO.
• Use the breathing circuit wye on an anesthesia
In the airway
machine that does not have an available CGO.
Close the APL valve on the absorber for faster
changes in the delivered oxygen concentration. 21%
Elsewhere in the patient
8%
Regardless of how the oxygen-air mixture is obtained,
monitoring of the delivered oxygen by the anesthesia provider 44% Elsewhere on the patient
is recommended to ensure that the gas mixture is as desired.
26%
On the patient
References
In the patient
1 New clinical guide to surgical fire prevention. Health Devices. 2009;38(10):314-332.
2 Accidents happen – an immediate action plan. The ECRI Institute website. Available at: On the head, neck, or upper chest
https://www.ecri.org/Products/PatientSafetyQualityRiskManagement/CustomizedSer-
vices/Pages/Immediate_Action_Plan.aspx. Accessed November 2, 2009.
OR Issues
SCORING
FIRE RISK
FOR SURGICAL PATIENTS
Fires in the operating room are a risk that requires prevention,
vigilance, and quick action to prevent patient injury. To heighten
awareness, the Christiana Care Health System (CCHS) in Newark,
Del., added a Surgical Fire Risk Assessment Score to its
Patient Identification and Surgical Site documentation form.

“What brought this issue to our attention were two surgi-

cal fires. One occurred in the electrophysiology lab and
the other in the OR with a patient having a carotid
endarterectomy. Both cases involved a high concentration
of oxygen, surgery above the xiphoid, and a heat source,”
Judith Townsley, RN, MSN, CPAN, director of clinical
operations for perioperative services, told OR Manager.
The chairman of the anesthesiology department, Kenneth

Silverstein, MD, developed the fire risk assessment score
The surgical team at Christiana Care Health Services in
after the fires were investigated by ECRI Institute Newark, Del., follows a surgical safety checklist as they per-
(www.ecri.org), a not-for-profit organization that form a pre-incision team briefing. The checklist is mounted on
researches health services and technology, and Russell the opposite wall and includes the components of the surgical
time out and the fire risk assessment score. Pictured, left to right:
Phillips & Associates (www.phillipsllc.com), consultants in scrub nurse Judy Saunders, CST; anesthesia provider Ron
fire, code compliance and emergency management. Castaldo, CRNA; surgeon Mike Conway, MD; assistant Paul
Aguilon (medical student) and circulator Kelly Saunders, RN.
Assigning a fire risk score
The fire risk assessment is performed by the entire surgical Score 3 = High risk.
team (anesthesia provider, surgeon and nurse) before the All three components of the fire triangle are present.
incision is made and is documented by the circulating Score 2 = Low risk with potential to convert
nurse, noted Denise Dennison, RN, BSN, CNOR, staff to high risk.
development specialist. This score is given when the procedure is in the
thoracic cavity, the ignition source is remote from an
The assessment requires the surgical team to identify the open oxygen source, the ignition source is close to
three key elements that are necessary for a fire to start – a closed oxygen source, or no supplemental oxygen
the fire triangle: is used.
• Heat Score 1 = Low risk.
• Fuel Only supplemental oxygen is being used.
• Oxygen
Each risk score has a fire protocol assigned to maximize
In the OR, three key risks are: patient safety. The documentation form allows the circu-
• Surgical site or incision above the xiphoid lating nurse to indicate that the high-risk protocol was
• Open oxygen source (i.e., patient receiving initiated. It also allows for documentation that sufficient
supplemental oxygen via face mask or nasal cannula) time was allowed for fumes to dissipate when an alcohol-
• Available ignition source (i.e., electrosurgery unit, laser based prep solution is used.
or fiberoptic light source)
Fire Risk Protocols

Score 3 = High risk
The circulating nurse and anesthesia provider take
these precautions.
Circulating nurse
• Verifies fire triangle, including verbal confirmation
of the oxygen percentage
• Ensures appropriate draping techniques to
minimize oxygen concentration under the drapes
• Minimizes ESU setting
• Assesses that enough time has been allowed
for fumes of alcohol-based prep solutions to
The surgical site fire risk assessment guide dissipate (minimum of 3 minutes)
(above) was developed by Kenneth Silverstein, • Encourages use of wet sponges
MD, anesthesiologist and chair of the • Ensures a basin of sterile saline and bulb syringe
anesthesiology department at Christiana are available for fire suppression
Care Health Services. He developed the
guide to help prevent surgical fires at
the hospital. Anesthesia provider
• Ensures that a syringe full of saline is in reach for
procedures conducted within the oral cavity
Communication heightens awareness • Documents oxygen concentrations and flows
Since adding the fire risk assessment to the OR docu- • Uses the MAC circuit for oxygen administration
initially at FiO2 of .30 using fresh gas flows of at
mentation, communication among the surgical team mem-
least 12 L/min.
bers as well as identification of the fire risk triangle have
vastly improved, noted Dennison.
Score 2 = Low risk with potential to convert
to high risk
“The secret to success of this process is that this formal Standard fire safety precautions are followed with the
communication and documentation makes everyone potential to convert to high-risk precautions if necessary.
involved aware of the potential risk of a fire,” Townsley
said. “Enhancing communication between providers has Standard precautions are to:
strengthened our focus on providing clinical excellence for • Observe alcohol-based prep drying times
our patients.” (minimum of 3 minutes)
• Protect heat sources (e.g., using the ESU pencil
holster)
References • Use standard draping procedure
Bruley ME. Surgical fires: Perioperative communication is essential to prevent this rare
but devastating complication. Qual Saf Health Care. December 2004;13:467-471.
Meltzer HS, Granville R, Aryan HE, et al. Gel-based surgical preparation resulting in Score 1 = Low risk
an operating room fire during a neurosurgical procedure: Case report. Neurosurg. Standard fire safety precautions are followed.
April 2005;102:347-349.
Paugh DH, White KW. Fire in the operating room during tracheostomy: A case report.
AANA J. April 2005;73:97-100.
Reprinted with permission from OR Manager, copyright ©2006.

By Kathleen Bartholomew, RN, RC, MN
Human beings rarely, if ever,

succeed at accurately perceiving
their own culture.
So deeply entrenched is culture that no one talks about

it: the unspoken rules and behaviors (called norms) are
never written down, and yet everyone knows them. We
learn these norms the hard way through the process of
assimilation into a culture. For example, when Shelli was
a new scrub nurse with only six months’ experience,
she failed to anticipate that the surgeon would need a
particular scalpel. Immediately, her experienced pre-
ceptor deftly handed the correct blade to the im-
patient surgeon with a glare in Shelli’s direction.
At that moment, Shelli learned that if she was not on top
of the surgeon’s needs, she would end up feeling
embarrassed and looking incompetent. Shelli did not
find this information in her orientation manual.
Breaking Free From Our Cultural Chains
Culture also determines what we see – and what we

don’t. Scrub nurses do not innately “know” which sur-
geon tolerates technical questions or joking and which
ones do not, or what subjects are acceptable to talk
about among their team. They figure this out. Humans
quickly pick up on these subtle cues and then act
accordingly. Like any group, operating teams learn
norms by induction and trial and error because the need
to belong is so strong. So without a conscious thought
(whether scrub nurse, anesthesiologist, tech or surgeon),
OR Issues
Group Think
When individuals merge and form a group there are always
things they can do, things they must do and things they
can never do. For example, healthcare workers do not
typically share their feelings in high-tech, high-pressure
environments because feelings are perceived by the
general culture to be “soft stuff.” Ironically, this belief couldn’t
be further from the truth. Feelings not only matter, but are
conveyed unconsciously, because 93 percent of all
communication is non-verbal. If you think someone doesn’t
like you, they probably don’t. In a study of collaboration
we mimic the behaviors of those around us in order to be among residents, nurses and physicians, the single most
accepted. After a while, no one even notices the subtle, important factor in producing positive collaborative
unspoken rules. And why would they? Everyone exhibits outcomes turned out to be affect. Our bodies consistently
the same behaviors. The norms are now downloaded into express what we feel.4
our subconscious mind.
Culture even determines our perception of the scrub

nurses’ work – much of which goes unnoticed. In a review
of 13 papers looking at scrub nurse skills, there were no
behaviors that could be classified as leadership or decision- Another overarching cultural imperative holds that in a
making.1 The vast amount of problem-solving, anticipation dangerous environment, the group must stay together in
and critical decision-making that scrub nurses demonstrate order to stay safe. In one case, a surgeon accidentally
constantly during surgery is invisible. began incising the wrong breast for a mastectomy proce-
dure. The incision was only an inch long when the circulator
In addition to operating room norms, each subgroup has its screamed and the physician stopped, acknowledged the
own specific norms as well. For example, residents learn mistake, and sewed up the cut. After the operation, the
quickly that asking questions is a sign of vulnerability and surgeon called his team together in the room and said:
weakness; and to protect each other no matter what.2 “I need to know that you are with me on this one. There is
Scrub nurses learn to assess situations without interrupting, absolutely nothing to be gained by telling this patient what
and they read surgeons’ demeanor to sense the appropriate happened. I’m asking for your support to tell her that the
time to ask a question. This is known as “prudent silence.”3 incision on her left breast was exploratory.”
Some group norms have to do with errors, i.e., “Don’t ever
speak about a sentinel event outside these walls.” And for This misuse of power tells us more about the culture this
those who break these unspoken rules, there are serious physician is ‘leading’ than any statistic ever could; and his
repercussions – the worst of which is being ostracized from use of coercion raises the impetus to be safe to a higher
the group. There is nothing more painful for any human status than even ethics.
being, no matter the role or education level.

S.T.O.P.™ FOR SAFETY.

It could be the difference between life and death. S.T.O.P.!!!
Perform “TIME OUT”
Verify correct:
Wrong site surgery has recently moved into the
Person X-rays
number one position as the most frequently reported Procedure
N/A
Implants
hospital error.1 This is despite a conscientious effort to Site & Side N/A
eliminate this problem before it occurs. What is needed Position Equipment

N/A
is another layer of safety...something that will improve Date: ______ Time: ______
our chances of correcting the mistake before it happens. Initials: _________
S.T.O.P. strip
Enter S.T.O.P. Surgical Drapes* from Medline. We just and sticker
made a good idea even better. S.T.O.P. (Surgical Time Out
Procedure) drapes are available in a variety of configura-
tions, and include a “S.T.O.P.” strip across the fenestration.
As a result, you can’t forget to take a time out to verify
the correct patient, procedure, side and site. Then all
that is left is to hand the sticker off to the circulating nurse
For a free sample of the S.T.O.P. Drape
to include in the medical record, documenting that the
system to evaluate for yourself, ask your
verification process was completed.
Medline representative, call 1-800-MEDLINE
or visit www.medline.com.
References
The Joint Commission. The Statistics page. Available at:http://www.jointcommission.org/NR/rdonlyres/D7836542-A372-
1
4F93-8BD7-DDD11D43E484/0/SE_Stats_12_07.pdf. Accessed March 13, 2008.

* Patent pending
In the operating room, each player has a specific role: sur- Groups quickly learn not to speak up about certain issues.
geon, scrub nurse, circulator, perfusion specialist, etc. Each One OR team feared they would be diminished in the eyes
role also comes with a set of expectations for behavior. On of their peers when a sentinel event was made public, missing
top of this, every operating room has its own unique culture. entirely the opportunity to use their experience for teaching,
For example, scrub nurses in the United Kingdom perceived improving the system and building a healthy culture around
their main responsibility was to not upset the surgeon and mistakes. Unknowingly, our well-intentioned but predictable
to keep the surgeon happy.1 responses perpetuate the predominant culture. Humans
under stress will consistently default to previously learned
Ignorance Squared behaviors and responses.
Educators often state that the worst knowledge deficit is
when “You don’t know what you don’t know.” So if we are The Behaviors We Can Expect
so deeply entrenched that we can’t perceive our own cul- • Human error - inadvertent action; inadvertently
ture, then how do we rationally and logically assess whether doing other than what should have been done;
our operating room is, for example, a just culture or a blame slip, lapse, mistake. CONSOLE
culture? A collegial interactive team or just a group of peo- • At-risk behavior – behavioral choice that
ple working in the same place at the same time? We learn increases risk where risk is not recognized,
about the culture by listening to their stories. or is mistakenly believed to be justified. COACH
• Reckless behavior - behavioral choice to
consciously disregard a substantial and
The Play of “Human Error”
unjustifiable risk. PUNISH
The drama in our worlds will tell us more about our culture
than anything else because it is riddled with feelings: anger,
shame, embarrassment, hurt and grief. These are powerful Standing up to the predominant culture is a monumental
emotions felt at one time or another by every member of the task. This quest is better undertaken as a team because of
team simply because we are human beings working in a the critical amount of support that is needed in any organi-
complex, high-stress environment with the same people zation to produce adaptive change. For example, at Cincin-
every day. When humans work that closely and frequently, nati Children’s Hospital, every employee computer when
their relationships become the dominant value. Dana Jack turned on displays an icon labeled “Patient Safety Tracker”
calls this “self silencing.”5 Healthcare workers silence them- in the upper right hand corner stating how long it has been
selves because they value the relationship with their cowork- since harm has come to a child in their care. If an event
ers more than anything (even the patient) and fear reprisal. occurs, you can then click on another box for details of the
On a very primal level we are keenly aware that our survival event, which are general knowledge. The result: no one
depends on the group’s survival. A deeply worrisome ex- loses focus. This admirable demonstration of transparency
ample of this comes from a new study where 80 percent of takes phenomenal leadership and support from the bedside
nurses demonstrated knowledge of best practice for oxy- to the boardroom.
tocin administration during delivery, yet only 22.5 percent
would actually implement the appropriate clinical action if In the healthcare culture, however, transparency and open
the physician asked them to increase the dose.6 There is dialogue are the exception rather than the rule. Instead of
nothing stronger than culture – not even education. Not these healthy behaviors, several other survival behaviors
upsetting the physician even trumps best practice. have been observed. Sometimes leaders inadvertently

“ The single greatest impediment to error prevention in the medical

industry is that we punish people for making mistakes.”
– Dr. Lucian Leape
divert their group’s attention away from the real issue In a healthy safety culture every surgeon, tech, scrub and
because it is too volatile, painful, or simply, unpredictable. In circulator would know about an error or near-miss as soon
this way, the group is once again united – although dys- as possible in order to produce a heightened sense of
functionally. In one emergency room, for example, staff were awareness and to decrease the chances of the same error
furious with the ICU and would complain incessantly about occurring again. Clearly, these events are complicated, and
how poorly they were treated by this department. As Dr. Phil it often takes time to gather information. But information is
would say, “What’s this doing for you?” In this case, as in shared as it is gathered with the whole team. Unbelievable
many others, having a common enemy united the group. as it seems, this is just not happening at most healthcare
Another behavior that fuels an unhealthy culture occurs facilities, and our well-respected leaders fail to see their own
when groups or individuals are at odds with each other. behavior. For example, one day a surgeon shared the details
They never sit down at the same table face-to-face. If they of a disturbing sentinel event that happened to him just a
did, then the rumors and gossip might end the saga that few days earlier. Yet his colleague sat next to him oblivious
sustains them. The sad reality is that well-intentioned people and uninterested in his dilemma because, after all, it didn’t
are unaware of the strong emotional maneuvers designed at happen to him – even though they worked in the same OR!
a very primal level to simply keep the group safe.
The Second Victim
Emotions and the Blame Culture In every sentinel event, there is more than one victim. The
Emotional drama is more prevalent in a blame culture than first is the patient – harm or vulnerability to harm is tangible,
a just culture because the ethos of a just culture re-focuses perceived and acknowledged. The victim’s emotional state
on the event as an opportunity to learn and share. When an is tended to very carefully. We invest a great deal of time and
event is submerged, defensive emotions will emerge larger emotional energy in understanding the impact of the error
than life every time. Another indication of a blame culture is on the individual and their family. Forms are filled out docu-
secrecy. Members of the team being kept in the dark about menting the error and we work diligently through root cause
a serious incident is another indication of a blame culture. analysis to change our system and processes so that the
“ What we know changes what we see.

What we see changes what we know.”
– Piaget
event never has the opportunity to occur again. But there philosophy, whereas others are engaged in a commitment-
are other victims as well whose pain is not so visible. driven philosophy. A consistent pattern emerged from the
research: a blame culture is more likely to occur in hierar-
In the healthcare culture, we seldom speak about the sec- chical organizations, and a just culture is more likely to occur
ond victim – the scrub, tech or surgeon who assumes in institutions that actively engage employees in the
whether rightly or not, that they could have anticipated or decision-making process.8 In other words, the greater the
prevented the event; who beat themselves up and privately number of hoops you have to jump through to get what you
grieve their role in the play of “Human Error.” The impact of need to do your job, the greater the hierarchy and the
mistakes on clinicians is devastating. Any healthcare worker greater the tendency toward a blame culture. Successful
will confirm the difficult process of forgiving themselves – patient safety programs are not top-down driven initiatives.
especially if the event results in harm or death. Unfortunately, They are a core value.
the current system frequently does not provide the conso-
lation and solace they so desperately need. Conclusion
In 1999 Dr. Lucian Leape, a professor at the Harvard School
Blame vs. Just Culture of Public Health, briefed a congressional sub-committee on
There is a movement in the healthcare industry to shift from the state of human error management in health care. Sadly,
a blame culture toward a just culture. This call to action is the statistics from a decade ago have not changed. An
being heralded by concerned patient safety advocates. A estimated one million people are injured by treatment errors
blame culture is characterized by secrecy, overt or covert at hospitals every year, resulting in an estimated 120,000
punishment for mistakes, ostracism and strong emotional deaths. But because of the punitive healthcare culture,
responses such as blaming and shaming. Individuals are Leape revealed that only two to three percent of major
often targeted (named) and the focus is “who did what?” errors are actually reported through incident reporting
rather than on system issues. This is “the way we’ve always systems, mostly because “workers often report only what
done it.” A just culture is characterized by open dialogue they cannot conceal.”9 Research specific to the operating
surrounding errors, inclusion of all involved, a clear under- room found that OR/PACU staff reported more frequent
standing of whether the error was human error, at-risk or witnessing of unsafe patient care.10 Our stories tell us that
reckless behavior and appropriate management response7 in the healthcare culture we value the safety of our group
as well as a focus on processes, learning and sharing. more than the patient, ethics or even best practice. How
can this change?
Research shows that the hospital culture in and of itself is a
good indicator of whether a just or blame culture prevails. A culture does not change overnight. Nor will any culture
Some hospitals have a command and control-based sharply change direction as a group. Imagine an army of 12

million healthcare workers marching shoulder-to-shoulder in

one direction. It’s dangerous for a single individual to fall out
of step. If we could only visualize the thousands of wounded
and deceased in one place, then the entire army would
immediately about-face. But we can’t. And we don’t.
People die and are harmed from healthcare-related errors

one-by-one; and they will only be saved one-by one as each
individual’s awareness rises above the group, and we
consciously and courageously decide to break the cultural
chains that bind us to our old familiar ways.
References
1. Mitchell L, Flin, R. Non-technical skills of the operating theatre scrub nurse: literature
review. Journal of Advanced Nursing. 2008;63(1):15-24.
ARE YOUR PHYSICIANS
2. Maxfield D, Grenny J, McMillan R, Patterson K., Switzler A. Silence kills: the seven
crucial conversations for healthcare. VitalSmarts and the American Association of
MAKING THE GRADE?
Critical-Care Nurses. 2005.
3. Riley RG & Manias E. Governance in operating room nursing: nurses’ knowledge of A recent survey graded
individual surgeons. Social Science and Medicine. 2006;62(6):1541-1551.
4. McGrail KA, Morse DS, Glessner T, Gardner K. What is found there: qualitative analysis physicians’ abilities to
of physician-nurse collaboration stories. Journal of General Internal Medicine. recognize, assess and
2009;24(2):198-204.
5. Jack, D. Silencing the self: woman and depression. Harvard University Press. 1993.
document Stage III
6. Simpson KR & Lyndon A. Clinical disagreements during labor and birth: how does and IV pressure ulcers
real life compare to best practice? The American Journal of Maternal/Child Nursing.
2009;34(1):31-39.
at a “D” level. Medline’s
7. The North Carolina Just Culture Journey [videotape]. North Carolina Board of Nursing new Pressure Ulcer
and North Carolina Hospital Association. Available at: http://www.justculture.org.
Accessed November 1, 2009.
Prevention Program MD
8. Khatri N, Brown GD. From a blame culture to a just culture in health care. Health Education CD contains every-
Management and Informatics, University of Missouri School of Medicine,
thing physicians need to brush up on their skills
Columbia. 2009.
9. Marx D. Patient safety and the “just culture”: a primer for health care executives in and comply with the new CMS Inpatient Prospective
support of Columbia University. Funded by a grant from the National Heart, Lung,
Payment System (IPPS).
and Blood Institute National Institutes of Health (Grant RO1 HL53772, Harold S.
Kaplan, MD, Principal Investigator). 2001.
“
10. Kaafarani HM, Itani KM, Rosen AK, Zhao S, Hartmann CW, Gaba DM. How does
The new MD Education component of Medline’s
patient safety culture in the operating room and the post-anesthesia care unit
compare to the rest of the hospital? American Journal of Surgery.2009;98(1):70-75. Pressure Ulcer Prevention Program is critical for
acute-care facilities to ensure that physicians
understand their role in recognizing and accurately
About the author documenting POA pressure ulcers.”
Kathleen Bartholomew, RN, RC, MN, has Michael Raymond, MD,
been a national speaker for the nursing pro- Associate Chief Medical Quality Officer,
fession for the past seven years. Her back- NorthShore University HealthSystem,
ground in sociology laid the foundation for Skokie Hospital, Skokie, IL
correctly identifying the norms particular to
health care – specifically physician and nurse
relationships. For her master’s thesis, she au-
thored Speak Your Truth: Proven Stategies To learn more about Medline’s Pres-
for Effective Nurse-Physician Communication, which is the only sure Ulcer Prevention Programs and
book to date that addresses physician-nurse communication. She FREE webinars for acute care and
also wrote Stressed Out About Communication, a book designed perioperative services, call your
for new nurses. Save 20 percent by using source code MB84712A
Medline representative, or visit
at www.HCMarketplace.com or call customer service at (800) 650-
6787. To increase performance with High Reliability Organization
methods, Kathleen has now partnered with ConvergentHRS.
©2009 Medline Industries, Inc.
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t h e
g i n g e
h a n l t u r
C r C u y
h e t e c i l i t
C a t r F a
Y o u
at
Special Feature
Connie M. Yuska, RN, MS
Recently my husband was hospitalized following a tract infection. And we know that too many indwelling
10-foot fall at work. We were thankful his injuries were urinary catheters are inserted. We also know that indwelling
not life-threatening, but he did have bilateral ankle and heel urinary catheters stay in too long.4
fractures. Given the immobility we knew was ahead, I was
discussing the treatment plan with a good friend who is a Components of Successful Culture Change
nurse. One of her first questions was, “They are going to Successful culture change consists of many components.
put in a catheter aren’t they?” My reply was, “I certainly The following are some key strategies you can try at your
hope not. I don’t want him to get a catheter-associated facility, including use of the new Guideline for Prevention
infection. That is the last thing we need with everything else of Catheter-Associated Urinary Tract Infections 2009,
that’s going on!” education and training, engaging front-line staff, a reward
program, and finally, being creative, having fun and tracking
This conversation verified what I have experienced for the progress.
majority of my career both as a staff nurse and as a chief
nursing officer. More likely than not if a patient was inconti- The Centers for Disease Control
nent or having difficulty getting to the bathroom, one of the and Prevention (CDC) Guideline
first requests would be an order for a urinary catheter. The The Healthcare Infection Control Practices Advisory
nurses believed that their primary intervention of catheter Committee (HICPAC) of the CDC recently published the
insertion would maximize the patient’s comfort and avoid Guideline for Prevention of Catheter-Associated Urinary
skin breakdown. Today we know that urinary tract infection Tract Infections 2009. This is an excellent reference to
is the most common healthcare-associated infection (HAI); review prior to initiating a catheter reduction program at
80 percent of these infections are attributable to an your facility. The document contains recommendations on
indwelling urethral catheter.1 One in four patients receives appropriate urinary catheter use and proper techniques for
an indwelling urinary catheter at some point during their urinary catheter insertion and maintenance. In addition, the
hospital stay and up to 50 percent of these catheters are guideline outlines strategies for quality improvement and
placed unnecessarily.2,3 surveillance programs and summarizes recommendations
for an administrative infrastructure to support a CAUTI
So, how do you change the culture at your facility if nurses prevention program.5
still want to place a catheter? We all know that changing
an organization’s culture can feel like turning a cruise ship Education and training
around in a wild and stormy sea. The perception of nurses A logical place to start is by designing a comprehensive
traditionally has been that putting a catheter in an inconti- education and training program. Having a program that
nent patient is the best standard of care. We have to provides the supporting framework for education also helps
change that perception. As we begin to collect data, the to organize and publicize the initiative. Medline’s ERASE
evidence is showing that avoiding catheterization protects CAUTI program will give you all the tools you will need.
the patient from acquiring a catheter-associated urinary

ALL NEW AND UPGRADED CONTENT.

WWW.MEDLINEUNIVERSITY.COM
Easier navigation to find what you need – faster.
Interactive courses and competencies And for facilities participating in the Pressure Ulcer
Continuing education courses are still available, and now Prevention and Hand Hygiene programs, all materials,
you can earn all credits for FREE! In addition, we are pre- and post-tests are now conveniently located
adding online competencies. Courses and competencies online at www.medlineuniversity.com.
are more interactive with more graphics, sound and
animation to make learning more fun. Log on to www.medlineuniversity.com today and
start earning CE credits —FREE.
Facility-specific features
Now each facility has the option of creating a group
account on Medline University. This will help you
and your facility view and keep track of all completed
courses.
The ERASE CAUTI Program for nurses (RNs and LPNs) is

a two-part educational program. Part One is a step-by-step
product training program on the ERASE CAUTI catheter
tray and insertion methodology. Part Two includes the
following four modules:
Module 1: Indications and Alternatives to Catheterization

Module 2: Aseptic Technique and Proper Insertion of
a Foley Catheter
Module 3: Care and Maintenance, Signs and Symptoms
of CAUTI
Module 4: Competency Validation
In addition, current practice guidelines, sample policies and

procedures and competency validation tools are included.
You have the opportunity to initiate the training at orientation
when a new employee joins your organization. This “sets
the stage” for the catheter culture in your facility. You are
setting the expectation that your staff will keep an inconti-
nent patient clean and dry without exposure to the unnec-
essary risk of acquiring a catheter-related urinary tract
infection. Then during your annual competency reviews for
your staff, you can reinforce the training and the new
“catheter culture.” This gives you a greater chance of hard-
wiring the change into your culture and ensuring that your
staff’s new viewpoint on catheterization is sustained.
Engaging front-line staff

It is also important to identify staff nurse champions at
the beginning of the program. Enlisting their help through a
formalized assignment is one good way to generate enthu-
siasm and support for the new program. Staff nurses have
very good ideas and usually know the best answer if we
remember to include them! Getting them involved in the
literature review and in planning the staff education roll-out Join the RACE
will solidify their role as “champions.” They also can be the to ERASE CAUTI
cheerleaders to encourage their peers to join the Race to
ERASE CAUTI!
Reward program
In sustaining any long-term change, it is extremely impor-
tant to recognize achievement. Staff work very hard, and

their efforts need to be recognized. Another part of the References

1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA
ERASE CAUTI Program is a reward component. Everyone practice recommendations: strategies to prevent catheter-associated urinary tract
infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50.
who successfully completes the course and achieves at 2. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces
least an 80% on the post test receives one CE credit, a cer- urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf.
2005;31(8):455-462.
tificate of completion and a pin to display on their ID 3. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape
badge or uniform. The pin recognizes individual achieve- Nursing Perspectives. February 3, 2009. Available at:
http://www.medscape.com/viewarticle/587464-4. Accessed July 6, 2009.
ment and provides an opportunity for the staff to talk 4. Sulzback-Hoke, Linda M. “Ask the Experts.” Critical Care Nurse. 2002,22:84-87.
about the program with patients, families and other Available at: http.//ccn.accnjournals.org/cgi/content/full/22/3/84. Accessed July 24, 2009.
5. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, Healthcare
healthcare professionals, keeping the program top-of-mind. Infection Control Practices Advisory Committee, Centers for Disease Control. Available
at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CAUTI_Guideline2009final.pdf.
Being creative, having fun and tracking progress

Since this is a Race to ERASE CAUTI, encourage your staff
to post statistics regarding the decline in catheter- associated
About the author
infections. Nursing units in hospitals or hospitals in systems Connie Yuska RN, MS began her career as a nurse in the spe-
can make this a fun, competitive event that results in cialty of otorhinolaryngology. Her clinical experience includes both
better patient care. Finally, celebrate when an individual or inpatient and outpatient care of head and neck oncology patients,
the entire facility crosses the finish line of achieving zero and she is certified in otorhinolaryngology and head-neck nursing. She
catheter-associated urinary tract infections. has held clinical manager and director of nursing positions in a
large academic medical center and also has experience in the
home care setting as the vice president of operations for a large
A Happy Ending academically affiliated home care agency in the Chicago area.
Although my husband did not have any incontinence, Connie later joined the executive suite as the chief nursing officer
he was non-weight bearing and thankfully, none of the of a large community hospital in Chicago, and she is currently a
nurses actually asked that a catheter be placed prior to sur- vice president of clinical services for Medline. In all of her leader-
gery. He did have a catheter placed during surgery, but it ship roles, she has been responsible for ensuring the delivery of
high quality, safe and cost-effective nursing care.
was taken out within 24 hours! The hospital staff did follow
the Guideline for Prevention of Catheter-Associated Urinary Connie is a 2003 graduate of the J&J/ Wharton Nurse Executive
Tract Infections 2009, which states “for operative patients Program. She is member of the Board of the Illinois Organization
who have an indication for an indwelling catheter, remove of Nurse Leaders and a member of the American Organization of
the catheter as soon as possible postoperatively, preferably Nurse Executives. In 2005, she was inducted into the 100 Wise
within 24 hours, unless there are appropriate indications for Women Program sponsored by Deloitte & Touche. In addition, she
has published several articles and chapters in oncology journals
continued use.”5
and textbooks.
I am happy to report that my husband was discharged from

the hospital to a rehabilitation facility, and he was able to
come home for Thanksgiving. This year I was very thankful
that he was in a hospital with an up-to-date catheter
culture, and he is on the road to recovery!
MEDLINE’S HAND HYGIENE COMPLIANCE PROGRAM

FOR ALL THE LIVES YOU TOUCH.
Now more than ever, hand hygiene compliance is crucial. The Hand Hygiene Compliance Program includes:
As of October 1, 2008, the Centers for Medicare & Medicaid • An instructor’s manual that takes the guesswork
Services no longer reimburses hospitals for eight hospital- out of planning lessons
acquired conditions, including catheter-associated urinary • A customizable plug-and-play CD that contains
tract infections, surgical site infections and bloodstream presentations, posters and more
infections.1 We know that hand hygiene is the number • Forms and tools to serve as reminders and
one line of defense against hospital-acquired infections.2 reinforcements
• A cost calculator to help you determine the cost
There’s no such thing as of prevention vs. the cost of an infection
“overeducating” when it comes • A rewards program to recognize those who
to hand hygiene. Enhance your complete the course
current strategy with Medline’s • Patient and family education materials
Hand Hygiene Compliance • CE-credit courses for staff
Program! • A how-to guide on enhancing your presentation skills
For an on-site presentation of the Hand Hygiene

Compliance Program and our Healthy Hands
Product Bundle, contact your Medline representative
References
1
Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital inpa- or visit www.medline.com/handhygiene.
tient prospective payment systems and fiscal year 2007 rates. Available at:
www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf.
2
Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Healthcare
Purchasing News. Available at: http://www.hpnonline.com/inside/2003-11/1103hygiene.htm.
We didn’t just design a

new tray, we designed a
way to make it hard for
healthcare workers to do
the wrong thing.
The new ERASE CAUTI program combines design, education
and awareness to tackle catheter-associated urinary tract
infection – the number one hospital-acquired infection.1
Design
The innovative one-layer tray design guides the clinician through
the process of placing a catheter to ensure aseptic technique.
Education
The acronym ERASE is easy to remember, reminding
the clinician to:
Evaluate indications – Does the patient really require

a catheter?
Design
Read directions and tips – Follow evidence-based Open up the
insertion techniques innovative one-layer
catheter tray and
see the intuitive
Aseptic techniques – Key design solutions support design for
aseptic technique yourself.
Secure catheter – A properly secured catheter will

reduce movement and urethral traction
Educate the patient – Printed materials tell the patient

how to reduce the likelihood of infection
Awareness
Join the Race to ERASE CAUTI! The current state of health
care demands that nurses play a leading role in identifying and
implementing CAUTI risk reduction strategies. Help us reach our
goal to introduce 100,000 nurses to the ERASE CAUTI system.
To sign up for a FREE webinar, “Innovation in the Preven-

tion of CAUTI,” go to www.medline.com/erase/webinar.asp.
Education
Click here for
details on nursing
education materials
that promote
evidence-based
practice. Awareness
Visit this section
to join 100,000
nurses in the
Race to ERASE
CAUTI.
Reference
1. Catheter-related UTIs: a disconnect in preventive strategies.
Physicians Weekly. 25(6), February 11, 2008.
Caring for Yourself
9 Habits of Very Happy People
By Wolf J. Rinke, PhD, RD, CSP
Economy sputtering; swine flu getting everyone upset;

lots of changes at my facility, and you want me to be
happy? You’re kidding, right?
Actually not! Because no matter how bad things seem to be,

it’s important to remind ourselves that Abraham Lincoln was
absolutely right when he said, “Most people are about as
happy as they make their minds up to be.” Happy people are
not happy because they are endowed with the happiness
gene—although researchers tell us that accounts for about
half of one’s potential for happiness—happy people are happy
because they realize that happiness is something they control
by doing certain things every day. So here are nine things you
can do that will make you happier:
1. Love what you do

I find it ironic that many people deny themselves the joy of their
work. Somehow they assume that work is a dirty four letter
word and that they must escape it as soon and as fast as pos-
sible so that they can get home and plop down in front of the
TV. (This by the way, is a great way to become more unhappy
and depressed.) I suspect it is because they have not found
what they love to do. The key word here is love—not like—
because once you find what you love to do you will not ever
have to “work” another day in your life. (By the way, it took me
36 years to find what I love to do, so don’t give up your search,
because when you find your passion, the quality of your life
will improve dramatically.) If you would like help with this, read
my book Make It a Winning Life: Success Strategies for Life,
Love and Business.

2. Chase your dreams

Happiness is often a byproduct of something that we are
going after—something that juices us. Think of children. When
are they the happiest? About two weeks before the Christmas
or Hanukkah holidays, or when they have ripped all the pres-
ents open? Once we have clearly-defined, specific, fire-
in-the-belly goals, we get turned on, and we become happy.
In other words, if your goal is to be happy—that’s what many
people in my seminars tell me—you won’t necessarily be
happy. You get happy from traveling the journey or reminding
yourself that you are doing something that improves the quality
of someone else’s life. Chasing your dreams cranks up your
internal body chemistry to such an extent that it energizes you
to achieve extraordinary results and may keep or may even
make you healthy.
Want proof? A good example is Lance Armstrong, who after

being diagnosed in 1996 with an advanced form of testicular
cancer that had metastasized to his brains and lungs, was
given only about a 50 percent chance of survival. After
receiving aggressive cancer therapy, including brain and
testicular surgery and extensive chemotherapy, he went on to
win the Tour de France—cycling’s most prestigious and
grueling race—seven times in a row from 1999-2005. (The
previous record was winning it five times.) And just when
everyone thought he was down and out, he returned to
competitive racing after four years of “retirement” to finish third
in the 2009 Tour de France. Not bad for someone who at
age 38 is considered old in the punishing sport of competi-
tive cycling.
3. Nourish an attitude of gratitude
A difficulty for many successful people is that they perpetually
look up the mountain, never down. To feel a sense of grati-
tude you must have goals—look up the mountain—but also
take the time to reflect on all that you have already achieved
and accumulated—look down the mountain.
If you need a bit of help with this, take advantage of the next
holiday season. Instead of buying gifts for people who already
have more than they will ever need, rally the whole family and
serve a meal at a homeless shelter. Or visit a third world coun-
try. For example, when I used to speak in the Pacific Rim, my
sense of gratitude was always renewed. Typically the client
booked me in a five-star hotel, which makes any of our five
star hotels pale in comparison. One of the hotels in Jakarta
even had a marble driveway. Not concrete, not flagstones—
marble. When I looked out of my 29th story window I saw
many other super-modern high-rise buildings. I also saw a
garbage dump several blocks away swarming with people –
people who were living on the dump in cardboard “houses”
and foraging for scraps. Stop right now, and be grateful for all
the love and abundance that surrounds you.
4. Love someone deeply psychoneuroimmunology, or PNI for short. (Want to know

Barbra Streisand was absolutely more? Read Dr. Pert’s books: Molecules of Emotions: The
right, “people who love people Science Behind Mind-Body Medicine and Everything You
are the luckiest people in the Need to Know to Feel Go(o)d.)
world.” Start by developing a
strong bond and lifetime relation- 6. Laugh more
ship with a significant other. Hav- That’s right – go ahead and
ing been happily married to my laugh right now. Can’t seem to
“Superwoman” for 41 years, I get it going? Go to the bath-
can attest that she by far is room, stick your tongue out,
my biggest source of joy and wiggle your nose and make the
happiness. (She got that name silliest face you can possibly
because she is a one-in-a-million mate, mother, business come up with and get yourself to
partner and confidant.) If you don’t have such a relationship, laugh. If you need more help, join
make it one of your top three fire-in-the belly goals, because a laughter yoga club, popular-
such a partner becomes increasingly more important as you ized in India, and now available
enter the later passages of your life. Extend that same love to all over the world including the
your family and your close friends. The greater your circle of United States (http://www.laughteryoga.org). Or consult with
loving relationships, the greater your happiness. a “certified laughter leader.” (Hey, I’m not making this stuff up!)
A good way to nurture this is to laugh more at yourself. It will
cause you to take yourself less serious—which is a great start
5. Treat your “body- because you are not nearly as important as you think you are.
mind” like a temple (I’m including myself in that statement; so don’t get bent out
Neuroscientist and pharmacolo- of shape). Laughter has innumerable benefits. It turns on your
gist Dr. Candance Pert, who dis- endorphins and other internal “drugs” that are far more pow-
covered the opiate receptor – the erful than anything you can ingest—legal or illegal. In fact, it is
cellular binding site for endor- so powerful that the late Norman Cousins used it as an “anes-
phins in the brain – calls our body thetic” to combat pain associated with his incurable disease.
and mind the “body-mind” be-
cause her work has unequivo- 7. Give more of what
cally demonstrated that the mind you want
and the body are one. Her work A shortcut to happiness is mak-
also shows that thoughts are ing other people feel happy.
things – things that manifest themselves in the body and in Why? Because life is like a mir-
your life. So if you think “bad” or negative thoughts, then that ror—whatever you give—is what
will have a negative impact on your body. And of course the you get. Make people happy and
reverse is true. Since the mind can have only one thought at you will be happier. Hate people
a time, get in the habit of monitoring your thoughts and self- and you will live in a hateful world.
talk by asking, “Is what I’m thinking about right now nega- Love people the way they are,
tive?” (The worst is hate.) If it is, it will move you away from and you will experience more
happiness and optimum health. On the other hand, positive love. You catch my drift. Actually
thoughts, such as love, kindness and appreciation will move you already knew that. And that’s why you are much more
you in a positive direction. This is so powerful that we now anxious to give a gift than get one. Happiness certainly does
have a whole science concerned with this phenomenon— not come from things. Otherwise the happiest people on

Be sure to never give up hope, no matter how bleak

it gets. And even more important, be sure not to
confuse inconveniences with problems.
earth would be lottery winners. They are not. In fact lottery 9. Keep Hope Alive
winners often become discouraged and depressed because Hope is an incredibly powerful
they become so obsessed with “stuff” that most are broke emotion. Without it not only do
three years after they have won the jackpot. “Superwoman” you become unhappy—you die.
and I have come to the realization that less is more. That is to No one has told that story more
say, the more stuff we have, the more problems and stress we powerfully than Dr. Victor Frankl
have. That’s why we evaluate every new opportunity by ask- in his book Man’s Search for
ing ourselves whether taking advantage of the new opportu- Meaning, in which he details the
nity will add to the quality of our lives. If the answer is yes, we role of hope in surviving the Ger-
go for it. If the answer is no, we don’t. man concentration camps. So
be sure to never give up hope, no
8. Develop a Positive matter how bleak it gets. And
Explanatory Style even more important, be sure not to confuse inconveniences
Professor Marty Seligman, of the with problems. Because many of the “problems” that we get
University of Pennsylvania, who ourselves all worked up about are inconveniences, not
has had a tremendous influence tragedies. When you are in the middle of one of these, a great
on getting psychologists to focus diagnostic is to ask yourself: “How will I feel about this five
on the good—what he has years from now?” And then act accordingly. To deal more ef-
dubbed “positive psychology”— fectively with the real tragedies—which will come—turn to the
wrote a number of powerful source of hope and inspiration that works for you. It may be
books addressing this topic religion, spirituality, meditation or listening to a great motiva-
(http://www.authentichappi- tional speech. (Just had to sneak that in there.) It will help you
ness.sas.upenn.edu/seligman.aspx). His research has keep hope alive and make you more optimistic and happier.
demonstrated that we can learn to be more optimistic by de-
veloping a “positive explanatory style” (PES). The way you do © 2009 Wolf J. Rinke
that is by focusing on the good stuff, especially when bad
things happen to you. In other words you learn to fake it until Dr. Wolf J. Rinke, PhD, RD, CSP is a keynote
you make it. Research has shown that people who have de- speaker, seminar leader, management con-
veloped PES, as opposed to a Negative Explanatory Style sultant, executive coach and editor of the free
electronic newsletters Make It a Winning Life
(NES) are able to evaluate “reality” more clearly—just the
and The Winning Manager. To subscribe go
opposite of what most people assume. Process “bad” news to www.WolfRinke.com. He is the author
more effectively, and you are more likely to accept what can’t of numerous books, CDs and DVDs including
be changed and move on. In short, PES enables you to Make it a Winning Life: Success Strategies for
inoculate yourself against the negative attitude “virus” and his Life, Love and Business; Winning Manage-
big cousin—depression. ment: 6 Fail-Safe Strategies for Building High-Performance Organi-
zations and Don’t Oil the Squeaky Wheel and 19 Other Contrarian
Ways to Improve Your Leadership Effectiveness. All are available at
www.WolfRinke.com. His company also produces a wide variety of
quality, pre-approved continuing professional education (CPE) self-
study courses including Beat the Blues: How to Manage Stress and
Balance Your Life, on which this article is based, available at
www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.
Olympic Figure Skater

Peggy Fleming
to Speak at Medline’s
AORN Breast Cancer
Awareness Breakfast
For the fifth year in a row,

Medline will be hosting a
complimentary breast cancer
awareness breakfast March 15,
2010, during the Association
of periOperative Registered
Nurses (AORN) Congress in
Denver, Colo. Olympic gold medalist and breast
cancer survivor Peggy Fleming will share stories
about her personal experience with breast cancer.
Each year since 2006, breakfast participants

have been inspired by celebrities who have won
the battle against breast cancer. In 2009 Medline
was proud to host TV journalist Linda Ellerbee.
Past speakers have included Dr. Marla Shapiro,
Rue McClanahan and Ann Jillian.
Save the Date!

Medline’s Breast Cancer
Awareness Breakfast
March 15, 2010 – 5:45 to 7:30 a.m
Speaker Peggy Fleming presents
“The Fight of a True Champion”
AORN Congress
Hyatt Regency at Colorado
Convention Center,
Denver, Colo.
Attendance by invitation
only. Contact your Medline
sales representative for
more information.

MEDLINE’S
PINK GLOVE
Thank You!
Providence St. Vincent
Medical Center
F ro m t h e h i g h e s t l e v e l s o f y o u r
o r ganization down through your entire
staff, we could not have picked a better
partner for the “Pink Glove Dance,”
video project.
Thank you for taking part in a

cause that touches us all.
Special Feature
DANCE
Boosting Hearts, Minds
and Support for Breast
Cancer Awareness
A YouTube™ Sensation
One early November morning, when the OR
staff of Providence St. Vincent Medical Center
was approached by Medline to take part in a little
breast cancer awareness video they were doing, little
did they know what an impact their participation
would soon make.
A little more than a month later, over six million people

across the globe have seen the “Pink Glove Dance” video.
The YouTube video phenomenon has been featured on

CNN, ABC World News with Charles Gibson, Fox &
Friends - Fox News Network’s national morning show,
and literally more than 100 local TV newscasts across
the country.
News stories about the video also span the Internet, from
the Huffington Post to the AOL home page. People can’t
stop talking about this video, which showcases more
than 200 hospital workers from the medical center in
Portland, OR. dancing in Medline’s pink gloves. Phone
calls, cards and e-mails are flooding both the hospital
and Medline. And more than 10,000 people have posted
comments about the video on YouTube. It has enter-
tained and inspired laughter and, for many, it has evoked
memories of their own battle with breast cancer or bat-
tles faced by loved ones.
One viewer wrote: “Wonderful! This brought tears to

my eyes as I am a survivor 13 years out and it reminded
me of the wonderful staff at Yale Oncology unit. Thank
you to all in the medical field. Please be sure to share
this with those who are going through treatments. I am
sure this will be helpful.” – mamakawecki55
Another said: “Given the type of work that they do,

it is good to see them having fun for a good cause.
Remember they are the ones who care for those with
cancer.” – seaglassfriends

Birth of an Idea The next few days were a blur of action. The hospital sent
Why would perfectly sane and incredibly busy hospital out a call for employee volunteers to dance in the video.
workers agree to dance in a YouTube video? The short Back at Medline, the wheels were in motion. Jay Sean’s hit
answer is to get people talking about breast cancer. But song “Down” was selected for the video and discussions
there’s more to the story. It all began at Medline’s Corporate took place to coordinate which areas of the hospital would
office when employees were brainstorming ideas to probe filmed, the number of staff participating in each shot and
mote their new Generation Pink™ glove (launched in the overall plan of events.
October). To further support Medline’s ongoing breast cancer
awareness campaign (visit www.medline.com/breast-can-
cer-awareness for details), they had already implemented a
promotion to donate $1 of every case purchased to the
National Breast Cancer Foundation to fund mammograms
for individuals who cannot afford them.
But they needed a big idea to help spread the word. So,
they asked, “What if we were to video healthcare workers
dancing in pink gloves? Could we produce a viral video?”
Little did they know. . .
The first step was finding the right hospital to partner with The Making of the Video
Medline to create the video. The Providence Health Sys- A week later, Medline product manager Emily Somers was
tem, a 26-hospital system in the northwest area of the at the hospital with a few boxes of pink gloves and the film
country, proved to be the perfect choice. The health system crew. More than 200 employees of all ages, departments
suggested Medline work with Providence St. Vincent Med- and skill levels answered the call to participate.
ical Center in Portland, which not only was willing to give full
access to each area of the facility for the video shoot, but “We had so many people who said, ‘You know, this
also shared Medline’s passion for breast cancer awareness. disease has touched my life. I want to be a part of it,’” said
“
I am very honored that Medline and
Providence St. Vincent Medical Center
used my song “Down” to promote and
support Breast Cancer Awareness.
I like that such a fun and light hearted
approach was taken to create aware-
ness for a serious disease that can
”
be cured if caught early.
– Jay Sean
Martie Moore, the chief nursing officer at Providence Monte Crawford, “the
St. Vincent Medical Center. mop man,” has become
one of the more popular
figures in the “Pink Glove
The filming took two days and Emily taught the volunteers
Dance” video.
basic dance moves to showcase the pink gloves. “In an
environment filled with sickness and gloom, the caregivers
brought incredible energy to the making of the video,
expressing their great heart and spirit,” Emily said. From
lab technicians and the kitchen help to surgical teams, they
all let loose, dancing throughout the hospital.
Touching People Around the World

Thousands of people across the globe have posted inspiring
comments about the video — even singer Jay Sean
responded by posting a link to the video on his website.
On his Facebook page he wrote, "The vid is awesome …
medicine will always be close to my heart and this is such
a worthy and important cause. So maybe I could have
been a doctor and a singer at the same time after all then?
Just brilliant."
17,000 Screaming Pink-Gloved Fans

To further spread the “Pink Glove Dance” message, more
than 17,000 passionate fans recently wore Medline’s pink
Emily Somers, Medline product manager – and the choreographer gloves at a live concert held in Chicago. With 34,000 pink
of the “Pink Glove Dance” – teaches the lab staff of Providence gloved hands swaying back and forth to a live performance
St. Vincent some dance moves during the shooting of the video. by Jay Sean singing his hit song “Down,” the arena took on
a surreal appearance of a dense forest of pink trees waving
in the wind. It was an unbelievable sight that brought tears
to the eyes of many in the audience.
TM
A world without breast cancer is in our hands.
Medline’s Generation Pink latex-free, third-generation vinyl exam gloves

have the comfort, barrier protection and price you love.
Even better, when you choose Generation Pink gloves, you’re helping
Medline support the National Breast Cancer Foundation.
Other ways to show your support:
Become a Facebook fan at: facebook.com/ Watch the “Pink Glove Dance” video at:
medlinebreastcancerawareness YouTube.com/watch?v=OEdvfyt-mLw
For more information on Medline’s exam gloves, please contact your

Medline representative, call 1-800-MEDLINE or visit www.medline.com.
©2009 Medline Industries, Inc. The cross-fingered pink glove hand image is a trademark of
Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
“ Pink
Glove
Dance
Video ”
Goes
• National news – ABC, CNN, FOX, MSNBC
• 17,000 fans donning pink gloves during
a live performance of Jay Sean’s hit
Viral! • Over 6 million views on YouTube
• Over 10,000 comments on YouTube
• More than 120 TV news stories
song, “Down” across the country
Support The Cause. Help fund free mammograms!

When you choose Generation Pink Gloves, a portion of the proceeds will be donated to the
National Breast Cancer Foundation to fund free mammograms for women who cannot afford them.
Depending on who you are (an individual or a facility), there are two sites to choose from
when ordering gloves.
• Individuals visit www.scrubs123.com
• Healthcare facilities visit www.medline.com/breast-cancer-awareness
• If you wish to donate directly to the National Breast Cancer Foundation,
visit the NBCF website www.nationalbreastcancer.org.
Healthy Eating
Cheesy Potatoes (12 servings) Nutrition

Information
• 16 oz. bag frozen hash brown potatoes Topping: Servings: 12
Calories: 296
(cubed or shredded) • 2 c. corn flakes
Fat: 12.7 g
• 16 oz. container sour cream • ¾ stick melted butter or margarine Sodium: 407.7 mg
• 1 can cream of chicken soup Fiber: 1.2 g
• ½ c. chopped onion
• 8 oz. bag shredded cheddar cheese
Directions: The Shannons regularly host parties at their home, where they
Mix together all ingredients and place in a baking dish. Top with have a fully outfitted game and entertainment room in the base-
crushed corn flakes mixed with the melted butter. Cover with ment. Dennis said his cheesy potatoes dish is a big favorite
foil and bake at 350 degrees F for 30 minutes. Remove the foil with guests. “It’s easy and inexpensive to make, and people
and bake an additional 20-30 minutes. really like it.”
Hint: To cut down on salt and fat, use low-sodium soup and re- With football season in full swing, the
duced fat cheese and sour cream. Shannons have been doing their usual
entertaining, and Dennis offered another
Shipping employee Dennis Shannon has worked at Medline’s quick, easy and inexpensive recipe:
Allentown, Penn. warehouse for 10 years. In his spare time, he Spread a thin layer of chive-flavored
enjoys cooking and entertaining. He said at his house, “I do the cream cheese onto a flour tortilla and
cooking and my wife does the baking, so it works out well.” then layer it with a slice of turkey breast
lunch meat, a piece of red leaf lettuce
and pimentos. Roll it up and cut into slices for an attractive and
delicious snack.

Forms & Tools
The following pages contain practical tools for implementing

patient-focused care practices at your facility.
FAQs about Catheter-Associated Urinary Tract Infection . . . . . . .79

CAUTI
Surgical Safety Team Communication . . . . . . . . . . . . . . . . . . . . .80

Surgical Fire Safety
Universal Protocol and Fire Risk Assessment . . . . . . . . . .81

Extinguishing a Surgical Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84
Preventing Surgical Fires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85
H1N1 Patient Handout (English) . . . . . . . . . . . . . . . . . . . . . . . . . .87

H1N1 (Swine Flu)
H1N1 Patient Handout (Spanish) . . . . . . . . . . . . . . . . . . . . . . . . .89
CAUTI-Patient Handout Forms & Tools
FAQs about
“Catheter-Associated
system, which includes the bladder (which stores the urine) and the kid- o Catheters are put in only when necessary and they are removed as
neys (which filter the blood to make urine). Germs (for example, bacteria soon as possible.
or yeasts) do not normally live in these areas; but if germs are introduced, o Only properly trained persons insert catheters using sterile (“clean”)
technique.
If you have a urinary catheter, germs can travel along the catheter and o The skin in the area where the catheter will be inserted is cleaned
ca be
• External catheters in men (these look like condoms and are placed over
What is a urinary catheter? the penis rather than into the penis)
A urinary catheter is a thin tube placed in the bladder to drain urine. •
Urine drains through the tube into a bag that collects the urine. A urinary aw
catheter may be used: Catheter care
• If you are not able to urinate on your own
o Healthcare providers clean their hands by washing them with soap
• To measure the amount of urine that you make, for example, during and wa
intensive care touching your catheter.
•
If you do not see your providers clean their hands,
• During some tests of the kidneys and bladder
please ask them to do so.
urinary tr -
o The catheter is secured to the leg to prevent pulling on the catheter.
germs tha - o Keep the bag lower than the bladder to prevent urine from backflow-
ing to the bladder.
there. Germs can enter the urinary tract when the catheter is being put in o Empty the bag regularly. The drainage spout should not touch any-
or while the catheter remains in the bladder. thing while emptying the bag.
if I have a catheter?
• Burning or pain in the lower abdomen (that is, below the stomach) •
• Fever • Always keep your urine bag below the level of your bladder.
• • Do not tug or pull on the tubing.
problems • Do not twist or kink the catheter tubing.
• •
So What do I need to do when I go home from the hospital?

• If you will be going home with a catheter, your doctor or nurse should
explain everything you need to know about taking care of the catheter.
Make sure you understand how to care for it before you leave the
hospital.
emoval or change of the catheter. Your doctor will deter- •
as burning or pain in the lower abdomen, fever, or an increase in the
What are some of the things that hospitals are doing to prevent catheter-
• Before you go home, make sure you know who to contact if you have
ques
ac
Co-sponsored by:
Surgical Safety Team Communication
JBK_OR12.3.qxp:Layout 1
Forms & Tools
BEFORE INDUCTION OF ANESTHESIA BEFORE SKIN INCISION BEFORE PATIENT LEAVES ROOM
Anesthesia: We are going to go over a checklist Surgeon arrives: Team introductions begin Circulator confirms items with surgeon / OR
12/28/09
to provide the safest possible care. followed by confirmation of items and anti- team before patient leaves OR.
cipated critical steps.
Anesthesia leads Surgeon leads Circulator leads
6:48 PM
Patient/staff has confirmed: Introductions: All team members Nurse confirms with OR team:
• Identification (name/DOB) • Please state name and role • Procedure name?
• Procedure • Specimen(s)/labelling?
Page 80
Surgeon confirms with OR team:

• Side/site • Estimated blood loss?
• Patient name, procedure
• Allergies • Any equipment/pick list issues?
• Operative side & site/mark visible
Consent verifies procedure? • Postop concerns?
• Correct positioning (patient/table)
Consent for blood or blood refusal? • Wound packing/dressing?
• Relevant images available/labelled?
Site/side is initialed?
• Implants available? Counts complete (instrument, sponge,
OR equipment available/working? needle)
• Specimen collection
Surgeon present in facility?
• Length of case/critical steps Anesthesia reviews
Monitors applied and functioning • Transfer to ____/oxygen needed
Anesthesia reviews
Anesthesia equipment and medical
check complete • ASA
• Antibiotic given or N/A Info from anesthesia provider.
Special airway equipment
Antibiotic prophylaxis ordered/ • IV access/fluids/blood products
Info from surgeon.
initiated (60min) • Specific patient concerns
Surgical Safety Team Communication
OR staff reviews Info from circulator/OR staff.

• Sterility/equipment/irrigation
Team members are encouraged solutions
to speak up when any problems • Fire Risk Assessment score
are noted. Team verbally agrees or corrects discrepancies Based on the WHO Surgical Safety Checklist, http://www.who.int/patientsafety/safesurgery/en
© World Health Organization 2008 All rights reserved.
UNIVERSAL PROTOCOL AND
FIRE RISK ASSESSMENT
(MNDPK(
OPFRM
Side 1
Planned Procedure: ___________________________________________________

12/28/09
_____________________________________________________________________ _____________
Date of Procedure
_____________________________________________________________________
6:48 PM
COMPONENT # 1 VERIFICATION PROCESS COMPONENT # 3 TIME OUT

Mark all that apply Sending Prep & Unit Doing The entire procedure team has performed a Time Out and all members
** indicates required field Unit Holding Procedure have verbally agreed.
Page 81
Name and date of birth confirmed ** Time out included the verification of: 1st 2nd 3rd
Patient/Decision maker verbalizes planned procedure Correct patient identity
Schedule confirms planned procedure Agreement on procedure to be done
Consent confirms planned procedure ** Correct site and side
History and Physical confirms planned procedure Diagnostic study confirmation of site and side
Diagnostic Study confirms planned procedure Availability of implants
Progress Record/Consult confirms planned procedure Availability of special equipment
Site marking required (go to Component 2) 1st Time Out: Time:_________ Initial:_______
Site marking not required nd
2 Time Out: Time:_________ Initial:_______
Date/Time: rd
3 Time Out: Time:_________ Initial:_______
Initial:
COMPONENT # 2 SITE MARKING (If required) FIRE RISK ASSESSMENT

Universal Protocol and Fire Risk Assessment
C After verification has been completed, the patient if able, will write “Yes” with a Procedure site or incision above the xiphoid 1 (Yes) 0 (NO)
permanent marker on or as near the site as possible: Open oxygen source (face mask/ nasal cannula) 1 (Yes) 0 (NO)
RIGHT ____________________ LEFT ___________________ Ignition source (cautery, laser, fiberoptic light source) 1 (Yes) 0 (NO)
Side marked by: SCORE 1 or 2: Initiate Routine Protocol Total Score:

Patient Family member (Relationship):____________ Healthcare Provider SCORE 3: Initiate High Risk Fire Protocol
(see side 2 for specifics)
Initial:________________ Time:________O#4 FIRE RISK ASSESSMENT ______
Initial:_______
Initials Signature/Title Print Name Initials Signature/Title Print Name
Forms & Tools
21020 S(36590)(0307)C OR – Universal Protocol

UNIVERSAL PROTOCOL AND FIRE RISK ASSESSMENT
(For Operating Room and Non-Operating Room Settings)
Side 2
COMPONENT # 1 VERIFICATION PROCESS
Purpose: To outline the process for identifying the correct person, correct procedure, and correct site for surgical and invasive procedures with involvement of
the patient or decision maker when possible.

A. The caregiver (RN/LPN, anesthesia provider, surgeon, resident, PA) beginning the verification process will initiate the form.
Forms & Tools
B. When care of the patient is transferred to a new care area, the new care giver will complete the appropriate columns and initial.
C. Mark (¥) only the boxes that indicate the method reviewed to confirm the planned procedure.
12/28/09
D. Resolve discrepancies identified through the verification process prior to moving the patient to the procedure area or prior to the initiation of the bedside
procedure/anesthesia regional block.
COMPONENT #2 SITE MARKING
Purpose: To clearly identify the intended site of incision or insertion.
6:49 PM
A. Document site marking for patients having surgical/invasive procedures involving laterality or digits. (Patients having surgical/invasive procedures involving
level(s) (i.e. spine or ribs) will have level(s) marked by the Licensed Independent Practitioner (LIP) performing the procedure or identified by the LIP using
radiographic techniques during the procedure.)
Page 82
COMPONENT #3 TIMEOUT
Purpose: To conduct a final verification of the correct patient, procedure, site and implants, if applicable.
A. Time out is completed prior to the start of the procedure and a designated person (circulating RN, assisting RN or tech) will complete the section and initial.
B. Mark (¥) only the boxes that indicate the components confirmed.
C. An additional Time Out is documented for a second procedure.
D. In the event that the physician performing the procedure leaves the patient or repositions the patient after the Time Out process has occurred, the Time
Out process is repeated and documented.
FIRE RISK ASSESSMENT
x Routine Protocol
1. FUEL:
A. When an alcohol based solution is used, use minimal amount of solution and allow sufficient time for fumes to dissipate before draping. Observe
drying time (minimum 3 minutes). Do not drape patient until flammable prep is fully dry.
B. Do not allow pooling of any prep solution (including under the patient).
C. Remove bowls of volatile solution from sterile filed as soon as possible after use.
D. Utilize standard draping procedure
2. IGNITION SOURCE:
A. Protect all heat sources when not in use. (cautery pencil holster, laser in stand by mode etc.)
B. Activate heat source only when active tip is in line of sight.
C. De-activate heat sources before tip leaves surgical site.
D. Check all electrical equipment before use.
x High Risk Protocol (includes all of routine protocol)
A. Use appropriate draping techniques to minimize O2 concentration (i.e., tenting, incise drape).
Universal Protocol and Fire Risk Assessment
B. Electrical Surgical Unit (ESU) setting should be minimized

C. Encourage use of wet sponges.
D. Basin of sterile saline and bulb syringe available for suppression purposes only.
E. Anesthesia Care Provider considerations:
x A syringe full of saline will be available, in reach of the anesthesia care provider, for procedures within the oral cavity.
x Documentation of oxygen concentration/flows. Use of “MAC Circuit” for oxygen administration.
JBK_OR12.3.qxp:Layout 1 12/30/09 9:00 AM Page 83
THE
CHOICE
IS YOURS.
Medline’s comprehensive line of facemasks
was designed to meet a variety of needs and
preferences, but all of our masks are united
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Forms & Tools Extinguishing a Surgical Fire
EMERGENCY PROCEDURE
EXTINGUISHING A SURGICAL FIRE
Fighting Fires ON the Surgical Patient
Review before every surgical procedure.
In the Event of Fire on the Patient:
1. Stop the flow of all airway gases to the patient.
2. Immediately remove the burning materials and have another team member extinguish them.
If needed, use a CO2 fire extinguisher to put out a fire on the patient.
3. Care for the patient:
—Resume patient ventilation.
—Control bleeding.
—Evacuate the patient if the room is dangerous from smoke or fire.
—Examine the patient for injuries and treat accordingly.
4. If the fire is not quickly controlled:
—Notify other operating room staff and the fire department that a fire has occurred.
—Isolate the room to contain smoke and fire.
Save involved materials and devices for later investigation.
Extinguishing Airway Fires

Review before every surgical intubation.
At the First Sign of an Airway or Breathing Circuit Fire, Immediately and Rapidly:
1. Remove the tracheal tube, and have another team member extinguish it. Remove cuff-protective
devices and any segments of burned tube that may remain smoldering in the airway.
2. Stop the flow of all gases to the airway.
3. Pour saline or water into the airway.
4. Care for the patient:
—Reestablish the airway, and resume ventilating with air until you are certain that nothing is left
burning in the airway, then switch to 100% oxygen.
—Examine the airway to determine the extent of damage, and treat the patient accordingly.
Save involved materials and devices for later investigation.
MS09445_1
Source: New Clinical Guide to Surgical Fire Prevention. Health Devices 2009 Oct;38(10):330. ©2009 ECRI Institute
More information on surgical fire prevention is available at: www.ecri.org/surgical_fires
Preventing Surgical Fires Forms & Tools
ONLY YOU CAN PREVENT SURGICAL FIRES

Surgical Team Communication Is Essential
The applicability of these recommendations must be considered individually for each patient.
At the Start of Each Surgery:
X Enriched O2 and N2O atmospheres can vastly increase flammability of drapes, plastics, and hair. Be aware of possible
O2 enrichment under the drapes near the surgical site and in the fenestration, especially during
head/face/neck/upper-chest surgery.
X Do not apply drapes until all flammable preps have fully dried; soak up spilled or pooled agent.
X Fiberoptic light sources can start fires: Complete all cable connections before activating the source. Place the source in
standby mode when disconnecting cables.
X Moisten sponges to make them ignition resistant in oropharyngeal and pulmonary surgery.
During Head, Face, Neck, and Upper-Chest Surgery:

X Use only air for open delivery to the face if the patient can maintain a safe blood O2 saturation without supplemental O2.
X If the patient cannot maintain a safe blood O2 saturation without extra O2, secure the airway with a laryngeal mask
airway or tracheal tube.
Exceptions: Where patient verbal responses may be required during surgery (e.g., carotid artery surgery, neurosurgery,
pacemaker insertion) and where open O2 delivery is required to keep the patient safe:
— At all times, deliver the minimum O2 concentration necessary for adequate oxygenation.
— Begin with a 30% delivered O2 concentration and increase as necessary.
— For unavoidable open O2 delivery above 30%, deliver 5 to 10 L/min of air under drapes to wash out excess O2.
— Stop supplemental O2 at least one minute before and during use of electrosurgery, electrocautery, or laser, if
possible. Surgical team communication is essential for this recommendation.
— Use an adherent incise drape, if possible, to help isolate the incision from possible O2-enriched atmospheres
beneath the drapes.
— Keep fenestration towel edges as far from the incision as possible.
— Arrange drapes to minimize O2 buildup underneath.
— Coat head hair and facial hair (e.g., eyebrows, beard, moustache) within the fenestration with water-soluble surgical
lubricating jelly to make it nonflammable.
— For coagulation, use bipolar electrosurgery, not monopolar electrosurgery.
During Oropharyngeal Surgery (e.g., tonsillectomy):

X Scavenge deep within the oropharynx with a metal suction cannula to catch leaking O2 and N2O.
X Moisten gauze or sponges and keep them moist, including those used with uncuffed tracheal tubes.
During Tracheostomy:
X Do not use electrosurgery to cut into the trachea.
During Bronchoscopic Surgery:

X If the patient requires supplemental O2, keep the delivered O2 below 30%. Use inhalation/exhalation gas monitoring
(e.g., with an O2 analyzer) to confirm the proper concentration.
When Using Electrosurgery, Electrocautery, or Laser:

X The surgeon should be made aware of open O2 use. Surgical team
discussion about preventive measures before use of electrosurgery,
electrocautery, and laser is indicated.
X Activate the unit only when the active tip is in view (especially if looking
through a microscope or endoscope).
X Deactivate the unit before the tip leaves the surgical site.
X Place electrosurgical electrodes in a holster or another location off the
patient when not in active use (i.e., when not needed within the next few
moments).
X Place lasers in standby mode when not in active use.
X Do not place rubber catheter sleeves over electrosurgical electrodes.
®
Developed in collaboration with the
MS09445_2
Anesthesia Patient Safety Foundation.
Source: New Clinical Guide to Surgical Fire Prevention. Health Devices 2009 Oct;38(10):319. ©2009 ECRI Institute
More information on surgical fire prevention, including a downloadable copy of this poster, is available at www.ecri.org/surgical_fires

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Forms & Tools H1N1 Patient Handout
H1N1 (Swine Flu)

What is H1N1 flu?
H1N1 influenza, or swine flu, is a respiratory
illness caused by type A influenza viruses. This
virus was originally referred to as “swine flu”
because it was thought to be very similar to flu
viruses that normally occur in pigs (swine) in
North America. H1N1 flu was first detected in
people in the United States in April 2009.
How does H1N1 flu spread?

H1N1 flu is contagious and is spreading between people. This virus may be transmitted in similar ways that other flu viruses
spread, through coughing or sneezing. A person may be able to infect another person one day before symptoms develop and
for seven or more days (longer for children) after becoming sick. It is possible that someone may become infected by touching
something with the virus on it and then touching his mouth or nose. Eating pork does not cause swine influenza.
What are the symptoms of H1N1 flu?

The symptoms of H1N1 flu include fever, cough, sore throat, runny or stuffy nose, body H1N1 Symptoms
aches, headache, chills and fatigue. Diarrhea and vomiting may also be associated with
H1N1 flu. Most people with the virus have recovered without needing treatment, but • Headache
hospitalizations and deaths have occurred. • Fever
• Fatigue
What should I do if I think I have H1N1 flu?
If you have flu symptoms, stay home and avoid contact with other people to avoid • Chills
spreading your illness. It is recommended that you stay home for at least 24 hours after • Runny or
your fever is gone, or if possible, until your cough is gone. If you have severe illness or stuffy nose
you are at high risk for flu complications, contact your health care provider.
• Sore throat
He or she will determine whether testing or treatment is needed.
• Cough
Seek emergency medical care for any of the following warning signs: • Body aches
In children: In adults:
• Fast breathing or trouble breathing • Difficulty breathing
• Bluish skin color or shortness of breath
• Not drinking enough fluids • Pain or pressure in the chest or abdomen
• Not waking up or not interacting • Sudden dizziness
• Being so irritable that the child does not want to be held • Confusion
• Flu-like symptoms improve but then return with • Severe or persistent vomiting
fever and worse cough • Flu-like symptoms improve but then return with
• Severe or persistent vomiting fever and worse cough
Page 1 Text courtesy of NursingCenter.com.

Images courtesy of Anatomical Chart Company.
Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
nursingcenter.com anatomical.com 5mcc.com

Forms & Tools H1N1 Patient Handout
How is H1N1 flu treated?

The CDC recommends the use of oseltamivir (brand
name Tamiflu) or zanamivir (brand name Relenza) to
treat and/or prevent swine influenza. These antiviral
medications may also prevent serious complications.
For treatment, antiviral drugs work best if started
within 2 days of symptoms.
What can I do to prevent H1N1 flu?

You can reduce your risk of contracting and spreading swine influenza
and other influenza viruses by:
• Coughing or sneezing into • Not touching your eyes, nose, or

your arm; avoiding close mouth because this is how germs
contact with people who have get into your body
respiratory symptoms such as
coughing or sneezing
• Staying home when you're sick • Keeping surfaces and objects

and getting as much rest (especially tables, counters, door-
as possible knobs, toys) that can be exposed
to the virus clean
• Washing your hands often • Practicing other good health habits,

with soap and water for including getting plenty of sleep,
15-20 seconds; using staying active, drinking plenty of
alcohol-based hand cleansers fluids, and eating healthy foods
is also acceptable
Check with your healthcare

provider to see if the
Lisa Morris Bonsall, MSN, RN, CRNP H1N1 vaccine is right for you.
Page 2 Text courtesy of NursingCenter.com.

Images courtesy of Anatomical Chart Company.
nursingcenter.com anatomical.com 5mcc.com
H1N1 Español por los Pacientes Forms & Tools
Virus de la influenza A subtipo H1N1

(anteriormente llamado de la «gripe porcina»)
¿Qué es la gripe por H1N1?
La gripe por H1N1, originalmente llamada
«gripe porcina», es la enfermedad respiratoria que
causa la infección por el virus de la influenza A
subtipo H1N1. A este virus originalmente se le llamó
virus de la «gripe porcina» puesto que se pensó que
era muy similar a los virus que causan gripe en los
cerdos (porcinos) en Norteamérica. El virus de la influenza
A subtipo H1N1 fue detectado por primera vez en humanos
en los Estados Unidos de Norteamérica en abril del 2009.
¿Cómo se propaga la gripe por H1N1?

La gripe por H1N1 es contagiosa y se propaga de persona a persona. El virus puede propagarse de manera similar a otros
virus de la gripe; a través de la tos o de los estornudos. Una persona puede infectar a otra un día antes de presentar síntomas
y durante siete o más días (más tiempo en los niños) después de haber enfermado. Existe la posibilidad de que una persona se
infecte al tocar una superficie contaminada con el virus si esta persona luego se pone las manos sobre la boca o nariz. Comer
carne de cerdo no causa gripe por H1N1.
¿Cuáles son los síntomas de la gripe por H1N1?

Los síntomas de la gripe por H1N1 incluyen fiebre, tos, dolor de garganta, nariz con Síntomas de A(H1N1)
mucosidad o tupida; dolor en el cuerpo, dolor de cabeza, escalofríos y fatiga. La mayoría
de las personas que han tenido el virus se han recuperado sin necesitar tratamiento, pero • Dolor de cabeza
ha habido otras que han necesitado hospitalización, y también otras que han muerto. • Fiebre
• Fatiga
¿Qué debo hacer si pienso que tengo gripe por H1N1? • Escalofríos
Si usted piensa que tiene síntomas de gripe quédese en casa y evite entrar en contacto con
otras personas para no propagar la enfermedad. Es recomendable quedarse en casa por lo • Nariz con
menos durante 24 horas después de que le haya pasado la fiebre, o si es posible, después mucosidad o tupida
de que le haya pasado la tos. Si está gravemente enfermo, o si pertenece a un grupo de alto
riesgo para desarrollar complicaciones, entre en contacto con su proveedor de atención • Dolor de garganta
médica. Él determinará si es necesario que le hagan análisis o que tome tratamiento. • Tos
• Dolores corporales
Busque atención médica de urgencias si presenta cualquiera de los
siguientes signos (señas) de alarma:
En niños: En adultos:
• Respiración acelerada o dificultad para respirar • Dificultad para respirar o sensación de «falta de aire»
• Tonalidad morada en la piel • Dolor o sensación de presión en el pecho o en
• No está tomando suficientes líquidos el abdomen
• No se despierta o no responde a las acciones • Mareo súbito
• Está tan irritable que no quiere que lo alcen • Confusión
• Los síntomas como de gripe mejoran pero • Vómito intenso o persistente
luego reaparecen con fiebre y tos más fuerte. • Los síntomas como de gripe mejoran pero luego
• Vómito intenso o persistente reaparecen con fiebre y tos más fuerte.
Página1 Texto por cortesía del centro NursingCenter.com.

Imágenes por cortesía de Anatomical Chart Company. nursingcenter.com anatomical.com 5mcc.com

Forms & Tools H1N1 Español por los Pacientes
¿Cómo es el tratamiento para la gripe por A(H1N1)?

Los Centros para el Control y la Prevención de Enfermedades de los EE. UU.
(CDC) recomiendan el uso de oseltamivir (nombre de marca Tamiflu) o de
zanamivir (nombre de marca Relenza) para el tratamiento y la infección,
o solamente para prevenir la infección por el virus de la influenza
A(H1N1). Estos medicamentos antivíricos también pueden prevenir
complicaciones graves. Para el tratamiento, los medicamentos antivíricos
funcionan mejor si se comienzan a usar en un lapso de dos días después
de que comienzan los síntomas.
¿Qué puedo hacer para prevenir la gripe por A(H1N1)?

Usted puede disminuir su riesgo de contraer gripe por A(H1N1) y de propagar
otros virus de la influenza de la siguiente manera:
• Tosiendo o estornudando sobre • No tocándose los ojos, nariz o

su brazo y evitando el contacto boca, pues ésta es la manera
cercano con personas que como los gérmenes llegan hasta
presentan síntomas respiratorios nuestro cuerpo.
tales como tos o estornudos.
• Quedándose en casa cuando está • Manteniendo limpias las superficies

enfermo y descansando el mayor y objetos (especialmente mesas,
tiempo que pueda. mesones, cerraduras de puertas)
que puedan estar expuestos al virus.
• Lavándose las manos con • Practicando otros hábitos saludables;

frecuencia con agua y jabón incluso dormir bastante, mantenerse
durante 15 a 20 segundos o activo, tomar líquidos en cantidad y
usando un limpiador para las comer alimentos saludables.
manos con base en alcohol.
Verifique con su proveedor

de atención médica para
determinar si la vacuna
contra el virus de la
Escrito por Lisa Morris Bonsall, MSN, RN, CRNP influenza A(H1N1) es
Traducido por Marcela D. Pinilla, M.H.E., M.T. (ASCP) adecuada para usted.
Página 2 Texto por cortesía del centro NursingCenter.com.

Imágenes por cortesía de Anatomical Chart Company. nursingcenter.com anatomical.com 5mcc.com
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Peggy Fleming Comes to Congress

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Rhonda J. Frick, RN, CNOR 13 Revised Universal Protocol for 2010

Perioperative Advisory Board SPECIAL FEATURES

Barb Fahey RN, CNOR Awareness Breakfast

Aligning practice with policy to improve patient care 3

THE OR CONNECTION I Letter from the Editor

Three Important National Initiatives

1 IHI Improvement Map

2 Joint Commission 2010 National Patient Safety Goals

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

3 Surgical Care Improvement Project (SCIP)

IHI Improvement Map: 70 Processes to Transform Hospital Care

1. Acute Myocardial Infarction (AMI) Core Processes 1. Central Line Bundle

2. Set Direction: Aims 2. CA-UTI

Joint Commission 2010 National Patient Safety Goals

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

Surgical Care Improvement Project (SCIP): Target Areas

Aligning practice with policy to improve patient care 7

As reported in the last issue of The OR Con-

To clarify, here are the key points to

Aligning practice with policy to improve patient care 9

Use silver to fight bacteria.

The $40 million investment, funded by the American Recovery

“We expect these programs to strengthen tracking and

Outpatient Surgery Magazine. September 8, 2009. Available at:

Aligning practice with policy to improve patient care 11

Hospital-specific public data

Statewide public data

State Reporting of Adverse Events

Joint Commission Update

by Connie Yuska, RN, MS

Aligning practice with policy to improve patient care 13

Joint Commission Update

Site Marking (UP.01.02.01)

Designed to break down barriers to surgical safety

1. The Gold Standard Safety Bundle: Includes

2. Innovative safety products: Surgical Time Out

among all members of the procedure team. Time-outs have

procedure and discuss situations in which exceptions to site References

Your hands will

Sterillium® Rub’s high alcohol content delivers a devastating

Sterillium® Rub’s balanced emollient blend leaves hands

To download a transcript of interviews with

BREAKING THROUGH HAND HYGIENE & SKIN CARE BARRIERS

About the Presenter

More important than ever before

Medline’s Pressure Ulcer Prevention Program now has a

Back to Basics Eleventh in a Series

The importance of proper patient positioning must not be Assessment

Aligning practice with policy to improve patient care 21

NO PRESSURE, JUST SUPPORT.

Recent studies have shown that pressure ulcers can start

Medline’s gel positioners are designed to help reduce

Gel positioners are one of several products recommended

To sign up for a FREE webinar on perioperative

ment and support of joints when

KEEP YOUR SURGICAL

The Braden Scale tells us that moisture is one of the

That’s why we developed the Sahara Super Absorbent