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The

Aligning practice with policy to improve patient care

Volume 3, Issue 3

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Risk Assessment
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OR Connection
Aligning practice with policy to improve patient care

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We've coded the articles and information in this magazine to indicate which patient
Content Key

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 5 Million Lives Campaign
• 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 above
initiatives, see pages 6 and 7.
Sue MacInnes, RD, LD
Editor

Alecia Cooper, RN, BS, MBA, CNOR


Clinical Editor

Andy J. Mills, MBA


Contributing Editor

PATIENT SAFETY
Mike Gotti
Art Director
6 Three Important National Initiatives for Improving Patient Care
9 A Focus on Prevention
Laura Kuhn
Copy Editor

18 Back to Basics: Applying Evidence-Based Information to


Jayne Barkman, RN, BSN, CNOR
Clinical Team
Improve Hand-Off Communication in Perioperative Services
Rhonda J. Frick, RN, CNOR 30 Patient Safety in Surgery
Anita Gill, RN Page 18
Megan Giovinco, RN, CNOR, RNFA
32 A Spotlight on “Never Events”
Kimberly Haines, RN, Certified OR Nurse 50 Why Is Pressure Ulcer Risk Assessment So Important?
Jeanne Jones, RNFA, LNC
Carla Nitz, RN, BSN OR ISSUES
Connie Sackett, RN, Nurse Consultant
Claudia Sanders, RN, CFA
15 Targeting Zero Healthcare-Associated Infections
Angel Trichak, RN, BSN, CNOR 26 Care Bundle for Surgical Site Preparation
33 A Latex-Free Victory!
Gail Avigne, RN
Perioperative Advisory Board

Shands Teaching Hospital (UFL), Florida


42 Supply Management for Perioperative Services Page 30

Caroline Copeland, RN MPH 44 A New Way to “Pack” It All In


Southern Hills Hospital & Medical Center 58 Fluid Flow Disruption?
Cathy Crandall, RN
HealthTrust Purchasing Organization, Tennessee
SPECIAL FEATURES
Larry Creech, RN, MBA, CDT
Carilion Health System, Virginia
14 Prevention Above All Discoveries Grants
Pat DʼErrico, RN, CNOR 28 Measuring What You Manage
Medical Center of Central Georgia, Georgia
36 Organ Donation
Barbara Fahey, RN CNOR
Cleveland Clinic, Ohio 62 Why Can’t We All Just Get Along? Page 33

Zaida Jacoby, RN, MA, M.Ed 77 Mark Your Calendar: Linda Ellerbee
NYU Medical Center, New York
91 Ami Lends a Hand
Sherron Kurtz, RN, MSA, MSN, CNOR, CNAA
Wellstar Kennestone Hospital, Georgia
Wayne Malone, RN
CARING FOR YOURSELF
Physicians Hospital, Texas 66 Hot to Set Priorities and Get the Job Done
Lynda Mansfield, RN, CNOR 68 Conquer Stress During Tough Economic Times
Orange County Memorial, California
78 Recipe: Bruschetta Delizioso
Jackie Minor, RN CNOR
Huntsville Hospital, Alabama
Page 36

Jennifer Misajet, BSN, MHA, CNOR


FORMS & TOOLS
Exempla St. Joseph Hospital, Colorado 80 Summary of SCIP Measure Changes
Pricilla Ranseur, RN, MSN, CNOR 82 Hand-Off Communication in the Perioperative Setting
Duke University Hospital, North Carolina
Margie Voyles, RN, MS, CNOR
85 SBAR Hand-Off Communication
Lakeland Regional Medical Center, Florida 89 Pressure Ulcer Prevention Checklist: Perioperative Services
Margery Woll, RN, MSN, CNOR
Rush North Shore, Illinois
Page 66

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.

© 2008 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,
October 1, 2008, seems like the distant past as we detection of foreign bodies left during surgery, to
break open the New Year with a new president, new name a few. Look on Page 32 for an index of arti-
regulations, new goals and many new processes. cles offering solutions that will address many of the
Many of you are addressing the 11 hospital-acquired 11 conditions.
conditions that will no longer trigger higher DRG
payments if they are acquired during the hospital The best solutions come from those of you who are
stay. Those conditions include: in the trenches. For that reason, Medline wants to
support and encourage these great ideas through
1. Objects left in surgery the Prevention Above All Discoveries Grant Pro-
2. Blood incompatibility gram. Medline will be awarding $1 million in grant
3. Air embolism money over several years. These awards are de-
4. Catheter-associated urinary tract infections signed to assist healthcare providers in developing
5. Pressure ulcers and testing creative solutions or interventions for re- This edition of
6.
7.
Vascular catheter-associated infections
Falls and trauma (including burns)
ducing or preventing hospital-acquired harms. For
more information on the Discoveries Grants, see

The OR Connection
is all about providing
8. Surgical site infections – mediastinitis Page 14.
solutions to help
after CABG
9. Surgical site infections following certain Finally, STOP and take time for yourself. Destress reduce hospital-
elective surgeries and refocus. Read how you can communicate acquired conditions.”
10. Certain manifestations of poor control of peacefully with other departments, set priorities and
blood sugar levels conquer stress. Let 2009 be the start of a great year!
11. Deep vein thrombosis of pulmonary
embolism following total knee replacement/hip Best Regards,
replacement procedure

Patient safety is not a trend, but a part of our daily


activities. 2009 will be a springboard for change as Sue MacInnes RD, LD
more and more hospitals embrace the inevitable.
This edition of The OR Connection is all about pro- P.S. Take a look below at the Reader Question for
viding solutions to help reduce hospital-acquired this edition. The winning response will receive a
conditions. copy of Take Big Bites by Linda Ellerbee, our
keynote speaker at our breast cancer awareness
In reviewing Medlineʼs Prevention Above All cam- breakfast at AORN Congress in March.
paign (Pages 9-14), you will find one solution after
another on ways to reduce infections, programs to
reduce pressure ulcers and products to assist in the

This Editionʼs Question


What have you done
to improve patient safety
in your operating room?

Please submit your response to orconnection@medline.com. Each


issue will feature a new question of the month and a winner will be
chosen for the best submission. Please submit early and often as
the best solutions are created by those who deliver patient care
every day!

4 The OR Connection
News Flash

DNV Joins Joint Commission and AOA UCLA study reveals smoking's effect
for Accreditation for CMS Payment on nurses' health, death rates
The Centers for Medicare & Medicaid Services (CMS) A new UCLA School of Nursing study is the first to reveal
has approved the first new hospital accreditation organi- the devastating consequences of smoking on the nursing
zation in more than 40 years, giving hospitals another profession. Published in the November- December edition
choice when seeking to participate in Medicare or Medi- of the journal Nursing Research, the findings describe
caid. The approval by Det Norske Veritas Healthcare Inc. smoking trends and death rates among U.S. nurses and
for conferring deemed status on hospitals adds to emphasize the importance of supporting smoking cessation
accreditation programs by the Joint Commission and the programs in the nursing field.
American Osteopathic Association, or certification by a
state survey agency. The current UCLA research explored changes in smoking
trends and death rates among female nurses enrolled in the
To learn more about DNV go to: Nurses' Health Study between 1976 and 2003, a span of
http://www.dnv.com/news_events/index.asp 27 years.

Older Blood Raises Infection Risk


According to the most recent data, the smoking

A study conducted at Cooper University Hospital, Cam-


rate among registered nurses nationwide is

den, NJ, and presented at the annual scientific meeting


nearly 12 percent.

of American College of Chest Physicians in late Octo- The rate of smoking among women in the Nurses' Health
ber, found that those who received a transfusion of Study declined from 33.2 percent in 1976 to 8.4 percent in
blood stored for 29 days or longer were twice as 2003. The number of cigarettes smoked per day also
likely to develop pneumonia, sepsis and other serious dropped. However, the daily number among current
infections compared with those who received stored smokers still averaged more than 15 cigarettes, or over half
blood kept for 28 days or less. Additional studies are a pack.
needed to determine the optimal storage period for blood to
prevent infections. Rules currently permit blood to be The entire story can be found at:
stored for 42 days. http://newsroom.ucla.edu/portal/ucla/new-ucla-study-
reveals-smoking-71590.aspx?link_page_rss=71590
To learn more about this study, go to:
http://www.chestnet.org/about/press/releases/200
8/CHEST/PDF/BloodStorage.pdf?zbrandid=3032&zid-
Type =CH&zid=1342800&zsubscriberId=751519175

Aligning practice with policy to improve patient care 5


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 5 Million Lives Campaign


Origin: Launched by the Institute for Healthcare Improvement (IHI) in December of 2006
Purpose: To prevent unintended physical injury resulting from or contributed to by medical care that requires
additional monitoring, treatment or hospitalization, or that results in death
Goal: To prevent five million incidents of medical harm over the next two years and to enroll more than
4,000 hospitals and their communities in the project.

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

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

2 Joint Commission 2008 National Patient Safety Goals


Origin: Developed by Joint Commission staff and a Sentinel Event Advisory Group
Purpose: To promote specific improvements in patient safety, particularly in problematic areas

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

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

3 Surgical Care Improvement Project (SCIP)


Origin: Initiated in 2003 as a national partnership. Steering committee includes the following
organizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the
Joint Commission
Purpose: To improve patient safety by reducing postoperative complications
Goal: To reduce nationally by 25 percent the incidence of surgical complications by 2010

SCIP aims to reduce surgical complications in 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

5 Million Lives Campaign: Twelve Interventions


1. Prevent pressure ulcers 9. Deliver evidence–based care for acute
2. Reduce methicillin-resistant staphylococcus myocardial infarction
aureus (MRSA) infection 10.Prevent surgical-site infections
3. Prevent harm from high-alert medications 11. Prevent central-line infections
4. Reduce surgical complications 12.Prevent ventilator-associated pneumonia
5. Deliver evidence-based care for congestive heart failure
By the numbers:
6. Get boards on board
• Over 4,000 hospitals currently enrolled
7. Deploy rapid response teams
• The Top 4 Interventions:
8. Prevent adverse drug events (ADEs)
1. Adverse Drug Events (ADEs) – 3,152
An IHI forum, “Celebrating 20 Years: The Future 2. Surgical Site Infection (SSI) – 3,047
of Health Care is Ours to Imagine,” was held in 3. Acute Myocardial Infarction (AMI) – 3,016
Nashville on December 8-11, 2008. www.ihi.org 4. Rapid Response Teams – 2,853

Joint Commission 2009 National Patient Safety Goals


• Improve accuracy of patient identification • Reduce risk of surgical fires
• Improve effectiveness of communication • Encourage patientʼs active involvement in their care
among caregivers • Prevent healthcare-associated pressure ulcers
• Improve medication safety (decubitus ulcers)
• Reduce risk of healthcare-associated infections • Identify safety risks inherent in patient population
(Expanded in 2008 to include either WHO (suicide, home fires)
or CDC Hand Hygiene Guidelines) • Improve recognition and response to changes in a
• Reduce risk of patient harm from falls patients condition
• Reduce risk of influenza and pneumoccocal • Implementation of Universal Protocol for preventing
disease through immunization wrong-site, wrong-person, wrong-procedure surgery

To learn more about the 2009 National Patient Safety Goals, go to www.jointcommission.org. New in 2009: New numbering system for
sorting in new electronic manuals and minor language changes for consistency.

Surgical Care Improvement Project (SCIP): Target Areas


1. Surgical-site infections
By the numbers:
• Antibiotics, blood sugar control, hair removal, normothermia
• 3,740 hospitals are submitting
2. Perioperative cardiac events data on SCIP measures, representing
• Use of perioperative beta-blockers 75 percent of all U.S. hospitals
3. Venous thromboembolism • Currently, SCIP has more than 36
• Use of appropriate prophylaxis association and business partners

SCIP is targeting two new measures for October 2009:


• Removal of urinary catheters within 48 hours post surgery
• A new, updated normothermia measure
To learn more, go to Page 9.
Visit www.qualitynet.org

Aligning practice with policy to improve patient care 7


A Focus on Prevention
Highlights from the Prevention Above All Forum

At the Prevention Above All Forum in August, nearly 100


chief nursing officers, chief medical officers and healthcare
“This conference was absolutely terrific,

quality executives from across the U.S. came to Chicago to


My knowledge has been increased
hear some of health careʼs top thought leaders discuss
greatly. Our ‘assigned row rep’ was
policy changes, patient safety strategies and targeted,
terrific, very helpful, anticipated our
evidence-based solutions for improving patient outcomes. needs before we knew them and was
There was a lot of information and excitement around the overall great!”
new reimbursement regulations that CMS put into practice Karin L. Boylard, Clinical Nurse Educator
October 1, as well as the patient safety themes that the Johnson Memorial Hospital
quality improvement organizations are working on.
CMSʼ new community approach
If you didn't get a chance to attend this yearʼs meeting, here to pressure ulcers
are five key things that you missed hearing about: In terms of healthcare policy changes
and their implications for care, one with
The key to cultural change: an astounding impact discussed at the
mutual cooperation built on real forum was CMSʼs new community
mutual respect approach to pressure ulcer prevention
With CMS revamping reimbursement Bratzler and care as outlined in the 9th Scope
for hospital-acquired conditions (HACs) of Work. Dale Bratlzer, DO, MPH, Med-
and expanding implementation of the ical Director of the Oklahoma Foundation for Medical Qual-
Quality Indicator Survey for long-term ity, provided some early information on how the epidemic of
Nance care facilities into more states, it wasnʼt the “ambulance acquired” pressure ulcer will be something
too surprising to hear Keynote Speaker John J. Nance, JD of the past and how this is the number one initiative for the
open the Prevention Above All Forum by saying “the core Quality Improvement Organizations (QIOs) right now.
culture of medical practice has to be drastically changed.”
Previously, CMS
Nance, founding member of the National Patient Safety reviewed cap-
Foundation and author of Why Hospitals Should Fly: The tured MDS data
Ultimate Flight Plan to Patient Safety and Quality Care, to help identify
touched on how the October 1 CMS reimbursement mile- nursing homes
stone for HACs provides the opportunity for healthcare that have high
providers to “re-commit” to improving patient safety by rates of pressure
becoming engaged professionals dedicated to barrierless ulcers. With the
communication. CMS 9th Scope
Be sure to visit the Prevention Above All Web

of Work, which
site at www.medline.com/special/PAA/ for

took effect on
continued updates and additional resources.

“Youʼre not only going to solve the CMS problems (of HAC
prevention),” said Nance. “But you are going to get to the August 1, CMS now directs QIOs to focus not only on nurs-
point of asking doctors ʻWhy donʼt we have 100 percent ing homes with a high incidence of pressure ulcers, but to
compliance on handwashing?ʼ and ʻIs it okay if my nurses take a closer look at hospitals in the same county and hold
remind you?ʼ That consistent cross-checking of each other, them accountable as well. So the QIOs are tasked with
completely devoid of professional defensiveness, and a real going in and working with both the hospital and the nurs-
caring for each other as full members of a team dedicated to ing home to reduce the rates of pressure ulcers. You
the patientʼs best interests, is the key to safe practice. can learn more about the 9th Scope of Work by visiting
www.providers.ipro.org/index/9SOW_summaries - 39k.
Why Hospitals Should Fly by John Nance is available at
www.whyhospitalsshouldfly.com.

Aligning practice with policy to improve patient care 9


A Focus on Prevention
Highlights from the Prevention Above All Forum

According to Bratzler, CMS is actively working on building • Pressure-relieving products


performance measures that will publicly report hospital pres- • Proper application and usage of prevention products
sure ulcer rates, and once they complete that there will be
a strong incentive for nursing homes and hospitals to work The following documents – currently in use at Krasnerʼs
together to figure out the best way to prevent pressure facility, Rest Haven-York – are also available:
ulcers. This new community focus represents how CMS is • Pressure Ulcer Protocol
starting to look at data outside of the hospital to see what is • Pressure Ulcer Protocol – Avoidable versus
happening in the hospital. For example, they are looking at Unavoidable Pressure Ulcers
things that happen in surgery and the effects 30 days and 60 • Pressure Ulcer Notification Fax
later, so the tracking systems from whether you are in the • Pressure Ulcer Risk Factors tracking chart
acute care setting or leave is going to ultimately look at • Wound Photo Documentation
every setting of healthcare not just one.
If you are interested in receiving any of these documents,
Learn more about Medlineʼs Pressure Ulcer Prevention please email us at orconnection@medline.com.
Program on Page 13.
“This was the ultimate forum,
“I want to take the [Medline] pressure unsurpassed, professional, phenomenal
ulcer program to our executive nursing speakers with the most up-to-date reliable
team – this program would be excellent education with statistical evidence. Kudos
in helping us to prevent pressure ulcers to Medline.”
and to improve our overall patient care Charles Gizara, Director, Clinical Operations
delivery.” Atlantic General Hospital
Debra Williams, Vice President/CNO
Garden City Hospital A proposed new SCIP measure
for October 2009 on timely
Implications of the CMS Guide- catheter removal.
lines on pressure ulcer prevention The proposed performance measure
and treatment focuses specifically on whether the
Thereʼs a great variability in terms healthcare provider attempted to
of how organizations prepared for the remove the catheter by the second
October 1 deadline and where they are post operative day (with surgery being
Wald
at on that continuum of preparation. day zero). This important performance
Krasner According to Diane Krasner, PhD, RN, measure that is now National Quality Forum endorsed will
CWCN, CWS, BCLNC, FAAN, Wound and Skin Care Con- be rolling out in October of 2009. A main driver behind this
sultant. A lot of that preparedness comes down to education. measure was a study led by Heidi Wald, MD, MPH, who
discussed the connection.
“If you just look at the pressure ulcer part of the CMS ruling,
thereʼs a high training and education component that each Wald, along with her co-authors of the study “Indwelling
facility is going to have to grapple with,” said Krasner. Urinary Catheter Use in the Postoperative Period,” reviewed
Krasnerʼs presentation highlighted the need for nurses data from 35,904 Medicare patients at 2,965 acute care hos-
to receive more education on: pitals across the United States to determine the relationship
• Risk assessment (interpretation of Braden Scale) between catheter use and postoperative outcomes. From
• Pressure ulcer staging that large number of patients that were operated on, they
• Proper positioning (including bed and chair) found that 86% of the patients had been catheterized, and
• Effects of moisture on the skin (including incontinence, that half of them had their catheter for more than two days –
humidity and maceration)

10 The OR Connection
a concern since patients whose catheters are in for a long pe- Warye distributed copies of APICʼs MRSA guidelines and a
riod of time post-operatively are at an increased risk of infection. DVD on hand hygiene geared toward patients. To download a
copy of the DVD video, please visit www.cdc.gov/handhy-
Previously research had already demonstrated the doubling giene. For more APIC resources, please visit www.apic.org.
of mortality rate with something as simple as a urinary tract in-
fection, but Dr. Wald and her colleagues were able to confirm
that indwelling urinary catheters that are left in place for longer
than two days postoperatively may result in catheter-acquired Medline
urinary tract infections (CAUTI) as well as an increase in 30- President
day mortality and an increased length of stay (to view the Andy Mills
confers with
study, please visit http://archsurg.ama-assn.org/cgi/content/ presenter
short/143/6/551). Dea Kent

How big of an issue is this? There are an estimated 26-36 mil-


lion operations performed in the United States each year and
Bratzler notes that every single study looking at patients with
similar risks, having the same operation, shows the mortality
rate doubling if they get a surgical infection. And in fact, a Uni-
versity of Pennsylvania study reviewing a large number of
operations performed demonstrated that when a patient has
a major complication of surgery, the risk of death is
increased by threefold within the next 60 days.

“I didn’t know Medline had these types of


products. And the supportive evidence was
excellent, how can we work together?”
Mary R. Lopez, Vice President, Quality Initiatives
Hospital Council Northern & Central California Guests get involved at the Prevention Above
All Presentation

APIC: Spreading knowledge,


preventing infection
Sometimes a few changes need to be
made in order to clarify goals and con-
tinue to move toward them. Kathy Warye,
CEO of the Association for Professionals
in Infection Control and Epidemiology,
Warye Inc. (APIC) shared the associationʼs rec-
ommendation of changing the title of Infection Control Pro-
fessional to Infection Preventionist with Prevention
Above All forum attendees.
A sampling of the items presented at the forum
“Language creates culture, and if the goal is around prevention,
then our name needs to incorporate prevention,” Warye said.

Aligning practice with policy to improve patient care 11


Prevention Above All
Targeted interventions, practical solutions

Medlineʼs six practical and targeted interventions The innovative packaging design is an improved delivery and
to help improve outcomes. communication system to help healthcare professionals better
There is compelling evidence that many hospital-acquired con- understand and more easily deliver wound care at the patient's
ditions (HACs), specifically those targeted by CMS as “never bedside. It replaces confusion with clear, step-by-step
events,” are preventable. And there are plenty of great prod- information, eliminating the clutter and highlighting
ucts and evidenced-based solutions available. The challenge critical information.
is implementing these solutions. There is a need to educate
caregivers, organize data and assist the healthcare provider Target: Objects
with process improvement. retained after surgery
The Prevention Above All
Combining innovative products with evidence-based solutions, Intervention: RF Detect
Medline strategically integrated a portfolio of focused and RF system designed to alert the OR nurse when a RF-tagged
achievable evidence-based solutions designed to fit into the surgical item remains in the patient before closing the procedure.
everyday processes and systems most healthcare providers This provides an added level of safety and an adjunct to the
already have in place. The six conditions targeted by Preven- counting procedure.
tion Above All and their complementary Medline product and
program solutions are: The system consists of three components: a micro RF tag
embedded in gauze, sponges and towels and a sterile hand-
Target: Catheter-Associated held wand that is connected to the third component, an easy-
Urinary Tract Infection (CAUTIs) to-use, self-calibrating console. By passing the wand back and
The Prevention Above All forth and side to side over the patient, hospital personnel will be
Intervention: Silvertouch Catheters able to accurately detect, within seconds, retained surgical
A bundled solution of advanced silver technology with disposables before site closure and rectify incorrect counts.
Medlineʼs Silvertouch™ Foley catheters and educational
training to reduce CAUTIs. Target: Hospital-
Acquired Infections
Silvertouch Foley catheters incorporate the power of silver The Prevention Above
through a patented process that binds silver ions to the All Intervention: Hand
catheterʼs lubricious coating, delaying the onset of biofilm for- Hygiene Compliance Program
mation. Educational materials provide summarizations of the A program of products that stresses appropriate application
major recommendations from the CDC, SHEA, APIC and others techniques and education to achieve hand hygiene compli-
provide a policy and procedure template guide for proper ance while dramatically improving the skin condition of health-
catheterization. Also included are validation tools that can be care workers.
utilized during training or re-education classes, and a trou-
bleshooting guide book and a poster to help caregivers work The Hand Hygiene Compliance Program contains three
through issues. products – Sterillium Comfort Gel™, Medline Remedy™ Skin
Repair Cream and Aloetouch® exam gloves – clinically proven
Target: Harm Avoidance to nourish dry skin. The program includes an intensive edu-
and Patient Satisfaction cational module developed by an expert panel of infection
The Prevention Above All Inter- control professionals. Healthcare workers can earn up to four
vention: Educational Packaging continuing education credits by completing the training program.
To help reduce medical errors, Medline redesigned its Advanced Additional components include testing for skill and competency
Wound Care packaging in a format that allows each package validation through the use of Visirub and a UV light box. Pa-
to serve as a 2-minute course on advanced wound care. tient education pamphlets, facility posters and a rewards pro-
gram are also included to reinforce positive behavior change.

12 The OR Connection
Target: Pressure Ulcers
The Prevention Above
All Intervention: Pressure Target: Wrong Site Surgery
Ulcer Prevention Program The Prevention Above All
Medline offers a Pressure Ulcer Prevention Program to fit Intervention: S.T.O.P. Drape
all disciplines, from physicians and OR nurses to CNAs, A surgical drape that incorpo-
RNs and LPNs. A program of products, tools and rates a “Time Out” sticker strip
resources to implement an effective prevention program that must be removed prior to the surgical case and provided to
and immediately begin reducing the incidence of pres- the circulating nurse to be placed on the patientʼs chart.
sure ulcers.
The Medline S.T.O.P drape has a sticker in the shape of a red
The Pressure Ulcer Prevention Program is a strategic prod- stop sign and tells the staff to stop, forcing them to remember
uct bundle to assist in reducing or preventing pressure ul- to perform the time-out procedure required prior to beginning
cers and incontinence-associated skin conditions, which surgery. The sticker provides a location to write and confirm the
may include dermatitis and skin tears. Products include patientʼs name, procedure, site and side, date, time and
Remedy™ Advanced Skin Care Products, Ultrasorbs® AP surgeonʼs initials. By requiring the surgeon to initial the sticker,
Dry Pads, Restore®/Remedy™ Adult Brief, and Supra DPS the surgical team is again reminded to perform the time-out
alternating pressure and low-air-loss mattresses. immediately prior to the incision.

The Perioperative Pressure Ulcer Prevention Program in-


cludes an educational DVD addressing pressure ulcer risk
assessment and prevention methods and strategies. Its ac- Wayne Brannock,
vice president of
companying product bundle includes Sahara OR Table clinical services
Sheets, Medline Gel Positioners and Pressure Redistribu- for Lorien Health
tion Table Pads. Systems in
Maryland asks
a question during
The comprehensive program also packages together edu- a session.
cation and training tools so a healthcare team can implement
an effective pressure ulcer prevention program and immedi-
ately begin reducing the incidence of healthcare-acquired
pressure ulcers. Included are workbooks, patient and Dr. Andrew Kramer
family education brochures and a rewards program. speaks to attendees
about patient safety.

Attendees review Medlineʼs Medline Chief Marketing Officer Sue MacInnes addresses attendees during the
Pressure Ulcer Prevention Prevention Above all Forum.
Program materials.

Aligning practice with policy to improve patient care 13


Special Feature

PREVENTION ABOVE ALL DISCOVERIES GRANTS:


Supporting the adoption of solutions
into everyday clinical practice

Medline is committing up to $1 million in over several years 2. The review committee will review letters of intent on a
to stimulate the gathering of solid evidence that supports the rolling basis (see list of review committee members).
adoption of solutions into clinical practice. A review panel, whose Acceptable letters will be assigned to the most appro-
members represent a breadth of research and practice knowl- priate research mentor, who will contact the applicant
edge, will select grant recipients to be awarded up to $25,000 and work with him/her to develop the letter into a full
each for pilot studies or $100,000 each for empirical studies. proposal of 5-7 pages in length, including a complete
budget. Proposal and budget guidelines will be sent
Objectives after approval of letter of intent.
To stimulate research that will lead to the development of new
targeted interventions aimed at reducing medical risks and 3. The review committee will review full proposals and
harms associated with hospital-acquired conditions (identified budgets on a rolling basis. Most of the projects that are
by CMS in 2008 IPPS final rule). chosen for full proposal submission will be funded;
• To test the costs and effectiveness of interventions and however, this process may involve a subsequent
programs designed to reduce the incidence of hospital- resubmission of a revised proposal so that the funded
acquired conditions. research plan is clear.
• To disseminate practical, evidence-based solutions
within and across hospitals, leading to a reduction in 4. Pilot studies will generally be up to six months in duration
hospital-acquired conditions. with a budget of about $25,000. Empirical studies can
be up to $100,000 and last up to a year or more in duration.
These awards are designed to assist healthcare providers in Pilot study grantees can go on to submit an empirical
developing and testing creative solutions or interventions for study proposal at the successful conclusion of the pilot project,
reducing or preventing hospital-acquired conditions. Recipients or applicants can apply for a full empirical study grant
of grant awards will be paired with a research mentor/consul- based on their initial letter of intent if they have an
tant through the grant program to develop methods and guide existing practice with evidence that they wish to evaluate.
the conduct of the study, ensuring that a rigorous research
process is followed. These studies can be small pilot studies 5. The final report for a pilot grant study should be a brief
aimed at developing and testing the feasibility of new solutions paper written for a Medline publication (Healthy Skin,
The OR Connection or Infection Prevention Now)
or larger evaluation studies to more fully test the costs, effec-
whether the grant is successful or not. The final report
tiveness or dissemination of evidence-based solutions.
for an empirical study is a paper to be submitted for
publication in a peer-reviewed journal.
Award Process
1. In response to our request for applications (RFA),
providers will submit a 2-3 page letter of intent providing
GRANT PROGRAM SCHEDULE
the following information:
Nov. 15 to Jan. 31, 2009
• The HAC(s) that the study will address
Accept and review letters of intent on a rolling basis
• Whether the letter is for a pilot or
empirical study Dec. 1 to Feb. 28, 2009
• The proposed solution Notification of acceptance and authorization to begin full
• The objective of the study proposal (due one month after notification of letter of intent)
• The proposed approach in as much detail as
you have thought it through at this point Jan. 1, 2009 to Apr. 30, 2009
• Expected output of the study Full proposals funded and projects started within
• Brief biography about the individuals involved, two months of proposal submission
including any experience in the area of focus
• Budget estimate, including the major expenditure
categories
OR Issues

Targeting

ZERO
Healthcare-Associated Infections

An exclusive report from APIC


By Kathy Warye, APIC executive director

In January of 2006, the Association for Professionals While few organizations in the early 2006 time frame were
in Infection Control and Epidemiology published APIC contemplating the possibility of reaching zero HAIs, zero
Vision 2012, a strategic approach to the future of the tolerance first emerged in 2000 when Julie Gerberding,
practice and profession. The first goal of the plan stated director of the CDC, introduced the concept. She noted that,
that APIC will “promote prevention and zero tolerance for over time, the goal of elimination had been applied to other
healthcare-associated infections (HAIs).”1 Since that time, public health concerns, such as TB and polio. Elimination
APICʼs approach has evolved and focused instead on pro- might not have occurred, but ambitious goals drove positive
moting a culture where targeting zero healthcare-associated change and dramatic reductions.
infections is fully embraced.
Making prevention a priority
Insertion of the word “culture” was an important addition, as As APICʼs strategic plan was taking shape, a small but
APICʼs intent is to promote a cultural change within health influential group of healthcare organizations were discovering
care wherein providers strive to eliminate preventable HAIs. that many more infections are preventable than previously
thought. They were setting goals to reduce HAIs significantly • Prompt investigation of HAIs of greatest concern to the
below previously accepted benchmarks, reaching and sus- organization and/or community and
taining them. With a declining arsenal of antibiotics to treat • Focus on providing real-time data to front line staff for
infections, it was increasingly clear that the traditional the purpose of driving improvements.
orientation toward control of HAIs needed to shift to one
where preventing the occurrence was the priority throughout Culture change in the OR
the institution. APIC was hearing from leaders across the Creating the culture change required to eliminate surgical
spectrum of health care, from providers to patients and site and other infections that begin in the OR will require
patient safety advocates. It was in this context that APICʼs commitment on the part of the entire OR team, from
leaders agreed that the Association should be at the fore- surgeons and anesthesiologists to operating room man-
front in promoting significant and sustained reductions in agers, nurses and technicians. The institutionʼs infection
preventable healthcare-associated infections. prevention experts can assist in the provision of real-time
data, application of performance improvement concepts
Since that time, APIC has moved forward to promote pre- (such as root cause analysis) and ongoing education and
vention and provided members with a host of resources to training for OR staff in the consistent application of key
help them set and reach ambitious goals for the reduction of infection prevention measures.
HAIs. Targeting Zero encourages all organizations to set the
goal of elimination rather than remain comfortable when New technologies and procedures, more virulent pathogens
local or national averages or benchmarks are met. Every and increasing resistance will continue to challenge the
single HAI impacts the life of a patient and family – even one healthcare community in its efforts to reduce HAIs. Because
should feel like too many. of this, even where large-scale cultural change and consis-
tent application of IPC measures exists – even when no
“Zero tolerance” explained break in practice can be identified – healthcare-associated
APIC also believes that willful non-adherence by healthcare infections will still occur. However, where the goal of zero
workers with proven infection prevention and control measures has been set and the culture is consistent with this goal,
should be unacceptable. References to “zero tolerance” APIC is confident that new approaches will emerge to bet-
today are generally intended as a response to unsafe ter protect patients from healthcare-associated infections.
behaviors and practices that place patients and healthcare
workers at risk. In the context of HAIs, zero tolerance doesnʼt To view APICʼs evidence-based guides on the elimination
mean that people or organizations should be penalized for of infection, archived webinars and other resources in the
infections that might not be preventable, but this language Targeting Zero program, please visit www.apic.org.
may be used to stress the need for accountability and a cul-
ture built on inquiry and learning as opposed to punishment. 1 Association for Professionals in Infection Control and Epidemiology, Inc. APIC Vision
2012. Available at: http://www.apic.org/AM/Template.cfm?Section=About_APIC&Tem-
plate=/CM/ContentDisplay.cfm&ContentFileID=4688. Accessed October 31, 2008.
A culture of targeting zero healthcare-associated infections
and zero tolerance for unsafe practices is characterized by
the following:
• Setting the theoretical goal of elimination of HAIs;
• An expectation that infection prevention and control (IPC)
measures will be applied consistently by all healthcare
workers, 100 percent of the time;
• A safe environment for healthcare workers to pursue 100
percent adherence, where they are empowered to hold About the author
Kathy Warye is the executive director of the Association for
each other accountable for infection prevention;
Professionals in Infection Control and Epidemiology, Inc., (APIC),
• Systems and administrative support that provide the a worldwide membership association providing 11,500 infection
foundation to successfully perform IPC measures; prevention professionals legislative and/or public relations strategies
• Transparency and continuous learning where mistakes on issues impacting the infection prevention and control profession.
and/or poor systems and processes can be openly APIC advances its mission through education, research, collabo-
discussed without fear of penalty; ration, practice guidance, public policy and credentialing.

16 The OR Connection
More than an ounce of prevention.

CAUTI PREVENTION
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?
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needed A B when possible
86 percent, 50 percent have catheters for longer than two days (intermittent catheters,
male external catheters)
after surgery, which is associated with increased likelihood of
urinary tract infections, 30-day mortality and longer hospital stays.1
Insert using Utilize bladder
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contact your sales representative, call 1-800-MEDLINE Reference
or visit us at www.medline.com. 1 Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use
in the postoperative period. Archives of Surgery. 2008;143(6):551-557.

©2008 Medline Industries, Inc. Medline and Silvertouch are registered trademarks of Medline Industries, Inc. www.medline.com
Back to Basics Ninth in a Series

Applying Evidence-Based Information


to Improve Hand-Off Communication
in Perioperative Services

By Alecia Cooper, RN, BS, MBA, CNOR

There are three very significant hand-offs that occur in Obviously, there are many opportunities to gather and
perioperative services for each patient who undergoes a communicate critical information that can affect and improve
surgical procedure. The first one is from the pre-operative patient care, prevent injuries and medical errors and ensure
patient care area to the holding room staff. The second one is that your patient has the safest and highest-quality surgi-
from the OR team to OR team members. The third one is from cal outcomes.
the OR team to the post-anesthesia care team.
Adverse events during surgery
There are also additional hand-offs that result for data gathered The list of what can go wrong during a surgical experience is
within each unit or area, depending upon information gath- long and intimidating. Foreign bodies, mislabeled pathology
ered during assessment periods. There can be hand-offs from specimens, operative fires, transfusion and medication errors
holding room staff to anesthesia and the assigned circulator and wrong site, wrong procedure, wrong person surgery are
as well as from circulator to circulator when being relieved for just some of the preventable hazards associated with surgery.1
breaks, lunch and at shift change. The last hand-off occurs Adverse events occur more often in surgery than in any other
when the PACU nurse hands off to the post-op caregiver. specialty, and disproportionately greater harm results from
surgical errors.2

In the surgical setting, a premium is placed on efficiency.


There are strict schedules that must be kept despite constant

18 The OR Connection
Patient Safety

interruptions from emergencies, add-ons, delays and compli- 1. Interactive communication that allows for the opportunity
cations. Time becomes a barrier to communication.2 Rushing for questioning between the giver and receiver of
the hand-off can lead to small, yet critical mistakes that can patient information.
ultimately harm patients.2 2. Up-to-date information regarding the patientʼs condition,
care, treatment, medications, services and any recent
Example: A patient who has been in an accident and requires or anticipated changes.
surgery also has a severe shoulder sprain. However, the staff 3. A method to verify the received information, including
members who transfer the patient to preoperative holding repeat-back or read-back techniques.
forget to mention this, so no one else – including the OR, 4. An opportunity for the receiver of the hand-off information
anesthesia, PACU or the floor – is aware of the shoulder to review relevant patient historical data, which may include
sprain. Throughout the care, nurses repeatedly manipulate previous care, treatment or services.
the patientʼs arm during repositioning, causing distress to the 5. Interruptions during hand-offs are limited to minimize
patient and worsening the patientʼs injury.2 the possibility that information fails to be conveyed or
is forgotten.

National Patient Safety Goal 2E The goal further states that an organization should implement
According to the Joint Commission, communication issues are a standardized approach to hand-off communication. Is your
the leading factor in root causes of sentinel events.3 For this process standardized?
reason, the National Patient Safety Goal 2E (NPSG.02.05.01)
was added in 2006. This goal reads as follows: “The [organi- Standardizing hand-off communication
zation] implements a standardized approach to hand-off com- Hand-off communication is defined as the “transfer of infor-
munications, including an opportunity to ask and respond to mation (along with authority and responsibility) during transi-
questions.”3 The elements of performance that are measured tions in care across the continuum for the purpose of ensuring
by the Joint Commission in an organizationʼs hand-off the continuity and safety of the patientʼs care.”4 It is the inter-
process include3: active delivery of accurate and current information about a
patient exchanged from one provider/caregiver to another. To
improve the reliability of workflows accomplishing their desired
goals, and to reduce the risk to patient safety, researchers

Aligning practice with policy to improve patient care 19


recommend structured communications and clear agree- Patient “Hand-Off” Tool Kit that includes nine recommenda-
ments about roles and responsibilities in a hand-off.5 tions for standardized hand-off policy development.4

A clear barrier to hand-off communication is the sheer number Popular hand-off communication systems
of individuals involved in the care of surgical patients. In a Here are four widely used hand-off communication systems:
recent study, it was revealed that the typical surgical patient • “I PASS the BATON” (Introduction, Patient, Assessment,
sees an average of 26.6 health professionals during their Situation, Safety Concerns, Background, Actions, Timing,
hospital stay, compared with the mean of 17.8 health profes- Ownership, Next)
sionals seen by medical patients.2 Therefore a standardized • “I-SBAR” (Introduction, Situation, Background, Assessment,
process for hand-off communication becomes critical in peri- Recommendation)
operative services to ensure that communication is thorough • “PACE” (Patient/Problem, Assessment/Actions, Continuing
and complete among all of the perioperative team members. [treatments]/Changes, Evaluation)
• “Five Ps” (Patient, Plan, Purpose, Problem, Precautions,
Choosing a standardized hand-off method and tool Physician [assigned to coordinate])
Healthcare providers have looked at other high-risk, high-
stakes industries such as aviation, aerospace, nuclear power All four systems are effective as long as there is adherence
and the military for new approaches that can be applied to to the following rules4:
healthcare hand-offs.2 Organizations have also used the Six 1. Conduct the hand-off face-to-face.
Sigma methodology framework to try and better understand 2. Be certain that the hand-off is two-way, with both participants
the process for hand-off communication.6 The development taking joint responsibility for ensuring accurate
of a standardized hand-off communications tool is a dynamic communication.
process that allows continued opportunities for improving the 3. Use verbal and written means of communication.
delivery of patient care.4 AORN has developed a Perioperative 4. Give as much time as necessary to ensure accurate
communication.

AORNʼs nine recommendations for standardized hand-off policy development4

Recommendation One Recommendation Six


Leadership should respond to the Joint Commission man- Design methods that facilitate instruction on and implemen-
date to improve hand-offs by initiating a program within each tation of effective communication and teamwork skills, as
facility, setting the priority and identifying the timeline. provided in TeamSTEPPS, which verify information transfer
with closed-loop communication tools (including check-back,
Recommendation Two read-back, call-out, etc.) for transferring important informa-
Consider using structured tools that can facilitate consis- tion, such as critical actions, medication doses and urgent
tency in communication exchanges. Examples include, but actions.
are not limited to, the “I PASS THE BATON,” “I-SBAR,”
“PACE” or the “Five Ps.” Each mnemonic is developed to Recommendation Seven
guide medical hand-offs and optimize information transfer. To meet this requirement, charts, written information and
reports/results should be available for review (as appropri-
Recommendation Three ate) by the oncoming provider(s).
When implementing training and process changes, use a
broad definition for hand-offs to include most care transitions Recommendation Eight
and information handling across the continuum of care. While developing hand-off policies and protocols, include a
clear statement of how and when responsibility is transferred
Recommendation Four during healthcare transitions.
Use a system, checklist, template or mnemonic that includes
updated information, recent changes in condition or circum- Recommendation Nine
stances and any anticipated changes or aspects of care that Teach and practice communication using established clear,
need to be observed or watched closely. common language among care providers during hand-offs.

Recommendation Five
Redesign the hand-off and shift change processes to pro-
tect against unnecessary interruptions, and allocate suffi-
cient time to the process.

20 The OR Connection
10 barriers to effective hand-offs 10 tips for effective hand-offs
1. Lack of education at nursing and medical schools 1. Allow for face-to-face hand-offs whenever possible.
2. Healthcare system that historically has supported 2. Ensure two-way communication during the
individual autonomy and performance hand-off process.
3. Lack of engagement of patients and families in the 3. Allow as much time as necessary for hand-offs.
care process 4. Use both verbal and written means
4. Resistance to change among staff of communication.
5. Lack of time for providers to devote to handoffs 5. Conduct hand-offs at the patient bedside whenever
6. Problems in the physical setting, including possible. Involve patients and families in the hand-off
background noise and interruptions process. Provide clear information at discharge.
7. Language barriers between clinicians and between 6. Involve staff in the development of hand-off
the clinician and the patient. Itʼs also important for standards.
clinicians to avoid abbreviations and ambiguous 7. Incorporate communication techniques, such as
terminology SBAR, in the handoff process Require a verification
8. Failures in mode of communication, such as fax process to ensure that information is both received
machine or email or the inability to locate the and understood.
patient record 8. In addition to information exchange, hand-offs should
9. Lack of definitive scientific research and data to clearly outline the transfer of patient responsibility
identify accepted hand-off best practices from one provider to another.
10. Lack of financial resources to implement 9. Use available technology, such as the electronic
standardized hand-off processes medical record, to streamline the exchange of timely,
accurate information.
10. Monitor use and effectiveness of the hand-off.
Seek feedback from staff.

TeamSTEPPS crewʼs attention being diverted from more critical tasks, the
TeamSTEPPS (Team Strategies and Tools to Enhance Per- Federal Aviation Administration enacted regulations to prohibit
formance and Patient Safety) is an evidence-based team- crew members from performing nonessential duties or activities
training curriculum used by the Department of Defense (DoD). (including conversation) while the aircraft is involved in the
It was developed by the Agency for Healthcare Research and phases of flight most commonly associated with error: taxi,
Quality (AHRQ). takeoff and landing.6

The DoD Patient Safety Program extended permission to This healthcare organization interpreted the sterile cockpit
AORN to customize its existing materials with a focus on concept for the clinical setting during the verbal transfer of
perioperative settings. This is what was used in the develop- patient information. Specifically, only patient-specific conver-
ment of AORNʼs tool kit. The TeamSTEPPS program is an op- sation or urgent clinical interruptions were permitted to occur
portunity for the surgical team to diminish the risk of error and during the hand-off process. They measured their perform-
improve patient outcomes by creating a structure to support ance improvement after implementing the system and found
standardized hand-offs and improve communications during they were able to reduce hand-off turnaround time from 15.3
care transistions.4 Within this kit are numerous tools, minutes to 9.6 minutes.
mnemonics and strategies to be used as templates. The
AORN tool kit is available for free and can be downloaded Formula 1 hand-offs
from www.aorn.org. Another healthcare organization has initiated a new hand-off
process modeled after routine pit stops in racing, which typically
One healthcare organization utilizing the TeamSTEPPS take less than 10 seconds. Each crew member has a specific
curriculum developed a team hand-off model. To minimize job that they know very well. The crew is prepared down to
interruptions and distractions during the hand-off process, this the smallest detail. Safety is the number one concern because
organization modified a concept championed by the aviation the consequences of errors can be life-threatening for both
industry – the “sterile cockpit.” In response to the increasing driver and crew. In contrast to pit stops, hand-offs can be
number of commercial airline accidents involving the cockpit chaotic events involving multiple simultaneous conversations.
Continued on Page 23

Aligning practice with policy to improve patient care 21


Searching for that
one last sponge?

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manually counting surgical sponges and instruments before, objects retained during surgery. Several major insurers
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tions performed nationwide, more than 1,500 cases of a surgical objects, the RF Surgical Detection System sets a
retained foreign body occur annually in the United States.1 new standard of patient care and safety in the operating
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Reference
1. Popovic JR, Hall MJ. 1999 National Hospital Discharge Survey. Advance data from vital and health
1-800-MEDLINE.
statistics. No. 319. Hyattsville, Md.: National Center for Health Statistics, 2001. (DHHS publication no.
(PHS) 2001-1250 1-0287.).

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

www.medline.com
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RF Surgical® is a registered trademark of RF Surgical Systems, Inc.
RF Surgical Detection System™ is a trademark of RF Surgical Systems, Inc.
This organization utilized a human factors expert along with the recipient is prepared to mentally process. Because of this,
members of the medical staff to study the unique maneuvers many organizations have developed structured communica-
of Formula 1 pit crews. They witnessed many behaviors that tion techniques such as checklists and read-back techniques.6
they then applied to patient hand-offs following surgery. Before The use of a checklist serves two purposes. It ensures that
the hand-off, the surgical team notifies the receiving care- critical information necessary for patient care is not over-
givers of any specific equipment that the patient will need so looked and it provides a consistent order in which infor-
that there is no scrambling to get it set up. The equipment can mation is communicated.
be ready and waiting upon arrival.
These tools serve to address those unique issues or critical
When the patient arrives, there is a routine process that is pieces of information related to continuity of patient care
standardized and takes place in the same order every time. between specialty areas.4 The hand-off checklist or docu-
First, all lines and tubes are untangled and reconnected qui- mentation tool will help ensure a standardized method for
etly and efficiently. Then, the team ensures that the patientʼs everyone to use. Although checklists can enhance memory,
condition is stable before the report begins. The final phase is longer lists might not be as effective. A checklistʼs content and
the report, which utilizes a handover checklist and surgeonʼs design must be prudent and strategic to gain its desired results.
summary. This occurs without distraction from transfer activi-
ties or competing conversations because the receiving team When providing the hand-off communication, remember these
is able to give their full attention to the transferring team as important communication techniques to ensure that there is
the report is given. The hand-off is smooth, efficient and – two-way interaction:
most important – safe.2 • Get the personʼs attention
• Make eye contact
Battling lost data in nursing hand-offs • Face the person
In a study done by Pothier, Monteiro et al, the hand-off of 12 • Use the personʼs name
simulated patients was observed over five consecutive hand- • Express concern
off cycles. Three hand-off styles were used and the amount of • Use a standardized communication technique
data loss was recorded for each style. The purely verbal hand- • Use a standardized communication tool/checklist
off style resulted in the loss of all data after three cycles. A • Re-assert as necessary
note-taking style resulted in only 31 percent of data being • Escalate if necessary
transferred correctly after five cycles. When a printed form
was included with the verbal hand-off, data loss was minimal. Transitions in care are prime targets for improved patient
The authors recommend that nursing and medical staff safety efforts. There are several strategies that have been
include a printed data sheet as part of the hand-off process.4 developed in high-reliability organizations that can be applied
to health care and have been successfully implemented with
AORN describes the preoperative brief as a powerful tool to positive results. For a sample hand-off policy and procedure
“bring the entire OR team onto the same page”; remove as well as checklists and other tools from Trinity Medical
incorrect assumptions; clarify the intended plan and contin- Center in Rock Island, IL, please refer to Pages 82-83
gency plans; obtain key information from surgeons, anesthe- and 85-86 in the Forms & Tools section. Trinity has been
sia providers, circulating nurses and surgical technologists or recognized by the Joint Commission as a model for
scrub nurses that enhances patient care safety and quality hand-off communication.
and develop counter-strategies for avoiding common pitfalls,
errors and complications.4

AORN recommends using four different Pre-Operative Intra-Operative Post-Operative Discharge Brief/Home
hand-off briefs, the Pre-Op Brief, Hand- Pre-Op Brief Hand-Off Post-Op Discharge
Off Briefs for Continuity, Post-Op Brief Briefs for Brief Brief
and Discharge Brief. The diagram to the Continuity
right displays the operating room briefs “Bring the OR Nurse-nurse Anesth to To the patient and
from the OR to discharge home. team onto the Anesth-anesth PACU nurse family for home
same page” by Tech-tech to inpatient care or home
Forms and checklists stating the plan provider health nurse with
To facilitate an individualʼs comprehen- clear diagnosis
sion of what is communicated, informa- and post-op plan
tion must be organized in a format that

Aligning practice with policy to improve patient care 23


Topics for hand-off checklists
Anesthesia provider may report: Perioperative nurse may report:
• Patient name, gender, age, procedure, physician • Baseline patient assessment
• History of present illness • Positioning during procedure
• History of chronic illness • Skin prep
• Relevant pre-op lab tests • ESU pad placement and removal assessment
• Type of anesthesia administered • Use of special equipment (laser, endoscope)
• Patient response to anesthesia agents • Intraoperative irrigation fluids
• Duration of anesthesia • Administration of medications or dyes from
• Reversal agents surgical field
• Narcotics • Implants, transplants, explants
• Antibiotics • Dressing
• Fluid replacement and type (I & O) • Drains, stents, catheters
• Invasive monitoring line • Sensory or motor limitations
• Vital signs • Prosthesis presence
• Allergies • Pressure ulcer risk assessment
• Other conditions • Other pertinent patient information
• Medications given • Information about the family or others waiting
• Complications related to the procedure for the patient
• Orders

Surgeon may report: Be sure to complete the CE


• Immediate orders
• Diagnostic tests for PACU
credit crossword puzzle on
• Interventions needed in PACU
Page 26!

References
1 Makary M, Sexton J, Freischlag J. et al. Patient safety in surgery. Ann Surg.
2006;243: 628-635.
2 Stokowski L. Perioperative Nurses: Dedicated to Safe Surgical Care. Available at:
http://www.medscape.com/viewarticle/562998. Accessed November 4, 2008.
3 The Joint Commission. National Patient Safety Goals: History Tracking Report 2009-
2008. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafe-
tyGoals/09_hap_npsgs.htm. Accessed November 4, 2008.
4 AORN. Perioperative Patient “Hand-Off” Tool Kit. AORN. Available at:
http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/. Accessed No-
vember 4, 2008.
5 Agency for Healthcare Research and Quality. Patient Safety and Quality: An Evi-
dence-Based Handbook for Nurses. AHRQ Publication No. 08-0043. April 2008.
6 Mistry K, Jaggers J, Lodge A et al. Using Six Sigma® Methodology to Improve Hand-
off Communication in High-Risk Patients. Available at: http://www.ahrq.gov/down-
loads/pub/advances2/vol3/advances-mistry_114.pdf. Accessed November 4, 2008

24 The OR Connection
Care Bundle for Surgical
Site Preparation
Following these steps for best practice
can help reduce the incidences of
surgical site infections.1

• Glucose control
• Preoperative CHG shower
• Appropriate hair removal
• Hand hygiene
• No razors
• Skin antisepsis
• Antimicrobial prophylaxis
• Normothermia

Reference
1. Mangram AJ, et al. The hospital
control practices advisory committee.
Guidelines for prevention of surgical site
infection. Infect Control Hosp Epidemiol.
1999;20(4): 250-278. Information
contained on this site pertains only
to the United States of America.

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Back to Basics Crossword Puzzle

Applying Evidence-Based Information


to Improve Hand-Off Communication
in Perioperative Services
1

4
5

7 8 9

10 11
12

13

14
15

16 17

18

19 20 21

22

23

24 25

26 27 28 29

30
31

32

33

34

1. Register (free) or log in


www.medlineuniversity.com

2. Click Free Courses tab


3. Locate the puzzle and click Learn
More, then Begin Course
4. Certificates are available online
after puzzle completion

26 The OR Connection
Across Down
1 Consider using structured _____ that can facilitate 1 A standardized process for hand-off communication
consistency in communication exchanges. becomes critical in perioperative services to assure
5 When providing the hand-off communication, that communication is _____.
express _____. 2 Be certain that the hand-off is two-way, with both
7 Teach and practice communication using participants taking _____ responsibility for ensuring
established clear, common _____ among care accurate communication.
providers during hand-offs. 3 When providing the hand-off communication,
9 According to the Joint Commission, communication _____ the person.
issues are the _____ factor in root causes of 4 _____ in care are prime targets for improved
sentinel events. patient safety efforts.
12 _____ the hand-off can lead to small, yet critical 6 When providing the hand-off communication,
mistakes that can ultimately harm patients. use a standardized communication _____.
13 A clear _____ to hand-off communication is the 8 Healthcare providers have looked at other
sheer number of individuals involved in the care of high-risk, high-stakes industries such as _____ for
surgical patients. new approaches that can be applied to hand-offs.
16 The National Patient Safety Goal 2E states that an 10 The use of a checklist ensures that critical
organization should implement a _____ approach information necessary for patient care is not _____.
to hand-off communication. 11 The _____ brief brings the OR team on to the same
18 Redesign the hand-off and shift change processes page by stating the plan.
to protect against unnecessary interruptions, and 14 When providing the hand-off communication, get
allocate sufficient time to the process. the other personʼs _____.
21 Give as much _____ as necessary for the hand-off 15 “I-SBAR” stands for introduction, _____,
to ensure accurate communication. background, assessment, recommendation.
22 Time becomes a barrier to _____. 17 While developing hand-off policies and protocols,
23 In the surgical setting, a premium is placed on _____. include a clear statement of how and when _____
24 A healthcare organization initiated the sterile _____ is transferred during healthcare transitions.
concept for the clinical setting during the verbal 19 TeamSTEPPS is an evidence-based team-training
transfer of patient information. _____ used by the Department of Defense.
2 7 _____ must be organized in a format that the 20 Another healthcare organization has initiated a new
recipient is prepared to mentally process. hand-off process modeled after routine _____ stops
31 _____ should respond to the Joint Commission in racing.
mandate to improve hand-offs by initiating a 25 Researchers recommend _____ communications
program within each facility. and clear agreements about roles and
32 When providing the hand-off communication, make responsibilities in a hand-off.
_____ contact. 26 There are _____ very significant hand-offs that
33 Adverse events occur more often in _____ than in occur in perioperative services for each patient
any other specialty, and disproportionately greater who undergoes a surgical procedure.
harm results from surgical errors. 28 The use of a checklist ensures a consistent
34 A checklistʼs content and design must be prudent _____ for information.
and strategic to gain its desired _____. 29 When providing the hand-off communication,
use the personʼs _____.
30 _____ communication is defined as the “transfer
of information during transitions in care across
the continuum.”

To receive one hour of CE credit, enter your answers


online at www.medlineuniversity.com

Aligning practice with policy to improve patient care 27


Measuring
What
You
Manage

We have all heard the old adage “If you canʼt measure So, the goal of the facility is great patient satisfaction.
it, you canʼt manage it.” Most folks in health care The measurement tool is the satisfaction survey.
strongly believe in this concept. So it will come as no sur-
prise to you that when I speak to healthcare executives Based upon recent research from a large hospital in the
about the work of LifeWings, I am always asked, “How do mid-South, if your goal is to improve patient satisfaction,
you measure this?” the management action should be to improve the team-
work of the healthcare team.
I think what they are really asking is, “What are the results
we can expect to see?” and “How can you document
Whether your goal is reduced mortality,
that?” Consequently, we spend quite a bit of time and effort
helping hospital executive teams create realistic data to eliminate bloodstream infections or to
collection and analysis plans to help them paint the improve patient satisfaction, providing
“before” and “after” pictures for their teamwork-based your caregivers with excellent teamwork
patient safety initiatives. Of course, by gathering and skills should play an important part in
analyzing data that builds the “after” picture, the client can
your improvement equation.
see in their measurement tool if the steps they are taking
are actually changing anything – are they hitting their
goal(s)? If not, they can take management action and What management action should an institution take if the
change or adjust the methodology to reach their goal(s). satisfaction score is not where theyʼd like it to be? By
adding a question to their satisfaction survey asking the
Teamwork: the key to patient satisfaction patient to rate the level of teamwork they experienced dur-
One common goal of most hospitals today is getting great ing their stay, the hospital mentioned above was able to
HCAHPS scores. CMS now publishes the results of these analyze the results of almost 30,000 surveys to discover
patient satisfaction survey scores on their Web site. What a .97 correlation between the “teamwork” rating and the
patients think about the care they received in your hospital patientʼs willingness to give a “Would Recommend” and
is now available for the whole world to see on the Internet. an “Overall Excellent” rating on their survey responses.

28 The OR Connection
Special Feature

Patients may not be expertly trained teamwork assessors,


but they seem to know good teamwork when they see it.
When your caregiversʼ teamwork is first rate, your patients
are going to give you an “Overall Excellent” rating and
“Recommend” your facility to their friends and family.

Using teamwork to improve your mortality rate Based upon recent research
This same research also showed a correlation between a from a large hospital in the
patientʼs “teamwork” rating and the mortality rate of the mid-South, if your goal
is to improve patient
hospital. The teamwork of the facilityʼs caregivers, as
satisfaction, the management
rated by the patient, controls approximately one third of
action should be to improve
the variation in mortality in that institution. If your goal is the teamwork of the
to provide better care and one of the measurement tools healthcare team.
for that goal is your mortality rate, then one of the man-
agement actions you should take to help reach that goal
is to improve your providersʼ teamwork skills.

Hereʼs one more example of these principles. The state of


Michigan began a state-wide initiative called the Keystone
Project to reduce or eliminate bloodstream infections in
patients in their hospitalʼs ICUs. To achieve this, one of
the tactics the facilities adopted was the use of a standard
protocol, accomplished with the aid of a checklist, to insert
a central line. The checklist and the training process on
how to use it were pretty near identical for every institu- Whether your goal is reduced mortality, to eliminate blood-
tion. Yet despite the similarity in protocol, process and stream infections or to improve patient satisfaction, providing
training, ICUs saw variability in their results. your caregivers with excellent teamwork skills should play
an important part in your improvement equation.
What causes the variability? Further analysis revealed the
most successful ICUs were those with a better safety cul-
ture as evidenced by a greater willingness to cross check
one another and to speak up to hold one another account-
able to abide by the protocol. In short, better teamwork.
If your goal is fewer bloodstream infections, and your
measurement tools are the level of compliance with the
protocol and the number of infections, the management
action you should take to help reach your goal is to
About the author
improve the teamwork of the folks in the ICU.
Stephen W. Harden is President of LifeWings Partners LLC and
co-founder of Crew Training International, Inc. (CTI), the parent
One of my favorite quotes about measurement is from the company of LifeWings. Prior to his position at LifeWings, he was
author Robert Heinlein. He says, “If it canʼt be expressed the principal courseware designer of CTIʼs Crew Resource Man-
in figures, it is not science; it is opinion.” One thing we agement (CRM) training for the U.S. Air Combat Command, Air
know about teamwork is there is a “science” to it. Team- National Guard, Air Force Reserve Command, Italian Air Force,
work has been clearly shown, by expression in “figures” Swiss Air Force, Belgian Air Force, domestic and commercial
(or numbers), to improve outcomes in health care. airlines, construction crews and hospital surgical teams.

Aligning practice with policy to improve patient care 29


Patient Safety in Surgery
Learning from aviation safety:
a call for formal "readbacks" in surgery

By Philip F. Stahel

The first fatal airplane crash in history occurred exactly 100 tients die in the United States every year as a consequence of
years ago, on September 17, 1908, when Army lieutenant medical errors [1], when we began to realize that there is some-
Thomas Selfridge died in a failed flight attempt with the thing "wrong with the system". While this unacceptably high
aviation pioneer Orville Wright. Since that time, aviation safety number has been chronically underrated in public recogni-
standards have significantly improved. Currently, the risk for an tion, an extrapolation of these statistics to professional aviation
American dying in an airplane crash is about 1:500,000, com- equals to about 200 jumbo jet crashes per year, or one 747
pared to a 1:20,000 chance of dying in a car accident. In crash every other day. This dramatic insight
the field of medicine, it was not until the shock- led to the design of the "100,000 lives
ing report by the Institute of Medicine in campaign" by the Institute for
1999 revealed that 100,000's of pa- Healthcare Improvement in

30 The OR Connection
Patient Safety

2004 [2]. By 2006, the campaign had surpassed its initial goal by complications [5]. Of these, 85% of adverse events related to
saving more than 120,000 lives through the implementation of communication breakdown occurred by verbal communication,
increased patient safety standards and algorithms [2]. These while only 4% were attributed to communication in written form
include the recent implementation of a standardized surgical [5]. This notion provides the basis for a call for written checklists
"time-out" to ensure the correct patient identity and correct pro- and formal verbal "readback" orders among healthcare profes-
cedure performed at the correct surgical site [3]. In addition, sionals who care for surgical patients, in order to avoid or
the implementation of formal, structured perioperative briefings reduce the high incidence of perioperative complications related
in the operating room have been shown to significantly reduce to a breakdown in communication. Interestingly, pilot readbacks
the incidence of wrong site surgeries [4]. represent a hallmark safety concept in professional aviation.
Despite those recent improvements, the analysis of the Ameri- While the current debate in aviation safety is related to optimiz-
can College of Surgeons' closed claims study revealed that a ing and correcting the modality of readbacks [6,7], this crucial
breakdown in communication before, during, or after surgery still form of communication is still virtually nonexistent among sur-
represents a significant source of errors which lead to patient geons. Dr. Eddie Hoover has characterized the issue to the
point, in a recent editorial: "Getting surgeons to readback orders
and instructions will age you 10 years, yet the Navies of the
world have demonstrated for eons that it improves efficiency,
promotes safety, and saves lives." [8].

Aligning practice with policy to improve patient care 31


I wish to emphasize that the implementation of verbal read-
back orders represents the 2nd National Patient Safety Goal
(NPSG) for 2009, as defined by the Joint Commission [9]. The
NPSG #02.01.01, aimed at improving the effectiveness of A Spotlight
communication among caregivers, is defined as such: "For
verbal or telephone orders or for telephone reporting of critical
on “Never Events”
test results, the individual giving the order or test result verifies
the complete order or test result by having the person receiv-
ing the information record and 'read back' the complete order As you know, as of October 1, 2008, CMS is no longer
or test result." [9]. reimbursing at a higher DRG for 11 conditions deemed
“never events.” Those conditions are listed below, along
with articles in this magazine that relate to them. We hope
In conclusion, I urge all healthcare professionals involved in
they help you enhance your facilityʼs prevention measures!
the care of surgical patients to contribute to improved patient
safety and reduced complications and sentinel events in 2009 1. Retained foreign object after surgery
by addressing the most frequent root cause for adverse out- “A Focus on Prevention” ..............................................Page 9
come in surgery: Ineffective communication. The implemen-
tation of formal standardized "readbacks" is a promising start. 2. Air embolism

3. Blood incompatibility
Competing interests “Organ Donation”........................................................Page 36
The author declares that he has no competing interests.
4. Stage III and IV pressure ulcers
Acknowledgements “A Focus on Prevention” ..............................................Page 9
I would like to thank Ms. Jan Minifie, Dr. Ted Clarke, and Dr. “Why Is Pressure Ulcer Risk Assessment
So Important?” ..................................................................Page 50
Kagan Ozer for helpful discussions related to this editorial.
“Fluid Flow Disruption?” ....................................................Page 58
“Pressure Ulcer Prevention Checklist” ......................Page 89
References
1. Institute of Medicine: To Err is Human: Building a Safer Health System. National
5. Falls and trauma (fractures, dislocations, intracranial
injuries, crushing injuries, burns)
Academy Press, Washington D.C.; 1999.
2. Wachter RM, Pronovost PJ: The 100,000 lives campaign: a scientific and policy
review. Jt Comm J Qual Patient Saf 2006, 32(11):621-627.
3. Michaels RK, Makary MA, Dahab Y, Frassica FJ, Heitmiller E, Rowen LC, Crotreau
6. Catheter-associated urinary tract infections
R, Brem H, Pronovost PJ: Achieving the National Quality Forum's "never events": “A Focus on Prevention” ..............................................Page 9
prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg “Targeting Zero” ..........................................................Page 15
2007, 245:526-32.
4. Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E, Rowen 7. Vascular catheter-associated infections
L, Behrens DC, Marohn M, Pronovost PJ: Operating room briefings and wrong site “Targeting Zero” ..........................................................Page 15
surgery. J Am Coll Surg 2007, 204:236-43. “Care Bundle for Surgical Site Preparation” ...............Page 26
5. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner
MJ, Gawande AA: Patterns of communication breakdowns resulting in injury to sur- 8. Surgical site infection – mediastinitis after coronary
gical patients. J Am Coll Surg 2007, 204:533-40. artery bypass graft (CABG)
6. Anderson DZ: Correcting readbacks. Aviation Safety 2008, 28(3):3. “Targeting Zero” ..........................................................Page 15
7. Correcting readbacks – letters to the editor. Aviation Safety 2008, 28(4):. “Care Bundle for Surgical Site Preparation” ...............Page 26
8. Hoover EL: Patient safety and surgeons – why the resistance? Arch Surg 2007,
“SCIP Fact Sheet” ......................................................Page 80
142:1127-8.

9. Surgical site infections following certain elective


9. [http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/].

procedures, including certain orthopedic surgeries,


and bariatric surgery for obesity
Published: 17 September 2008 “Targeting Zero” ..........................................................Page 15
Patient Safety in Surgery 2008, 2:21 doi:10.1186/1754-9493-2-21 “Care Bundle for Surgical Site Preparation” ...............Page 26
“SCIP Fact Sheet” ......................................................Page 80
This article is available from: http://www.pssjournal.com/content/2/1/21

© 2008 Stahel; licensee BioMed Central Ltd. 10. Certain manifestations of poor control of blood
sugar levels
This is an Open Access article distributed under the terms of the Creative Com-
mons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, pro-
vided the original work is properly cited. 11. Deep vein thrombosis or pulmonary embolism
following total knee replacement and hip
replacement procedures
Address: Department of Orthopaedic Surgery, Denver Health Medical Center,
University of Colorado School of Medicine, 777 Bannock Street,
Denver, CO 80204, USA “SCIP Fact Sheet” ......................................................Page 80
Email: Philip F Stahel - philip.stahel@dhha.org

32 The OR Connection
OR Issues

A Latex-Free Victory!
One OR’s success
An interview with members of the River Oaks Hospital OR Team

Kim Gordon, RN, BSN, CNOR, is the products nurse When facilities contemplate where to start combating latex
at River Oaks Hospital, a 14-room OR in Jackson, intolerance, one of their most frequently ordered commodities
Mississippi. In her role, Kim was constantly ordering pops into mind: gloves. Latex gloves have the highest con-
replacement gloves for all of the services and special needs centration levels of allergenic proteins and therefore are the
of the medical and surgical staffs. She was responsible for greatest threat to staff members and patients who are intol-
erant to latex.3
the inventory of approximately 12 different types of gloves
in sizes 5 ½ to 9.
What worked at
River Oaks
At best, it was a difficult task. Kim knew To help consolidate gloves and convert River Oaksʼ OR to a
that her facility needed to standard- latex-free environment, Kim asked product representatives to
ize glove types and reduce their initiate a glove trial. When selecting new gloves, it is impor-
inventory. At the same time, she saw tant to establish criteria for the
an opportunity for the hospital to ad- decision. Examples include
dress a rising concern in the OR com- product availability, viral pen-
munity – latex allergies. etration test results, color, tex-
ture, finish, length, primary
Latex allergies among material, pinhole levels and
healthcare workers elongation levels.4
The American Latex Allergy Association
estimates that between 8 and 17 percent of Kimʼs product representative
all healthcare workers are sensitized to natural set up a station in a high-traffic
rubber latex.1 Studies have suggested that the area and asked the medical and
costs of healthcare workersʼ disability compen- surgical staff to try on latex-free
sation due to latex allergies justifies or signif- polyisoprene gloves with and
icantly offsets the cost of conversion to a without an interior aloe vera coating.
latex-free environment.2

Aligning practice with policy to improve patient care 33


These gloves were made readily available to the staff for pro-
cedures while the likes and dislikes were addressed by the rep-
resentative.

The evaluations were tallied and the majority of the surgical


staff approved the conversion and 100 percent are now using
latex-free gloves. Through the conversion, Kim reduced her
massive inventory to four types of gloves – two types of latex-
free gloves and two gloves that a handful of surgeons re-
quire.

Addressing cost concerns


Facilities have a tendency to believe that synthetic gloves are Left to right: Doug Morrison, Sharon Grisham, Kim Gordon and Dwayne
not cost effective. However, conversion and simplification can Braxton – members of the Surgical Services Team at River Oaks
lead to cost savings through inventory management. Kim was Hospital who assisted with the latex-free conversion.

able to demonstrate this by minimizing her glove stock from


12 to four different types of gloves. Although Kimʼs glove
usage did not decrease, she was able to minimize waste and What is a latex allergy?
increase efficiency. It is estimated that more than three million people in
the United States suffer from a latex allergy.5 The
Kim summarizes the overall impact of Mayo Clinic defines “latex allergy” as “a reaction to
converting to latex free gloves to be: certain proteins found in natural rubber latex, a prod-
uct manufactured from a milky fluid derived from the
1. “We improved our patient care by providing a safer,
rubber tree (Hevea brasiliensis) found in Africa and
latex-free environment without increasing costs.”
Southeast Asia.”6 When people have latex allergies,
2. “The conversion has created new, much needed space
for us. Eliminating so many different kinds of gloves freed their bodies mistake latex for a harmful substance.6
up three storage system carts in our central supply area.”
3. “The majority of our staff has been pleased with the Milder reactions to latex include skin redness, rash,
conversion. It has certainly cut down on confusion. itching and hives. More serious reactions include sneez-
There is a comfort in knowing that there are two types ing, itchy eyes, scratchy throat and asthma. In severe
of gloves to choose from in our OR and both will cases, sinusitis, rhinoconjunctivitis, anaphylaxis and gas-
provide safe care for our patients.” trointestinal problems can also occur.7

Other latex-free options


Gloves are not the only items purchased by medical facilities References
that contain latex. Some hospitals are beginning to purchase 1 American Latex Allergy Association. Latex Allergy Statistics. Available at:
latex-free surgical packs. Other facilities have created a latex- http://www.latexallergyresources.org/topics/LatexAllergyStatistics.cfm. Accessed
November 5, 2008.
safe unit or latex-safe rooms. This does not mean, however, 2 Phillips VL, Goodrich MA, Sullivan TJ. Health care worker disability due to latex
that these rooms are 100 percent latex-free because there are allergy and asthma: a cost analysis. American Journal of Public Health.
still some products on the market without a latex-free option. 1999;89(7):1024-28.
3 Lenehan GP. Latex allergy: separating fact from fiction. Nursing. 2004
The “latex-safe” designation simply means that there is a Feb;Suppl:12-7; quiz 17-8.
severely limited or small amount of latex that is kept or allowed to 4 Lillis K. Hospitalʼs latex-free program fits like a glove – what works. Healthcare
enter into the room. At River Oaks, Kim also focused on convert- Purchasing News. 2002 Sept.

ing to latex-free Foley trays, tubing and arthroscopic cannulas.


5 Dyck RJ. Historical development of latex allergy. AORN Journal. 2000
Jul;72(1):27-9, 32-3, 35-40.
6 MayoClinic.com. Latex allergy. Available at: http://www.mayoclinic.com/health/latex-
Another option for assisting patients with latex sensitivity is cre- allergy/DS00621. Accessed November 5, 2008.
ating a latex-free cart. This cart could be easily transported to 7 Stout G. Creating a latex-safe environment. Infection Control Today Magazine.
Available at: http://www.infectioncontroltoday.com/articles/051feat2.html. Accessed
patients with latex allergies without having to convert and en- November 5, 2008.
tire room or unit to a latex-free environment. Medical staff will
then only be permitted use the latex-free supplies on the cart
while working with the patient.

34 The OR Connection
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36 The OR Connection
Special Feature

Organ Donation
Overcoming obstacles and objections

By Jeanne M. Jones, RN

As nurses, we know firsthand that when you are A personal experience


in the emergency room and a massive injury My niece, Diane, lost her husband, Joe, two years
comes through those doors, a multitude of ago after battling the waiting list. For patients to
decisions are being made very quickly. One of the receive a transplant, they must be “sick enough” but
important decisions is often organ donation and not “too sick” to receive a healthy organ. Every time
unfortunately, many of our patients have not made Joe was on the list, we prayed for a match. Every
their wishes known beforehand. Organ donation is time he was too sick, we prayed that modern medicine
important for obvious reasons, and millions of people could buy us more time. Joe and Dianeʼs children
believe in its value. However, problems can crop up always said things like, “When Daddy gets his trans-
when itʼs actually time for the donation. plant, we can go to Disney” or “When Daddy gets his
transplant, we can do the things we used to do.” Joe
Victims of trauma were not planning on dying – and never got that organ and their lives have changed
they might have very strong feelings on whether they more than any of us could imagine.
want to participate in this final act. But, unless they
inform their family members of their wishes, the Diane and her two children have joined forces with
decision-making quest can be terrible. Joeʼs parents and siblings to educate everyone they
can on the value of this potentially life-saving decision.

Continued on Page 39

Aligning practice with policy to improve patient care 37


S.T.O.P. for safety.

It could be the difference If you would like to receive a free sample


between life and death. of the S.T.O.P. Drape system to evaluate for
Wrong site surgery has recently moved into the yourself, ask your Medline representative or
number one position as the most frequently call us at 1-800-MEDLINE.
reported hospital error.1 STOP!!!
STOP!!!
Perform
P erform “TIME
“TIME O OUT”
UT”
This is despite a conscientious effort to eliminate this Verify
V erify ccorrect:
orrect:
problem before it occurs. What is needed is another layer Person
Person
Procedure
P rocedure
of safety...something that will improve our chances of Site
S ite & Side
S ide
correcting the mistake before it happens. Date:
Date: _______
_____ Time:
Time: ______
______
Surgeon’s
S urgeon’s Initials:
Initials: ______
____
Enter S.T.O.P. Surgical Drapes* from Medline.
We just made a good idea even better. S.T.O.P. (Surgical
Time Out Procedure) drapes are available in a variety of
configurations, 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 to include in the medical record, documenting that
the verification process was completed. S.T.O.P. strip and sticker

References
1 The Joint Commission. The Statistics page. Available at: http://www.jointcommis-

sion.org/NR/rdonlyres/D7836542-A372-4F93-8BD7-DDD11D43E484/0/SE_Stats_12_07.pdf.
Accessed March 13, 2008.

www.medline.com
* Patent pending

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
They have worked with insurance companies, the
senate in New Jersey, local citizen groups and other sup- Organ donation myths
porters throughout the state to spread the word. “I canʼt donate because Iʼm too old/young/sick.”
According to the DHHS, there are no strict upper
In July of 2008, Bill S755/A2083, known as the New Jer- or lower age limits when it comes to organ dona-
sey Hero Act, was signed by Acting Governor Richard tion.5 There are very few illnesses that completely
Codey. New Jersey is the first state to require organ do- exclude people from donating. The exceptions are
nation decisions before applying for a driverʼs license and HIV, active cancer and systemic infections.5
mandatory high school education regarding organ donation.1
“My religion prohibits it.”
It is hoped that other states will follow the example of this Most religions encourage organ donation or leave
first-in-the-nation initiative. You can learn about your the decision to be made by the individual. To view
stateʼs policies on organ donation by visiting a listing of the official stances taken by churches,
http://www.donatelife.net/CommitToDonation/. please visit http://organdonor.gov/donation/
religious_views.htm.
Who is on the transplant waiting list?
According to information from the Department of Health “I have to donate my whole body.”
and Human Services (DHHS), there were 100,238 waiting The DHHS details four different types of donation.
list candidates as of October 20, 2008.2 Kidneys are the They are6:
organs needed by the largest number of waiting list can- • Organ and tissue donation from living donors
didates, accounting for 76 percent of all organ needs.3 • Donation after brain death
Other commonly needed organs include lungs, hearts, • Donation after cardiac death (DCD)
intestines, livers and the pancreas.3 • Whole body donation

What can be donated?


Doctors can currently perform transplants of the kidneys,
heart, lungs, liver, pancreas and intestines.4 Corneas, the
middle ear, skin, heart valves, bone, veins, cartilage, tendons
and ligament can be used to restore sight, cover burns,
repair hearts, replace veins and mend damaged connec-
tive tissue and cartilage.4 Stem cells, blood and platelets
are also needed.4

How to encourage donation at your own facility


In 2003, the DHHS created the Organ Donation Break-
through Collaborative with the goal of “saving or enhancing
thousands of lives a year by spreading known best practices
to the nationʼs largest hospitals, to achieve donation rates
of 75 percent or higher in these hospitals.”7

The Collaborativeʼs members represent all members of


the organ donation and transplant community – critical
care nurses, organ procurement and transplant coordina-
tors, hospital administrators, physicians, clergy, social
workers, family members of organ donors and transplant
recipients.7

Aligning practice with policy to improve patient care 39


References
1 The State of New Jersey Office of the Governor. Acting Governor Codey Signs
New Jersey Hero Act. Available at: http://www.nj.gov/governor/news/news/2008/
Victims of trauma approved/20080722a.html. Accessed October 20, 2008.
2 OrganDonor.Gov. Waiting list candidates. Available at: www.organdonor.gov.
Accessed October 20, 2008.
were not planning 3 Transplant Living: Organ Donation and Transplantation Information for Pa-
tients. Organ Facts. Available at:
on dying – and they http://transplantliving.org/beforethetransplant/organfacts/default.aspx. Accessed
October 20, 2008.
might have very strong 4 OrganDonor.Gov. What Can Be Donated. Available at:
http://organdonor.gov/donation/what_donate.htm. Accessed October 20, 2008.
5 OrganDonor.Gov. Who Can Donate. Available at: http://organdonor.gov/dona-
feelings on whether tion/who_donate.htm. Accessed October 20, 2008.
6 OrganDonor.Gov. Types of Donation. Available at: http://organdonor.gov/dona-
they want to participate tion/typesofdonation.htm. Accessed October 20, 2008.
7 Tamburri LM. The role of critical care nurses in the Organ Donation Break-
in this final act. through Collaborative. Critical Care Nurse. 2006;26(2).

Critical care nurses are an integral part of the donation


process. In this spirit, the Collaborative made the follow-
ing recommendations to critical care nurses to aid them
in turning best practices into common practice in their
intensive care units7:
• Refer all potential donors: Identify potential donors in
your unit, familiarize yourself with your facilityʼs criteria
for clinical triggers and promptly get in touch with your
organ procurement organization (OPO).
• Partner with your OPO: Introduce yourself to OPO
coordinators and help them become part of your team.
• Become a donor “champion”: Talk to your fellow
nurses and colleagues about the importance of organ
and tissue donation.
• Advocate for your patients and their families: Honor
your patientsʼ last wishes, including those related to
organ donation. Be sure that families are aware of the
donation option.
• Educate yourself and your colleagues: One option
for education is to invite your OPO to conduct in-service
training sessions in your unit.
• Be a change agent: Focus on system issues, examine
what your facility is doing right and determine what
needs to change to better your organ donor policies.
• Understand the data: Compare your hospitalʼs data
on organ donation to national benchmarks.

About the author


Jeanne M. Jones, RN has 40 years of perioperative experience.
She is currently a clinical nurse product specialist.

40 The OR Connection
Customized solutions.

Anesthesia Supply
Management Solutions
Does your anesthesia storage need help? When you part-
ner with Medline, your anesthesia supply management
world will be revolutionized.

With Anesthesia Complete Delivery System (ACDS*), all


anesthesia supplies will be par level packaged in a stan-
dardized drawer insert, which is then used to restock the
anesthesia case carts. This decreases the time it takes
staff to order, receive and stock shelf supplies.

Taking care of your needs every step of the way


Each program is custom designed based on your facility’s
anesthesia supply requirements. Medline’s® ACDS will …
• Increase staff productivity and satisfaction
• Improve inventory control
• Increase space utilization
• Improve charge/cost capture
• Eliminate outdated product
• Enhance supply standardization For your free cost-savings analysis,
• Enhance compliance with the Joint Commission, contact your sales representative or
AORN and SCIP call 1-800-MEDLINE.

* Patent pending

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
OR Issues

Supply Management for


Perioperative Services
How to get your inventory
under control

42 The OR Connection
By Ned Turner

When perioperative leaders think about their world, they think about patient care.
And Iʼm sure all of us agree that if we or our loved ones need to undergo surgery, thatʼs ex-
actly where we want the clinical staff to be focused!

While talking about supply management for perioperative services doesnʼt sound very clinical,
perioperative leaders also know that supply management is a significant portion of their
budget and their world. In fact, 50 percent of a typical OR budget is consumed by
supply acquisition costs.1 When you begin to factor in inventory, systems support and staff
handling of product, that figure can climb even higher.

Letʼs take a look at one of the biggest obstacles to successful supply management
– inventory.

Getting your inventory under control


When hospital CFOs mentions the word “inventory” to key hospital directors, theyʼre often
talking about inventory reduction. While many ORs doubtless have the capability to reduce
inventory, itʼs still crucial that the right products are in the right place, at the right time. Simply
cutting back on inventory might not make your OR more cost effective and might even
create a situation that could affect patient care, patient and staff safety and surgeon and
staff satisfaction.

So what can you do to get your inventory under control without making any sacrifices in
safety or satisfaction? Here are five suggestions.

1. Organization
Orderly and organized supplies are often more effectively managed.

2. Systems
An effective OR materials management system and accurate reporting tools are critical
for effective inventory management.

3. Staff
Staff members who are focused and well-trained on supplies can allow clinical staff to remain
focused on patient care.

4. Consignment
Consignment can be a great tool for high-cost supplies such as implants, grafts and
custom packs.

5. Annual inventory counts


Although annual inventory counts can be time-consuming and a task that volunteers rarely
line up to help with, these counts are vital to managing inventory and identifying obsolete
supplies.

Look for more supply management stratagies in future issue of The OR Connection.

References
1 Davis E. Educating perioperative managers about materials and financial management.
AORN Journal. 2005;81(4):798-812.

About the author


Ned Turner has spent the past 29 years working in surgical supply
manufacturing and supply management consulting. Ned joined Medline in
2003 after a lengthy career at Cardinal Health that included serving as Area
Manager of the Western U.S. He is currently the vice president of
Medlineʼs Sterile Procedure Tray Division – Sales and Supply Manage-
ment Consulting Services.

Aligning practice with policy to improve patient care 43


44 The OR Connection
OR Issues

A New Way to “Pack” It All In


An interview with members of St. Vincentʼs perioperative team

Think about the last time you put a surgical pack Each Med-Pack user also has an online “eBook” created
together. You probably had a lot to think about. Could you for them. This eBook contains:
lower costs? Increase productivity? Are all of the products • Component lists
youʼre ordering latex-free? Is there any way to standard- • Pack history
ize it all? • Documents
• Pack images
On average, operating room supplies account for more • Pack changes
than 50 percent of a hospitalʼs budget.1 It makes • Eco-friendly components
sense that youʼd want to get as much bang for your
buck as possible! As you can see, the eBook is a great way to keep critical
documents together – without creating a mountain of paper.
In the spring of 2008, Medline launched a program to
reduce the headaches typically associated with pack Since its launch, hospitals throughout the country have
management. Med-Pack is a Web-based, real-time pack adopted Med-Pack at their facilities. We wanted to share
management tool that was created following intense input one facilityʼs success story with you.
from focus groups and advisory boards.
St. Vincentʼs story
Med-Pack, which is available to any St. Vincent Health is the largest health-
Medline pack customer, operates care employer in the state of Indiana,
through a series of iViews, which are with 17 health ministries serving 45
essentially microsites supplying specific counties in the central portion of the
information to users. Examples of iView state. It is also a member of the
topics include Safety, Analysis Tools, Catholic Healthcare System and As-
Alerts, Savings, Standardization and cension Health, the nationʼs largest
Supply Management, plus many more. not-for-profit.

The goal of each of these iViews is to St. Vincent Indianapolis Hospital is


quickly provide critical information in a ranked nationally for cardiac, stroke,
hassle-free format. Users simply click on orthopedic and gastrointestinal care. It
an iView icon to get the material they is also Indianaʼs only hospital to be
need, eliminating the need to jump from recognized for excellence in four spe-
Web site to Web site to track down cialty areas by HealthGrades, the
information on latex-free options, St. Vincent Carmel Hospital leading provider of independent hos-
industry initiatives, etc. pital ratings in the U.S.2

Aligning practice with policy to improve patient care 45


Easy to use
The goal was to make Med-Pack so intuitive
that users would be up and running in min-
utes. The program is made up of a series of
icons called iViews. Each iView is a microsite,
supplying data specific to your account. Here
are some of the most popular iViews.

eBook OR Corner Safety

Left to right; Vicky Smith, Gussie B. Johnson, Barb


Weimer, Karen Fox, Sondra Jones and Francie Dolder

Becky Hodson is the OR Materials Team Leader at St.


Vincent and estimates that the facilityʼs 10 operating
Analysis Tools Alerts Savings

rooms perform around 150 bariatric surgeries a month in


addition to other types of procedures. With the hospitalʼs
high volume of surgeries, Becky has found Med-Packʼs
time-saving features especially beneficial. Spend Standardization Supply

Simplifying pack changes


and Trend Management

Before using Med-Pack, Becky recalls that surgical


packs would have to be built by arranging to have a This gives her time to alert staff that a change is coming
sales rep visit the facility and complete paperwork. Mak- and prevent potential frustration. Itʼs also easy to identify
ing pack changes required more back-and-forth with pa- the most recent pack versions on St. Vincentʼs
perwork. Now, Becky can view her packs online and shelves because Med-Pack automatically changes the
request changes with a few clicks of her computer last letter in the packʼs product number each time a pack
mouse. This comes in handy because team leaders at is altered.
St. Vincent meet once a month to discuss any changes
they would like to make Standardization
with packs, which could Becky has also used Med-Pack to help make strides
create more time-drain- toward St. Vincentʼs goal of pack standardization
ing paperwork with an- across its multiple facilities.
other system. All pack
changes are approved by “When you can have one pack, why have three out
the management team. there?” she said.

Vicky Smith, CST, Spine In one instance, Becky was able to use Med-Pack
Team Lead at St. Vincent to view the pack used at a sister facility by one of St.
Indianapolis, appreciates Vincentʼs top-volume orthopedic doctors. Since that
how Med-Pack enables surgeon was also practicing at the Carmel location,
Vicky Smith her to see when a pack Becky was able to standardize using his pack at both
change is about to occur. locations.
Continued on Page 48

46 The OR Connection
Everything you need to
know about your packs
at your fingertips.

Introducing Med-Pack, an interactive, Talk to your sales representative to obtain


real-time data management tool for sur- a Med-Pack login and experience Med-Pack
gical procedure pack management. for yourself.
Whether you’re an OR director, materials manager or
GPO administrator, Med-Pack has many different
“iViews” that provide specific information to help you
manage your surgical packs and your OR.

• View photographs of your packs and components


• View inventory in real time
• Get alerts for pack changes
• Run safety and latex analyses on your packs
• Run reports by component, pack or discipline

Featuring OR Corner, where


you can find the latest indus-
try news, hot topics and
industry calendar of events.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Cost savings
Both Vicky and Becky praised Med-Pack for its ability to call
attention to cost savings options.

“I like that I can see item costs and have the option of
checking to see if there are savings available,” said Vicky.

To learn more about how Med-Pack could benefit your own


facility, please contact your Medline sales representative.

References
1 Davis E. Educating perioperative managers about materials and financial manage-
ment. AORN Journal. 2005;81(4):798-812.
2 St. Vincent Health. St. Vincent Indianapolis Hospital. Available at: http://www.stvin-
cent.org/ourlocations/hospitals/indianapolis/default.htm. Accessed November 13, 2008.

Clinical Logistical Financial

eBook

Pack Detail

Pack Image

Safety Center

Safety Analysis

Lu McKee and Becky Hodson


Latex Analysis

Safety Articles

Supply Management

Alerts

Inventory

Savings

Analysis Tools

Standardization

Component Utilization

OR Corner

Hot Topics

Link to Industry Experts

Note: iViews can host clinical, operational or financial information.


Which iViews would be most helpful to you?

48 The OR Connection
We’re
setting
a new
standard
in patient
safety.

G O L D S TA N D A R D S A F E T Y P R O G R A M

Medline is proud to introduce our Gold Standard Safety 3. AORN Checklist: Wrong site, wrong procedure,
Program, designed to break down barriers in surgical wrong patient surgery prevention.
safety compliance by offering products, analysis tools 4. Med-Pack™: Electronic pack audit and a
and checklists to help you reach your safety goals. review of safety components.

The program offers four levels of safety options: To learn more about the Gold Standard Safety
1. The Gold Standard Safety Bundle: Includes six Program, contact your Medline sales represen-
products to serve as visual safety reminders to reduce tative, call us at 1-800-MEDLINE or visit
needle sticks and wrong site surgery. www.medline.com.
2: Innovative safety products: Surgical Time Out
Procedure (S.T.O.P.™) Drapes (patent pending),
RF Surgical® Detection System and Universal
Electrosurgical Pads.

www.medline.com

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Why is
Pressure Ulcer
Risk Assessment
So Important?

Letʼs examine what a patient and nursing student have to say!


By Alecia Cooper, RN, BS, MBA, CNOR
About 70 percent of
My name is Euretha and I have a story to tell you. I think it ago this past September, I have lived all pressure ulcers
could help folks like you who work in hospitals and nursing alone and got along pretty well caring occur in people 70
homes alike. My granddaughter is studying to become a nurse for myself. But as of late, I have been years and older.1
and she thinks what she and I have learned about my experi- getting “blue” more often than not. I
ence can help everyone. So I agreed to help. donʼt have much of an appetite and I canʼt get around as well
as before. I become dizzy in the early mornings and I have
I am 79 years old and have been in pretty good health all of my taken a fall several times. Most of my friends are either too sick
life until I started getting feeble these last few months. Since to get out much or they have passed on.
the passing of Theodore, my beloved husband, three years

50 The OR Connection
Patient Safety

On November 1, I went to stay at Happy Valley Nursing Home


for what I thought was only temporary, no more than a couple of
months. Today is Christmas Day and I hope the kids get here
soon as I just cannot bear the thought of being away from
home on my favorite holiday. As hard as I tried to persuade
him otherwise, Dr. Hill said I am not ready to leave yet. You see,
what I have not told you yet is that I had one of those dizzy spells
14 days after I came to Happy Valley.

It was early that morning when I got out of bed to go to the bath-
room. I lost my footing, slipped and fell hard on my right hip and
it broke. We were not sure it was broken at first, but once I got
to the hospital, they were sure. I had surgery and a stay in the
hospital and then came back
Why is pressure ulcer risk
to Happy Valley with this
doggone bedsore on my assessment so important?
other hip. It is not healing too Because it helps identify which
well. In fact, it just keeps get- patients or residents may benefit
ting worse. Those “blue” most from preventable measures.2
days have just been getting
worse. I thought I would cry The best way to prevent pressure
all day when Dr. Hill let me ulcers may be through the use of
know that he now thinks that evidence based of pressure ulcer
this bedsore could be risk assessment tools.3
infected.

This whole situation worried my poor granddaughter, so she


talked to one of her nursing instructors who gave her an idea
for a school research proj-
ect. She said she needed my Confinement to a bed or chair
help. Imagine that. I get to for a week has been found to
help her figure out what could increase the prevalence of pres-
have prevented my bedsore sure ulceration by 28 percent.4
from developing after I broke
my hip.

I asked her how could I possibly help, and she told me that we
needed to go through every event from the time my injury
occurred until the bedsore developed. She explained that she
would take every part of the story and research the prevention
measures that, if they had been done, might have prevented that
bedsore from developing. To prove her point, she brought me an
article to read that she found in one of her nursing journals. That
article said that the experts say bedsores can be prevented in
most cases. If all this is true, then I think we need to all work
Then things got worse. I tripped walking back from the mailbox together to prevent them from happening. Oh, I know that mis-
a few months back and skinned my arm, my nose and bruised takes can happen unintentionally. People can forget when they
my left hip. My whole body was bruised up pretty bad. My are working so hard, under stressful situations, Lord knows I
daughter June insisted that I go see my doctor, Dr. Hill. I have have nothing better to do to occupy my time these days. Hereʼs
been cared for by Dr. Hill for more than 30 years and pretty much a look back at what was going on when that bedsore developed.
think he is one of the smartest doctors I know of, so when he told
me that he thought it was time for me to go live in a nursing November 15, 2007
home, only for a while, so I could get stronger, eat better and 5:47 a.m.
find out what was causing all these dizzy spells, I didnʼt much I remember that I had tossed and turned all night, and even
argue with him. though I was still so tired, I just could not fall back to sleep no
Continued on Page 53

Aligning practice with policy to improve patient care 51


No pressure, just support.
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.

Our gel positioners are available in a wide variety of


shapes and sizes to meet your needs. To learn more
about Medline’s comprehensive Pressure Ulcer
Prevention Program, contact your sales representative
or visit www.medline.com/pressureulcerprevention.

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.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. www.medline.com
matter how hard I tried. So I One pressure ulcer can cost 2. Was an admission pressure ulcer risk and skin
got up to use the bathroom an average of $43,180. CMS assessment performed, documented and compared
and fix my dentures so I and other providers to the assessment performed at the nursing home?
could go to breakfast. Maybe will not reimburse for the
I got up too fast, or I was additional costs associated 9:57 a.m.
dizzy for some reason, but as I am rolled down the hallway to the X-ray department for the X-
with hospital-acquired
soon as my feet hit the floor, rays that Dr. Hill ordered. The boys moved me from my
pressure ulcers.5
I slipped and fell hard on my stretcher to a very hard and very cold table in a darkened room.
right hip. I think I remember A very nice lady came in and
hearing something snap, but Iʼm not certain. I yelled for help explained what was going to 70 percent of nurses consider
and that nice girl Sheila ran in and found me lying on the floor. happen. Pictures were taken their basic wound education
She told me not to move if possible and she quickly ran to get of my chest and hip and then to be insufficient.7
some help. The head nurse came in and they got me stretched those sweet boys came back
out as best they could and said they called my doctor and an and moved me off that hard table and back to that uncomfort-
ambulance was on the way to come get me and take me to able stretcher and I was rolled back to the emergency room.
Mercy Medical Center so I could be checked out. When I got back, Dr. Hill was waiting on me and the first thing I
asked for was a drink of water as I was so parched. I remem-
7:46 a.m. bered that I had not had anything to drink since before 8 p.m. the
The ambulance came to take me to the hospital (1 hr and 59 night before and nothing at all to eat since dinner. He said he
minutes after the incident occurred). I looked at the very knew that I was dry, but it was unsafe to give me anything to drink
small stretcher with that tiny mattress – I donʼt think it could have until we knew whether I needed surgery. I asked if they could
been more than one or two inches thick – and worried how they please hurry and find out.
were ever going to get me on and off that safely, but they did.
And trust me, it was one of the most uncomfortable beds that I Nurses need more education in: 8
have ever laid on. They • Risk assessment (interpretation of Braden Scale)
strapped me in and got me Pressure ulcer incidence is • Pressure ulcer staging
into the ambulance. I was in over 60 percent for high-risk • Proper positioning
so much pain, but the emer- patients with femoral fractures • Effects of moisture on the skin (including incontinence,
gency medical personnel told and/or hip fractures.1 humidity and maceration)
me they could not give me • Pressure relieving products
anything to dull it until I was checked out at the hospital. I could • Proper application and usage of prevention products
not even have anything to drink. I think that was the worst part,
but they said if I needed to have surgery it could hurt me. 11:02 a.m.
The nurse comes in to tell me that the X-rays show that my right
8:37 a.m. hip was indeed broken and that the surgeon, a Dr. Cloud, or one
I am rolled off the ambulance and rolled into the hospitalʼs emer- of his assistants would be here
gency room. Finally, after some confusion, I am moved from that soon to discuss the plan for sur- The incidence of pressure
tiny stretcher to a bigger bed that was a little wider, but that mat- gery with me. I was getting so ulcers occurring as a result
tress was not much better than the one before. They nurses and tired of just laying in one spot for of surgery may be as high
doctors told me that I had to lie still while they checked me out, so many hours, but she explained as 66 percent.8
otherwise I might further injure my hip. For what seemed like for- to me that they had to keep my
ever, they checked me out. body straight so I did not injure
Then they told me they had Pressure ulcers are defined my hip more. I asked her what time it was, and when she said
called Dr. Hill and that he was as areas of localized damage 11:02, I realized that it had been over six hours since I fell and
on his way, but had given to the skin and underlying that I had been in one position for as many hours. No wonder I
them orders over the phone tissue caused by pressure, was getting so stiff. If I could have only turned over and had a
for me to have an EKG, a shear, or friction.6 glass of water.
chest X-ray and an X-ray of
my hip. Also, June and the kids had arrived by now and they For consideration:
let June come back to sit with me for a while until it was 1. Did the stretcher pads used in the ambulance
time for me to go to the X-ray department. and in the emergency room have pressure
redistribution capability?
For consideration: 2. Were pressure-relieving devices used to frequently
1. Was a pressure ulcer risk and skin assessment reposition the patient?
performed and documented on admission
to the nursing home?

Aligning practice with policy to improve patient care 53


11:35 a.m. an immobilizer was positioned Pressure ulcers can develop
Dr. Cloud comes in, intro- Key causes of OR-related between her legs to keep her within two to six hours of the
duces himself and explains pressure ulcers8: in proper body alignment, she onset of pressure.1
that I need to have surgery. was rolled onto her bed and
• Immobility during the
He was dressed in what taken to the recovery room,
procedure While AORN guidelines
looked like pajamas with a where she remained for two
white coat and a blue cap.
• Pressure on bones close recommend pressure relief
hours until she was stable
He told me that he had been to the skin surfaces for surgeries lasting
enough to be taken back to
in surgery all morning and • Diminished tissue tolerance her own room. Iʼll let Granny longer than 2 hours, pressure
that he had one more proce- • Excessive moisture tell you how she was feeling ulcers can start to form in as
dure to finish and then he when she got out of surgery. few as 20 minutes.9
would be able to get me all
fixed up. I told him how sore I The most frequent predictors For consideration:
was and how much pain that of perioperative pressure 1. Was the OR table pad a pressure redistribution pad?
hip was giving me, so he told ulcers have been found to be8: 2. Were all bony prominences and pressure points
the nurse to give me a shot • Increasing age of the padded appropriately to minimize pressure that might
for pain and that he would go occur during a surgical procedure?
patient
ahead and have me moved
• A patient diagnosed with
to the surgery holding area, 6:00 p.m.
where they could get me
diabetes or vascular
June and the kids were all waiting for me when I got to my room.
ready for surgery. About 20 disease
There was a pitcher of water waiting and that was the first thing
minutes later, a boy who was • Vascular procedures I wanted – a cold drink. My nurse for the evening came in and in-
dressed like Dr. Cloud came troduced herself and checked me out. They gave me some broth
in and told me he was there to roll me up stairs to where the Sur- to eat a little later. My hip was beginning to hurt again, so they
gery Department was located. I said my goodbyes to June and gave me some more pain medicine and I drifted back to sleep.
the kids and they told me not to worry, that I was going to be I guess I was really tired because I slept more that evening than
fine. I told them I knew that, I just wanted to get this over with. I had in weeks. I woke up a few times during the night and
needed some more pain medicine, but then I went right back
1:08 p.m. to sleep.
I am finally being rolled According to AORN, surfaces
back to the operating room in the OR for both positioning For consideration:
to get this old hip fixed. and transporting patients 1. Was the patientʼs skin thoroughly cleansed and
They started an IV in the should be smooth and intact inspected after surgery before leaving the operating
holding area and gave me because surfaces that hold room to ensure that there was no pooled blood or prep
some medicine that was moisture or wrinkle contribute solutions under bony prominences?
making me very drowsy. I to skin breakdown.8
now had on one of those November 16, 2007
blue hats, too. They moved 7:00 a.m.
me over to a table that looked just as uncomfortable as that Breakfast arrives and I am The greatest incidence of
gurney I had been lying on for the past five or six hours. After awake and ready to eat. new-onset postoperative
that, I donʼt remember much, so I have to turn the story over Soon afterward, the day shift pressure ulcers for elderly
to my granddaughter to explain what happened in surgery. nurse comes in and says she patients with hip fractures
has to check me out head to
occur within the first two
For consideration: toe. In doing so, she finds a
1. Each time the patient was moved from stretcher postoperative days.4
big red mark on my left hip
to stretcher and table to table, were the staff well and asked me if it had been
trained in transfer and positioning techniques there before I arrived at the hospital. I told her it hadnʼt been as
that reduce friction and shear? far as I knew, but that I had been falling easily and bumping into
things so it was possible that I was there and I didnʼt know it.
Granny was positioned on her left hip, prepped and draped with There was still some paint from surgery and a few blood spots on
a full-body drape and only her right hip exposed to the op- my skin, so she got some soap and water and cleaned me up
erative field. The procedure started at 1:45 p.m. and was com- real good. My granddaughter can tell you what came out of all
pleted at 3:30 pm., lasting one hour and forty-five minutes. of this.
During the surgery, Granny has some reasonable blood loss
and the hip was irrigated with antibiotic fluid. At 3:45 p.m., after
Continued on Page 56

54 The OR Connection
The program
you need ...

right when you need it most.


Pressure Ulcer Prevention Program For the OR
“In many of the recent legal cases I have reviewed following Topics addressed in
facility acquired pressure ulcers, I have seen that an increasing the program include:
number are occurring in post surgical patients. A pressure I. Implications of the New CMS
ulcer prevention program for perioperative services that Payment Provision
addresses risk assessment as well as comprehensive II. Incidence of Perioperative Pressure Ulcers
prevention measures is more critical than ever.” III. Perioperative Risk Factors
– Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN, IV. Perioperative Assessment
Wound and Skin Care Consultant
V. Perioperative Prevention Measures

Studies suggest that the incidence of pressure ulcers occurring


To learn more about Medline’s Perioperative Pressure
as a result of surgery may be as high as 66 percent.1 With
Ulcer Prevention Program, contact your Medline
that in mind, Medline has developed a companion program
representative, call 1-800-MEDLINE or visit us at
to its highly successful Pressure Ulcer Prevention Program
www.medline.com.
especially for perioperative services.

Reference
1 Recommended practices for positioning the patient in the perioperative
practice setting. In: Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2008.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
For consideration: higher acuity, requiring more All members of the healthcare
1. Should soap and water be used to cleanse patients resources and services to be team need to know their
at high risk for development of pressure ulcers? provided and at a higher cost responsibilities and how their
burden for both the payer tasks relate to each other in
By now, you must know the rest of the story. Granny was in the and the provider. Added on the prevention and manage-
hospital for five days after surgery and then returned to Happy top of this is the at-risk con- ment of pressure ulcers.
Valley Nursing Home. The reddened area eventually devel- dition for the development of
oped into a Stage III pressure additional complications, such as additional pressure ulcers,
ulcer that is now infected. When a Stage I pressure deep vein thrombosis, pulmonary embolism and additional
From my research, we have ulcer develops, the risk for infections.
developed a protocol for additional ulcers on the
the prevention of pressure same individual is reported Prevention is paramount. It begins with proper risk and skin
ulcers that includes a com- to increase tenfold.4 assessment, combined with proper prevention measures
munity effort between the (including the appropriate prevention products). The cement that
nursing home and acute-care facility to prevent facility-acquired holds it all together is proper education and training of personnel
pressure ulcers. In Grannyʼs case, the ulcer could have devel- across the complete continuum of health care, including the
oped due to pressure, moisture, friction, shear, poor nutri- community of hospitals, nursing homes and emergency
tion, tissue injury or tearing, but most likely from a combination medical professionals.
of all of these factors. Not all pressure ulcers are avoidable, but
many are. I encourage you to work closely within your medical Refer to the Forms & Tools section to learn more about how
community to make sure your pressure ulcer prevention meas- you can prevent pressure ulcers at your facility.
ures and protocols are up to date and that everyone is fully
trained to execute them appropriately. This story is a fictional account based on the real-life experiences
of the author.
Critical steps
Critical steps in pressure ulcer prevention and healing include8: References
1 Medical News Today. Clinical Trial Shows 96% Improvement In Pressure Ulcer
• Identifying the individual resident at risk for Healing Among Nursing Home Residents. Available at: http://www.medicalnewsto-
developing pressure ulcers day.com/articles/39327.php. Accessed September 3, 2008.
• Identifying and evaluating the risk factors and 2 Ayello E, Braden B. Why is pressure ulcer risk assessment so important? Nursing.
2001;31(11):74-80.
changes in the patientʼs condition 3 Walsh K, Bennett G. Pressure ulcers as indicators of neglect. Nursing & Residential
• Identifying and evaluating factors that can be Care. 2000;2(11):536-539.
removed or modified 4 Maklebust J. Pressure ulcers: The great insult. Nursing Clinics of North America.
2005;40(2):365-389.
• Implementing individualized interventions to attempt 5 CMS, Proposed Changes to the Hospital IPPS and FY2009 rates;
to stabilize, reduce or remove underlying risk factors http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf accessed October 24, 2008.
• Monitoring the impact of the interventions 6 Lepisto M, Eriksson E, Hietanen H, Lepisto J, Lauri, S. Developing a pressure ulcer
risk assessment scale for patients in long-term care. Ostomy/Wound Management.
• Modifying the interventions as appropriate 2007;53(10):34-38.
7 Zulkowski K, Ayello E, Wexler S. Certification and education: Do they affect pres-
Risk factors sure ulcer knowledge in nursing? Advances in Skin & Wound Care. 2007;20(1):34-38.
8 AORN 2008 Perioperative Standards and Recommended Practices, “Recom-
Risk factors for pressure ulcer development include8: mended Practices for Positioning the Patient in the Perioperative Practice Setting.”
• Impaired/decreased mobility 9 Akridge J. Pressure ulcers hit a sore spot in the OR. Healthcare Purchasing
• Decreased functional ability News. August, 2007.

• Co-morbid conditions
• Drugs that may affect wound healing
• Impaired diffuse or localized blood flow
• Resident refusal of some aspect of care and treatment
• Cognitive impairment
• Exposure of skin to urinary or fecal incontinence
• Under-nutrition, malnutrition and hydration deficits
• History of a healed ulcer

For Happy Valley Nursing Home, they not only had to provide
care for Eurethaʼs mending hip, they also had to deal with her fa-
cility-acquired pressure ulcer, which had become infected.
Euretha was now a much more complex resident with a much

56 The OR Connection
It all adds up. The Pressure Reducing OR Table P

Pressure Free is treated with Ultra-Fresh, making it antimicrobial


throughout. It is also antifungal, fluid proof, stain, fungal and fire
resistant—making it reusable and easy to clean.

To learn more about our


pressure reducing table
pads, contact your Medline
representative, call
1-800-MEDLINE or visit
Pressure Free, Medline’s new OR table pad features 3 layers of www.medline.com.
foam covered in our exclusive Nirvana “Memory” Foam which not
only completely conforms to the patient’s body contours and
Pressure Free
gently cradles delicate bony prominences but keeps its shape
OR table pad
throughout even the longest procedure. All of this is encased in
our state-of-the-art Proknit ticking to eliminate the “hamocking
effect” seen in other vinyl pads.

www.medline.co
Fluid
Flow
Keep your surgical patient desert dry

Disruption?

By Jayne Barkman RN, BSN, CNOR

As Joe and Sandy walked down the hall


to the lounge, they almost collided with
paramedics running down the hall and push-
ing a stretcher carrying an intubated young man.
Joe and Sandy exchanged glances, turned around and
scurried after the paramedics into OR 3.

They assisted the paramedics and anesthesiologist in lifting


the patient from the stretcher onto the operating room bed. manʼs clothing. The attending poked his head into the
Joe then grabbed a gown and a pair of gloves from the room. “Letʼs go!” he barked. Sandy inserted a temperature-
room stock supply to scrub in and help Tom, the scrub sensing Foley and Laura, the room circulator, poured be-
nurse, finish setting up. Sandy secured the patient to the tadine over the patientʼs chest and abdomen. Sandy tied
bed with the safety strap and began cutting off the young up the attending and two surgical residents as Joe and

58 The OR Connection
OR Issues

Tom draped the patient. Within in a minute, the young fluid light was blinking on the machine. Sandy grabbed a
manʼs abdomen was opened. Blood immediately began bottle of sterile water and added the fluid to the machine.
pouring out. The low fluid light continued to blink an amber warning.
Sandy called the control desk and requested an additional
“Get me another cell saver. Come on, I need more hypo/hyperthermia machine. When the machine arrived,
suction!” the surgeon yelled. Sandy delivered another cell she disconnected the faulty machine, inserted the warm-
saver tubing to the field and Joe handed it off to the perfu- ing blanket tubing into the new machine, plugged it into the
sionist as the whirl of the second cell saver machine filled wall and turned the machine on. The low fluid light began
the room. Sandy and the anesthesiologist checked five blinking on the new machine. Sandy went to the anesthe-
units of emergency release blood as a CRNA squeezed siologist and explained what was happening. Mike, the
the packed cells into the patient. Sandy and Joe then anesthesiologist, asked for some warm blankets that he
counted the additional packs of lap sponges that Sandy then wrapped around the patientʼs head.
had tossed onto the field and began placing the soiled According to a report from the ECRI
sponges from the kick bucket into the sponge counter Institute, an evidence-based practice
bags. Next, Sandy carefully wiped up the blood that had center, injuries related to the use of
pooled around the surgeonʼs feet and showed the anes- a warming/cooling blanket tend to
thesiologist the blood-soaked bath towels so that he could
incorporate the blood on the towels into the blood loss es-
occur in lengthy procedures in which

timate. Soon, the attending had the bleeding under con-


the aorta is cross clamped.

trol. When things slowed down, Sandy read the accident


details provided by the paramedics. The patient had suf-
“Clamps on,” the surgeon said as the anesthesiologist fered an aortic injury due to deceleration when he
noted the time. The attending asked for an 18 woven graft. slammed into another vehicle while running a red light.
Before opening the graft to the field, Sandy and Joe verified When Joe asked to do the initial counts, Sandy was sur-
the graft size. Jim, the senior resident, and the attending prised at how quickly the past three hours had gone. At the
surgeon changed sides of the table. Jim asked for some end of the case, Laura brought the ICU bed into the oper-
3-0 prolene suture and began sewing the graft into the ating room. Sandy stood by the OR bed with warm blan-
patientʼs ruptured aorta. The anesthesiologist motioned for kets to cover the patient as Joe removed the drapes and
Sandy to come to the head of the bed. He asked her to Lisa secured the dressing. As she was placing the blan-
check the warming blanket, as both the bladder and kets on the patient, Sandy realized the draw sheet and the
esophageal temperatures registered at 35 degrees. linen on the OR bed were saturated with fluid. She asked
Laura to get a couple of bath towels to dry off the patient.
Sandy checked the hypo/hyperthermia machine. The low A dry draw sheet was placed under the patient, who was
Continued on Page 61

Aligning practice with policy to improve patient care 59


Keep your surgical patients desert dry.
Medline’s Sahara® Super Absorbent OR table sheets 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 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 learn more about Sahara OR table sheets and
your OR turnover time and help reduce cross contamina- Medline’s comprehensive product line, contact your
tion risk through a combination of disposable products. Medline representative, call 1-800-MEDLINE or visit
us at www.medline.com.
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.

www.medline.com
then lifted onto the ICU bed. The patient was gently turned
As with
so Sandy and Laura could assess the patientʼs skin, which
any surgical
was intact with no redness noted. As the patient was being complication,
transported out of the OR, Sandy pulled the fluid-saturated prevention
sheets off the OR bed and placed them in the laundry is the key.
hamper. She examined the reusable warming/cooling
blanket and realized there was no fluid left in the blanket.
She could not see a hole in the blanket, but nonetheless
disconnected the blanket from the machine and placed it related to the use of a warming/cooling blanket tend to
in the trash. occur in lengthy procedures in which the aorta is cross
clamped. ECRI recommends the following when using a
A couple of days later, after she had transported a patient hypo/hyperthermia blanket in the operating room1:
to the CVICU, Sandy decided to check on the young man • The blanket should be covered with a sheet.
with the ruptured aorta. She poked her head into the • The circulating water temperature as well as the patient
CVICU room. The patient was lying on his side, asleep. temperature should be monitored.
His nurse, Jennifer, was in the room doing her charting. • The thermostat on the unit should be set at a maximum
Sandy asked how the patient was doing. Jennifer replied temperature of 42 degrees Celsius.
that he was progressing remarkably well, and his main • The machine should be used and maintained according
complaint was pain on his back where it appeared pres- to the manufacturerʼs recommendations.
sure ulcers were developing. Jennifer and Sandy gently
lifted the blankets off the patientʼs back. There were red- Additional recommendations from the ECRI Institute to
dened areas on both scapulae as well as a four-inch long avoid skin injuries in the operating room include1:
red area on his thoracic spine. They covered the patient. • Check the OR bed mattress for sufficient padding
and thickness.
Back in the OR, Sandy found Joe. She gave him an update • Verify that the patient safety strap is not placed too tightly,
on the patientʼs condition and the pressure ulcers devel- restricting circulation or placed over a grounding pad or
oping on the patientʼs back 48 hours postoperatively, quite ECG electrode.
possibly related to lying on the fluid-saturated operating • Lift anesthetized patients rather then rolling or
room bed linens. tugging them.
• Avoid pooling of solutions under the patient.
Preventing pooling fluids and pressure ulcers
Great care is taken by preoperative nurses to avoid the Todayʼs technology offers impervious disposable fabrics to
formation of pressure ulcers in surgical patients. Bony cover the operating room bed. Some of these fabrics trap
prominences are padded and towels are placed to avoid fluid, wicking moisture away from the patient. This helps
pooling of solutions under the patient. The use of water- to reduce the possibility of the patient lying on wet bed
based hypo/hyperthermia systems in the operating room linens during the operative procedure, potentially resulting
should not be overlooked as a potential cause of pressure in the formation of a pressure ulcer.
ulcer formation in operative patients.
Keep your patient desert dry. As with any surgical compli-
Minute holes in water-based hypo/hyperthermia blankets cation, prevention is the key.
might not be evident until the pressure from the weight of
a patient is placed onto the blanket, causing the fluid in the Reference
1 ECRI Institute. Skin Injury in the OR and Elsewhere. Available at:
coils to leak out. According to a report from the ECRI http://www.mdsr.ecri.org/summary/detail. aspx? doc_id=8185. Accessed Novem-

Institute, an evidence-based practice center, injuries ber 4, 2008.

Aligning practice with policy to improve patient care 61


Two out of three
employees feel that the flow
of communication between
the departments of their
facility is poor.

All information is
important, but different
disciplines value and prioritize
it in different ways.

62 The OR Connection
Special Feature

Why Can’t We All


Just Get Along?
Improving relationships within
healthcare facilities

By Dayna Lowe, Clinical Instructor

Does your facility have a failure to communicate?


If it does, youʼre not alone. Surveys show that two out of three employees
feel that the flow of communication between the departments of their facility
is poor.2

First and foremost, healthcare providers, no matter what their discipline,


want to give their patients the best possible care. If this is true, why are
there so many problems? It all comes down to communication.

Hospitals claim that nursing homes never seem to send the right paper-
work with their patients. Certainly it is not always this bad, but we are all
guilty of similar thoughts from time to time.2 Nursing homes often say that
hospitals transfer all of their complex problems to them.

Although important, communication takes time – time that many people


simply do not feel they have.

Healthcare facilities are only getting bigger. Many hospitals are part of a
larger system that not only includes acute care facilities but outpatient serv-
ices, doctorsʼ offices, rehabilitation centers and long-term care facilities.
Departments that need to communicate many be a floor away from each
other or miles apart in different buildings. Even with email and phones so
readily available, important information still gets forgotten.2

How can you help your own facility?


So what can you do? There is no one simple solution for breaking down the
barriers of communication between healthcare providers of different
organizations. Improvements need to be tailored to the needs of each
facility. However, there are some basic guidelines that we can all follow.

First of all, the information that is truly important and necessary needs to be
identified. So often, time is wasted sifting through documents and repeating
the same piece of information over and over. All information is important,
but different disciplines value and prioritize it in different ways. Communi-
Continued on Page 65

Aligning practice with policy to improve patient care 63


We take
blood pressure cuffs
personally.

A study found that 77 percent of blood pressure cuffs focus on their primary concern – the patient – instead of
wheeled from room to room in a hospital were contami- hunting down connectors.
nated.1 Choosing Medline disposable blood pressure
cuffs is great way to battle those bugs. To learn more about Medline disposable blood
pressure cuffs and our Blood Pressure Cuff Stan-
Medline’s Blood Pressure Cuff Standardization Program, dardization Program, please contact your Medline
which helps ensure that virtually all blood pressure representative, call us at 1-800-MEDLINE or visit
monitors accept the same www.medline.com.
cuff connector, allows the
1 De Gialluly C, Morange V, de Gialluly E, Loulergue J, van der Mee N,
cuff to follow the patient
Quentin R. Blood pressure cuff as a potential vector of pathogenic microor-
throughout their stay and ganisms: a prospective study in a teaching hospital. Infect Control Hosp
then be discarded. This Epidemiol. 2006 Sept;27(9):940-3.

helps to reduce the likelihood


of cross contamination and
also frees up caregivers to

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. www.medline.com
cation checklists for different departments could be devel- another. They must communicate in an efficient and proper
oped so that only necessary information is shared and manner. Last but not least, they need to ensure that the best
nothing is missed. They would ensure the sharing of “need to possible communication tools are available and that their staff
know” rather then “nice to know” information.2 has adequate training on their use. Staff must learn to work
with new technology and with each other. They must
Properly conducted team-building remember that this is all done for the
exercises can dramatically improve how good of the patient.
well department heads and staff mem-
bers work with each other. Typically, this
Communication checklists
References

requires the use of an outside profes-


for different departments 1 Plsek P. Interdepartmental communication in a
large hospital. Available at: http://www.plexusinsti-
sional with experience getting fellow
could be developed so
tute.org/ edgeware/archive/think/main_tales9.html.
employees to unite as a team. Part of Accessed September 2, 2008.
that only necessary
these exercises could also include staff
information is shared 2 Katcher BL. How to improve interdepartmental
communication. Available at: www.discovery-
rotating to other facilities to see “how the and nothing is missed.
surveys.com/articles/itw-017.html.
other half lives.” Not only does this give Accessed September 2, 2008.
everyone a better understanding of what 3 Spring Valley Hospital Medical Center. High marks
for prompt ER care. Available at: http://valleyhealth.
other facilities do, it also gives employ- uhspublications. com/winter2007/story2.html.
ees a more rounded perspective of how Accessed September 2, 2008.
the work of the organization is con-
ducted and the importance of sharing
information between departments. It About the author
is also a great way for different or- Dayna Lowe has been a surgical tech-
nologist for six years. She currently
ganizations to get to know one another.2
works at a hospital in Florida and as an
Instructor of Surgical Technology at
Facilities need to look into available com-
Central Florida Institute.
munication technology and train their
staff how to use communication tools
properly. Without adequate education,
these tools can be used incorrectly,
causing more problems then they solve.

As we plunge headlong into the 21st


century, health care will only continue to
get bigger and more complex. Staff will
be expected to provide skilled services faster then ever
before. Administrators and managers of these organizations
must set good examples for their staff. They must be able
to put aside any personal differences and work with one

Aligning practice with policy to improve patient care 65


How to Set Priorities
and Get the Job Done

When you donʼt set priorities, you tend to follow the path Popularized in Brian Tracyʼs book Eat That Frog!, the idea
of least resistance. Youʼll pick and sort through the things here is that you tackle the biggest, hardest and l e a s t
you need to do and work on the easiest ones, leaving the appealing task first thing every day. Just knuckle down and
more difficult and less fun tasks for a “later” that, in many do it, and the rest of the day will be a breeze.
cases, never comes. Or, worse, the “later” may come just be-
fore the action needs to be finished, throwing you into a whirl- The second approach is for people who thrive on accom-
wind of activity, stress and regret. There are three basic plishment, who need a stream of small victories to get through
approaches to setting priorities, each of which probably suits the day.
different kinds of personalities.
If you thrive on accomplishments – move big rocks
The first is for procrastinators, people who put off unpleas- Maybe youʼre someone who fills your time fussing over little
ant tasks. tasks. Youʼre busy all the time, but somehow, nothing impor-
tant ever seems to get done. You need the wisdom of the
If you are a procrastinator – eat a frog! pickle jar. Take a pickle jar and fill it up with sand. Now try to
Thereʼs an old saying that if you wake up in the morning and put a handful of rocks in there. You canʼt, because thereʼs
eat a live frog, you can go through the day knowing that the no room.
worst thing that can possibly happen to you that day has
already passed. The day can only get better! If itʼs important to put the rocks in the jar, youʼve got to put
the rocks in first. The pickle jar is all the time you have in a

66 The OR Connection
Special Feature

If you thrive on
accomplishments –
move big rocks

day. You can fill it up with meaningless little busy-work tasks,


leaving no room for the big stuff, or you can do the big stuff I. Important and Urgent
II. Important and Not Urgent
To put it into practice, sit down tonight before you go to bed III. Not Important but Urgent
and write down the three most important tasks you have to IV. Not Important and Not Urgent
get done tomorrow. In the morning, take out your list and
attack the first “big rock.” Work on it until itʼs done or you canʼt If youʼre really on top of your time management, you can
make any further progress. Then move on to the second, and minimize Q1 tasks, but you can never eliminate them – a car
then the third. Once youʼve finished them all, you can start in accident, someone getting ill, a natural disaster. These things
with the little stuff. all demand immediate action and are rarely planned for.

The third approach is for the more analytic types, who need After youʼve plotted out your tasks on the Covey quadrant
to know that theyʼre working on the objectively most important grid, according to your own sense of whatʼs important and
thing possible at this moment. what isnʼt, work as much as possible on items in quadrant II
(and quadrant I tasks when they arise).
If you are analytical – use the Covey quadrants
If you just canʼt relax unless you absolutely know youʼre working Spend some time trying each of these approaches on for size.
on the most important thing you could be working on at every Itʼs hard to say what might work best for any given person.
instant, Stephen Coveyʼs quadrant system might be for you. In the end, setting priorities is an exercise in self-knowledge.

Covey suggests you divide a piece of paper into four Reprinted with permission from www.mercola.com.
sections, drawing a line across and a line from top to bottom.
Into each of those quadrants, you put your tasks according to
whether they are:

Aligning practice with policy to improve patient care 67


Conquer Stress During
Tough Economic
Times
By Wolf J. Rinke, PhD, RD, CSP

68 The OR Connection
Caring for Yourself

Housing market imploding? Your 401(k) down


the tubes? Uncle Sam bailing out everyone ex-
cept you? No wonder stress is at an all-time high,
to the point that many stress-related diseases are
increasing logarithmically. (Things are so bad that
the Occupational Safety and Health Administration
has classified stress as a workplace hazard.) Even
though some stress is good for us – for example,
the excitement (stress) you experience when you
are getting ready to go on vacation or start a new
project – most other forms of stress, especially the
type that you experience when you feel out of con-
trol, are bad for us (dysfunctional stress). It turns on
your fight or flight response and causes your body to
produce more adrenaline and hormones such as
cortisol, norepinephrine, epinephrine and DHEA-S,
which increase your blood pressure and pulse,
tense your muscles and diminish the effectiveness
of your immune system. Dysfunctional stress will
lead to fatigue, frequent headaches and upset
stomach. Long-term dysfunctional stress con-
tributes to chronic health problems such as
high blood pressure, heart disease, depres-
sion and memory loss. It may also lead to
family breakdowns and injuries, especially on
the job. To manage stress during tough eco-
nomic times, I recommend you master the most
powerful stress reduction technique of all time. It
consists of just three steps:

Three steps to stress reduction


1. Change the changeable
Donʼt like something? Change it! Your stocks driv-
ing you nuts? Sell them! Is the media giving you acid
indigestion with their incessant stream of bad news?
Turn off the TV! Donʼt fret, complain or whine … just
do it! Remember, you donʼt have to do anything you
donʼt want to do. All right, you caught me. There is
one thing you have to do – die. Everything else is a
choice. So what can you do? Get rid of the words “I
have to.” Using these three little words generates
“victim” behavior patterns. And victims experience
dysfunctional stress, which will make you sick.

2. Remove yourself from the unacceptable


Find something unacceptable? Get out of the way!
Your credit card debt interfering with your sleep?

Aligning practice with policy to improve patient care 69


1. Hang out with positive people
Negative people drain your battery. Positive people charge
your battery. So minimize the time you are together with
“stinking thinking” people.

2. Recognize that you are not your job


Although we define much of who we are by what we do,
you are a lot more than your job. You get paid what you are
worth in the marketplace based on supply and demand, not
based on who you are. Getting little pay does not mean that
you are not a worthy person. In fact, you may be the most
worthy human being on this planet.

3. Get your life in balance


If youʼre experiencing problems at home and at work, youʼll
accelerate the burnout process. So think creatively, and
develop a strategy for balancing personal and professional
demands. For example, if you know youʼll be working late
all week, arrange to meet your family for dinner one of
those evenings at a nearby restaurant or plan a weekend
Start paying them off now and cut up all your credit cards
outing. Recognize that the most important things in life are
except one for true emergencies. Being followed by some-
relationships – not stuff! So make time for the real important
one who is overdosing on road rage? Move out of her way
things in your life: your spouse, your children, your parents
and let her have a “coronary” without your help. Working
and your friends.
for a toxic boss? Start shopping for a new one. Whatever
you do, just do it without fretting, whining … I know youʼre
4. Cut the electronic umbilical cord
catching on!
Too many of us simply no longer know how to relax. When
we leave work to go home or on a vacation, we not only
3. Accept the unchangeable
take work with us, we are still tied into the office via pager,
There are lots of things beyond your control – for example,
email, cell phone or our “crackberries.” Discipline yourself
the crashing global economy. Regardless of how much you
to turn those things off. (Heads up: you are not nearly as
stress yourself, you will likely not be able to change it. So
important as you think you are.) Better yet, donʼt even give
let it go. And then there are your parents. No matter how
out your cell phone number. I use mine only for bona-fide
much you would like them to be different, they wonʼt be. So
emergencies. Also, leave work at work so that you can set
love them the way they are, not the way they ought to be.
aside time to relax and recharge – recreate yourself.
(By the way, that is a great prescription for getting along
with all people!) Getting older – accept it. You are beautiful
5. Reduce your commuting time
just the way you are! Donʼt sweat your chronological age –
If you are commuting more than one hour a day, itʼs time to
something that you canʼt change. Instead, take care of your
move. One hour a day means that you are wasting about
body. Thatʼs something you can have a positive impact on
30 working days per year. Plus, you are already stressed by
right now.
the time you get to work. If you must commute, get in the
habit of listening to motivational and educational CDs – it
15 stress-reduction strategies will reduce your perceived commuting time dramatically. (If
Once you have mastered the basic three, here are 15
you donʼt know where to start, go to www.WolfRinke.com.
additional stress-reduction strategies to help you kiss stress
We have several powerful CDs to choose from.)
good-bye once and for all.
Continued on Page 73

70 The OR Connection
Small in size.
Big on safety.

Sometimes smaller is better! The transthermal backing on 9100 Series electrosurgical pads
provides a barrier of moisture; it is waterproof and fluid resist-
At just 15 square inches, the Medline Universal Pad with propri-
ant. The backing allows heat to escape 25% faster than the
etary Safety Ring meets the same thermal performance stan-
foam traditionally used on grounding pads, reducing the risk of
dard as traditional electrosurgical pads up to 33% larger in
excessive heat buildup.
conductive surface area.

For more information on the impact the Universal


Despite its smaller size, this pad is big on safety. The propri-
Pad 9100 Series can have in your OR, contact your
etary Safety Ring allows the pad to be oriented in any direction
Medline sales representative or call 1-800-MEDLINE.
and also reduces corner and edge effect by more uniformly dis-
persing electrosurgical current over the entire conductive
surface of the pad.
Electrosurgical Pad
9100 Series

Manufactured by 3M
Medical Division
www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Jeepers, creepers...
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You canʼt manage time. We all get the same 24 hours every
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(Have you ever noticed that all of us make time for all the
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your high pay-off items are and do them when you are at
6. Find a boss who knows how to MBA – manage your best. For most of us, thatʼs in the morning. And donʼt
by association forget to make vacation and play time a priority.
If you report to a toxic boss, someone who constantly
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itʼs time to look for a new boss, or at least stay away from If youʼre having problems with a family member or someone
your current boss as much as you can. (Seagull manage- at work, arrange to meet and discuss the situation. By
ment is when the boss flies in, makes a lot of noise, eats opening the lines of communication, youʼll set the stage for
your lunch, craps on you and flies back out.) If you are a a fair resolution. You might even find out that what seemed
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Weʼve made our lives too simple. Make yours more difficult
by conducting your next meeting while walking (walk and 13. Celebrate more often than you think is wise
talk), use a stand-up desk, park in the farthest spot from Set attainable and measurable goals for each of your
the door, take the stairs, walk into the bank instead of using projects, whether they are at home or at work. Then cele-
a drive up window, mow your lawn with a push mower, and brate each baby-step accomplishment with small rewards,
so on. such as taking time to go out to lunch with your spouse
or colleagues. It will keep you motivated and increase
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Do approximately 30 minutes of aerobic exercise every
other day, such as jogging, biking or fast walking. Alternate 14. Reduce information
that with resistance exercise like lifting weights or using a Most of us suffer from TMI – too much information. So when
“gym” machine. And be sure to start every exercise session you need to make a decision, avoid whatʼs referred to as
with light warm-up exercises and end with a comprehen- “decision optimization” in systems language. (A friend of
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Youʼll be surprised how refreshed you feel just by taking believe that most of us need lots more reminding and less
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as taking three very deep breath and exhaling slowly, going to do the right thing – we just forget what we already know.
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Aligning practice with policy to improve patient care 73


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74 The OR Connection
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given to Ellerbee for her coverage of the lished in 2000, won her raves among mid- giving inspirational speeches to others.
Clinton investigation), a duPont Columbia dle school readers. Both of Ellerbeeʼs She is as direct with women as she is with
Award and six Emmys. previous adult books—And So It Goes, a kids; they understand that she understands
humorous look at television news, and their lives.
These days, Ellerbee and her work can be Move On, stories about being a working
seen all over the television universe. Lucky single mother, a child of the ʻ60s and a Although Ellerbee has won all of televi-
Duck has and continues to produce prime- woman trying to find some balance in her sion's highest honors, she says itʼs her two
time specials for ABC, CBS, HBO, PBS, life—have been national best sellers. Eller- children whoʼve brought her the richest
Lifetime, MTV, Logo, A&E, MSNBC, SOAP- beeʼs recent book, also a best seller, Take rewards. Ellerbee spends her personal time
net, Trio, Animal Planet and TV Land, Big Bites: Adventures Around the World in New York City and Massachusetts with
among others. Ellerbee was honored with and Across the Table, a tribute to her love of Rolfe, her partner in work and life and their
an Emmy for her series, When I Was a Girl, travel, talking to (and eating with) strangers, dogs, Daisy and Dolly.
which aired on WE: Womenʼs Entertain- and, according to Ellerbee, “oh, just making
ment network. trouble in general.”

Aligning practice with policy to improve patient care 77


Healthy Eating

Bruschetta Delizioso
A delicious and easy appetizer!

5 tomatoes (chopped)
Ingredients

1/2 cup extra-virgin olive oil

2 tablespoons balsamic vinegar


5 fresh basil leaves (julienne cut)
1 bulb of garlic
1 loaf of French bread
Salt and pepper to taste

Preheat oven to broil. Combine the tomatoes, extra-virgin


Directions

olive oil, balsamic vinegar, basil, salt and pepper in a


medium bowl. Set the bowl aside. Slice the loaf of French
bread so that each slice is about one-half inch thick. Place
the bread on a cookie sheet and toast on the top rack of the
oven. Once the bread has turned a golden-brown color, flip
each piece in order to toast the other side. Remove the
bread from the oven once both sides have been toasted.
Peel the garlic cloves and rub directly on each side of the
toast. Spoon the tomato mixture on top of the bread Note: This recipe, created by Emily MacInnes, won an award at
and serve. Medlineʼs Employee Appreciation Week International Cook-Off!

78 The OR Connection
Forms & Tools

The following pages contain practical tools for implementing


patient-focused care practices at your facility.

SCIP
Fact Sheet ..................................................80

Policy and Procedure ..................................82


Hand-Off Communication

Perioperative SBAR ....................................85


Endoscopy SBAR........................................86

Pressure Ulcer Prevention


Checklist ................................................89

Aligning practice with policy to improve patient care 79


FACT SHEET
Summary of SCIP Measure Changes for 10/1/08+ Discharges

All Measures:
x For the exclusion data element Clinical Trial, notes were added that the patient must be enrolled in the
trial during this hospital stay. There must be a signed consent in the medical record and the trial must be
studying patients with the same condition as the measure set being abstracted.

VTE-1 and VTE-2:


x Patients whose surgeries lasted < 60 minutes or whose hospital stays were < 3 calendar days will be
excluded from SCIP-VTE-1 and 2. The algorithms were revised to reflect this. With this change, the data
element Discharge Time is no longer necessary and was removed from the data dictionary.

Data Element and Table Changes

Data Element
New Clarification Change
or Table
Beta-Blocker ¥ x Documentation of a time associated with the last dose of
Perioperative the beta-blocker is necessary to verify that it was taken
within the perioperative time frame. If the patient arrives on
the day of surgery and there is documentation that the
beta-blocker was taken on that same day prior to
admission, the abstractor can select “Yes.”

Beta-Blocker ¥ x The data element Sex will be used in the algorithm to


During exclude male patients.
Pregnancy

Contraindication ¥ x Physician documentation of a bleeding risk associated with


to VTE surgery, such as the normal risk described in the operative
Prophylaxis permit, will not be considered a contraindication to
pharmacological prophylaxis.

Discharge Time ¥ x Because cases with a hospital stay ” 3 days are excluded
from the VTE measures, the data element Discharge Time
is no longer necessary.

Other Surgeries ¥ x Implanted or pocketed cardiac devices that are performed


without general anesthesia will be abstracted as “Yes” for
Other Surgeries because the antibiotic prophylaxis given
for these procedures could interfere with the prophylaxis
for the principal procedure.

Summary of 10/1/08 SCIP Manual Revisions Page 1 of 2


Hospital Interventions QIOSC/Hospital Quality Measures Special Study

80 The OR Connection
September 2008
Data Element
New Clarification Change
or Table
Preoperative Hair ¥ x Documentation that does not reflect actual hair removal,
Removal such as surgeon documentation in the operative report
that the patient was “shaved and prepped,” should not be
considered when answering this data element.
x Hair removal that is documented as performed with
scissors will be collected with Value 3 – Clippers.
x Exclusions were added for non-surgical site hair removal
and hair removal performed during the patient’s daily
hygiene routine.

Surgery End ¥ x The inclusion terms are now prioritized as 1st, 2nd and 3rd.
Time The data sources are no longer prioritized.
x Priority order applies to items in the inclusion table, not to
source document. Also, the synonyms in the lists are
alphabetized, not prioritized.

x The Notes for Abstraction were modified to be consistent


with the instructions for Surgical Incision Time.

Surgical Incision ¥ x The priority lists were changed to more accurately reflect
Time the wording commonly found in operating room
documentation.
x Priority order applies to items in the inclusion table, not to
source document. Also, the synonyms in the lists are
alphabetized, not prioritized.

x The Notes for Abstraction were modified to be consistent


with the instructions for Surgery End Time.

Vancomycin ¥ x Allowable Value 2 was revised to include MRSA


colonization or infection.
x Allowable Values 1, 3, 4, 7 and 9 can be documented by
persons other than physician/APN/PA or pharmacist.
Allowable Values 2, 5, 6, 8 and 10 must still be
physician/APN/PA or pharmacist documentation.

Table 1.3 Beta- ¥ x 5 medications were added to the table of beta-blockers.


Blockers

Table 2.1 ¥ x Doripenem was added to the antibiotic table.


Antimicrobial
Medications

For a complete list of changes please see the “Release Notes,” located in the Specifications Manual for National
Hospital Quality Measures for discharges 10/1/2008. The manual can be found at
http://www.qualitynet.org/dcs/ContentServer?cid=1192804535739&pagename=QnetPublic%2FPage%2FQnetTier3
&c=Page

This material was prepared by Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for
Oklahoma, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services. The contents presented do not necessarily reflect CMS policy. 4-728-OK-0908

Aligning practice with policy to improve patient care 81


Summary of 10/1/08 SCIP Manual Revisions Page 2 of 2
Hospital Interventions QIOSC/Hospital Quality Measures Special Study
September 2008
Forms & Tools Hand-Off Communication

Hand-Off Communication in the Perioperative Setting

Policy • Holding area RN reports to anesthesia, the surgeon


• “Hand-offs” are interactive communications that allow and the circulating RN
the opportunity for questioning between the giver and • Circulating RNs report to the PACU RN and/or the
receiver of patient information. patient care unit RN
• Anesthesiologists report to the PACU RN and/or to
• Hand-off communication includes: the patient care unit RN
• Accurate patient information regarding care, • Surgical team (surgeon, nurse, surgical technologist)
treatment and services transfer of on-call responsibility
• Patientʼs current condition and diagnosis • Surgeon hand-off from the perioperative area to
• Recent or anticipated changes in the patientʼs inpatient units
condition • Critical laboratory and radiology results
• What to watch for in the next interval of care disseminated to the surgical team

• Specific examples of times when the transfer of Procedure:


responsibility for the surgical patient, i.e., hand-offs, • Healthcare professionals shall be allotted the time
occur include, but are not limited to, the following: for hand-off patient communication and to ask and
• Shift change or break relief answer questions with minimal interruption. It is
• Physician to surgeon/nurse to nurse/surgical hoped that this will lessen the amount of information
technician to surgical technician transfer of that might be forgotten or simply not conveyed.
patient responsibility
• When surgeons and nurses are transferring the • Healthcare professionals shall find a quiet area to give
patient to another level of care within or outside of a verbal report (hand-off communication) to ensure
the organization accurate, clear and concise information is given with
• Patient care unit RN/ambulatory care RN report to a minimum of interruptions.
the holding area RN

I-SBAR: An example of hand-off communication


Introduction Situation Background Assessment Recommendations

State name Pre-op diagnosis History/past Vital signs Pain control


and unit hospitalization
NPO status Isolation required IV pump
State patient (# of hours) Infection control/
name, age, isolation Pain assessment Family communication
gender Procedure
Primary language Medications EKG
Mental status
Sensory impairment Activity/mobility/ Treatments
Patient stable/ falls risk
unstable Special needs: spiritual, Radiology
cultural, learning, Risk factors
Allergies communication
Other issues
Advance Directive Religious needs:
refuses blood
Code status
transfusion
Family (location,
Disposition of patient
contact person/
belongings
number)

82 The OR Connection
Hand-Off Communication Forms & Tools

• Hand-off communication shall be conducted Operating room team to post anesthesia care unit:
face-to-face. • Surgical procedure (completed vs. planned)
• Anesthesia
• Healthcare professionals shall give each other the • Estimated blood loss
opportunity to ask questions, answer questions and • Input and output (i.e., straight catheter, Foley)
read-back or repeat-back information, as needed. • Allergies
• Medications (received intra-op)
• The following is an example of a generic hand-off • Significant medical history (i.e., contact precautions)
communication that may be used. • Family contact information
• Equipment needs (i.e., sequential
Perioperative hand-off communication: compression devices)
• Other issues (i.e., blood products, anesthesia
• At specific points within the perioperative continuum, concerns)
specific communications shall occur and shall include,
but are not limited to:
References
Joint Commission. Improving Hand-off Communications: Meeting National
Patient care unit/holding area to operating room: Patient Safety Goal 2E. Joint Perspectives on Patient Safety. 2006;6(8):9-15.
• Patient identification http://www.jcipatientsafety.org/15427/. Accessed May 8, 2007.

• Planned surgical procedure


AORN. “Perioperative Patient 'Hand-Off' Tool Kit, http://www.aorn.org/
PracticeResources/ToolKits/PatientHandOffToolKit/.
• Site marking Last Accessed September 28, 2007.
• Planned anesthesia type
• Allergies Reprinted with permission from Medical Consultants Network, Inc.

• Antibiotics to be given
• Significant medical history
• Family contact information
• Other issues (i.e., NPO, blood products available)
• Last voided
• Equipment needs
• Pre-operative medications

Change of shift/breaks/lunch relief:


• Procedure
• Surgeon plan and preferences (where we are in
the case)
• Anesthesia
• Allergies
• Significant medical history
• Counts
• Irrigation
• Medications
• Instrumentation on and off field
• Specimens on and off field
• Tubes, lines, equipment

Aligning practice with policy to improve patient care 83


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©2008 Medline Industries, Inc.
84 a registered trademark of Medline Industries, Inc.
www.medline.com
SBAR Hand-Off Communication Forms & Tools
Label

TMC Perioperative Hand-Off Communication Date:


Family MD: DNR: Yes No Modified Method of transfer: IV Fluids:
Wheelchair Cart
Isolation/Infection: Ambulatory
Surgeon: IV Access: PICC
Mobility: Bedrest Assist

S
MRSA ! VRE ! Saline Lock
Ambulatory
Anesthesia: C Diff ! Other ! Central Line
Peripheral
Fall Risk:
Admitting Diagnosis: NPO: Yes No Mental Status:
Low ! High ! Alert
O2 Needs: Restless
NKA Communication: Confused
Allergies: HOH R L Combative
Core Measures Vision Impairment: Speech Clear: Yes No
Unresponsive
Contacts Glasses !
SCIP/SIP CHF Non-English speaking
Past Medical History: Initial vitals: TPR _____________ Pre-op Antibiotic:
Diabetes HTN CAD PVD B/P_________02 Sat_____________ Time:
CVA Arthritis Renal disease Height________Weight__________

B
COPD Asthma Seizure Admission Blood Glucose___________ Med Given:____________Time______
Pacer/AICD
Med Given:____________Time______
ASA Score __________
Other: ETOH Smoker Med Given:____________Time______
H&P Yes No
Dentures/Partials/Loose teeth

*No B/P ______ arm* Pre-procedure verification: Yes No


Site Marking: Yes No N/A Last pain med:
Anesthesia: MAC Local Foley: Yes No Pain Control: (circle one)
General Spinal Block Epidural Straight Cath: Yes No PCA Epidural Intermittent IV
PO N/A
Procedure/Operation: OR Intake: Medication:
Blood/Blood Products:
Duramorph: Yes No
__________________________ OR Output:

A
EBL: PACU discharge pain score_______

Dressings: Pertinent Assessment Findings: Med Reconciliation completed !


Operation End Time:____________
Penrose: Yes No Packing: Yes No PACU Vitals: PACU Intake:
Drains: JP Hemovac Cardiac Rhythm________________
NG gravity suction G-tube IV #____IV credit on Transfer_________
Stryker Reinfusion start time: Treatments: TEDS SCD’s CPM
Chest Tube: Suction Water Seal Heimlich ASA________ PACU Output: Foot Pumps Polar Care Binder

Misc. Information: Family Notified: Yes No Pre-op RN Sig: __________________

Intraop RN Sig:___________________________

R Postop RN Sig:___________________________

Call______________for any
questions @ ext.___________.

This document is not a part of the permanent medical record

Aligning practice with policy to improve patient care 85


Forms & Tools SBAR Hand-Off Communication
Label
TMC Endoscopy Hand-Off Communication Date:
Room/location:
DNR: Yes No Method of transfer: IV Fluids:
Admitting MD: Modified Wheelchair Cart Ambulatory
IV Access: PICC
Mobility:

S
Surgeon: Isolation/Infection: Saline Lock
Bedrest Assist Ambulatory Central Line
MRSA ! VRE !
Peripheral
C Diff ! Other ! Fall Risk:
Admitting Diagnosis: Low ! High ! Mental Status:
NPO since: _________ Alert
Communication: Restless
NKA HOH R L
Confused
O2 Needs:
Speech Clear: Yes No Combative
Allergies: Unresponsive
Vision Impairment: Non-English speaking !
Contacts Glasses

Past Medical History: Initial vitals: TPR _____________ Do home meds include:
B/P_________02 Sat_____________
Diabetes HTN CAD PVD Height________Weight__________ B/P ____

B
CVA Arthritis Renal disease Cardiac_____
COPD Asthma Seizure ASA Score __________ Diabetes: oral____ insulin_____
Pacer/AICD MAO inhibitor_____
H&P Yes No
Other: ETOH Smoker Pain Status:____________________
Pre-procedure verification: Yes No
*no B/P ______ arm*
Site Marking: Yes No N/A
Anesthesia: MAC Medications given:
Procedural Sedation
Demerol __________
Procedure/Operation: Aldrete Score:__________________
Fentanyl __________

EGD Versed ____________ Cardiac

A ERCP Rhythm:________________________
Peg Tube
Bronchoscopy Cetacaine Spray: Time____________
Colonoscopy Endo discharge pain score_________

Polypectomy: Yes No Other Med:______________________

Reversal agent: Yes No Med Reconciliation Completed !


__________________________ ________________________________

Misc. Information: Family Notified: Yes No Pre-op RN : ___________________

Procedural RN :___________________________

R Postop RN: ______________________________

Call______________for any
Questions @ ext.___________.

This document is not a part of the permanent medical record

86 The OR Connection
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Bovie is a registered trademark of Bovie Medical Corporation.
Pressure Ulcer Prevention Policy and Procedure Forms & Tools

Pressure Ulcer Prevention Checklist: Perioperative Services

Yes No Position Comments/Notes


Responsible

Do you have a policy and procedure for skin and risk assessment that addresses:
a. How and when a patient is considered at risk for
development of a pressure ulcer and in need of
prevention intervention(s)?
b. Who is responsible for developing, implementing
and monitoring the prevention care plan?
Do you have prevention protocols for staff to
implement when specific pressure ulcer risk factors
are identified?
Do you have a policy and procedure for positioning patients at risk for pressure ulcer that addresses:
a. Pressure redistribution OR table pads for
procedures lasting longer than two hours?
b. The use of gel table pads when indicated?
Do you warm your patients 30 minutes prior to the
surgical procedure to maintain core body
temperature intraoperatively?
Does the individualized care plan for each patient at
risk for pressure ulcers address the following
prevention interventions:
a. Pressure, friction and shear reduction
1. Pressure redistribution OR table pads or
overlays (foam, gel)?
2. Positioning/repositioning techniques?
3. Positioning devices (foam, gel, wedges, etc.)
to prevent pressure on bony prominences?
4. Mechanical aids (lifts, slide boards, sliding
sheets) for lifting, moving and
positioning/repositioning?
5. Protection for head, elbows and heels?
6. OR tables of sufficient sizes to fit your
patient population?
b. Skin care
1. Does skin inspection occur prior to and
immediately following the surgical procedure?
2. Is skin is kept dry during the surgical
procedure with minimal exposure to moisture,
perspiration and drainage?
3. Is it ensured that warming blankets are not
placed between the pressure redistribution
table pad and the patient in high-risk patients?

Aligning practice with policy to improve patient care 89


Forms & Tools Pressure Ulcer Prevention Policy and Procedure

Yes No Position Comments/Notes


Responsible

4. Is skin cleansed with a skin-cleansing agent


and thoroughly dried as soon as the surgical
procedure is complete (before moving to the
holding room)?
5. Do you minimize skin-drying factors?
Do your protocols address repositioning patients
whenever possible (head, heels, arms etc.) in long
surgical procedures at least every two hours?
Are there adequate supplies and equipment for staff to
provide prevention interventions to all patients who
require them?
Does the care plan include routine monitoring of the
effectiveness of the prevention interventions?
Is there a protocol for when the prevention care plan
should be evaluated and revised?

90 The OR Connection
•••••••••••••••••••••••••••••••••

Ami Lends a Hand


By Laura Kuhn
The OR Connection staff writer

When Ami arrived at work and obtained her “I agree,” Ami said. “But maybe using lotion
assignments for the day, she learned that would help moisturize your hands so sani-
the patient in Room 210 had contracted tizing them wouldnʼt hurt. You know, itʼs a
Clostridium difficile. She proceeded to myth that the alcohol in those sanitizers
the isolation cart to obtain her personal makes them sting. It only stings if
protective equipment before entering your skin is already compromised.
the room. And you could always find a little
bottle of it to carry around with you
The patientʼs name was Jeffrey, and so itʼs always available.”
he was three days post inguinal
hernia repair. Dr. Payton sighed. “Look, Ami, I
know. Iʼll talk to you later, okay?”
“How are you feeling today, Jeffrey?” With that, he was off to his next patient.
Ami asked him. “Iʼm so sorry to hear
about the infection. Weʼre going to do Ami stood in the hallway for a
everything we can to make sure that moment, deciding what to do. Then
you donʼt pick up any other infections. she smiled to herself and walked to the
Iʼm sure Dr. Payton will be by soon to nursesʼ lounge. She picked up the phone
check in on you.” and dialed the facilityʼs hand hygiene
product vendor.
Ami had no more than said his name when Dr.
Payton walked into the room. He had been a surgeon at A few days later, Dr. Payton entered his office to find
the hospital for as long as anybody could remember and sample-sized bottles of hand lotion and the same hand
was beloved by his patients for his gentle bedside manner. sanitizer that the hospital used. He laughed to himself and
tucked the bottles inside his coat pocket.
“Hello there, Jeffrey,” Dr. Payton said. “You should be able
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

to get back to skiing in six to eight weeks, if you take care of The next day, Ami saw Dr. Payton in the hallway. He
yourself. Now, letʼs get a look at my handiwork.” He peeled caught her attention, took the bottle of hand sanitizer out of
Jeffreyʼs bandage back to inspect his wound. Then, satis- his pocket, applied it to his hands and waved at her before
fied, he placed the bandage back over the wound. entering a patientʼs room.

“Everything looks good,” Dr. Payton told Jeffrey. “We need Ami smiled and gave him a thumbs-up.
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

to get this nasty infection cleared up so that we can get you


home. Iʼll stop by later and check in on you again.” He stood
to leave, and Ami followed him from Jeffreyʼs room.

“Dr. Payton, I noticed you didnʼt sanitize your hands before


touching Jeffrey,” she said to him quietly once they were in
the hallway.

Dr. Payton sighed. “I know, Ami, but this cold weather is


really wreaking havoc on my skin. If I sanitized my hands
all the times weʼre supposed to, they would be unbearably
sore. And letʼs face it, this is a job where I need my hands
to be in good condition!”
Stay tuned for the continued adventures of Medline’s family
of nurse dolls, Ami, Angel, Alice Aurora and Anastasia!

Aligning practice with policy to improve patient care 91


The Hottest Debut at AORN!

Want to meet the NEWEST ADDITION


to Medline’s family of nursing dolls?
You’ll have to stop by our booth at AORN Congress
in Chicago! We’ll give you just one hint to the newest
doll’s identity … you asked for it!

www.medline.com

MKT208305/LIT167R/15M/SEL5