Beruflich Dokumente
Kultur Dokumente
Volume 2, Issue 3
Make
2008
Your Best Year
EVER!
CMS
NEVER
Slaying the
“SUPERBUGS” EVENTS
Back to Basics:
Perioperative
Patient Positioning
FREE CE CREDIT!
See page 32
Subscribe to
The
OR Connection
Aligning practice with policy to improve patient care
About Medline
Medline, headquartered in Mundelein, IL, CARING FOR YOURSELF
manufactures and distributes more than 100,000 72 How to Make 2008 Your Best Year Ever
products to hospitals, extended care facilities,
surgery centers, home care dealers and agencies 78 How Does Your Body’s Shape Influence Your Health?
Page 48
and other markets. Medline has more than 700 86 Best Day/Worst Day
dedicated sales representatives nationwide to
support its broad product line and cost 92 Recipes for Strong, Healthy Living
management services.
Dear Reader,
Our world in health care as we’ve known it is chang- Recently, we invited a group of perioperative direc-
ing. This past August, the final rule for the Inpatient tors and infection control practitioners to discuss
Prospective Payment System (IPPS) was released. innovations in health care, ways to improve perform-
This marks the beginning of change in reimburse- ance and challenges that they faced on a day-to-day
ment for hospitals. As a result of the new ruling, the basis. We asked the group to rank their biggest
hospital-acquired conditions (HAC) provision will go concerns as they relate to HACs. Interestingly we
into effect October 1, 2008. Eight conditions were found many similarities in their answers. Here was
selected by the Centers for Medicare and Medicaid the result of the perioperative rankings:
Services (CMS) based on three criteria: 1) the
condition was high cost, high volume, or both; 2) it 1 Objects left in surgery (62 percent)
was assigned a higher paying DRG when present 2 Surgical site infections (62 percent)
as a secondary diagnosis; 3) it was reasonably 3 Pressure ulcers/vascular catheter-associated
prevented through the application of evidence-based infections (25 percent each)
guidelines. These newly announced conditions are
as follows:1
There was strong public support for CMS to pay less Sue MacInnes, RD, LD
for conditions that are acquired during a hospital stay. Editor
And so, in less than a year from now, there will be a
financial impact if a patient acquires any one of these
eight conditions after they have been admitted.
1. Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions. Available at: http://www.cms.hhs.gov/Hospital
AcqCond/06_Hospital-Acquired%20Conditions.asp. Accessed November 26, 2007.
Content Key
We've coded the articles and information in this magazine to indicate which patient
care initiatives they pertain to. Throughout the publication, when you see these
icons you'll know immediately that the subject matter on that page relates to one
or more of the following national initiatives:
• IHI's 5 Million Lives Campaign
• Joint Commission 2007 National Patient Safety Goals
• Surgical Care Improvement Project (SCIP)
We've tried to include content that clarifies the initiatives or gives you ideas and
tools for implementing their recommendations. For a summary of each of the above
initiatives, see pages 8 and 9.
4 THE OR CONNECTION
Special Feature
Continued
Reimbursements won’t just be reduced 2% treatment), but the balance of evidence may
annually for failing to report on quality measures; point in a different direction,” Keckley added.
they will be denied altogether when hospitals
fail to take steps needed to ward off the eight Under the new rules, CMS will not pay hospitals
conditions that are, as CMS put it in a Fact for the higher costs of treating patients for the
Sheet on its FY 2008 IPPS final payment eight “hospital-acquired conditions” assigned
rules, "reasonably preventable through as secondary diagnoses, unless the secondary
application of evidence-based guidelines." diagnoses were “present on admission.” The
eight conditions subject to the new policy
“Traditionally, we have been keen on what we Oct. 1, 2008, are:
do and our processes, but we have taken the
position that outcomes are out of our control,” 1. Catheter-associated urinary
Keckley observed. “This ruling is a step in tract infections
the direction of saying the results of what 2. Vascular catheter-associated infections
we do should be how we are judged, how 3. Mediastinitis, a surgical site infection
we are paid.” following coronary artery bypass
graft surgery
How will the policy shift affect perioperative 4. Pressure ulcers
practice? "If we are following our standards
to ensure patients are getting the best care
possible, then these new [CMS] rules for non-
payment shouldn't be an issue. Unfortunately,
these ‘never events’ do occur," acknowledged
“ This ruling
is a step in the
direction of saying
5. Falls
6. Retained objects in surgical patients
7. Blood incompatibility
8. Air embolisms
Jane Kusler-Jensen, RN, BSN, MBA, CNOR, Also included in the FY 2008 IPPS final rule
the results of what
FABC, director of perioperative services with we do should be were five new quality measures that hospitals
Columbia St. Mary's Healthcare system in will have to report in order to qualify for
Wisconsin and a member of AORN's Board the full annual payment schedule updates.
how we are judged,
of Directors. "This new ruling may force all how we are paid.” Several will directly affect perioperative
healthcare professionals to take a closer look managers, including reporting cardiac surgery
at their practice and lead to greater support from risk patients with controlled 6 a.m. postoperative serum glucose,
managers and other hospital quality departments." reporting surgery patients with appropriate hair removal and
reporting surgical patients on beta blocker therapy before
Keckley believes the new IPPS rules and a host of outcome- admission who received a beta blocker during the
based reimbursement policies to follow in future years will perioperative period.
pose a challenge for hospital administrators and department
managers to move beyond “the old model in which the doctor CMS will also be working to create codes to identify ventilator-
or surgeon says what goes, and the manager’s job is to associated pneumonia and to determine when septicemia and
accommodate them, even though we know that in some deep vein thrombosis are not present on admission and preventa-
cases it may lead to substandard outcomes.” ble in the hospital. These additional conditions may be added
to CMS' list of nonpayable conditions for the next fiscal year.
Under the old model of perioperative practice, “the surgeon is
captain of the ship,” Keckley explained. “Under the new model, Carina Stanton and Cathy Sparkman contributed to this story.
the focus is on optimal outcomes, and the surgeon becomes
Reprinted with permission from AORN (www.aorn.org) AORN Manage-
part of a team, working in a coordinated effort to establish ment Connections (October 2007) online newsletter. Copyright © AORN,
evidence-based processes of care and measure the outcome Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231.
of those processes,” he said.
The Association of periOperative Registered Nurses (AORN) is the national
association committed to improving patient safety in the surgical setting.
The focus on outcomes adds the concept of “effective care” With over 41,000 members, AORN is the premier resource for perioperative
to the ongoing healthcare industry focus on “safe care,” Keckley nurses, advancing the profession and the perioperative professional with
noted. The goal isn’t just to avoid harm to the patient or care- valuable guidance as well as networking and resource-sharing opportunities.
AORN is recognized as an authority for safe operating room practices
givers but to use evidence-based practices to develop treatment and a definitive source for information and guiding principles that support
plans that will yield optimal outcomes, he said. “The system day-to-day perioperative nursing practice. For more information, visit
now rewards doctors for making these judgments (about www.aorn.org.
6 THE OR CONNECTION
The National
Quality Forum Checking in with IHI
What’s ahead
Facts at a glance in 2008
Origin
In a report issued in 1998, a Presidential Commission
recommended the creation of a national forum in which
healthcare’s many stakeholders could, together, find Strengthening the “National • Seeking, at the hospital level,
ways to improve the quality and safety of American Learning Network”: The [5 Million to create a critical mass of
healthcare. The National Quality Forum (NQF) was Lives] Campaign currently has field successful facilities on each
incorporated as a new organization in May 1999. offices (often consisting of state intervention in each state.
hospital associations, quality • Connecting with new audiences
Purpose improvement organizations and and stakeholders (e.g., payers,
To improve the quality of American healthcare by setting other state-level stakeholders in purchasers, policymakers,
national priorities and goals for performance improvement, quality and safety) in every state, patients and families)
endorsing national consensus standards for measuring and several affinity groups for rural,
and publicly reporting on performance, and promoting
pediatric and public facilities. These Execution: We must transfer the
the attainment of national goals through education and
field offices, together with local practical approaches and methods
outreach programs.
mentor hospitals, provide energy of those hospitals that succeed
The National Quality Forum has broad participation and support to area facilities as most rapidly and completely to all
from all branches of the healthcare system, including they pursue improved quality. In the participating facilities, with a specific
national, state, regional and local groups representing next year, the Campaign will emphasis on the leadership roles,
consumers, public and private purchasers, employers, strengthen the national learning management structures and skill
healthcare professionals, provider organizations, health network that these organizations sets that enable significant change.
plans, accrediting bodies, labor unions, supporting comprise by A major activity here includes the
industries and organizations involved in health care focusing on several levels: identification of at least one mentor
research or quality improvement. • Seeking, at the national level, hospital (i.e., a high-achieving hos-
to better coordinate improvement pital willing to coach other facilities)
Strategic goals
priorities and support activities for every intervention in every state,
1. NQF-endorsed standards will become the primary
standards used to measure the quality of healthcare with partners like AHA, AMA, taking us to a critical mass of suc-
in the United States. ANA, CMS, CDC and the cessful facilities across the nation.
2. NQF will be the principal body that endorses national Joint Commission.
healthcare performance measures, quality indicators • Seeking, at the state level, to Enrolling 4,000 hospitals
and/or quality of care standards. empower local field offices to
3. NQF will increase the demand for high-quality better support local improvement Conducting measurement
healthcare. activities through an infusion of studies: In order to thoroughly
4. NQF will be recognized as a major driving force for expert support, quality improve- assess national progress, the
and facilitator of continuous quality improvement of ment training and other helpful Campaign will be conducting or
American healthcare quality.
resources. In addition, inviting helping to design several studies
the most successful state efforts to track national change in mortality,
Organizational goals
1. Promote collaborative efforts to improve the quality to document their “recipes for harm and performance on the
of the nation's healthcare through performance success” and act as laboratories Campaign interventions.
measurement and public reporting. for improvement to lead the rest
2. Develop a national strategy for measuring and of the nation. To learn more,
reporting healthcare quality. • Seeking, in large public and visit www.ihi.org
3. Standardize healthcare performance measures so private systems, to establish
that comparable data is available across the nation. and support ambitious aims
4. Promote consumer understanding and use of for improvement.
healthcare performance measures and other
quality information.
5. Promote and encourage the enhancement of system
capacity to evaluate and report on healthcare quality.
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.
Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission
offers guidance to help organizations meet goal requirements.
This year’s new requirements have a one-year phase-in period that includes defined expectations for planning,
development and testing (“milestones”) at 3, 6 and 9 months in 2008, with the expectation of full implementation
by January 2009.
SCIP aims to reduce surgical complications in four 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.
8 THE OR CONNECTION
Patient Safety
NEW FOR SCIP is eagerly awaiting the official draft of CMS’s 9th Scope of Work to determine future
2008! program updates and changes.
Also available:
Sterillium® Comfort Gel™
for non-surgical
hand antisepsis
Putting SUPERBUGS
on the DEFENSIVE
By Theo Francis
The Wall Street Journal
14 THE OR CONNECTION
Special Feature
Hospitals are prime breeding grounds and other infections. Some hospitals Hospitals have long attempted to keep
for antibiotic-resistant "superbugs" that have found a marketing opportunity in infection rates low, but the spread of
kill tens of thousands of Americans each infection prevention: They are pushing resistant strains has made the fight that
year. But most people have had no way overall infection rates toward zero – and much more urgent in recent years. Last
of knowing how well their hospital keeps advertising it. They are trumpeting preven- week, concerns came to a head with a
these bacteria – and infections in general tion efforts, such as campaigns to improve new study showing that antibiotic-resistant
– under control. hand washing. And some are tracking infections are probably far more extensive
patients who have been infected with than previously thought. The study pub-
That is starting to change. Nineteen states superbugs such as methicillin-resistant lished in JAMA, the Journal of the Ameri-
have adopted laws in recent years Staphylococcus aureus, or MRSA, and can Medical Association, concluded that
requiring hospitals to report overall monitoring them to prevent the spread. MRSA causes 94,000 infections a year.
infection rates publicly, with more likely The study estimated that MRSA, one of
to follow suit. And Thursday, nearly two "This is one of those cases where the biggest infection concerns in hospitals,
dozen federal lawmakers, headed by quality is also the best business case," contributes to nearly 19,000 deaths. The
Pennsylvania Rep. Tim Murphy, says Jonathan Perlin, chief medical vast majority were linked to health care,
proposed legislation requiring officer at hospital chain HCA Inc., which including hospitals, nursing homes,
nationwide public reporting. has enlisted staffers and visitors alike in dialysis and others.
its own campaign to keep germs away
So far, just four states have published from patients. At the same time, recent student
some infection rates for individual hospitals, illnesses and deaths have prompted
and only one state, Pennsylvania, breaks While antibiotic-resistant infections have school closings in some states. And
out different types of infections. But even gotten the attention of late, hospitals have starting next year, Medicare will no longer
where patients can't find state-mandated long struggled with infections of all kinds. reimburse hospitals for some infections
infection reports, they can increasingly Common bacteria including Staphylococ- acquired after admission, in an effort
get information from their local hospital cus aureus can infect the bloodstream, both to encourage vigilance and to
about practices to prevent super-bugs urinary tract, lungs or surgical incisions save money.
of patients whose immune systems are
already compromised. Over time, some
strains of these bacteria have developed
Continued
16 THE OR CONNECTION
Broader Testing On their own, some hospitals have been
Some states are also beginning to mandate turning to a variety of new technologies to
broader testing specifically for MRSA, try to cut down on infections, particularly
since patients can carry the bug and superbugs, ranging from antibiotic-coated
spread it without showing signs of infection. catheters to work surfaces made of copper,
Pennsylvania will soon require hospitals which has antimicrobial properties, as
to test high-risk patients, including those well as software. For several years, many
admitted from nursing homes. In August, hospitals have also participated in federally
New Jersey and Illinois adopted legisla- sponsored programs to reduce surgical
tion requiring hospitals to identify patients complications, including infections acquired
carrying MRSA and isolate them, in the hospital.
among other provisions.
Write to Theo Francis at theo.francis@wsj.com4
Don Goldmann, senior vice president of URL for this article:
SURGICAL
SITE
INFECTIONS
By Shawn Boynes
The Association for Professionals in Infection • View from the OR: Partnering About APIC
Control and Epidemiology, Inc. (APIC) for Prevention APIC’s mission is to improve health
launched a nationwide series of educational • Working Towards A Zero and patient safety by reducing risks
programs this past spring to showcase best Infection Rate of infection and other adverse
practices related to preventing surgical site outcomes. The Association’s more
infections. The APIC Grand Rounds: Protecting Featured presenters are nationally than 11,000 members have primary
Patients from the Risk of SSIs is underwritten recognized experts, including: responsibility for infection prevention,
by an unrestricted educational grant from • Marilyn Jones, RN, MPH, CIC, BJC control and hospital epidemiology
ETHICON, INC. and provides a comprehensive Healthcare (St. Louis, Mo.) in healthcare settings around
approach to understanding the nature and • Charles Edmiston Jr. PhD, MS, CIC, the globe, and include nurses,
risks associated with surgical site infections. Froedtert Hospital (Milwaukee, Wis.) epidemiologists, physicians, micro-
This programming is particularly important • Sina Matin, MD, Baylor Health Care biologists, clinical pathologists,
given CMS’s recent decision that reimburse- Systems (Irving, Texas) laboratory technologists and public
ment for SSIs will cease as of October 2008. • Maureen Spencer, RN, M.Ed, CIC, health practitioners. APIC advances
New England Baptist Hospital its mission through education,
Preventing surgical site infections requires (Boston, Mass.) research, collaboration, public policy,
engaging professionals across the continuum • Lillian Burns, MT, MPH, CIC, practice guidance and credentialing.
of health care, including infection prevention Greenwich Hospital
and control professionals, operating room (Greenwich, Conn.)
nurses, physicians and hospital administrators. • Elizabeth Duthie, RN, PhD,
For this reason, the SSI Grand Rounds NYU Hospitals Center (New York, N.Y.)
emphasizes a team approach to the reduction • Kristina Dreifuerst, MSN, RN,
of SSIs, concentrating on the partnership APRN-BC, CWOCN,
between the operating room and infection University of Wisconsin School of
prevention and control. Nursing (Madison, Wis.)
• Michael McGuire, MD, FACS,
The Grand Rounds program provides a St. Johns Hospital (Santa Monica, Calif.)
framework for addressing clinical impact of • Ramon Berguer, MD, FACS,
SSIs as well as the financial impact on Contra Costa Regional Medical Center
healthcare facilities. Practical presentations (Martinez, Calif.)
provide ways to develop a program for the
elimination of SSIs using evidence-based About the author For more information about the
practices and include: Shawn Boynes is the senior director of Grand Rounds, including the
education for the Association for Professionals
• Sustaining System-Wide SSI 2008 schedule,
in Infection Control and Epidemiology, Inc.
Rate Reductions visit www.apic.org.
• Reducing the Risks of SSI:
Medical Techniques
18 THE OR CONNECTION
Do you know the difference? By Lillian Burns, MPH, CIC
Wearing of rings or other jewelry when There are a few clinical situations that
providing routine care might be acceptable, also require an additional handwash.
but in high-risk settings, such as the operating The exceptions and appropriate measures
room, all rings and other jewelry should be are as follows:
removed. A simple and practical solution is • Heavily soiled hands should be carefully
to suggest that healthcare workers wear their rinsed, then washed with soap and
ring(s) on necklaces as pendants like many water, being careful not to spread con-
do who scrub in surgical procedures.16 taminants on clothing or surroundings.
When wearing a gown, the gown should
Hand antisepsis be changed and then the hands should
The term “hand antisepsis” is commonly be disinfected.18
defined as “disinfection of hands with an • If contamination occurs due to a puncture
antiseptic agent that prohibits growth and or glove perforation, gloves should be
development of microorganisms.” In line with removed, hands should be disinfected
this definition, the CDC, IHI (Institute of and new gloves should be applied.
Healthcare Improvement) and WHO recom- • Other than with the above exceptions,
mend using an alcohol-based hand antiseptic the following applies: If an additional
for disinfecting hands.14,16,17 Therefore, if handwash is desired, it should be per-
an indication requires hand antisepsis, formed after antisepsis.18 If hands are
handwashing with antimicrobial soap and washed prior to using a hand antiseptic,
20 THE OR CONNECTION
Sterillium® Comfort Gel®
Also available:
Sterillium Rub
for surgical hand
antisepsis
that Sterillium Comfort Gel achieves reductions of ≥ 5 log10 (≥ 99.999 percent) on a broad
while using up to 50 percent less volume per application.* Independent in vitro testing demonstrated
22 THE OR CONNECTION
Sensicare Surgical Gloves ®
Let us care for your hands and change your opinion on latex-free gloves
Medline’s Sensicare surgical gloves with aloe have demonstrated the ability
to moisturize and soothe dry, chapped hands.When these conditions are
improved, hand hygiene rates increase.
Sensicare surgical gloves with aloe are specially formulated with ISOLEX®, a
proprietary synthetic polyisoprene that has the physical properties of natural
rubber latex.
References
1 Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control
Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. American Journal of Infection Control.
2002 Dec;30(8):S1-46.
2 Larson E, Kretzer EK. Compliance with handwashing and barrier precautions. Journal of Hospital Infection. 1995;30:88-106.
3 West D, Zhu YF. Evaluation of aloe vera gel gloves in the treatment of dry skin associated with occupational exposure. American
Journal of Infection Control. 2003;31:40-42.
4 McCormick R, Buchman T, Maki D. Double-blind randomized trial of scheduled use of a novel barrier cream and an oil-containing
lotion for protecting the hands of health care workers. American Journal of Infection Control. 2000;28:302-10.
5 Larson EL, 1992, 1993, and 1994 Association for Professionals in Infection Control and Epidemiology Guidelines Committee. APIC
guideline for hand washing and hand antisepsis in health care settings. American Journal of Infection Control. 1995;23:251-69.
References
1 Kramer A, Schwebke I, Kampf G. How long do
nosocomial pathogens persist on inanimate sur-
faces?
A systematic review. BMC Infect. Dis. 2006;6:130.
2 McGinley KJ, Larson EL, Leyden JJ. Composition and
density of microflora in the subungual space of the
hand. J Clin Microbiol.1988;26:950-953.
3 Hedderwick SA, McNeil SA, Lyons MJ, Kauffman CA.
Pathogenic organisms associated with artificial finger-
nails worn by healthcare workers. Infect Control Hosp
Epidemiol. 2000;21:505-509.
4 Gross A, Cutright DE, D’Allessandro SM. Effect of
surgical scrub on microbial population under the
fingernails. Am J Surg. 1979;138:463-467.
5 Pottinger J, Burns S, Manske C. Bacterial carriage by
artificial versus natural nails. Am J Infect Control.
1989;17:340-344.
6 McNeil SA, Foster CL, Hedderwick SA, Kauffman CA.
Effect of hand cleansing with antimicrobial soap or
alcohol-based gel on microbial colonization of artifi-
cial fingernails worn by health care workers. Clin
Infect Dis. 2001;32:367-372.
7 Kownatzki E. Hand hygiene and skin health. J Hosp
Infect. 2003;55:239-245.
24 THE OR CONNECTION
Back to
Perioperative
Patient
Positioning
BASICS
Sixth in a Series
26 THE OR CONNECTION
Patient Safety
By Alecia Cooper, RN, BS, MBA, CNOR
“
“Vulval injury due to perineal post on fracture table.”
S
man undergoing internal fixation of a femur fracture.”
“Lower limb acute compartment syndrome after
”
colorectal surgery in prolonged lithotomy position.”
cary as they sound, all of the above are examples of real outcomes that occurred following
routine surgical procedures. We cannot say that every one of these injuries was caused due
to improper positioning, nor can we say that each injury could have been prevented. What
we can say is that improper positioning and lack of prevention and safety measures can
result in patient injury and lead to debilitating consequences, even death. Intraoperative
Intraoperative positioning injuries are devastating for both patients and surgical team members. function of unre-
skin injury is the
1 Pressure ulcers
duration of the
pressure and
2 Alopecia the location of
3 Nerve injuries
the pressure on
4 Physiologic compromises
the body surface.
Injury mechanisms that contribute to positioning include pressure (i.e., gravity), friction and
shear forces.¹
The risk of pressure
ulcers occurring as
As part of their 5 Million Lives campaign, IHI that did not respond to physical therapy. The
hyperextended.
states that because surgical patients who are patient alleged a lawsuit and the jury found
under anesthesia for extended periods of time for the plaintiff.6
often have an increased risk of developing
pressure ulcers, all surgical patients (pre-operative, In surgery, arms on arm boards are not extended
intraoperative, post-anesthesia) should re- more than 45 degrees, which increases the
ceive a skin assessment and risk assessment. likelihood that a surgeon or other caregiver
Caregivers should then implement prevention could inadvertently lean on the arm while
strategies such as ensuring repositioning and carrying out the surgical procedure. This can
placing patients on appropriate redistribution lead to ulnar nerve injury. The standard of
surfaces for all surgical patients who are iden- care when arm boards are used is to have
tified as being at risk.3 CMS has declared that the arms positioned with palms up, with plenty
as of October 1, 2008, hospitals will no longer of padding under them and with extensions
be reimbursed for eight preventable “hospital- of 45 degrees or less. Elbow protection is
acquired conditions,” several of which are often recommended.7 Respiratory function
associated with surgical procedures. One
Physiologic compromise
can be decreased by
of the eight is pressure ulcers.4
The most common example of physiologic
mechanical restriction
28 THE OR CONNECTION
events, anesthesia-related events, medical
equipment-related events and fire. As of June
30, 2007, there have been 534 op/post-op
Ask these very important questions
complications, comprising 11.9 percent of all before each patient procedure:
reported sentinel events – third only to wrong
site surgery and suicide. The op/post-op cate- 1. How many people will be needed to transfer the patient to
gory includes injuries from patient positioning, the operating table and to safely position the patient?
but only if the injury resulted in death. Also,
this category includes all unexpected patient Tip: Never transport or begin movement of the patient
deaths as a result of all surgical complications.9 until the appropriate number of personnel is available.
Therefore, there is not a reporting system that
captures the total number of patient injuries 2. What positioning devices will be needed to adequately and
due to surgical positioning. completely support the patient in the necessary position to
perform the operation?
Prevention of positioning injuries
The first step in preventing positioning errors
Tip: Have all necessary positioning devices and
is the development of a zero-tolerance atti-
padding materials in the operating room prior to
tude toward preventable patient injury among
transporting the patient.
all perioperative healthcare providers. This at- 3. Will the plan for positioning provide for airway management,
titude then lends itself very easily to imple- ventilation and monitoring access for the anesthesia
mentation of the necessary steps to prevent care provider?
and protect patients from injury. A comprehen-
sive positioning safety initiative must include
best practice, education and best products –
Tip: If the answer is no, change the positioning plan
Age
are available to allow for minimal patient exposure
Skin condition
n
5. Do I know the pressure points for the position that my
Nutritional status
n
patient may be prone to due to patient positioning?
Preexisting conditions (e.g., vascular,
n
immunocompromise)
Tip: Refer to the pressure points labeling exercise on
Type of anesthesia
Length of surgery
n
n
n Position required
External pressure
should be made.11
pressure (i.e., 23
to 32 mm Hg) can
cause occlusion
mattress pads are not effective in reducing There are several books and educational
and education
capillary interface pressure because they programs available to those seeking to provide
quickly compress under heavy body areas. additional training and education on patient
For years, pillows, blankets and molded foam positioning. A few include:
devices have been used to not only pad bony
prominences but to position patients on surgi- Textbooks
cal tables. These devices typically produce
only a minimum amount of pressure reduction Surgery, 13th Edition by Jane C.
n Alexander’s Care of the Patient in
and are not adequate for patient positioning.11 Rothrock (Published by Mosby)
Foam and gel pads provide better support for
padding of bony prominences. They are also Technique, 11th Edition by Nancymarie
n Berry & Kohn’s Operating Room
30 THE OR CONNECTION
Programs for purchase adequately.10 Education ensures that all prac-
n Periop 101: A Core Curriculum titioners have the knowledge and skill to apply
Available at: www.aorn.org the policies, education and training effectively.
n Safely Positioning the Surgical Patient Best products ensure that the items we use
AORN Video Library to protect our patients provide the protection
Available at: www.cine-med.com we expect.10
The perioperative nurse’s role The “Back to Basics” series was developed
in patient positioning due to our belief that perioperative profession-
At many facilities, the anesthesia provider als should adhere to basics of practice and
assumes the responsibility for patient positioning. incorporate new technologies with evidence-
In no way does this practice obliterate the based strategies to improve patient outcomes.
responsibility of the RN circulator to ensure Our readership is requesting “Back to Basics”
proper patient care alignment and tissue integrity topics in order to provide in-service, education
for each patient. For specific injury risks and and training in their facilities. The OR Connec-
safety considerations to be followed when tion is dedicated to continuing this service and
positioning the patient, we have provided a wants to hear from you regarding future “Back
copy of AORN’s Injury Risks and Safety to Basics” topics. Email your requests for
Considerations when Positioning Patients future “Back to Basics” topics to
on Page 94. This tool is designed to assist acooper@medline.com.
caregivers in making sure patient injury does
not occur.
hour of
To receive one r your 1
te
CE credit, en ne at 2
answers onli sity.com
niver
www.medlineu
3 4
5 6
7
8
9 10 11 12 13 14
15 16 17 18
19 20
21 22 23
24
25
26
27
28
29
32 THE OR CONNECTION
Across Down
3 Best practices include _____ that identify 1 Injury mechanisms that contribute to
the requirements for each surgical position. positioning include pressure, _____ and
5 The most common cause of _____ nerve shear forces.
injury in surgery is arms on arm boards not 2 The standard of care when arm boards are
being extended more than 45 degrees. used is to have arms positioned with palms
7 Intraoperative skin _____ is the function of up and to ensure adequate _____.
unrelieved pressure, duration of the 3 Patients are most vulnerable to respiratory
pressure and the location of the pressure compromise in the _____ position.
on the body surface. 4 ____ ensures that all practitioners have the
9 The operating room is a high-risk knowledge and skill to apply the policies,
environment for the development of _____. education and training effectively.
(2 words) 6 Pressure ulcers originating during surgical
12 The most common example of physiologic procedures may appear within a few hours,
compromise is effects to the respiratory but the majority present one to three
system due to positioning interfering with _____ after surgery.
the patient’s _____ system. 8 Positions such as lithotomy and
18 Potential positioning injuries include Trendelenburg’s can cause redistribution
pressure ulcers, _____, nerve injuries, and congestion of the _____ supply.
and physiologic compromises. 10 Beginning October 1, 2008, hospitals will
19 The result of pressure ulcers occurring as no longer be _____ for eight preventable
a result of _____ is thought to be as high “hospital-acquired conditions.”
as 66 percent. 11 After repositioning or any movement of the
21 Before the patient is transferred from the patient, procedure bed or devices that
operating table, a thorough visual attach to the procedure bed, the patient
assessment should be performed and should be ______ for body alignment.
_____ in the patient’s record. 13 Category 488, operative/post-op
23 Pressure alopecia is an under-recognized complications, currently ranks _____
and rare complication of _____ surgery. overall in the number of sentinel events
24 Pressure ulcers are _____ injuries that reported.
develop rapidly. 14 Alopecia has been documented as a
25 The Joint Commission collects _____ event precursor for pressure ulcer development
data for all operative injuries. when occurring after sustained immobility
26 Preoperative identification of _____ for and pressure to the _____.
pressure ulcers is imperative. 15 The first step in _____ positioning errors is
27 Positioning _____ should be provided for the development of zero tolerance toward
each surgical position and its variations. preventable patient injury among all
28 Procedures lasting longer than two and perioperative healthcare providers.
one-half to three hours significantly _____ 16 Best _____ ensure that the items we use to
the patient’s risk for pressure ulcer protect our patients provide the protection
formation. we expect.
29 After positioning, the perioperative nurse 17 Patients under anesthesia for extended
should _____ the patient’s body alignment periods can have an increased risk of
and tissue integrity. developing pressure ulcers, so all surgical
patients should receive a skin _____ and
risk assessment.
20 Before the patient _____ the operating
theater, assessment for positioning needs
1. Register (free) or log in
www.medlineuniversity.com
should be made.
2. Click Free Courses tab
22 Firm and stable positioning devices help
3. Locate the puzzle and click Learn More,
then Begin Course distribute pressure evenly and _____ the
4. Certificates are available online after potential for injury.
puzzle completion
COUNTING ACCOUNTABILITY
36 THE OR CONNECTION
to SafetyNet is analyzed to look for patient
safety trends and assists AORN in developing
educational programs, recommended practices
Retained sponge costs $2.4 million
A first-grade teacher in Pembroke Pines, Fla. was
and position statements to assist perioperative
nurses in providing safe patient care.
awarded $2.4 million in damages after a foot-long
According to SafetyNet data, several factors sponge was left inside her abdomen during a
contribute to variable sponge counts. These routine cesarean section.1
factors include distraction, such as the
circulating nurse leaving the room to obtain Karlene Chambers gave birth to her first child on
additional supplies during the counting September 11, 2001. She began to experience
process; excessive talking when counts are
excruciating pains in her abdomen shortly after
performed; sponges packed into cavities and
counts not being performed but documented the birth and returned to the hospital to find out
as having been done.1 what was wrong.
To reduce the likelihood of a retained foreign She was initially prescribed antibiotics for what she
object, AORN and the American College of was told was an infection. When the antibiotics did
Surgeons recommend that sponge counts
not alleviate her pain, the same physician who had
be performed in a systematic order, such as
smallest to largest, and according to national
performed her C-section, ordered an X-ray of her
standards and facility policy. Other recom- abdomen. The X-ray revealed that a one-foot surgical
mendations by the agencies include providing sponge had been left in her uterus after she gave birth.
adequate personnel to support safe practices;
using only X-ray detectable sponges, towels An X-ray alone would not have revealed the sponge
and instruments in surgical sites; developing if the manufacturer had not attached a blue thread to
and reviewing policy and procedures related
it to make it X-ray detectable.
to counting to promote consistent practices
and utilizing technology such as radio
frequency detection to ensure that all Reference
sponges, towels and instruments are MSNBC.com. Woman awarded $2.4 million after surgical sponge
removed from the patient.1 left in abdomen. Available at:
http://www.msnbc.msn.com/id/21128136/.
To learn more about SafetyNet and Accessed October 15, 2007.
the Patient Safety First initiative, visit
ww.patientsafetyfirst.org.
Reference
Best practices for preventing a retained foreign body.
AORN Journal. 2006;84(1) Supplement 1:S30-S36.
38 THE OR CONNECTION
OR Issues
Heat loss in a patient in the operating room can be from conduction, convection,
radiation and/or evaporation.3 Conduction heat loss begins in the preoperative holding
area lying a on cool stretcher and continues in the OR while lying on the table. Military
personnel doing nighttime tactical operations where concealment is essential can
lose a significant amount of heat by being in close contact with rocks or outside walls
over a prolonged period. Heat loss by convection involves the ambient air moving How hypothermia develops
over the body, decreasing the body’s core temperature. Because air is technically a Hypothermia develops
fluid, the analysis of heat transport from the patient involves convection. When a body during general anesthesia
in three phases:
is submerged in water, heat loss from convection is 32 times greater than when it is
exposed to air. Heat loss from radiation is the process where a person’s body radiates 1. Initial rapid reduction in core
heat away from the body and into the room. Evaporation is the loss of heat via temp after anesthesia induction
perspiration, open wounds and natural secretions. resulting from internal redistribu-
tion of body heat
General anesthesia takes away the body’s natural responses to increase heat pro- 2. Core temp decreases at a rate
determined by the difference
duction. Heat loss is common because anesthetics alter thermoregulation, prevent between heat loss and production
shivering and produce peripheral vasodilatation. All perioperative and anesthesia
3. When sufficiently hypothermic,
personnel should always keep in mind that once the core temperature of a patient thermoregulatory vasoconstriction
begins dropping, it will continue to drift unless actions are taken to help prevent is triggered and core-to-peripheral
worsening hypothermia. Postoperative warming should not be a routine substitute flow of heat is restricted
for maintaining intraoperative normothermia.
Through simple actions, we can disrupt the cascade effect of hypothermia. Active
“prewarming” for 30 to 60 minutes usually minimizes hypothermia. Having the patient References
undress in a warm environment and covering them with warm blankets preoperatively 1 Dorland. Dorland’s Illustrated
aids in the prewarming. Commercial gown heaters are on the market and act as a nice
Philadelphia, Pa.: Saunders; 2007.
Medical Dictionary, 31st Edition.
adjunct to the warm blankets. Warming of the OR table with forced warm air and/or
2 Spry C. Essentials of Periopera-
warm blankets reduces the convection heat loss aspect. Intraoperative use of forced-air tive Nursing, Third Edition. Boston,
blankets, with the recommended associated blankets, and warmed intravenous solutions Mass.: Jones and Bartlett Publish-
all aid in the heat retention of the patient. Airway heating and humidification are ers; 1997.
3 Barash PG, Cullen BF, Stoelting
ineffective4; however, I have found that certain airway filters and single-limb anesthesia
RK, eds. Clinical Anesthesia, 2nd
circuits help preserve normothermia. Edition. Philadelphia, Pa: JB Lippin-
cott; 1992.
Measuring of the patient’s temperature is vital and continuous intraoperative core 4. Roizen MF, Fleisher, LA.
temperature can be obtained from the pulmonary artery, distal esophagus, tympanic
Second Edition. Philadelphia, Pa.:
Essence of Anesthesia Practice,
membrane and nasopharynx. The rectum, mouth, axilla and bladder can be used except Saunders; 2002.
in cardiopulmonary bypass. If there is any vital discrepancy between intraoperative and
immediate postoperative temperatures, a core temperature should be sought to verify
the patient’s temperature status.
With the number of warming adjuncts at our disposal, all perioperative and anesthesia
personnel should be cognizant of our patients’ physiological need to stay warm, and
help deter the “worst part of surgery.”
Adding to the complexity of this risk for the patient are the emerging airborne
infectious diseases, which can make their way into the operating room (OR).
A case in point involves the emergence of drug-resistant strains of tuberculosis
(TB), particularly XDR-TB (strains which are extensively drug resistant). In
addition to XDR-TB, the potential for emergence of pandemic influenza, possibly
from strains causing avian influenza, and recent experience with worldwide
SARS pandemic are other unwelcome visitors to the OR.
Masks
Filtration products
Breathing bags
Anesthesia accessories
Laryngeal masks
Endotracheal tubes
Oral airways
Laryngoscopes
Oxygen therapy
PREVEN TIN G
M EDIA
STIN Mediastinitis,
inflammation
By Denice Summerlin, RN
46 THE OR CONNECTION
Infection prevention measures
for cardiac patients:
Step 1: Assess all cardiac patients prior to Step 9: Use a surgical prep solution containing
surgery for common clinical risk factors, i.e., CHG (chlorhexidine) to provide maximum
diabetes, immune deficiency, malnutrition, hepatic residual kill.
dysfunction, alcohol or drug abuse, COPD,
smoking and obesity. Step 10: Administer prophylactic antibiotics
within one hour of the surgical incision and
Step 2: For scheduled procedures, assess pa- postoperatively for a minimum of 48 hours.
tients prior to admission for signs and symptoms
of secondary infection. One example would be Step 11: Utilize maximal barrier precautions
Nare cultures preoperatively for MRSA as part (AAMI Level 4) for surgical gowns and surgical
of the pre-admission protocol. drapes around all fenestrations.
Step 3: Instruct use of chlorhexidine showers Step 12: Segregate surgical instruments
the night before surgery and the morning of surgery. between the graft harvest site (leg) and the chest
cavity instruments.
Step 4: Warm patients for a minimum of 30
minutes prior to the surgical procedure. Step 13: Closely monitor and document blood
loss intraoperatively.
Step 5: Implement preoperative, individualized
insulin protocol for diabetic patients before and Step 14: Consider using endoscopic vein har-
after surgery. vesting (EVH) technology for vein graft harvest.
The advantages of EVH are the reduced trauma
Step 6: Utilize alcohol-based hand antiseptic to the leg and the painless and faster mobilization
products prior to patient contact and for the of the patients.6
surgical scrub prior to donning surgical gloves.
Step 15: Consider silver antimicrobial
Step 7: Assure that all supplies, personnel and dressings postoperatively.
equipment are ready and available prior to bring-
ing the patient into the OR and beginning the Step 16: Assure that all pertinent information
surgical procedure to prevent any unnecessary regarding the surgical procedure and patient
intraoperative delays. tolerance is documented and communicated
at the time of hand-off in the critical care unit.
Step 8: Do not shave the surgical site. Clip
only the hair necessary for operative preparation
immediately before the surgical procedure.
Tips for
“Going Green”
in the
Operating
Room
By Ann Shimek
Healthcare facilities are faced with limited abilities to channel the stream of
waste due to government regulations, restrictions on incinerators and the decreasing number
of landfills that will accept medical waste.1 Couple this with escalating environmental concerns
for our planet and layer on top of that the call for “zero tolerance” in strategies to stop the
spread healthcare-associated infections.
All of this is leading to more product introductions, more chemicals and more single-use products.
What’s an operating room to do? After giving this some thought, I started making a list of how
we could possibly initiate a “Go Green” strategy in the OR and remarkably came up with an
entire list of ways to begin!
We’ve also provided a list of 20 tips for effective recycling and waste segregation in your facility.
Read through the list and see how many of these practices you’re already using – and how
many you can add to your routine!
See if you can add to the list and take this as a challenge to “Go Green” in your practice setting!
48 THE OR CONNECTION
“Go Green”
Tips for the OR1
and Prosthetics
“joint”
A Surgical site infections (SSIs) are the
most common healthcare-associated
Who is at risk?
Even though the infection rate has
infection in surgical patients. Current data decreased considerably over the years
concern
tell us that SSIs occur in 2.6 percent of all there are still factors that will put some
operations and lead to increased cost patients at a higher risk than others.4
and increased length of stay (LOS).1
The Centers for Disease Control and Health concerns such as
Prevention (CDC) define SSIs as those diabetes, obesity, history of
infections occurring within 30 days of an smoking, rheumatoid arthritis,
operation, and within one year if an
implant was placed surgically.
periodontal disease, HIV,
hemophilia, malnourishment,
Developing an infection in any orthopedic
advanced age and immune
procedure with or without implants can
suppressive therapy increase
be devastating, but when an implant is a patient’s chances of acquiring
infected you have major trouble. Studies an infection and should be taken
show that the incidence of SSIs is greater into consideration.5
in total joint arthroplasties than other
Table 1: Participation in orthopedic procedures (see Table 1). Other risks that might put the total joint
mandatory surveillance of
SSI in orthopedics2 replacement candidate at a greater
risk include psoriasis (especially at the
Total no. Total no.
Trusts Procedures no. SSI % infected incision site), previous prosthetic joint
infections and a lengthy operative time,
Total Procedures 146 4242 593 1.44
Total hip prosthesis 109 16809 208 1.24 especially if that time is longer than 2.5
Hip hemiarthroplasty 71 5364 217 4.05 hours.3
Knee prosthesis 96 15792 102 0.65
Open reduction long 26 3277 66 2.01 What to look for
bone fracture
There are two major categories of post-
operative join infections: early and late.
As long as the world’s population lives Early (or Type I) infections occur at the
to be older, the incidence of degenerative time of surgery and symptoms are noted
joint disease and consequently the within one month.4 Early infections
need for prosthetic joint replacement present as painful red, swollen wounds.
will continue to grow. Inevitably, some of Purulent drainage is common and there
these patients will acquire an infection of are usually complaints of continuous pain.
their prosthesis. Although the rates are Systemic symptoms, such as an elevated
down, postoperative infections in total temperature, occur as well.3 These infec-
joint arthroplasties are still a serious tions are usually caused by hematomas
concern.3 that act as bacterial culture mediums.
They can also be triggered by super- and prosthetic loosening.5 An X-ray of scrubs can greatly reduce the
ficial wound infections spreading to the area will show destruction of bone chances of these bacteria infecting
the periprosthetic space.4 around the prosthesis. Most surgeons the surgical site.3
will suspect infection when this is
Late (or Type II) infections are also seen, but there is no way to definitively Clothing that can act as a barrier
thought to originate at the time of diagnose it. Direct microscopic exami- between these bacteria scales and
surgery, but the onset of symptoms nation and bacteriological cultures of the patient is also necessary. Over
is delayed. These patients present tissue samples obtained during the the years, different kinds of occlusive
between six months to two years revision procedure are the most surgical gowns have been produced
after an operation. Delay in onset common ways to obtain a definitive that are as effective, less costly to
occurs because the bacteria are able diagnosis.3 make and more comfortable to wear.
to adhere to the prosthesis and survive These materials are impermeable
undetected beneath a coating of Prevention is the best treatment to bacteria, yet permeable to air.3
“slime” that the organism formed.3 1. Preoperative IV antibiotic
The patient will begin to note pain administration is considered Operating rooms must be ventilated in
and inflammation at the operative to be the most successful way such a way to keep bacteria removed.
site. These symptoms, as well as to reduce infection rates. One such system is called laminar
findings on examination, are often 2. The number of personnel in the air flow. These systems produce large
non-specific and akin to those surgical room should be kept to a amounts of clean air that is continu-
seen with aseptic loosening of minimum and traffic in and out ously pumped into the room, changing
the prosthesis.3 of the room should be limited to the entire room air volume up to
essential tasks. five hundred times an hour.3
Diagnosis 3. Copious amounts of irrigation, both
The diagnosis of a prosthesis infection plain saline and antibiotic-infused,
is not easy because the results are are often utilized before insertion
so similar to those of aseptic joint of prosthetic components.6
loosening. Additionally, in the postop-
erative period, signs and symptoms Two major carriers of bacteria in an
often noted with infection (swelling, operating room are the staff and the
redness and drainage) are seen as patient. Thousands of bacteria are
normal postoperative changes.4 found on our body surfaces and travel
through the air on tiny scales of skin.
Images produced by CT scans and Even healthy people produce about
MRIs are often distorted by artifact one thousand of these bacteria-
caused when metallic images are carrying scales each minute. Proper
filmed in this way.4 Bone scans can- handwashing techniques and appro-
not differentiate between infection priate preoperative patient skin
52 THE OR CONNECTION
SILVASORB®
PERFORATED SHEET
Treatment
When faced with an infection, the
surgeon considers individual patient
characteristics, timing of the diagnosis
Spotlight on silver dressings
and the organism causing the infection.
An additional prevention strategy with increasing interest is the use
Although there are a few treatment
of silver dressings, which can provide localized broad-spectrum options, surgical removal of the
antimicrobial properties and an additional line of defense.8 prosthesis is almost always necessary.7
Silver does not promote bacterial resistance and is effective in Antibiotic therapy is used in con-
treating resistant bacterial species. The antimicrobial efficacy of silver junction with other treatments. Alone,
antibiotics are ineffective because
dressings depends on the silver content, the dressing formulation
bacteria attach themselves to the
and the way the dressing is made. A 1 percent silver sulphadi-
prosthesis and form a protective
azine cream has historically been used for burn wounds, and there barrier of slime that antibiotics are
are now silver dressings emerging on the market that are less toxic unable to penetrate. Once the revision
than silver sulphadiazine.9 Several dressings on the market are has been performed, patients are
impregnated with sustained-release ionic silver. Most of these usually on antibiotics for six weeks.
dressings absorb fluid from the wound bed and have The dose and type of antibiotic
used depends on the specific
antimicrobial protection.9
bacteria found.4
Studies are currently being proposed to measure the impact of Some patients might not be able to
applying silver directly into the surgical wound prior to closure. tolerate or refuse to have revision
surgery. These patients are often put
on suppressive antibiotic therapy for
the rest of their lives. It has been
demonstrated that in these patients,
infection was suppressed for four
years in about 60 percent of
all cases.4
54 THE OR CONNECTION
Imagine ensuring patient safety with standardized
56 THE OR CONNECTION
What is meant by a standardized
sterile procedure pack program? Top 10 benefits of a standardized
Take a quick survey of the following items
included in your current procedure packs
procedure pack system
and also stocked on your shelves: 1. Less OR traffic
Q
2. Standardization of commonly used items, i.e.,
Needle counters: How many variations
do you currently have in your packs?
needle counters, medication labels, skin markers,
electrocautery pencils, etc.
Surgical gowns: Are they the 3. Appropriate levels of protection for surgical gowns
appropriate level of protection for the according to the procedure being performed
procedure to be performed? Are they the
correct size?
4. Increased space in supply areas
5. Improved staff productivity
Which components contain latex and
which ones are latex-free?
6. Streamlined orientation process
7. Less risk for error
Are safety blades, needles and 8. Fewer SKUs to order and inventory
syringes immediately available? 9. Reduction in waste
Are sterile skin markers at 10. Overall cost savings to the system
your fingertips?
In most cases, your pack manufacturer will It is not just a dream. Standardization can
come in and do most of the work for you! become a reality. We invite you to join us
References
The work is in analyzing the components and try it. Then we can live in a world 1 World Health Organization,
used in each procedure, determining like where OR supplies can be as one.... Fifty-Fifth Word Health Assem-
bly, Provisional agenda item
items and agreeing to standardize on the 13.9, A55/13, March 23, 2002.
one best component that will meet the 2 Kohn LT, Corrigan JM, Donald-
needs of 90 percent of the end users. It Please refer to the Form & Tool on son MS, eds. To Err Is Human:
Page 103 for Tips for Building a
really is that simple and can be performed System. Washington, DC:
Safe Pack.
Building a Safer Health
CBL addresses Competency-based learning is a very powerful To fully understand the impact of CBL at Humber,
the requirements foundation for the construction of any e-based you need to know a little about the facility.
or closed loop systems training modules. CBL HRRH has 600 beds on three campuses. They
necessary to targets the crucial skills and practices that directly employ more than 3,000 staff and have more
perform a skill, contribute to the overall organizational goals. than 700 credentialed physicians and two oper-
but it also com- The reason that it works so well with e-learning, ating room sites with 15 operating rooms and
i.e., learning through electronic media, is because three cysto rooms. Personnel at the facility
municates clear
it enables organizations to deliver content or perform more than 23,000 day surgeries and
expectations and learning objects to individuals. Proponents of CBL 8,000 inpatient surgeries per year.
enhances critical typically choose this learning method because
thinking skills. it leads most directly to learning opportunities HRRH is a regional pediatric center and a
that are intensely focused and are populated by member of the Child Health Network in Canada,
learners and employers who are chiefly inter- as well as a regional dialysis center. They are
ested in the shortest route to results.1 located in an ethnically diverse community in the
North-West region of Metropolitan Toronto. Patients
HOW DOES CBL FIT INTO come from more than 140 countries and together
PERIOPERATIVE NURSING? speak more than 80 different languages.
According to Sharron Abramson, RN, clinical
nurse practice leader of operating rooms at CBL AT HRRH
Humber River Regional Hospital (HRRH) in Humber’s perioperative staff is as diverse as its
Weston, Ontario, CBL is a method of learning patients. This became apparent to Abramson
that addresses the requirements necessary to four years ago when she took the position of
perform a skill, but it also communicates clear clinical practice leader, responsible for clinical
expectations and enhances critical thinking skills. education, orientation and advancing clinical
It utilizes electronic media as well as preceptors practice throughout the organization.The current
and many forms and tools to assess and program was not meeting their departmental
measure skills and competency. Abramson needs. The orientation program then consisted
says it not only works in perioperative services, of a six-inch binder and a one-week class.
but CBL has improved the orientation process Following the class, the trainee was assigned to
and resulted in greater longevity and satisfaction work with a staff member to apply the knowledge
among employees at her facility. learned in the class and from reading the manual.
Not only was the manual overwhelming, but the
interpretation of data varied to a great extent step according to the task and protocol and each
among new employees based upon their diverse step is assessed for accuracy and completeness.
cultural backgrounds. The caregiver also performs the self-assessment
on the same set of competencies and in the
A COMMON LANGUAGE same manner.
When dealing with learning outcomes, a common
language set is critical.2 The need for a common Results provide a measurement of individualized
language was well established at HRRH. For performance gaps that can be addressed one on
example, aseptic technique as well as handling one by either the clinical educator or the preceptor
of sharps had differing interpretations among assigned to the orientee. Performance gap
diverse cultures and countries where many of the analysis is a simple method to gather information
caregivers had previously trained and practiced. about the competency skills and knowledge
This diverse perioperative staff needed a stan- that exists in an organization.2 Through per-
dard set of definitions to be established. Ac- formance gap analysis, individual results are
cording to Abramson, not everyone had the addressed one by one until the competency
same frame of reference. Therefore, concepts skill is mastered.
and practices varied greatly. Learning through
reading a manual and attending one week of TRAINING METHODOLOGY
class was not providing the necessary results. Once performance gaps are identified, CBL
goes to work to train the individual according to
ASSESSMENT Humber’s standards of care in perioperative
The next step following the establishment of a services. The cornerstone of this program is the
common language is to determine the caregivers’ CD that houses all of the information contained
current skills and competencies. This is accom- in the six-inch binder (which still exists and is
plished through multiple assessment strategies. still provided) as well as the many forms and
Abramson believes in both a self-assessment training tools and support materials. The CD
and an assessment by preceptors who are materials are offered online at Humber and are
assigned to help train the caregivers in the a convenient way to access information that
clinical area. A generic tool for tasks is provided might have become foggy over time. Abramson
and each individual is expected to perform each makes it her responsibility to keep the learning
task according to the established competency. CD and online data up to date and current.
Each procedure has been broken down step by
60 THE OR CONNECTION
The typical training course takes approximately Nurses at Humber learn to both circulate and
12 weeks, start to finish, but the CD remains scrub surgical procedures. Typically, the training
available to all as a resource. The original begins in the general surgical specialty. Then
program also included videos, which have all the caregiver progresses to plastics and basic
been updated and incorporated into the CD orthopedics. At this point in the program, it is
and online program. established whether the individual is going to
be able to master perioperative nursing. While
When asked where she came up with the pro- most are successful, there have been those
gram’s contents, Abramson responded that she who have not found that the operating room
pulled data from three primary sources: Associa- is the best fit for them.
tion of periOperative Registered Nurses (AORN),
Operating Room Nurses Association of Canada FEEDBACK LOOPS
(ORNAC) and the Australian College of Operat- As a new employee goes through the program,
ing Room Nurses (ACORN). the ongoing assessment pinpoints any specific
problem areas and one-on-one guidance is pro-
“I used the best from all three organizations to vided. Feedback is continuous through a team
Feedback is
develop this program that has significantly approach, consisting of the educator, resource
continuous evolved over the last five years,” Abramson nurse, a buddy system and self-assessment.
through a team said. She added that AORN does an excellent Individual learning plans are communicated
approach, job with identifying the theory and rationale to the caregiver as needed via Humber’s
behind its recommended practices and standards, email system.
consisting of
while ORNAC is, in her opinion, more proce-
the educator, dure-driven. ACORN has included evidenced- Expectations are clearly defined, instructions
resource nurse, based underpinning to their standards. are provided and the caregiver is provided
Abramson maintains that blending materials resources that they can refer to as needed.
a buddy
from the three sources provides a standard The clinical educator spends time observing
system and method of training and sets both clear and and assures that basic skills are solid before
self-assessment. common expectations for each caregiver. caregivers move on to more advanced skills.
When questions arise, evidence-based criteria
are relied upon to support standards and proto-
cols. Abramson provided an example of when
this strategy came in handy. Some employees
had become accustomed to wearing surgical
masks inappropriately – or not wearing them at
all – at their former places of employment. By
providing evidenced-based criteria, a standard
for Humber was established.
OBSTACLES TO CBL
When about the biggest challenges she has
experienced during the development and imple-
mentation of CBL, Abramson said the number
one challenge was gaining the support of senior
nurses. She said she heard comments such as
“Why are you babying them?” and “We had to
learn by trial and error!” Next, when new care-
givers were placed with senior nurses as resource
nurses or preceptors, the senior nurses had dif-
ficulty in “letting go” and letting the new caregivers
perform tasks on their own.
They’re often compared, but just how do Canada and the United States measure up against each
other in terms of health systems and other health-related issues? We’ve assembled this chart for
your reference. Take a look – do any of the figures surprise you?
Reference:
1 World Health Organization. World Health Statistics 2007. Available at: http://www.who.int/whosis/whostat2007/en/index.html.
Accessed November 13, 2007.
62 THE OR CONNECTION
References THE BIGGEST BENEFITS To learn more about the CBL program at Humber
1 Squires P. Concept
Competency-based models ultimately rely on and how it could benefit your own facility, or to
Paper on Supporting
Competency-Based measurable assessment. If a proposed compe- request a copy of the CBL CD, you are invited
Learning, Applied Skills tency cannot be described and measured in to contact Abramson via the information below.
& Knowledge, LLC.
ways that are comprehended by all, learners
2 Voorhees RA. can go back and repeat only the areas of The OR Connection thanks Sharron Abramson
Competency-based
learning models: deficiency versus repeating an entire program. and Humber River Regional Hospital for
A necessary future. sharing this information and their success
In: Voorhees RA, ed.
Abramson listed the following as the top with our readers!
benefits of a CBL program:
Measuring What Matters:
Competency-Based
• It allows everyone to understand To contact Sharron Abramson:
Learning Models in
“ How
I got
into this
mess
in the
first
place.
”
When healthcare facilities need
partners…look to your vendors.
By Wayne Malone
of a large hospital. In this department, The conversation went on, but you get the
no holidays/nights/weekends lifestyle.
her a status report. I assured her that even
though we were six months behind schedule,
we would open on time. Her obvious question
– “How?” – was met with a simple “I don’t
Really, I did.
know, but we will.” What I lack in judgment,
But Deby started calling “just to ask a couple
I more than make up for in confidence.
of questions” and then to invite me to “come
take a look at the new hospital.” After a while,
After several very long days on the phone
like a trout that keeps seeing a fly in front of
spent trying to track down vendors, sales reps
his nose, I bit. I became the first (and so far,
and distributors, I caught a break. Our admin-
only) Director, Perioperative Services in the
istrative team had contracted with a medical
history of Patients Medical Center, a brand-
supply company to handle the bulk of our supply
new hospital in Pasadena, Texas. It took Deby
needs, and they wanted to bring the sales
so long to convince me to take the job that we
representative in to meet me. Our “new” rep
had a running joke: “By the time you actually
was an old acquaintance. I breathed an
get down here and start, you won’t have
immediate sigh of relief that at least our
anything to do.”
supplies would get here on time. Assuming
Right.
we could figure out which ones to order….
66 THE OR CONNECTION
The pre-op holding room/PACU,
stocked and ready for opening day.
68 THE OR CONNECTION
facility and hasn’t been updated in several
years. And this is where having a vendor that
acts like a partner paid dividends. We’d find
out a week or less before a case that we
“
needed something but didn’t have it. Our part-
ner worked miracles, and, lo and behold, the
needed item would show up at our doorstep I had allowed my
the day before we needed it. Sometimes two
days before. enthusiasm and
One day, our vendor overheard a conversa- my confidence to
tion about instruments that I was having at the
front desk. He casually said, “You know, if
you need help with instruments, we have an
write checks that
inventory of the most common ones. I can
have our instrument expert give you a call.” my team and I
He did better than that. The product manager
for their instrument line actually flew down
here, made copies of our hand-written count
sheets, and talked at length with our new
sterile processing department and OR staff
regarding physician preferences, wants,
now had to cash.
”
needs and obstacles. A few days later, I had a
quote covering all our outstanding instrument
needs as well as a list of alternate sources for
those instruments not already in their rather
large inventory. We not only solved our instru-
ment problem, we also got a jump-start on our
computerized instrument inventory and count
sheets. The vendor actually sent us all of our
count sheets, in spreadsheet format, with
all the instrument names, model numbers
and quantities, ready to print.
I have also spent time Epilogue: So, how did it turn out?
with a specialist from the We opened our doors in late April 2007
orthopedics line (casting with an intentionally small surgery sched-
materials, postop shoes, ule. We had three surgical techs and two
slings, et cetera), one
nurses. We did 32 cases, using one OR
from wound care (ostomy
suite at a time. By October 2007, we were
supplies, wound care
doing more than 400 cases per month.
products, specialty dress-
ings) and…well, you get I now have a perioperative services staff
the idea. The benefit here of 40, and we’re continuing to grow. Our
is that I didn’t have to make all those initial average room turnover time is an eye-
Dr. Glen Garner,
contacts, nor do I have to dive into my office popping 7.8 minutes, and we intend to
general surgeon, gives
2008
BEST your
year ever!
7
Seven strategies
to help you thrive
By Wolf J. Rinke, PhD, RD, CSP
72 THE OR CONNECTION
Caring for Yourself
2 Value yourself
Who is your most important patient, client or customer? If you answered “me!”
you have the right answer. This is super important because I’ve found that
most healthcare professionals are really great at taking care of others –
however, they often forget themselves! Want proof? Ask anyone in sales what
it takes to be a sales superstar, and they will tell you that you've
got to love what you sell. Notice I said love, not like! Even
though you are probably not in sales, even in health
care you sell yourself all the time! You sell your-
self, your ideas, your proposals, your be-
liefs etc. to your patients, boss, spouse,
children and even your pet. And for you
to be able to do that successfully,
Continued
74 THE OR CONNECTION
ceed faster. To help me with this, I've obsolete. In this era of rapid change, the
developed this axiom: If I don't feel like only way you can maintain a competitive
doing something, I go do it. If I really feel advantage is to invest in the most impor-
like doing something, I think about it tant resource you own – you! Read at
twice. For example, I'm sitting in front of least half an hour every day. Reading at
my computer and writing this article on least one nonfiction book every year puts
an incredibly beautiful fall day. The awe- you ahead of about 45 percent of the
some colors of the leaves and the U.S. population. If, however, you want to
sparkling sunshine are beckoning me make it into the top 3 percent of the pop-
to go out and go hiking with my Super- ulation, you'll have to devour 16 books a
woman — that's my sweetheart of almost year. Listen to motivational and educa-
40 years. Yet, after thinking about it, I tional audio programs in your car. By lis-
discipline myself to sit here and do what I tening only half the time while in your
really don't want to do. Here is a bonus car, you'll earn the equivalent of two
strategy that will enable you to make it to three-credit college courses every year.
the top even faster, especially if you are Attend seminars and courses. After all,
employed: Figure out what your boss learning from other peoples' experiences
does not like to do, and do more of it! (OPE) is a shortcut to success. If you still
make the same mistake I made for many
years by saying, “Yeah, but my employer
6 Invest in yourself
It's been said that if you want to earn
more, you've got to learn more. And it's
won’t pay for continuing education!” then
it’s time to read this paragraph again to
true. Statistics tell us that if you have a figure out who the ultimate beneficiary is.
high school diploma, you'll earn an aver-
age of $750,000 in your lifetime. With a
bachelor’s degree, that figure jumps to
approximately $1.5 million. With a pro-
7 Maintain balance
All my life I was materialistically motivated
– until that fateful day in December 1997.
fessional degree, such as an MD, JD or Superwoman and I were on our way to
PhD, you'll earn about $3 million. But Paris, France. Both of us were very ex-
don't stop there! Take a look at how cited. Marcela was going to one of her
much of your disposable income you favorite cities, and I was on my way to
spent on your own development during speak to more than 300 managers from
the past 12 months. If it is less than 3 19 different countries. We had an un-
percent, it is likely that you are becoming eventful trip until we got to France, when
78 THE OR CONNECTION
Eat smart, move often
The good news is you can lose excess body fat no
matter where it's located. Combining a sensible eating
plan with a realistic exercise program is your best bet
for success. Remember — you always should talk
with your doctor before beginning any diet or exer-
cise program. Use these tips to get started:
Snack sensibly
• Always keep sliced fruits and vegetables on hand.
Low-fat, low-calorie snacking between meals will
help you avoid overeating.
• Focus on eliminating processed foods from
your diet.
Add aerobics
Activities such as walking, biking, dancing or swimming About the Book:
keep your heart healthy and burn calories. Gradually In this accessible guide, trusted women's
work your way from 30 to 60 minutes of aerobic exer- health author and exercise physiologist
cise at least three times a week, if possible. Talk with Miriam E. Nelson presents the information
your doctor before beginning a new exercise routine every woman needs to know to maintain a
healthy back. Complete with clear explanations,
or significantly increasing your activity level.
practical advice, and lively anecdotes from
women who have benefited from this simple
Start strength training and effective program, the book reveals:
Resistance training helps build muscle and works off • the major causes of back pain in
additional calories. Slowly develop a routine of 10 to women;
12 exercises that target your major muscle groups, • how stress and other emotional
factors play a key role;
and do them two times a week.
• a straightforward exercise program
to improve flexibility, strength, and
aerobic fitness-designed specifically
for women;
• what you need to know to create a
back-friendly home and office; and
• explanations of what medical options
are available-and how to know when
they might be necessary
By Marla Shapiro, MD
80 THE OR CONNECTION
Caring for Yourself
“
I felt like my identity was
being stripped away.”
It was a routine mammogram, but when the X-ray was done, the
radiologist asked for a magnified view of my right breast. She needed to get
a better look at something.
I wasn't anxious. I knew that this was fairly routine. If the breast tissue is
dense, the X-ray film can be difficult to interpret.
But when she came back, the news wasn't good. She tried to be reassuring,
but her eyes were fixed on the floor as she suggested that I undergo
a biopsy.
I could feel the fear rising. I knew I was in trouble. After all, I was a doctor too.
But on that day, Friday, Aug. 13, 2004, without warning, I switched roles and
became a patient. It was foreign territory for me, and now, having spent 14
months there, I have to admit the journey has not been easy. The biopsy
led to surgery that ultimately confirmed I was suffering from invasive
breast cancer.
In many ways, where Dr. Marla ended and just Marla began was poorly
defined. My profession was inextricably woven into the very fabric of who
I was – someone taught to be a clear thinker and problem solver whose
decisions are based on evidence, even if it's just the best that science can
offer at the moment.
However, this disease does not only affect women. The NBCF also notes
that approximately 1,700 men are diagnosed with breast cancer each year.
It will kill roughly 450 of them.
82 THE OR CONNECTION
go away, like a cold does. When we
told him it was something that had to
be beaten, he walked around for
days, boxing imaginary demons in
the air.
84 THE OR CONNECTION
Tips for Early Detection
The most important thing any woman can do to fight breast
cancer is to practice tips for early detection. Many women
are not familiar with the territory, so here are some early
detection tips, signs and symptoms from the National
Breast Cancer Foundation, included as reminders.
Below are some situational examples to stimulate your mind and help you start thinking about
your own best and worst days!
We want to hear
from YOU!
Please email stories about your
best and worst days at work
to smacinnes@medline.com.
We will share many of the
responses in future issues
of The OR Connection!
86 THE OR CONNECTION
Caring for Yourself
WORST day
“Ironically, the best day I ever spent in my eight years in hospital PR was also the worst. Our local
high school had a shooting this past spring and the victim was brought to the hospital. The entire
Communications Department, save me, was out of the office at a seminar three hours away. Being a
part-time writer, I had to step up and do interviews with national news agencies, over the phone with
NPR, etc., which was a huge learning experience. And we were the heroes, because our staff saved
this kid’s life (he was shot four times, three in the torso). But not soon after, his mom is in the paper
trashing the hospital for not covering his bills, etc.
The good and the bad. That’s working in a
hospital for me.”
”
needed immediate surgery as well.
Since I lived close to the hospital, it
wasn’t uncommon for them to call me
when they needed additional help. I
agreed to cover the third emergency
with the stipulation that I was relieved
if either of the other two teams finished
before I did. The three emergencies
were young men in their early twenties
who were drag racing on their motor-
cycles and collided. My patient was
nearly severed in half and arrived
in the OR with CSF running out of his
nose. None of these young men were
surgical candidates, but because of
their young ages the surgeons decided
to try and save their lives. Needless to
say, all three died on their respective
OR tables. One poor decision changed
the lives of three families forever.
S
Conquering Cancer with a Nurse Hero
o many nurses say they got into nursing
because they wanted to help people.
Diana is no exception. Even at an early age,
she knew she would go into health care. She
has worn many hats. She began her career
as a candy striper and nursing home volunteer.
She entered the world of perioperative services
as a surgical scrub technician and then went on
to become a registered nurse.
88 THE OR CONNECTION
Diana with her friend
Colleen Cannon at a
triathlon in Fort
Desoto, Fla.
“All of my
life I was
taught that
the gift of life
was just that
A cancer diagnosis, chemotherapy and the importance
– a gift – so an outpouring of support of taking her meds.
Shortly thereafter, Diana was diag-
enjoy every nosed with stage IIIC ovarian cancer. Embracing the future
She underwent two major surgeries We are happy to report that Diana’s
possible and a total of eight rounds of cancer is in remission and that she is
chemotherapy, both IV and intraperi- back to work as the charge nurse for
minute!” toneal. Diana admits that this was a pediatric surgical services in the OR
very frightening time for her. “I cried, where she used to run the board.
but I just couldn’t let this get the best She is an excellent perioperative
of me,” she said. She attributes being nurse and everyone is happy to have
a nurse, athlete and generally positive her back on the team.
person as the reasons she was able
to do this. Diana has always loved the outdoors
and being active. While in school,
From the beginning, everyone around she ran on the track team and now
Diana pitched in with cards, phone finds running is a great stress re-
calls, parties, fundraisers and “just liever. She runs marathons and en-
believing.” “I cannot begin to tell you durance races. A physician friend got
about the cards and money people her started on triathlons and she en-
gave us. The pictures sent and par- joys the challenge. She and Jamie
ties that were thrown were just what recently finished the last of a series
I needed. All of these things helped of triathlons to raise money for
me get through the tough times,” ovarian cancer.
Diana said.
Diana is a truly amazing nurse,
Her friend Jamie kept everyone up athlete and person. She is a source
to date on Diana’s progress. Friends of inspiration to many of her friends
came out of the woodwork to cook, and colleagues – not only because of
clean house and even mow the lawn! the illness she beat, but the passion
Her dad was with her for her chemo she puts into everything she does.
appointments and follow up. Family
flew in to visit and help. One of her In Diana’s own words: “You know, all
brothers is even a nurse with chemo of my life I was taught that the gift of
experience! He was able to help life was just that – a gift – so enjoy
her understand the side effects of every possible minute!”
I
t didn’t seem possible to Aurora, Angel, Ami and Anastasia Aurora laughed, thinking of how much the profession had
that the holidays were upon them once again – hadn’t they evolved. One of the next pictures she saw was a woman who
just finished the last of the turkey soup and turkey sand- was almost unrecognizable underneath her stark white gown
wiches? And yet here they were, all four sisters at home and surgical mask.
again, just like it used to be when they were children.
Synchronizing days off from their busy nursing schedules “They thought white emphasized cleanliness,” Aurora remarked
had been a challenge! to her mother. “I can’t imagine wearing a white gown in a bright
operating room – it would be blinding!”
Aurora had settled in for a nice, quiet evening in the family living
room. She was sprawled on the floor in front of the fireplace, “Not to mention how unpleasant it is to see red blood splashed
basking in the warmth and flipping through an old family photo on a white gown!” laughed her mother. “Thank goodness they
album that she had found in the attic while helping her mother started switching to green and other colors.”
locate holiday decorations.
Aurora flipped another page in the album and came face-to-face
She knew that her mother was not the first family member to with a black-and-white photo of a fair-haired nurse in a trim
enter the nursing profession, but Aurora was still surprised to white uniform, a graduate nurse’s cap and a dark cape.
see woman after woman in the photo album dressed in variations
on nursing attire. “Who’s this?” she asked her mother.
Her mother walked into the room, arms filled with garland, and Her mother grinned. “That’s your great-aunt Alice,” she said.
stopped to look over Aurora’s shoulder. “Oh, the stories I could tell you about her!”
“Oh, that brings back memories,” she said. “My mother put that Just then, Angel, Ami and Anastasia burst into the room. “Mom,
album together for me when I couldn’t decide whether or not I you promised us that this would be the year you would share
wanted to go into nursing. Those are the women in our family your secret pecan pie recipe,” Ami said. “Let’s go!”
who have been nurses. Funny to see how uniforms have
changed, isn’t it? Their mother glanced back at the photo of Alice once more.
“I guess we’ll have to talk about Alice another day,” she told
“You should have heard the stories my grandmother told me Aurora. “But I promise her story is worth the wait.”
about assisting with surgery in the early 1900s,” her mother
continued as she wrestled with the garland. “Oftentimes, surgeries Stay tuned to future editions of The OR Connection to
were performed in private residences. When it came to sterili- learn more about the sisters and meet the next addition
zation, they just dusted down the walls and wiped the floor with to their family!
a damp cloth!”
Ingredients:
Your favorite champagne or sparkling cider
Fresh strawberries with the stems intact
Recipes for Strong, Chocolate hazelnut spread (such as Nutella®)
Several tbsp of heavy cream
Healthy Living. Wash the strawberries and chill them. Place a cup of the
chocolate hazelnut spread in a double boiler or fondue pot
and heat slowly. Add 1 to 2 tbsp of heavy cream and heat
From strongwomen.com
over low temperature until it is the consistency of heavy
cream.
To serve warm: Sit around the table and dip the strawberries
in warm chocolate using a fondue pot. Eat immediately.
Mim’s Meltaways
Makes 45 to 60 cookies
Ingredients:
¾ c ground unblanched hazelnuts or blanched almonds
¼ c whole-wheat flour
½ c all-purpose flour
4 oz (1 stick) unsalted butter, at room temperature
½ c confectioner’s sugar, plus more for sifting
Grated zest of one orange
1 tsp vanilla
92 THE OR CONNECTION
Forms & Tools
The following pages contain practical
tools for implementing patient-focused
care practices at your facility.
Hand Hygiene
Indications for Hand Hygiene ................101
Surgical Packs
Safety Checklist ........................................103
Supine Pressure points, including occiput, scapulae, • Padding to heels, elbows, knees, spinal
thoracic vertebrae, olecranon process, column, and occiput alignment with hips,
sacrum/coccyx, calcaneae, and knees. legs parallel and uncrossed ankles.
Neural injuries of extremities, including brachial • Arm boards at less than 90-degree angle
plexus and ulna, and pudendal nerves. and level with floor.
• Head in neutral position.
• Arm board pads level with table pads.
Chest compression, iliac crests • Chest rolls (ie, clavicle to iliac crest) to
allow chest movement and decrease
abdominal pressure.
Breasts, male genitalia • Breasts and male genitalia free from torsion.
Lateral Bony prominence and pressure points on de- • Axillary role for dependent axilla.
pendent side • Lower leg flexed at hip.
• Upper leg straight with pillow between legs.
94 THE OR CONNECTION
Forms & Tools
PATIENT POSITIONING
Greater trocanter
Heel
Hip
4. 5. 6. 7.
Supine
Ischial tuberosity
Knee
Lateral foot
Lateral leg
Neck
14.
Occiput
Posterior knee
Sacrum
Shoulder
8. 9. 10. 11. 12. 13. 15. 16. 17.
Thoracic area
Prone
Toes
Under strap
18.
Lateral
96 THE OR CONNECTION
Forms & Tools
PATIENT POSITIONING
1.
2.
3.
4.
29. 5.
6.
7.
8.
9.
10.
11.
26. 27. 28. 30. 31. 12.
Trandelenburg 13.
14.
15.
16.
17.
18.
19.
20.
33. 21.
22.
23.
24.
25.
32. 26.
27.
28.
29.
30.
34. 31.
32.
35. 36. 37. 38.
33.
Lithotomy 34.
35.
36.
37.
38.
PURPOSE:
To outline the nursing management of the surgical patient during the process of
operative positioning.
LEVEL:
Shall be performed by surgeon and RN with assistance from support staff (*required MD order).
SUPPORTIVE DATA:
The patient’s position: (1) should provide optimum exposure and access to the operative site, while
sustaining body alignments, circulation and respiratory functions, and skin integrity; (2) must
provide access to the patient for adminstration of intravenous fluids, drugs, and anesthetic agents,
and (3) should afford as much comfort to the patient as possible.
Nurse needs to make the following assessments prior to starting the procedure.
• Assess patient’s size and identify any existing respiratory, skeletal,
or neuromuscular limitations.
• Determine position of choice by consulting surgeon’s preference card for the scheduled
procedure and/ or posting slip.
EQUIPMENT:
• Foam rings
• Eggcrate padding
• Wilson Frame
• Gel pads
• Bean bags (Vac-Pack)
• Laminectomy frame
• Bolster
• Horse shoe head rest
98 THE OR CONNECTION
Policy & Procedure
PATIENT POSITIONING
Steps:
1. Do not allow instrument table, mayo stand, 17. Place a small pillow under calves supporting the
or other equipment to rest on or put pressure full length of the lower legs.
on patient. a. Care must be taken not to put pressure on
popliteal space.
2. Do not allow surgical team members to lean b. This helps to minimize pain in patients with
on patient. low back pain.
10. Assure that legs and / or ankles are not crossed. Lithotomy Position:
23. Assure that patient’s buttocks do not extend
11. Avoid having body surfaces in contact with over the break in the bed. Pad sacrum with
one another. foam or other padding if necessary.
12. Assure that patient is not touching any exposed 24. Raise and lower legs with knees together
table parts or hanging over sides. simultaneously, very slowly, and never abduct
legs without first externallu rotating the hip.
13. Check catheters, tubes, and drains for patency
once patients is positioned. 25. Position thighs so they do not exert pressure
on the abdomen or groin.
14. Assure that kidney rest on OR bed is at
lowest position. 26. Secure arms on arm-board or across abdomen.
15. Place padding under heels and head. If foam ring 27. Adjust and secure safety belt as in #9 above
is used, do not remove foam from hole. Removing before and after lithotomy position. The safety
the center could diminish circulation. belt should be secured over the thighs during
anesthesia induction and emergence. The
16. Position arms on arm board or secure under draw safety belt may be used over the abdomen
sheet at patient’s side. Palms should either turned during the surgery if it does not get in the way
toward the patient or turned down. Pad elbows with of the procedure (e.g. gynecological laparoscopy).
towel or foam.
28. Pad legs at any points where they come in 42. Stabilize patient using safety belt and/or 3”
contact with stirrup. Use safety straps if applicable. adhesive tape across hips and secured to OR
Table. Assure that female breast and male
Prone Position: genitalia are free from compression.
29. Provide chest rolls (bath blanket wrapped in
eggcrate foam) or laminectomy frame, a pillow 43. Elevate head on folded towels and/ or foam
for under the feet and padding for ear, eyelids, padding.
and cheeks.
44. Do not allow kidney braces (if used) to come in
30. Assure that there is no compression of female direct contact with patients.
breast (place laterally if necessary) or
male genitalia. 45. Refer to owner’s manual if Vac-Pak is used.
31. Position arms either at patient’s side with palms Frog-Leg Position:
turned inward or upward or over the head on arm 46. Provide four to six folded blankets to elevate
boards. If positioned over the patient’s head, they and support knees and legs.
should be slowly lowered toward the floor and
brought up in an arc while the elbow is flexed. 47. Secure feet to OR bed with 3” adhesive tape.
Protect feet from adhesive using folded towel.
Securely support the elbow and shoulder during
this movement. Specialty Tables:
48. Refer to reference materials supplied
32. Secure safety belt 2” above knees. by manufacturers.
Before eating
Removing gloves
Before shift
After breaks
*Gloves should be worn for all types of contact if the patients is on isolation precautions.
Answer Key
Hand Hand Use of a Handwash
Indication antisepsis antisepsis Use of gloves skincare with soap
before after lotion
Before eating
Before shift
After breaks
*Gloves should be worn for all types of contact if the patients is on isolation precautions.