The

Aligning practice with policy to improve patient care

Volume 6, Issue 1
FREE CE!

Special
AORN
Issue!
Breast Cancer
Awareness
Section Page 84

Turn up the heat on

HYPOTHERMIA Man on a
Mission: Hand
Hygiene Expert
Nurse Leaders Professor
Rate Patient
Experience #1 Didier Pittet
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Content Key
We've coded the articles and information in this magazine to indicate which patient
care initiatives they pertain to. Throughout the publication, when you see these icons
you'll know immediately that the subject matter on that page relates to one or more of
the following national initiatives:
• IHI's Improvement Map
• Joint Commission 2009 National Patient Safety Goals
• Surgical Care Improvement Project (SCIP)

We've tried to include content that clarifies the initiatives or gives you ideas and tools
for implementing their recommendations. For a summary of each of the initiatives,
see pages 8 and 9.
 PATIENT SAFETY
Editor
6 Mission: Improving Hand Hygiene
Sue MacInnes, RD, LD
8 Three Important Initiatives for Improving Patient Care
Clinical Editor
Alecia Cooper, BS, MBA, RN, CNOR
10 Patient Safety News
Senior Writer 11 Provider Preventable Conditions
Carla Esser Lake 14 Turn Up the Heat: Avoiding Surgical Complications with
Creative Director Adequate Patient Warming
Mike Gotti
30 ClearCount Clearly Makes a Difference in Patient Safety at
Clinical Team Hunt Regional Hospital Page 14
Jayne Barkman, BSN, RN, CNOR
34 VAP: What is the Perioperative Nurse’s Role in Prevention?
Lorri Downs, RN, BSN, MS, CIC
Margaret Falconio-West, BSN, RN, APN/CNS,
47 The Quest to Improve Staff and Patient Safety: How One
CWOCN, DAPWCA Health District Converted to Latex-Free Surgical Gloves
Rhonda J. Frick, RN, CNOR 61 Unity Hospital: Utilizing Medline’s ERASE CAUTI Program
Anita Gill, RN
Kimberly Haines, RN, Certified OR Nurse
OR ISSUES
Rebecca McPherson RN, MSN
Carla Nitz, BSN, RN
40 The Ins and Outs of Hernias and Ways to Repair Them
Claudia Sanders, RN, CFA 79 Upcoming Green Events & Green Facts Page 68

Megan Shramm, RN, CNOR, RNFA 84 Study of Breast Biopsies Finds Surgery Used Too Extensively
Angel Trichak, RN, BSN, CNOR
101 Less Invasive Surgery Just as Effective for Some
Perioperative Advisory Board Breast Cancer Patients
Larry Creech, RN, MBA, CDT
Carilion Clinic, Virginia
SPECIAL FEATURES
Sharon Danielewicz, MSN, RN, RNFA
Cedar Park Regional Medical Center, Texas 5 International Hand Hygiene Expert Urges U.S. to Use
Tracy Diffenderfer, MSN, RN “Five Moments” to Reduce Infection
Page 77
Vanderbilt University Medical Center, Tennessee 56 Nurse Leaders Survey Results: Patient Experience Is #1
Barb Fahey RN, CNOR
68 12 Ways to Reduce Hospital Readmissions
Cleveland Clinic, Ohio
77 Medline Joins Greening the Operating Room Initiative
Susan Garrett, RN
Hughston Hospital Inc., Georgia 78 Medline Launches Sustainability Program
Zaida I. Jacoby, MA, MEd, RN 88 Celebrating Six Years of Spreading Breast Cancer Awareness
NYU Medical Center, New York
92 Straight from the Heart: Quotes About the Pink Glove Dance
Jackie Kraft, RN, CNOR
95 Beyond a Reasonable Doubt: Open Communication Helps
Huntsville Hospital, Alabama
Jill Eikenberry Raise the Bar for Breast Cancer Awareness Page 92
Tom McLaren
Florida Hospital, Florida
Susan Phillips, RN, MSH, CNOR CARING FOR YOURSELF
University of North Carolina Hospitals 102 How to Energize Your Team
Donna A. Pritchard, BSN, MA, RN, CNOR, NE-BC 110 Recipe: Aunt Judy’s Tortilla Roll-Ups
Kingsbrook Jewish Medical Center, New York
Debbie Reeves, MS, RN, CNOR
FORMS & TOOLS
Hutcheson Medical Center, Georgia
Diane M. Strout, BSN, RN, CNOR
113 Highlights of AORN’s Revised Recommended Practices
for Surgical Attire Page 102
St. Joseph Medical Center, Washington
120 CDC Hand Hygiene Poster
121 How Well Do You Know Pressure Points?

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

©2011 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
 The OR Connection
Letter from the Editor
Last night I had the opportunity to have dinner with Professor
Didier Pittet (one of the foremost authorities on hand hygiene).
He spoke with great energy and passion about a number of
pertinent topics, including The World Health Organization’s
Hand Hygiene Campaign, the “Five Moments of Hand
Hygiene,” and the hand hygiene compliance rates of most
facilities in the United States as compared to other countries.
What a fascinating man he is. One of his achievements is
being appointed Commander of the British Empire (or CBE,
an international honor that includes knighthood). This honor
was awarded by Queen Elizabeth II in 2007 for his services
in the prevention of healthcare-associated infection in the
United Kingdom. He told the story, with great charm and
humility, of what is was like to be “knighted” by the Queen of
England for his contributions to safety and health care. He
said that while it was a great honor, it was also quite stressful,
as he was allowed to bring only two people with him to the
actual ceremony … he chose his two daughters. You can
probably imagine their pride as they got to watch their dad
become only the second person from Switzerland ever to
be so honored.
I was enthralled, sitting across the table from this icon of
healthcare safety and listening to his stories of knighthood,
his early training and his current projects, which include
recording the English narration for the “Hand Hygiene
Dance Video,” originally performed and filmed at the
University of Geneva. (Our cover photo for this edition is from
the recording session.) Watch for an online link to the final
production to be printed in an upcoming issue of The OR
Connection!
Dr. Pittet’s visit was just one of the amazing experiences I’ve
had in the last few weeks. Barely a week ago I met with Dr.
Haywood, Senior Vice President and Chief Medical Officer
of VHA, and his team to discuss research pertaining to
4 The OR Connection
HCAHPS, the patient experience survey that is on the minds
of many nurse executives. I think it is so important to be
aware of the concerns and priorities of hospital administration,
so I’ve included on page 56 very recent survey results on
what’s most important to nursing leaders today.
Prior to Dr. Haywood’s visit, I had met with Kaiser Perma-
nente on the West Coast to talk about healthcare innova-
tions that can be explored and tested. I don’t mean
innovations that are made up in a lab or in some corporate
office, but real-life examples of how healthcare professionals,
thought leaders and industry can work together to make
your jobs simpler and to make the chaos of everyday
practice easier to navigate. We’ve all been accustomed to
how things have always been done. But this is a new era of
change designed to support the healthcare worker while
improving care. And you are a very important part of this
model.
This edition of The OR Connection is being launched at the
AORN 58th Congress, March 18-24, 2011, in Philadelphia,
Pennsylvania – my hometown. For those attending the Con-
gress, Medline has included a list of items on page 66 that
we will be featuring at our Booth #3408. If you don’t get a
chance to attend, but you would still like information on any
of our programs or products, please give me a call at
847-643-4093. Although we would love to tell you more
about our products and programs, we are just as interested
in your ideas for innovation, so my line is open to you. This
is our biggest issue yet. There are so many things going on
in our industry, I’m sure within these pages there is something
that will be of interest you.
Sincerely,
Sue MacInnes
VISIT MEDLINE BOOTH #3408 AT AORN CONGRESS

Coming to America:
International Hand Hygiene Expert Urges U.S.
to Use ‘Five Moments’ to Reduce Infection
International hand hygiene expert Professor Didier Pittet,
MD, MS traveled from Geneva, Switzerland to Chicago this
spring to partner with U.S. healthcare workers to improve
hand hygiene compliance.
Dr. Pittet emphasized that despite hand hygiene’s proven ben-
efits in reducing infection, “It’s very frightening first to realize
that the compliance is so low,” he said. “On average it’s around
40%, at the best, and it’s not rare that when you come in a
unit or a ward the average compliance will be around 20%.”
Dr. Pittet began his visit to Chicago at a recording studio where
he recorded English narration for a short film that promotes the
World Health Organization’s (WHO) “Five Moments for Hand
Hygiene.” The film is called “O Les Mains!” – translated in Eng-
lish it means “Raise your Hands.” Dr. Pittet currently uses
the film, which features professional dancers, to encourage
and teach proper hand hygiene techniques at his hospital in
Geneva. With Medline’s help, Dr. Pittet hopes to get the video
to go “viral” to inspire healthcare workers in the U.S. and
around the world to learn proper hand hygiene.
Aligning practice with policy to improve patient care 5
Special Feature
“Five Moments for Hand Hygiene” defines the key times for
hand hygiene, presents a unified vision on proper hand hygiene
technique and promotes a strong sense of ownership.
While in Chicago, Dr. Pittet, along with Mark Chassin, presi-
dent of The Joint Commission, also addressed more than 200
senior clinicians and infection preventionists at Loyola Univer-
sity Medical Center in Chicago. Their unified message was
clear – a highly compliant and successful hand hygiene
program starts at the top of an organization with its leader-
ship. The event, called “Safe Care Town Hall Forum” was
co-hosted by Medline and Loyola, and is the first in a series of
patient safety forums to be held around the country.
Dr. Pittet also spoke before medical and nursing students at
Loyola’s Stritch School of Medicine. Dr. Pittet believes teaching
healthcare professionals about proper hand hygiene techniques
early in their careers will instill good habits that will stay with
them long term.
 Mission:
Improving hand hygiene
Joint Commission Center for Transforming Healthcare
Targeted Solutions Tool for Hand Hygiene

Joint Commission-accredited hospitals now have access to
an interactive tool that simplifies processes for solving
healthcare quality and safety. The Targeted Solutions
Tool™ (TST) encapsulates the work of the Joint Com-
mission Center for Transforming Healthcare and pro-
vides step-by-step processes to measure
performance, identify barriers to excellent perform-
e
Commission. “Consistent excellence in hand hygiene is vital
to our larger aim of eliminating preventable health care-asso-
ciated infections. The Targeted Solutions Tool provides hos-
pitals with powerful new knowledge and methods they
can use right away to make substantial advances toward
this goal.”

Ide
anc

ance, and implement proven solutions. Data validates effectiveness of hand hygiene tool
nti
orm

At the start of the project in April 2009, the par-

fy
erf

Bar

The first set of targeted solutions focuses on ticipating hospitals were surprised to learn that
e p

rie

improving hand hygiene. It was created by their rate of hand hygiene compliance aver-
sur

rs
Mea

eight of the country’s leading hospitals and aged 48 percent. By June 2010 they had
healthcare systems working with the reached an average rate of 82 percent that
Center. The TST provides accredited had been sustained for eight months.
hospitals the foundation and Nineteen small, medium and large hos-
Implement Proven Solutions
framework of an improvement pitals across the country also collabo-
method that, if implemented well, will improve hand hygiene rated with the Center to test the work of the original eight
compliance and contribute substantially to reducing health hospitals and provide guidance on the development of the
care-associated infections. solutions that are now available through the TST. These
hospitals are experiencing similar gains as the original eight.
The complimentary data-driven tool provides validated and
customized solutions to address particular barriers to excel- For a free electronic copy of the Targeted Solutions Tool for
lent performance. Self-paced and confidential, the TST offers hand hygiene, “Hand Hygiene Factors and Solutions,” go to
instantaneous data analysis. http://www.centerfortransforminghealthcare.org/tst.aspx.

“I encourage hospital leaders to use these tools to identify Medline Industries, Inc. is a proud sponsor of the Center for
very specific ways to improve their hand hygiene programs,” Transforming Healthcare Endowment Fund.
said Mark R. Chassin, MD, MPP, MPH, president of the Joint

6 The OR Connection
 ®
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 Three Important National Initiatives
for Improving Patient Care
Achieving better outcomes starts with an understanding of current
patient-care initiatives. Here’s what you need to know about national
projects and policies that are driving changes in care.

1 IHI Improvement Map

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

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

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

2 Joint Commission 2011 National Patient Safety Goals

Origin: Developed by Joint Commission staff and the Patient Safety Advisory Group
(formerly the Sentinel Event Advisory Group)
Purpose: To promote specific improvements in patient safety, particularly in problematic areas

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

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

3 Surgical Care Improvement Project (SCIP)

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

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

8 The OR Connection
 Patient Safety

IHI Improvement Map: 73 Processes to Transform Hospital Care

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

3 New Key Processes as of June 2010 Top 5 Key Processes Shared by Improvement Map Users
1. Anticoagulation Management 1. Central Line Bundle
2. Essential Care for Frail Older Patients 2. CA-UTI
3. Glycemic Control in Non-Critically Ill Patients 3. Anti-Biotic Stewardship
4. Falls Prevention
5. Heart Failure Core Processes

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

Joint Commission 2011 National Patient Safety Goals

Effective January 1, 2011:
• Improve the accuracy of patient identification. • The organization identifies safety risks inherent in
• Improve the effectiveness of communication its patient population.
among caregivers. • Universal Protocol for Preventing Wrong Site,
• Improve the safety of using medications. Wrong Procedure, and Wrong Person Surgery.™
• Reduce the risk of healthcare-associated
infections.
• Accurately and completely reconcile medications
across the continuum of care.

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

Surgical Care Improvement Project (SCIP): Target Areas

1. Surgical infections
By the numbers:
• Antibiotics, blood sugar control, hair removal, perioperative • 3,740 hospitals are submitting
temperature management data on SCIP measure #9, representing
• Remove urinary catheter on Post Operative Day (POD) 1 or 2 75 percent of all U.S. hospitals
2. Perioperative cardiac events • Currently, SCIP has more than 36
• Use of perioperative beta-blockers association and business partners
3. Venous thromboembolism
• Use of appropriate prophylaxis

Visit www.qualitynet.org

Aligning practice with policy to improve patient care 9

 PATIENT SAFETY NEWS

134,000 Medicare patients per month hurt at hospitals1

The Department of Health and Human Services recently
released its findings that about 134,000 Medicare patients
experienced adverse events in hospitals during a single
month in 2008. About 44 percent of the events were con-
sidered to be preventable. The cost to treat the affected
patients was estimated at $324 million.

The Centers for Medicare and Medicaid Services (CMS)

responded that it will aggressively pursue efforts to expand
adverse event reporting and the types of events that are
considered reportable. Only six states currently require
public reporting of medical errors.

New suggestions for blood glucose National Patient Safety Foundation

management during outpatient surgery launches new membership organization
The Society for Ambulatory Anesthesia (SAMBA) issued a for healthcare professionals
consensus statement at the end of 2010 outlining glucose
The American Society of Professionals in Patient Safety
management suggestions for anesthesia providers. The
(ASPPS) is a new membership organization launched by the
significant practice changes include:2
National Patient Safety Foundation (NPSF). It is seeking mem-
• Preoperative advice to the patient regarding the use
bers from across the spectrum of healthcare disciplines to
of their anti-diabetic drug on the day of surgery
help extend the group’s agenda of accelerating the delivery of
• The use of rapid-acting insulin rather than regular
safe patient care and establishing consistency in safety prac-
insulin during surgery
tices and tools. The organization plans to implement a certi-
• Use of the 1500/1800 formula for determining the
fication program to validate competencies and practices that
dose of insulin
are proven to reduce medical errors. Information on mem-
• Avoiding the temptation to normalize blood glucose
bership and the May 2011 Patient Safety Congress can be
levels in patients with inadequately controlled levels
found at www.npsf.org/hp/ASPPS.php.

References
1. Hospitals hurt 134,000 Medicare patients a month. Outpatient Surgery
Magazine. November 30, 2010.
2. SAMBA issues suggestions for blood glucose management in diabetic
patients. Outpatient Surgery Magazine. December 2010.

10 The OR Connection
 Patient Safety

Provider Since the summer of 2008, the Centers for Medicare and
Medicaid Services (CMS) has encouraged states to model their
Medicaid payment rules after the federal Medicare program.
Preventable Now, the Affordable Care Act (ACA) has mandated that the
Medicare rules for withholding payment for “never events” now
Conditions: be extended to state-run Medicaid programs. The Affordable
Care Act (ACA) requires the new rules extension be effective

Expanding July 1, 2011.

The eleven CMS-recognized preventable conditions are:

Never Event/No-Pay • Retained items after surgery
• Air embolism

Regulations • ABO blood incompatibility

• Catheter-associated urinary tract infection (CAUTI)
• Pressure ulcers
• Central line-associated bloodstream infection (CLABSI)
• Surgical site infection (SSI)/mediastinitis
• Falls and certain other traumas
• SSI after certain elective procedures
• Poor glycemic control manifestations
• Deep vein thrombosis (DVT)/pulmonary embolism (PE)

This list is exhaustive for Medicare, but for Medicaid CMS has
intentionally granted states the flexibility for including other con-
ditions beyond the eleven that CMS has already identified.

The different nature of Medicaid and the services it pays for has
created a new set of terminology to learn. HAC, hospital-
acquired condition is now passé, as is HCAC, the more generic
healthcare-acquired condition. The preferred new term is
provider preventable condition, or PPC. The definition of a PPC
is “a condition that could have reasonably been prevented

Aligning practice with policy to improve patient care 11


through the application of evidence-based guidelines.” PPCs
would encompass the same healthcare-acquired conditions as
defined for Medicare purposes, plus other PPCs defined by
states and approved by CMS.
Perhaps more significant than the “what” of a PPC is the
“where” it may occur. CMS proposes using PPC as an umbrella
term for both hospital and non-hospital conditions identified by
a state for nonpayment. PPCs would encompass hospital-
acquired conditions, as defined for Medicare purposes, and
other PPCs applicable to service settings beyond the inpatient
hospital setting. CMS notes that preventable conditions can
occur in an outpatient hospital, nursing facility and ambulatory
care settings. The denial of claims for PPCs happening in any
of these environments is a significant expansion of the existing
regulations.
12 The OR Connection
CMS “no pay for never events” policy used to
be Medicare only. In July it’s set to be part of
all 50 state Medicaid plans.
What does all this mean?
Like any significant policy change such as this one, there will be
both expected results and unexpected consequences. The
original Medicare claims denials for HACs are running at
approximately $20 million per year. Over the next five years, the
Medicaid claims denials for PPCs are expected to total $35 mil-
lion, or an average of an additional $7 million per year. The Med-
icaid savings are divided approximately 60/40 between Federal
and state savings.
There will be costs associated with this new rule, too. CMS
estimates that both states’ and providers’ regulatory and
reporting compliance will be relatively small. Providers, however,
will incur additional costs to reduce PPCs. These costs may be
from hiring more nurses and infection control professionals as
well as training staff on best practices for PPC prevention.
Equipping staff with evidence-based products and programs
that help deliver better outcomes may be seen as an additional,
but very necessary cost as well. Most hospitals have taken
these PPC prevention steps to comply with Medicare rules.
However, most non-hospital health care settings will now find it
necessary to make expenditures to address the PPCs that
occur in their environment.
While the explicit purpose of the regulation is cost containment
through administrative action, the implicit purpose is the public
benefit of an overall reduction in PPCs and a corresponding
increase in healthy years of life. CMS is quick to point out, how-
ever, that the regulation itself is not responsible for the better
health of the population, but rather the responses made to it by
hospitals and other care providers.
For more information, visit: https://www.federalregister.gov/
articles/2011/02/17/2011-3548/medicaid-program-payment-
adjustment-for-provider-preventable-conditions-including-health
SAFETY
DESERVES
ATTENTION

MEDLINE GOLD STANDARD SAFETY COMPONENTS

Medline’s Gold Standard safety products stand out against the
sea of blue in the OR to alert the surgical team to focus on safety.
Promote Correct-Site Surgery
Our Surgical Time Out Procedure (S.T.O.P.™)
safety products alert the surgical team to
perform a time-out verification and help reduce
the risk of wrong-site surgery.

Support Sharps Safety Practices

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

Improve Fluid Disposal Safety

The Safety-Splash™ fluid management system
converts biohazardous fluids into a solid, For a FREE sample bundle, email
minimizing the risk of exposure. goldstandard@medline.com.

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

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

Avoiding Surgical Complications

with Adequate Patient Warming
14 The OR Connection
SCIP-Inf-101
“Measure: Surgical patients should be actively warmed during surgery or have at least
one recorded body temperature equal to or greater than 96.8 degrees Fahrenheit
within 30 minutes prior to the end of anesthesia to 15 minutes after anesthesia ends.
(Patients with intentional hypothermia are excluded from this measure.)”

In 2003, the Joint Commission and the Centers for Medicare and
Medicaid Services (CMS) teamed up to align their common meas-
ures. In the process, they decided to add a set of measures for Sur-
gical Infection Prevention (SIP), which was quickly added as a core
measure set.2 In July, 2006, SIP was renamed the Surgical Care
Improvement Project (SCIP).

Members of the SCIP Steering Committee include the Association

of periOperative Nurses (AORN), the Joint Commission, the Centers
for Medicare and Medicaid Services (CMS), Agency for Healthcare
Research and Quality (AHRQ), American College of Surgeons
(ACS), American Hospital Association (AHA), American Society of
Anesthesiologists (ASA), Centers for Disease Control and Prevention
(CDC), Department of Veterans Affairs, and the Institute for Health-
care Improvement (IHI).3 This national partnership of organizations
works together to improve the quality of surgical care.

To date, SCIP has introduced 10 measures, plus three others

specifically addressing cardiac patients and venous thromboem-
bolism. All measures are to be followed in order to reduce surgical-
site infections and other complications of surgery. (For the complete
list of all SCIP Measures, turn to the back of this article.)

SCIP-Infection (Inf.)-10, also known as SCIP Measure 10 – “Surgery

Patients with Perioperative Temperature Management,” went into
effect October 1, 2009.4 When the measure was first adopted, the
best available temperature management evidence was on patients
having colectomies while under general anesthesia. Consequently,
the measure initially focused on this population.

Currently, SCIP-Inf.10 applies to patients of any age undergoing

surgical or therapeutic procedures while under general or neurax-
ial anesthesia for one hour or more. It does not include patients
undergoing cardiopulmonary bypass.5

Continued on Page 17
 Innovation in Patient Warming

Underbody Warming for All

Patients and Procedures
For protection from unintentional hypothermia in patients
undergoing surgery, PerfecTemp is an excellent alternative
to forced-air warming systems.

While other systems use disposable blankets to force

warm air on top of patients, PerfecTemp’s unique
surgical table pads offer.
• Efficient underbody warming as effective as
forced-air systems for preventing unintentional
hypothermia.1
• More accurate patient monitoring
• Complete patient access
• Silent operation
• Reduced staff time
• No blowing air
• Energy conservation

PerfecTemp™
Flexible and durable carbon heating
element for uniform heating.

OR Patient Warming System

References
1. Egan C, Bernstein E, Reddy D, et al. A Randomized Comparison of Intraoperative Warming With the LMA PerfecTemp
and Forced Air During Open Abdominal Surgery.

©2011 Medline Industries, Inc. Medline and PerfecTemp are registered trademarks of Medline Industries, Inc.
 CE Article

Under SCIP-Inf-10 clinicians must either actively warm patients

during surgery or record a body temperature of 36 degrees C (96.8 Intraoperative core temperatures
degrees Fahrenheit) or higher within 30 minutes before or 15 minutes
immediately after the end of anesthesia. Clinicians must provide clear about two degrees Celsius below
documentation of the temperature during active warming or in rela-
tion to the end of anesthesia.
normal increase the incidence
of wound infection threefold and
What causes perioperative hypothermia?
As warm-blooded creatures, human beings’ organ systems are prolong hospitalization by about
designed to operate within a narrow temperature range. Hypother-
mia occurs when a person’s body loses more heat than it can pro-
20 percent.5
duce, leading to a core body temperature drop. In nature, we know
what makes us cold and we can respond. Exposure to cold air
encourages us to get out of the cold or bundle up. Being damp
causes us to seek drier conditions. We put on jackets or seek shel-
ter to get out of the wind. In the OR, perioperative hypothermia is
common, resulting from the effects of anesthesia on the body’s ther-
moregulatory control system.6

Many factors can contribute to unplanned perioperative hypother-

mia, including cool air temperature in the OR, length of surgery (the
longer the surgery, the greater the likelihood of hypothermia occur-
ring), blood and fluid loss, and effects from anesthesia, which alters
the patient’s ability to regulate body temperature. A patient’s body
type can also affect heat loss. Very thin, malnourished patients as
well as those who are very young or elderly are more susceptible to
perioperative hypothermia.7

Elderly patients are more susceptible to hypothermia for a number

of reasons. The body's ability to regulate temperature and to sense
cold may lessen with age. Comorbidities that affect temperature reg-
ulation are more likely in older adults, including conditions such as
hypothyroidism, stroke, severe arthritis, Parkinson’s disease, and
neuropathies including diabetic neuropathy. They are also frequently
more dehydrated and malnourished than the general population.
Finally, medications including some antipsychotics and sedatives
(both of which are used more frequently in long-term care settings)
can impair the body’s ability to regulate its temperature.

Core body temperature changes occur in three stages, beginning

with the onset of general anesthesia. During the first hour, redistrib-
ution is the main cause of potential perioperative hypothermia.

Aligning practice with policy to improve patient care 17

 CE Article

During this stage, warmer blood from the core is allowed to mix
with cooler blood from the rest of the body. The blood cools as
Did you know?
it circulates, and the cooled blood that returns to the heart can
Some patients report that shivering and being
cause a decrease in body temperature8 of up to one degree
cold are worse than surgical pain. Hypothermia
Celsius.7
can cause a vigorous shivering response, which
increases carbon dioxide production and increases
Redistribution is followed by the second phase, which occurs
oxygen consumption 400 to 500 percent.10
during the second and third hours of anesthesia, during which
heat loss exceeds the body’s ability to produce heat. During this
phase, warming the patient can effectively limit further heat loss.
Finally, after about three to five hours of anesthesia, the patient’s
Complications associated with perioperative hypothermia
Hypothermia, which is defined as having a core body temperature
temperature reaches a plateau, which usually remains constant
of less than or equal to 36 degrees Celsius or 96.8 degrees
for the remainder of the surgery, regardless of how long the rest
Fahrenheit, is associated with several complications and an in-
of the procedure takes.
creased risk of death. Perioperative hypothermia can result in: 11
UNINTENDED HYPOTHERMIA • three times the incidence of surgical site infection
• increased bleeding and increased need for blood transfusions
Typical Pattern of Hyp • three times the risk for cardiac complications
• a higher risk for developing pressure ulcers
0 • prolonged recovery after surgery

Preciptious drop in
Surgical site infection. Hypothermia causes the blood vessels
patient temperature to constrict, decreases blood flow to tissues and decreases oxy-
-1
within the first hour of genation of surgical wounds, allowing a more favorable environ-
6CORE TEMP ($C)

anesthesia induction ment for bacterial growth. In 1996 Andrea Kurz, MD, and
colleagues published a study involving 200 colorectal surgery
-2
patients; 100 were randomly assigned to undergo surgery with
warming and the other 100 without warming. For those who did
not receive warming, the final mean intraoperative core temper-
-3
ature was 34.7 degrees Celsius. The final mean temperature for
those who were warmed was 36.6 degrees Celsius. Surgical
wound infections were found in 19 percent of the hypothermic
0 2 4 6 group and in six percent of the normothermic group. The
ELAPSED TIME
authors concluded that intraoperative core temperatures about
two degrees Celsius below normal increase the incidence of
After inducing anesthesia, a patient’s
core body temperature drops rapidly.9 wound infection threefold and prolong hospitalization by about
20 percent.12

Melling et al. also conducted a study of wound infection rates

following surgery. The random controlled trial included 421
patients and resulted in a four percent infection rate among
patients who received local warming and 15 percent among
those who were not warmed.8

Continued on Page 20

18 The OR Connection
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One suspected cause of surgical site infections has been
understood to be a lack of oxygen, in particular bactericidal
oxide radicals. As a drop in core temperature leads to vaso-
constriction to preserve heat in the body, less oxygenated blood
flows to a wound site on the skin. That reduction in available
oxygen at the wound site makes it more conducive to bacterial
growth. One study found that dissolved oxygen (pO2) is a
strong predictor of infection. Measuring levels of subcutaneous
oxygen in post-surgical patients, he found that none with an
oxygen tension greater than 90 mmHg developed a SSI
whereas 43 percent of patients with an oxygen tension between
40 and 50 mmHg did develop a SSI.
Increased blood loss. A meta-analysis published in 2008 by
Daniel Sessler, MD, professor and chair of the Department of
Outcomes Research at Cleveland Clinic, and colleagues found
that less than one degree of hypothermia is enough to increase
blood loss by about 16 percent and increase the need for in-
traoperative transfusion by about 22 percent. Normothermia,
however, was associated with a reduced chance of blood loss
and a reduced need for transfusion.13 Similarly, an earlier study
by Schmied and colleagues in 1996 also found that mild hy-
pothermia can increase blood loss and the need for transfusion
during surgery.14
20 The OR Connection
Published evidence shows
high rates of complications
among hypothermic surgical
patients, making it important
for perioperative professionals
to keep patients warm.
Cardiac complications. A 1993 study by Johns Hopkins anes-
thesiologist S.M. Frank, MD, and colleagues revealed that a
greater number of hypothermic patients (36 percent) experi-
enced myocardial ischemia compared with normothermic
patients (13 percent). The incidence of angina postoperatively
was also greater among the hypothermic group (18 percent)
compared with the normothermic group (1.5 percent).15 All 100
subjects in the study underwent a vascular reconstruction
procedure.
It is important to recognize the difference between unintended
hypothermia that leads to cardiac conditions, and the growing
practice of therapeutic, induced hypothermia in cardiac patients.
Unintentional hypothermia (perioperatively or otherwise) can lead
to an unusually slow or irregular heart rate, which manifests as
a weak or slow pulse or other arrythmias.16 Therapeutic hy-
pothermia is an evidence-based intervention that attempts to
lower core temperatures to around 33 degrees Celsius
for 24 hours after a cardiac event for the purpose of improving
neurological outcomes.
Perioperative pressure ulcers. Because of circulatory and
metabolic changes that occur during surgery, the etiology of
perioperative pressure ulcers is more complex than those that
 CE Article

occur in medical patients. 17 In a 2001 study researchers

hypothesized that patients’ capacity to withstand mattress pres-
sures during surgery would increase if hypothermia were
prevented. They performed a randomized control trial to explore
the relationship between tissue viability and patient core
temperatures during surgery and to test the hypothesis that
patient warming would reduce the incidence of pressure ulcers.
Their trial involving 324 surgical patients resulted in an eight
percent pressure ulcer incidence among patients who were
warmed with a forced air over-blanket, versus a 65.4 percent
incidence among patients who were not warmed.18

Prolonged recovery. Rainer Lenhardt, MD, clinical director of

the Neuroscience-Anesthesia Intensive Care at the University of
Louisville School of Medicine, and colleagues hypothesized that
intraoperative hypothermia may prolong immediate surgical
recovery by increasing the potency of the anesthetic, delaying
drug metabolism or depressing cognitive function. They followed
150 patients undergoing elective major abdominal surgery and
discovered that hypothermic patients required about 40 minutes
longer than normothermic patients to reach fitness for discharge.19

Length of stay in the post-anesthesia care unit (PACU) is an

important issue for health care managers. PACU nurses care for
a small number of patients because of the high level of attention
and care needed by a person recovering from anesthesia. Some
have calculated that the personnel cost for two-hours in the
PACU stay is similar to the personnel cost for a full day on a general
care unit in a hospital.20 In an era of cost control, decreasing
recovery time is economically desirable for the institution.

Warming methods
As summarized above, published evidence shows high rates of
complications among hypothermic surgical patients, making it
important to maintain normothermia. There are several kinds of
surgical warming devices available.

Types of warming devices include forced air over or under the

body; circulating warm-water devices; or conductive, active
warming devices, which include under-the-body warming
mattresses or over-the-body warming blankets. In addition to
requiring perioperative professionals to maintain normothermia
in patients, SCIP-Inf.-10 also requires clear documentation
regarding the use of active warming devices.11

Aligning practice with policy to improve patient care 21

 How to prevent perioperative hypothermia
Although SCIP recommends keeping patients warm during
surgery, it does not recommend how to keep them warm.21
Nursing organizations, including the Association of
periOperative Registered Nurses (AORN) and the American
Society of Perianesthesia Nursing have developed standards
for preventing hypothermia during surgery. The following
are highlights from AORN’s “Recommended Practices for
Prevention of Unplanned Perioperative Hypothermia.”22
Recommendation I
The perioperative registered nurse should assess the
patient for risk of unplanned perioperative hypothermia.
Recommendation II
The perioperative registered nurse should develop
a plan of care to minimize the risk of unplanned
perioperative hypothermia in patients identified at risk.
Recommendation III
Equipment to monitor core temperature should be
selected based upon reliability and access to the route.
III.a.1
There are four reliable sites for measurement of core
temperature:
• Tympanic membrane. The tympanic membrane
temperature, measured by a thermocouple, is the
preferred method in many perioperative and postoperative
areas. This method is noninvasive, and the monitoring
site receives blood supply from the carotid artery, which
supplies the thermoregulatory center of the hypothalamus.
• Distal esophagus. The distal esophagus is considered
a desirable site to measure temperature, particularly in
the operating room, and is less prone to artifact than most
others. It is an alternative to the pulmonary artery and is
widely used intraoperatively. Placement of the probe in the
lower fourth of the esophagus prevents artifactual cooling
of the probe by respiratory gases.
• Nasopharynx. The nasopharynx is another reliable
monitoring site for intraoperative measurement because it
approximates core temperature. A thermistor probe is
inserted through the nares to the nasopharynx.
Measurements may be influenced by the temperature
of inspired gases and often are 0.5 degrees Celsius
lower than pulmonary artery temperatures.
22 The OR Connection
• Pulmonary artery. The most accurate measurement
of the core body temperature is through the pulmonary
artery, which is bathed in blood from the core. This
invasive form of monitoring, however, is not justified
solely for temperature assessment.
Recommendation IV
The core temperature of patients at risk for unplanned
hypothermia should be monitored pre-operatively,
intraoperatively and postoperatively.
Recommendation V
Interventions should be implemented to prevent
unplanned hypothermia.
Recommendation VI
Warming devices should be used in a manner that
minimizes the potential for patient injuries.
Recommendation VII
Competency
Personnel should receive initial education and competency
validation and updates on the prevention of unplanned
hypothermia and the use of warming equipment.
Recommendation VIII
Documentation
Patient assessments, the plan of care, interventions
implemented, and evaluation of care to prevent unplanned
perioperative hypothermia should be documented.
Recommendation IX
Policies and Procedures
Policies and procedures for prevention of unplanned
hypothermia should be developed in collaboration with
anesthesia care providers, reviewed periodically, revised as
necessary, and readily available in the practice setting.
Recommendation X
Quality
A quality improvement/management program should
be in place to evaluate the structure, process, and
outcomes of interventions used to protect patients from
unplanned perioperative hypothermia.
 Methods of Patient Warming
Warm IV Fluids
Conductive Warming Devices
Warming Blankets
Forced Air
Circulating Water Garments
Increased Operating Room Temperature
In an interview with OR Manager, perioperative hypothermia
expert Dr. Sessler stated that it doesn’t matter which warming
method is used as long as the patient’s temperature is approx-
imately normal at the end of the surgery.21 Dr. Sessler is a lead-
ing researcher in surgical warming and has co-written many
studies on how hypothermia affects surgical patients and the
effectiveness of warming devices.
Warm IV fluids. Warming IV fluids is another way to increase
body temperature, but only under certain circumstances.
AORN’s “Recommended Practices for Prevention of Unplanned
Perioperative Hypothermia” states:22
“Warming intravenous (IV) fluids should be considered only if
large volumes (i.e., more than two liters/hour for adults) are
being administered. Warming IV fluids to near 37 degrees Cel-
sius (98.6 degrees Fahrenheit) prevents heat loss from the
administration of cold IV fluids and should be considered as an
adjunct to skin surface warming. When less than two liters of
volume is given, fluid warming is of limited value because fluid-
induced cooling is minimal.”
Conductive warming devices. One type of patient warming
pad on the market is an electrical resistive/conductive device
that warms underneath the patient’s body. It takes the place of
an existing OR table mattress pad. The device incorporates dual
fiber optic interface temperature sensors under the pad cover
Aligning practice with policy to improve patient care 23
near the patient’s skin to continuously monitor and control the
heat generation of the pad. Warming can begin as soon as the
patient is positioned on the OR table. The anesthesiologist can
select one of five preset temperatures of 37, 38, 39, 40, or 40.5
degrees Celsius. The heating element is placed below one inch
of viscoelastic memory foam to provide pressure redistribution
for the patient. The entire pad is encased in a fluid proof cover
and all seams are sealed to prevent penetration by spilled fluids,
meaning the mattress can be cleaned and reused, eliminating
unnecessary environmental waste. In addition, because the
patient is warming from underneath, blankets need not be
placed on top of the patient, allowing for greater surgical access.
The device also operates with no noise.
Warming blankets. Warming blankets are one option that is
portable, easy-to-use and effective. The downside, however, is
that nurses must make multiple trips to and from the blanket
warming cabinet to ensure the patient always has a warm blanket.
This can reduce efficiency and increase laundry costs.23 Also,
adding too many layers of warmed cotton blankets is ineffective
in raising the patient’s body temperature. The first blanket can
reduce heat loss by 33 percent, however, adding another blanket
only adds another 18 percent reduction in heat loss. Adding
three or more blankets adds no further warming.8
Forced air warming. Another widely used option is forced air
warming. The system consists of a warming unit and a remov-
 able disposable blanket. The warming unit, which resembles an
industrial vacuum cleaner, draws in air from the room and
warms it to a specified temperature. The warm air is then
pumped through a hose into a disposable blanket that covers
the patient. According to Dr. Sessler, operating rooms tend to
use forced-air warming covers because they are effective, safe
and inexpensive. The blowers are often provided, and the blan-
kets are inexpensive.21
One difficulty with forced air warming is that it cannot always
sufficiently warm a large enough surface to maintain normoth-
ermia during very large procedures when the patient is not in
the supine position. For example, it can be difficult to maintain
normothermia in a patient undergoing a colectomy in the litho-
tomy position. So much skin is exposed that there is not enough
surface area to warm. In cases like this, a combination of patient
warming devices and an ambient operating room may be the
solution for maintaining normothermia.21
Some surgical staff reject the use of forced air warming because
it can contribute to field contamination and the unit itself can be
a source of pathogens. Another criticism of forced-air warming
is that it can create too warm an environment for the surgeon.8
The blowing can also create a considerable amount of noise in
the OR.
Circulating water garments. These devices circulate water
through a segmented garment that is wrapped around the
anterior and posterior sides of the patient. This is in contrast to
circulating water mattresses, which the patient lies on in a
supine position, thereby warming the posterior side of the body.
Research conducted by Dr. Sessler has shown that circulating
water garments and energy transfer pads warm patients about
50 percent better than forced air because they warm both over
and under the body. These systems tend to be more costly,
however, experts argue the cost is justified by better patient out-
comes when compared with other warming methods.
The following is an excerpt from a study by Taguchi et al., which
compares the efficacy of circulating water garments versus
forced air to maintain perioperative normothermia.6 To read the
study in its entirety, go to www.ncbi.nlm.nih.gov/pmc/arti-
cles/PMC1409744/?tool=pubmed. Akiko Taguchi, MD, is an in-
structor in the Department of Anesthesiology at Washington
University in St. Louis, MO.
24 The OR Connection
“Differences in perioperative patient warming systems result
largely from what tissues are in contact with what heating ele-
ment and the available surface area. Heat transfer also depends
on physical characteristics of the heater-skin interface. For
example, the surface area of the lung is enormous, but airway
heaters and humidifiers transfer trivial amounts of heat because
the thermal capacity of air is small.
With any cutaneous warming system, heat transfer into the ther-
mal core depends on skin temperature, tissue insulation, and
circulatory convection of heat within the body. Device efficacy
thus depends on which surface area is heated because the core
is relatively isolated from distal skin surfaces. But most impor-
tantly, cutaneous heat transfer depends on skin temperature.
Nearly all commercially available patient-warming systems are
electrically powered; there is, therefore, no intrinsic physical limit
to the calories that can be provided. Instead, the limitation is al-
ways the skin temperature that can be tolerated without undue
risk of burns.
Despite the high heat capacity and thermal conductivity of water,
the efficacy of conventional circulating-water mattresses is mod-
est. Poor efficacy results because 1) the posterior surface is a
relatively small fraction of the body surface area, 2) this area is
poorly perfused because the weight of the body compresses
cutaneous capillaries, and, 3) most heat is lost via radiation and
convection from the anterior surfaces rather than conduction
Despite the high heat
capacity and thermal
conductivity of water, the
efficacy of conventional
circulating-water
mattresses is modest.
 For most patients, raising the room
temperature to more than 73.4º F may
reduce the severity of hypothermia.
into the operating-table mattress. As might thus be expected,
the circulating-water garment transferred only 21 kcal/h across
the posterior skin surface. This is more than reported previously
with a conventional circulating-water mattress, possibly be-
cause of a better interface material. However, it is roughly the
same change in cutaneous heat transfer that is provided by a
single cotton blanket in a normothermic subject.
Anterior surface heat transfer was comparable with each warm-
ing system, and the change in anterior surface heat gain from 0
to 0.5 elapsed hours averaged ≈65 kcal/h with each treatment.
Heat transfer per anterior unit area was thus similar with each
system. A corollary of this observation is that virtually the entire
difference between the two tested warming systems resulted
from heat transfer into posterior surfaces, that is from the portion
of the circulating-water garment that acts as mattress. Core
temperature increased 0.4 degrees Celsius/h faster with circu-
lating water than forced air, a result that is consistent with Jan-
icki et al. Although not tested in this study, our results suggest
that heat transfer and core rewarming with the circulating-water
garment would be similar to that provided by combining a
forced-air cover and a conventional circulating-water mattress.
The core and peripheral thermal compartments were of similar
size (e.g., weight). However, active warming increased periph-
eral tissue heat content roughly three times as much as the core
over the course of the study. The differences were even more
pronounced during the initial warming phase. For example,
peripheral heat content after one hour of circulating water
increased 114 kcal whereas core content increased only
34 kcal. The analogous values for forced air were 71 and 9 kcal.
Peripheral compartment heat content thus increased 60-80 kcal
more than the core compartment with each device. These data
indicate that tissue insulation restricted rapid flow of heat from
the periphery to the core. In other words, applied heat was
constrained by the insulating properties of peripheral tissues,
thus significantly limiting the rate at which core temperature
increased.
That peripheral tissues insulated the core and slowed heat
transfer in our volunteers is consistent with observations of Plat-
Aligning practice with policy to improve patient care 25
CE Article
tner et al. who found that peripheral tissues isolate the core from
heat applied to the skin surface in the post-anesthetic period.
Similarly, Szmuk et al. found that core rewarming was slowed by
postoperative vasoconstriction. In contrast, peripheral-to-core
heat transfer is unimpeded during anesthesia, whether subjects
are vasodilated or vasoconstricted. The critical distinction
amongst these studies is that volunteers were fully anesthetized
in the later protocols whereas they were unanesthetized in the
former ones. Although our volunteers remained intubated, they
were very lightly anesthetized and fully vasoconstricted. It is thus
unlikely that they were given sufficient anesthesia to cause di-
rect arteriolar vasodilation that seems to be critical for rapid pe-
ripheral-to-core heat transfer.
Although core temperatures were virtually identical at onset of
warming, peripheral tissue temperature was slightly cooler on the
circulating-water day. This lower initial skin temperature and greater
initial core-to-peripheral tissue-temperature gradient increases the
apparent efficacy of circulating water. However, the tissue tem-
perature difference was only a few tenths of one degree Celsius
and thus unlikely to have substantially altered the results.
Traditional circulating-water mattresses are associated with ‘pres-
sure-heat necrosis’ (i.e., burn) that results when tissue com-
pressed by the weight of the patient is simultaneously warmed.
Gali et al. recently reported the case of a 67-year-old woman who
developed burns on her back after 6.5 hours of surgery while
being warmed with the same circulating-water garment we used.
Thus, when using this system, clinicians should consider any risk
factors such as age, length of surgery, and nutritional status,
which may predispose a patient to skin injury.
In summary, the circulating-water garment transferred more heat
than forced air, especially during the first hour of warming, with
the difference resulting largely from posterior heating. Excessive
heating of peripheral thermal compartment indicates that pe-
ripheral tissues insulated the core, thus slowing heat transfer. ”
Increasing operating room temperature. When active skin
warming is not feasible or skin warming by itself is inadequate for
maintaining normothermia, increasing the room temperature is
 an option. For most patients, raising the room temperature to
more than 23 degrees Celsius (73.4 degrees Fahrenheit) may
reduce the severity of hypothermia.22
Combining warming techniques
Some have suggested the need for a holistic approach incor-
porating several different warming techniques to adequately
warm a patient. Overall, depending on the surgeon, the surgi-
cal team, and patient and the circumstances, the best method
of active warming may vary.23
Conclusion
Looking to the future, as surgical team awareness and further
research into normothermia continues to develop, even more
effective patient-temperature management devices are sure to
follow. Warming device experts predict the development of more
sustainable technologies that can be cleaned and re-used,
unlike forced air warming which creates environmental waste
with its disposable blankets. In addition, developing effective
equipment that covers less of the body surface than forced-air
warming or circulating water devices can offer greater conven-
ience and access for anesthesiologists and surgical teams.23
References
1 Measure Information Form. SCIP-Inf-10. Available at:
http://www.hsag.com/App_Resources/Documents/SCIP_LS3_Inf10_MIF.pdf.
Accessed February 25, 2011.
2 Surgical Care Improvement Project. The Joint Commission Web site. Available at:
http://www.jointcommission.org/surgical_care_improvement_project/. Accessed
March 4, 2011.
3 National SCIP Partnership Developing to Reduce Surgical Complications. The
Leapfrog Group website. Available at:
http://www.leapfroggroup.org/news/leapfrog_news/144968. Accessed February
27, 2011.
4 Gunn M. SCIP expanded normothermia measure to go into effect for all surgical
patients in October. AORN Management Connections. July 2009. Available at:
http://www.aorn.org/News/Managers/July2009Issue/Normothermia. Accessed
February 25, 2011.
5 Wagner VD. Patient safety chiller: unplanned perioperative hypothermia. AORN
Journal. 2010; 92(5):567-571.
26 The OR Connection
6 Taguchi A, Ratnaraj J, Kabon B, Sharma N, Lenhardt R, Sessler DI, et al. Effects
of a circulating-water garment and forced air warming on body heat content and
core temperature. Anesthesiology. 2004; 100(5):1058-1064.
7 Lynch S, Dixon J, Leary D. Reducing the risk of unplanned perioperative
hypothermia. AORN Journal. 2010; 92(5):553-562.
8 Weirich TL. Hypothermia/warming protocols: why are they not widely used in the
OR? AORN Journal. 2008;87(2):333-344.
9 Sessler D & Todd M. Perioperative heat balance. J Amer Soc Anesth. 2000;
92(2):578.
10 Paulikas CA. Prevention of unplanned perioperative hypothermia. AORN Journal.
2008; 88(3):358-364.
11 Wagner VD. Patient safety chiller: unplanned perioperative hypothermia. AORN
Journal. 2010; 92(5):567-571.
12 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the inci-
dence of surgical-wound infection and shorten hospitalization. The New England
Journal of Medicine. 1996;334(19):1209-1215.
13 Rajagopaian S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hy-
pothermia on blood loss and transfusion requirement. Anesthesiology.
2008;108(1):71-77.
14 Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases
blood loss and transfusion requirements during total hip arthroplasty. The Lancet.
1996; 347(8997):289-292.
15 Frank SM, Beattie C, Christopherson R, Norris EJ, Perler BA, Williams GM et al.
Unintentional hypothermia is associated with postoperative myocardial ischemia.
Anesthesiology. 1993; 78(3):468-476.
16 Mayo Clinic Researchers Confirm Value of Therapeutic Hypothermia. February 18,
2011. Available at: http://www.mayoclinic.org/news2011-rst/6184.html. Accessed
March 4, 2011.
17 Rogan J. Pressure ulcer risk during the perioperative period focusing on surgery
duration and hypothermia. Wounds. 2007; 3(4):66-74.
18 Scott EM, Leaper DJ, Clark M, Kelly PJ. Effects of warming therapy on pressure
ulcers—a randomized trial. AORN Journal. 2001; 73(5):921-938.
19 Lenhardt R, Marker E, Goll V, Tschernich H, Kurz A, Sessler DI, et al. Anesthesiol-
ogy. 1997;87(6):1318-1323.
20 Waddle JP, Evers AS, Piccirillo JF. Postanesthesia care unit length of stay: quanti-
fying and assessing dependent factors. Anesthesia and Analgesia 87. 1998;
87(3):628-633.
21 Mathias JM. Taking steps to keep OR patients warm. OR Manager.
2006;22(12):14-16.
22 Recommended Practices for Prevention of Unplanned Perioperative Hypothermia.
In: 2010 Perioperative Standards and Recommended Practices. Denver, CO: As-
sociation of PeriOperative Register Nurses; 2010.
23 Cantrell S. New normothermia measure heats up patient-temperature manage-
ment. Healthcare Purchasing News. March 1, 2010. Available at: http://www.hp-
nonline.com/inside/2010-03/1003-IC.html. Accessed February 25, 2011.
 Patient Safety Quality Measures for the
Surgical Care Improvement Project
Measure
Prophylactic antibiotics are
SCIP-Inf-1 administered one hour prior to
incision.
Prophylactic antibiotics are
consistent with current
SCIP-Inf-2
guidelines (specific to each type
of surgical procedure).
Prophylactic antibiotics are to be
discontinued within 24 hours
after anesthesia end time.
SCIP-Inf-3
The discontinuation time
extends to 48 hours for cardiac
surgery patients.
Cardiac surgery patients with
controlled 6 a.m. blood glucose
SCIP-Inf-4
(”0 mg/dL) for the first two
postoperative days.
Surgery patients with
appropriate surgical site hair
SCIP-Inf-6 removal. No hair removal, hair
removal with clippers, or
depilatory is appropriate.
Surgical patients with urinary
catheter removed on
Postoperative Day 1 or
Postoperative Day 2 with day of
SCIP-Inf-9
surgery being day zero. (This
measure does not apply to
certain urological, gynecological
or perineal procedures.)
Rationale Strategy
Studies find that the lowest incidence of post- x Include administration and documentation of
operative infection is associated with the antibiotic in the surgical time out.
antibiotic administration during the one hour
x For one-hour antibiotics, the antibiotic is hung
prior to surgery. The risk of infection
in pre-op, a surgical team member administers
increases progressively with greater time
and documents the antibiotic infusion.
intervals between administration of the
antibiotic and the skin incision.
Use an agent that is safe, cost-effective, and x The use of pre-printed orders that include the
has a spectrum of action that covers most of recommended antibiotic will assist surgeons
the probable intraoperative contaminants for with choosing appropriate antibiotics.
the operation. First- or second-generation
x Vancomycin is appropriate if there is a risk of
cephalosporins satisfy these criteria for most
MRSA.
operations, although anaerobic coverage is
needed for colon surgery.
Administration of antibiotics for more than a x Begin antibiotics in the PACU.
few hours after the incision is closed offers no
x Administer cephalosporins every 6 hours
additional benefit to the surgical patient.
rather than every 8 hours.
Prolonged administration increases the risk of
Clostridium difficile infection and the x Antibiotics are not provided for more than 24
hours after surgery without appropriate
development of antimicrobial resistant
documentation.
pathogens.
Hyperglycemia in the immediate x Blood glucose levels are monitored from pre-
postoperative phase increases the risk of op through 48 hours post operative.
infection in both diabetic and non-diabetic
x The use of an insulin protocol for treating
patients; the higher the level of
hyperglycemia with an insulin drip is strongly
hyperglycemia, the higher the potential for
recommended.
infection in both patient populations.
There is no strong evidence to contraindicate x Take ALL razors out of the peri-operative area.
preoperative hair removal; however, there is
x Instruct patients not to shave the surgical site.
strong evidence against hair removal with a
razor. Shaving is considered inappropriate.
It is well-established that the risk of catheter- x Create a system of alerts or reminders to
associated urinary tract infection (UTI) identify all patients with urinary catheters and
increases with increasing duration of assess the need for continued catheterization.
indwelling urinary catheterization.
x Develop guidelines and protocols for nurse-
directed removal of unnecessary urinary
catheters and management of postoperative
urinary retention.
x Consider the use of external catheters for
cooperative males
Aligning practice with policy to improve patient care 27
 Measure
Surgical patients should be
actively warmed during surgery
or have at least one recorded
body temperature equal to or
SCIP-Inf- greater than 96.8° F within 30
S 10 minutes prior to the end of
anesthesia to 15 minutes after
anesthesia end time. (Patients
with intentional hypothermia are
excluded from this measure.)
Surgery patients on beta-
blockers prior to admission
SCIP-
should continue beta-blocker
CARD-2
therapy during the perioperative
period.
T most common postoperative complications
Surgery patients with
recommended venous
SCIP-VTE- thromboembolism (VTE)
1 prophylaxis ordered anytime
from hospital arrival to 48 hours
 after Anesthesia End Time.
Surgery patients who received
appropriate venous
thromboembolism (VTE)
SCIP-VTE-
prophylaxis within 24 hours prior
2 variability related to the initiation of
to Anesthesia Start Time to 24
hours after Anesthesia End
Time.
This material was prepared by Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Arizona, under contract with
the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do
not necessarily reflect CMS policy. Publication No. AZ-9SOW-6.2.3-110609-01
28 The OR Connection
Rationale
Research has correlated impaired wound
healing, adverse cardiac events, altered drug
metabolism, and coagulopathies with
unplanned perioperative hypothermia. A study
by Kurtz, et al. (1996), found that incidence of
culture-positive surgical site infections among
those with mild perioperative hypothermia
was three times higher than the normothermic
perioperative patients.
The American College of Cardiology and the
American Heart Association recommend
continuation of beta-blocker therapy in the
perioperative period as a class I indication,
and accumulating evidence suggests that
titration to maintain tight heart rate control
should be the goal.
Despite the evidence that VTE is one of the
and prophylaxis is the most effective strategy
to reduce morbidity and mortality, it is often
underused.
The frequency of venous thromboembolism
(VTE), which includes deep vein thrombosis
and pulmonary embolism, is related to the
type and duration of surgery, patient risk
factors, duration and extent of postoperative
immobilization, and use or nonuse of
prophylaxis.
Timing of prophylaxis is based on the type of
procedure, prophylaxis selection, and clinical
judgment regarding the impact of patient risk
factors. The optimal start of pharmacologic
prophylaxis in surgical patients varies and
must be balanced with the efficacy-versus-
bleeding potential. Due to the inherent
prophylaxis for surgical procedures, 24 hours
prior to surgery to 24 hours post surgery was
recommended by consensus of the SCIP
Technical Expert Panel in order to establish a
timeframe that would encompass most
procedures.
Strategy
x Use aggressive warming measures during
surgery.
x Ensure accurate documentation of post-
operative temperature.
x Instruct patients to take their beta blockers the
day of surgery.
x Educate in-house clinicians about the
importance of patients receiving their beta
blockers the day of surgery, even while the
patients are otherwise NPO.
x Meet with physician office staff to ensure
consistent instructions to the patients.
x Use pre-printed orders that include nationally
recommended guidelines for VTE prophylaxis.
x A “hard stop” would be not to allow patients to
leave the recovery area until VTE orders are
completed by the surgeon.
x Ensure that surgeon “preference” cards mirror
national guidelines.
x Pharmacists should assist surgeons with
understanding the risk of bleeding with
pharmacological interventions.
x (Please note that rates for SCIP-VTE- 2 may
be lower than those for SCIP-VTE-1 as a result
of more stringent criteria. SCIP-VTE-2 requires
documentation that prophylaxis was ordered
and actually started, whereas SCIP-VTE-1
requires only documentation of an order. )
x Organizations with decreased VTE 2 rates
should assess their processes to determine
why physician orders are not being
implemented.
 CE Test

Turn Up the Heat

Avoiding Surgical Complications
with Adequate Patient Warming

True/False
1. Extremely thin and malnourished patients are more 8. In the Scott study, what was the incidence of
susceptible to perioperative hypothermia T F pressure ulcers among patients who were not
warmed during surgery?
2. SCIP Inf.-10 went into effect April 1, 2007. T F a. 72.5 percent
b. 15.3 percent
3. Forced air warming is a widely used option for patient c. 65.4 percent
warming. T F d. 22.8 percent

4. Cool air temperature in the operating room can 9. Which of the following is NOT a known complica-
contribute to unplanned perioperative hypothermia. T F tion of perioperative hypothermia?
a. Surgical site infection
5. Perioperative hypothermia can cause a drastic drop in b. Prolonged recovery
blood pressure. T F c. Myocardial ischemia
d. Pneumonia
6. Some surgical professionals reject the use of
forced air warming because it can contribute to 10. During anesthesia, core body temperature
field contamination. T F changes occur in ____ stages.
a. Three
b. Five
Multiple Choice
c. Two
7. A 2008 study by Sessler and colleagues found that less d. Seven
than one degree of hypothermia during surgery is
enough to increase blood loss by about ___ percent.
a. 25 Visit www.medlineuniversity.com
b. 46 and login or create an account.
c. 16 Choose your course to take
d. None of the above
the test and receive
1 FREE CE credit.

Courses approved for continuing education by the Florida Board

of Nursing and the California Board of Registered Nursing.

Aligning practice with policy to improve patient care 29

 Patient Safety
ClearCount Clearly Makes a Difference
in Patient Safety at Hunt Regional Hospital
By Rebecca McPherson, MSN, RN
The following is a true story shared by nurses Kathy Magee and
Emily Sundee from Hunt Regional Hospital, Greenville, TX.
Imagine this scenario
A patient arrives at the hospital for a scheduled abdominal sur-
gery. Everything is running on time. The patient is placed on the
operating room table, a Time Out is called, and anesthesia is
administered. The patient is intubated and placed on a
mechanical ventilator. The sponges are counted by the circulator
nurse and the scrub nurse. The surgery begins. The procedure
is going well; however, the surgery extends through a shift
change for the scrub nurses. Upon arrival of the second shift,
the patient experiences a large amount of blood loss and packs
of sponges are counted and quickly used. As the surgeon
focuses on recognizing the reasons for blood loss, the nurses
are instructed to order a back up blood supply for the patient.
The surgeon controls the bleeding and begins to close the
patient’s incision. The staff realizes there is an unreconciled
sponge count. The staff attempts to recover the missing sponge.
30 The OR Connection
Many questions and concerns arise such as:
• Could it be in the patient’s cavity?
• Was it thrown away in the linens?
• Did we miscount?
• Is it possible the previous shift made the error?
The surgeon quickly decides to use the SmartWand-DTX and is
able to locate and retrieve the missing sponge. The patient has
a good outcome.
Exploring technology
Hunt Regional is community-based hospital with 192 beds
located in Greenville, Texas. The organization takes pride in a
culture of innovation and transparency. If any staff member says
“this is a safety issue” it’s viewed as very important and the lead-
ership team is committed to following up and resolving the con-
cern. Hunt Regional is dedicated to patient safety and quality
outcomes. That is one of the reasons they were the first hospi-
tal in the state of Texas to begin using ClearCount. Hunt Regional
realizes that retained objects is a standard problem for hospitals
nationwide.
Continued on Page 32
 INTRODUCING

“Retained Surgical Items”

AORN’s latest confidence-based learning (CBL) module.

AORN’s Confidence Based Learning (CBL) is a

unique educational program that is designed to
help you achieve mastery in both knowledge and
confidence of that knowledge when providing care
that meets AORN Standards and Recommended
Practices. CBL is used to train, teach and retain
perioperative professionals. CBL supports the
learner in reducing time to master knowledge and
increasing retention of critical information.

Visit Medline booth # 3408 or Clear Count booth # 537

at AORN Congress for a FREE DEMO of the “Retained
©2011 Medline Industries, Inc. Surgical Items” module.
 The retention of a foreign object is considered a serious and pre- Hunt Regional Hospital
ventable event by the National Quality Forum.1 The Centers for
Medicare & Medicaid Services (CMS) includes the retention of
foreign objects in its list of hospital-acquired conditions for which
reimbursement will not be provided.2 The Joint Commission cat-
egorizes the unintended retention of a foreign object as a sentinel
event.3 The Joint Commission’s sentinel event statistics reported
360 instances of unintentional retention of a foreign body during
the period of 2005 through March 2010.4

National adverse event data demonstrates that retained surgical

items are the most frequent and costly surgical “Never Events,”
with surgical sponges representing the bulk of these incidents.
Human error is a reality; however, Hunt Regional Hospital
According to CMS, the cost of a retained foreign object (RFO)
accepted responsibility, and their objective is to address retained
after surgery is $62,631 per hospital stay.5 In addition to hospi-
surgical sponges head-on. They could not accept just any solu-
tal costs, RFOs can produce major litigation expenses. The total
tion. Efficiency is important to them as well, particularly in the
cost of an RFO, including legal defense, indemnity payments,
healthcare reform climate.
and surgical costs unreimbursed by CMS, would be approxi-
mately $166,135. At the previously quoted incidence of 1 in
The nursing team was highly focused on patient safety. After fur-
5,500 operations, the cost of an RFO amortizes to approximately
ther research, they discovered publications from AORN that
$30 per operation.
made them aware of new technology for the prevention of
retained sponges.
The concern of retaining sponges or foreign objects can occur
even when the staff follows procedures. The risk elevates with
Surgeons also prefer using ClearCount and SmartWand.
emergency procedures, deviation from planned procedures, type
According to Joshua K. Trussell, MD, board certified general sur-
of procedure, patients with a higher mean body-mass index
geon, Primary Care Associates Affiliated and medical director of
(obesity), and failure to count or inaccurate counts during the
the Trauma Program at Hunt Regional Medical Center in
procedure.7 The longer the patient spends on the operating
Greenville, Texas, “Using the lap sponge and raytec (X-ray gauze)
table, the greater the chance of developing pressure ulcers.
have not changed practice or the way I operate, in fact, they are
The incidence of postoperative pressure ulcers may be as high
very user friendly and increase the level of confidence of the
as 66 percent.8 The Institute for Healthcare Improvement (IHI)
physician.”
estimates nearly one million people develop pressure ulcers each
year, with some 60,000 deaths related to complications. The
About the author
cost of treatment ranges up to $11 billion annually.9
Rebecca McPherson, MSN, RN, is vice president of clinical serv-
ices for Medline Industries, Inc. Prior to joining Medline, Rebecca
Hunt Regional made the commitment to reducing or eradicating
worked at Sherman Healthcare Systems as the director of opera-
the incidence of retained surgical sponges by recognizing that
tions for the immediate care centers. Her background also includes
even one such event is one too many.
emergency nursing.

ClearCount benefits the patient and the organization by:

• reinforcing safe, efficient, quality care
• creating reassurance for the physician and staff that there
is another system they can rely on to account for all sponges
• increasing staff productivity, avoiding time spent to
relocate sponges
Using ClearCount does not take the place of manually counting
sponges; however, it serves as reinforcement that the sponges
have all been accounted for. Practitioners should continually
check for RFOs before closing body cavities and develop safety
practices to minimize errors. Hunt Regional is committed to end-
ing retained lab sponges; they created a policy to use ClearCount
for all open abdominal cases in addition to the nurse counting.
1. Centers for Medicare & Medicaid Services. Hospital-acquired conditions
(present on admission indicator)[online]. 2009 Feb 19 [cited 2009 March11].
2. National Quality Forum. Serious reportable events in health-care 2006 update:
a consensus report. Washington (DC): National Quality Forum; 2007.
3. Joint Commission. Facts about the sentinel event policy [online]. 2008 Mar 20
[cited 2009 Mar 11].
4. The Joint Commission. Sentinel event statistics: updated through March 31, 2010.
5. Centers for Medicare & Medicaid Services. CMS fact sheets. CMS proposes
additions to list of hospital-acquired conditions for fiscal year 2009 [online]. 2008
Apr 14 [cited 2009 Apr 7].
6. Cima, RR, Kollengode A, Garnatz J, et al. Incidence and characteristics of potential
and actual retained foreign object events in surgical patients. J Am Coll Surg
2008;207(1):80-7.
7. The Joint Commission. Foreign Objects retained After Surgery. Patient Safety Link
e-Zine. 2009; 5(1).
8. ERCI. Pressure Ulcers. HRC Risk Analysis. 2006;3(Nursing 4):1-37.
9. OR Manager. Save Our Skin: Periop team rally to prevent pressure ulcers in the
OR. 2008; (24)3.

32 The OR Connection
 The benefits of counting
and detection in one
advanced system.

The SmartSponge® System takes the worry

out of finding and counting surgical sponges

There’s no greater relief than getting an accurate surgical

sponge count. The SmartSponge System counts, locates
and recounts each sponge up to 80,000 times during a
single surgery. And because it is the only FDA-approved
system that uses radio-frequency identification, it uniquely
identifies each sponge , so you can use the SmartWand-DTX™
to find missing sponges below, beside or inside a patient

A quick demonstration of how the ClearCount SmartSponge

System can make your time in the O.R. a little less stressful.
Call your Medline representative for details.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
SmartSponge is a registered trademark and SmartWand-DTX is a trademark of ClearCount
Medical Sloutions.
 VA
34 OR Connection
 What is the
Perioperative
Nurse’s Role
in Prevention?
By Lorri A. Downs RN, BSN, MS, CIC

Healthcare-acquired ventilator-associated pneumonia (VAP) can be

very costly. According to the available literature, the average cost
associated with this complication can be as high as $40,000 per
patient.1 With all organizations looking to prevent costly complications
and provide evidence-based medicine, it is critical for every nurse to
understand ventilator-associated pneumonia (VAP) and how to prevent it.

The main role for perioperative nurses is awareness. Awareness is

key, as the most concerning aspect of VAP is the high mortality rate.

AP
Data published in February 2011 suggest that catheter-associated
bloodstream infection (CABSI) and VAP cause more than two-thirds
of the deaths resulting from healthcare-acquired infections (HAIs), and

Ventilator- that they are five times as deadly as the other HAIs.2 Certainly, in the
operative arena, the anesthesiologist manages the patient’s airway.

Associated Once the patient is recovering in the PACU the VAP bundle of activi-
ties can be implemented promptly. The current literature suggests that
55 percent of VAP cases are preventable with current evidence-based
Pnemonia strategies.2

The Institute for Healthcare Improvement (IHI) published a “ventilator

bundle” in 2006 and updated this bundle in May 2010. The bundle is
a set of strategies healthcare workers can implement to help
reduce the risk of VAP. The recent update has placed oral care with
a Chlorhexidine (CHG) mouth rinse on the list of activities to help
reduce the risk of developing VAP.

The IHI Ventilator Bundle as of May 20103

➢ Elevation of the head of the bed 30-45 degrees

unless medically contraindicated
➢ Daily “sedation vacations” and assessment of
readiness to extubate
➢ Peptic ulcer disease prophylaxis
➢ Deep venous thrombosis prophylaxis
➢ Daily oral care with Chlorhexidine (CHG)

Aligning practice with policy to improve patient care 35

 Joint Commission 2012 National Patient Safety Goal NPSG.07.06.01
Elements of Performance4

Perform daily sedation interruption in accordance

11. During 2012, plan for full implementation of this 6
NPSG January 1, 2013. Note: Planning may with the patient’s medical plan of care. Note:
include a number of activities, such as assigning This requirement is not applicable for patients
responsibility for implementation activities, creating that do not have a medical plan for weaning off
timelines, identifying resources, and pilot testing. the ventilator.
Perform hand hygiene before and after providing Measure and monitor ventilator-associated
2 7
care to ventilated patients. (See also PSG.07.01.01) pneumonia prevention processes and outcomes
Position and maintain ventilated patients by doing the following:
3
(except those with medical contraindications) • Selecting measures using evidence-based
in semirecumbent positions. guidelines or best practices
Provide regular antiseptic oral care to patients in • Monitoring compliance with evidence-based
4
accordance with product guidelines. guidelines or best practices
• Evaluating the effectiveness of prevention efforts
Perform daily assessment of ventilated patients to
5
determine their readiness to wean off the ventilator
or to be extubated. Note: This requirement is not
applicable for patients that do not have a medical
plan for weaning off the ventilator.

36 The OR Connection
“55 percent of VAP cases are preventable
with current evidence-based strategies.
“
Additional focus on VAP
Other healthcare organizations, including The Joint Commission
and the Centers for Medicare and Medicaid Services, are also
looking to target VAP prevention. The Joint Commission will be
adding VAP to the 2012 National Patient Safety Goals under
NPSG.07.06.01.

“Medicare stopped providing reimbursement for treatment of

eight largely preventable conditions, three of which it deemed
“never events” and five “reasonably preventable.” Three of the
five “reasonably preventable” conditions are HAIs; namely, CBSI,
CAUTI, and SSI. VAP is being considered for inclusion in an
expanded list scheduled for release in 2011.”2

What’s new? Oral care! Oral care! Oral care!

Oral care with 0.12% Chlorhexidine gluconate oral rinse twice a
day has been found to significantly decrease the risk of
acquiring ventilator-associated pneumonia. A 2009 study
published in the Journal of Intensive Care Medicine found that
“simple low cost oral care protocols implemented in the SICU
can significantly decrease the rate of infection and subsequently
the costs associated with these infections. The cost savings
were $140,000 – $560,000 savings related to infection of
prevention of VAP. The total cost of the oral care program was
$2187.49.”1
So, how do we hardwire the importance of oral care into all
patient care providers? Education and competency testing is
the key to sustainability of clinical practices. Clinical education
programs with these components can help move the needle
to hospital wide compliance as opposed to unit-based
compliance. Oral care and VAP prevention activities do not stop
once the patient leaves the PACU, the SICU or the medical/
surgical units for ventilated patients.
At the end of the day “it may not be an attainable goal of
preventing 100% of HAIs, but comprehensive implementation
of prevention strategies could prevent hundreds of thousands of
HAIs and save tens of thousands of lives and billions
of dollars.”2
About the author
Lorri Downs, RN, BSN, MS, CIC is a board-
certified infection preventionist and vice president
of infection prevention for Medline Industries, Inc.
She has a diverse portfolio of more than 25 years
in the nursing professions. Her expertise focuses
on infection prevention surveillance at large acute
care organizations, plus ambulatory and public
health settings. Lorri has developed hospital
infection control programs and local emergency preparedness plans,
and she has lectured on various infection prevention topics.
References
1. Sona CS, Zack JE, Schallom ME, McSweeney M, McMullen K, Thomas J, et al.
The impact of a simple, low-cost oral care protocol on ventilator-associated
pneumonia rates in a surgical intensive care unit. Journal of Intensive Care
Medicine. 2009; 24(1):54-62.
2. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams, K, Brennan PJ.
Estimating the proportion of healthcare-associated infections that are reasonably
preventable and the related mortality and costs. Infection Control and Hospital
Epidemiology. 2011; 32(2):101-114.
3. Implement the Ventilator Bundle. Institute for Healthcare Improvement (IHI)
website. Available at: http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/
Changes/ImplementtheVentilatorBundle.htm. Accessed February 28, 2011.
4. The Joint Commission 2012 National Patient Safety Goals. Hospital
Accreditation Program. NPSG.07.06.01.

Aligning practice with policy to improve patient care 37

 Ventilator-Associated Pneumonia
can be deadly.
VAPrevent can be easy.

Convenient,
space-saving
packaging

VAPrevent
follows IHI
Ventilator Bundle
guidelines. With
this checklist,
you can too.

Sequential dispensing
system and thumb grip for
easy, one-at-a-time access
— in the right order
Evidence-based innovation in oral care for ventilator patients

VAPrevent is a comprehensive system to give your staff the tools to deliver excellent oral
care. And for ventilator patients, excellent oral care may be part of the difference between
ventilator-associated pneumonia and staying healthy.

The three parts of the VAPrevent program you’ll want to know:

Product
Only Medline gives you these three options for oral care: IHI-recommended
chlorhexidine gluconate (CHG), the alcohol-free moisturizing of Biotene®,
or the proven antisepsis of hydrogen peroxide. Procedure kits feature
innovative components, like graduated suction catheters and toothbrushes
with integrated gum and tongue scrubbers. Breakthrough package design
communicates and educates, all while leaving less waste behind. And the
intuitive stack-pack design with its one-at-a-time dispenser makes it easy
for caregivers to stay on track with care protocols.

Clear visuals let

you identify the
right kit quickly
for your patient’s
needs

Program
When your staff knows how to use a product appropriately, its effectiveness
increases greatly. That’s why Medline developed the Medline VAP program,
which helps build knowledge and clinical skills with educational modules
for both novice and experienced clinicians, as well as an online interactive
competency for oral care. A program manager helps you implement your
program and stays active as you progress, providing 90-day reports to
help you track your incidence of VAP.

Price
If you expected a VAP program this innovative would come at a price
premium, you’re in for a pleasant surprise. VAPrevent from Medline
comes to you for five to ten percent lower than competitors. In a tough,
pay-for-performance environment, VAPrevent represents a major value.

To schedule your evaluation of the VAPrevent System,

contact your Medline representative or call
1-800-MEDLINE (633-5463).

References
1 Bingham M, Ashley J, De Jong M, Swift C. Implementing a unit-level intervention to reduce the probability
of ventilator-associated pneumonia. Nursing Research. 2010; 59(1): S40-S47.
2 Trouillet J, Chastre J, Vuagnat A, Joly-Guillou M, Combaux D, Dombret M, et al. Ventilator-associated
pneumonia cased by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998. 157(2):531-539.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 THE INS
AND OUTS
OF HERNIAS
AND WAYS
TO REPAIR
THEM

40 The OR Connection
 OR Issues

By Alecia Cooper, RN, BS, MBA, CNOR

Documentation of hernias goes back to ancient times. Physicians in

Alexandria used tightly-fitting bandages as treatment for a hernia, and a
Phoenician statuette circa 900 BC portrays the bandaging.1 It’s debatable,
however, whether hernia surgeries were performed at that time. Fast forward
to 1884, when Bassini introduced a surgical hernia repair that resulted in a
very low (2.7 percent) recurrence rate. Today, the Lichtenstein procedure con-
tinues to dominate the world of hernia repair.2

What is a hernia? Types of hernias

A hernia is the abnormal protrusion of part of an organ or tis-
sue through a weak spot or other abnormal opening in a wall
of muscle or other tissue. The condition can develop in various
parts of the body, but hernias occur most commonly in the ab-
dominal region, where part of the intestines or intra-abdominal
fat bulge through the weak spot in the abdominal muscle.
Patients with hernias may notice a bulge under the skin and
feel pain when lifting heavy objects, coughing or during pro-
longed standing or sitting. Any motion or action that increases
intra-abdominal pressure will exacerbate the symptoms of a
hernia. The pain may be sharp and immediate or a dull ache
that gets worse toward the end of the day.
Hernias can be congenital, meaning they occur during fetal
development, or acquired. A hernia can be acquired from
increased intra-abdominal pressure causing by heavy lifting,
prolonged coughing, prostate problems or bowel irregularity.
A common property of all hernias is that once they are present,
they are permanent until surgically repaired.
Each type of hernia has its own descriptive name, and the list
of types is quite extensive. The most common types of her-
nias, however, are inguinal (in the groin), umbilical (at the belly
button), and incisional (at the site of a previous operation).
An inguinal hernia occurs in the groin where the abdominal
folds of flesh meet the thighs. It is often the result of increased
pressure within the abdomen due to lifting, coughing or strain-
ing. This type of hernia occurs more often in males because it
follows the tract that develops when the testes descend into
the scrotum before birth. In females, the inguinal hernia follows
the course of the round ligament of the uterus.
An umbilical hernia occurs with weakness in the umbilicus
(belly button). This type of hernia occurs most often in infants
and children.
An incisional hernia is a frequent complication of abdominal
surgery, with a reported incidence of up to 20 percent.3 This
type of hernia that can develop at the site of a surgical incision
that fails to heal properly, causing tissue weakness. This hernia
also can occur when excessive strain is placed on the tissue at
the incision site.

Aligning practice with policy to improve patient care 41

 Any type of hernia may become strangulated. This is a very
dangerous condition that can appear suddenly and requires
immediate medical attention. A strangulated hernia is one that
is tightly constricted. As any hernia progresses and bulges out
through the weak point in its containing wall, the opening in the
wall tends to close behind it, forming a narrow neck. If this
neck is pinched tightly enough to cut off the blood supply, the
hernia will quickly swell, becoming strangulated. Severe, con-
tinuous pain, redness, and tenderness are signs that the her-
nia may be entrapped or strangulated. Unless the blood
supply is restored promptly, gangrene can set in and may
cause death.4
Surgical repair of a hernia
Although various supports and trusses are available to try to
contain a hernia, the most effective treatment is surgical repair
of the weakness in the muscle wall where the hernia pro-
trudes.
Approximately 700,000 hernia repair operations are performed
annually in the United States.5 Many are performed by the
conventional open surgical method. The rest are performed
using a laparoscope.6
Several different surgical techniques have been developed
over the years to repair hernias. Most techniques are based on
the simple idea of closing the opening in the muscle wall. In the
past, the opening was simply sutured closed, however, the
preferred repair method today is the use of mesh fabric placed
over the area for reinforcement. Outpatient surgery is clinically
feasible for at least 75 percent of adults with primary inguinal
hernias whether the operation is performed using an open or
laparoscopic technique, and most patients can go home the
same day the operation is performed.7
Open surgery. Before the introduction of hernia mesh, all her-
nias were repaired by simply suturing together the opening
where the hernia was protruding. A 2004 follow up of a ran-
domized controlled trial of suture versus mesh repair of an
incisional hernia concluded that mesh repair results in a lower
recurrence rate and less abdominal pain and does not result
in more complications than suture repair. The researchers who
conducted the study even recommended abandoning suture
repair of incisional hernia altogether.3
42 The OR Connection
Surgical hernia mesh
In the United States, as of 2003, more than 90 percent of all
inguinal and incisional hernias were repaired with mesh, and
that number is likely higher today. This method has proven to
be more secure than closing the hernia using only sutures and
nearly eliminates the possibility of the hernia opening
up again.7
The tension-free hernioplasty with mesh, known as the
Lichtenstein operation, was introduced in the 1980s by Irving
Lichtenstein and colleagues. The technique is known for its
quickness and simplicity to perform. It is also generically
referred to as the plug and patch technique. It’s nearly pain-
free for patients and allows for a prompt return to work. What’s
more, it is the recommended operation of first choice for
uncomplicated unilateral inguinal hernia in men.7
The open hernia repair is performed from the outside through
an incision in the groin or the area of the hernia. The incision
extends through the skin and subcutaneous fat, allowing the
surgeon to get to the level of the defect. This technique is
usually done with a local anesthetic and sedation, but may be
performed using a spinal or general anesthetic.
Laparoscopic surgery. Laparoscopic hernia repair uses
small incisions, telescopes, a camera and a square of surgical
mesh material that acts as a patch over the opening. Com-
pared to open surgery, laparoscopic hernia repair may offer a
quicker return to work and normal activities with decreased
pain for some patients.
Continued on Page 44
 Revolutionary technology
for exceptional results.

ASSURE™ Surgical Mesh – REVIVE™ Surgical Mesh –

for the repair of ventral hernias for the repair of inguinal hernias

Both ASSURE and REVIVE feature our proprietary

polyurethane Biomaterial, which offers the advantages
of both a synthetic and a biologic mesh:
• The architecture and design to mimic
tissue in-growth of a biologic mesh1,2
• The strength and economical price
of a synthetic mesh

For more information, contact your Medline

representative at 1-800-MEDLINE or
References: visit Medline.com.
1. “A Comparative Morphologic Evaluation of Synthetic Surgical Mesh Materials
in a Rat Model of Body Wall Repair” (ASSURE 26W Rat Study).
2. “In-Vivo Evaluation of Biomerix Polypropylene Composite Mesh in a Rat Body
Wall Model” (REVIVE 26W Rat Study).

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Assure and Revive are trademarks of Biomerix Corporation.
 On the downside, laparoscopic surgery most often requires
“ The large proportion of mankind who
general anesthesia, which poses more risks to the patient. It’s
also more difficult to perform than open surgery, it takes longer
and it costs more. In the United States less than 20 percent of
all hernias are treated laparoscopically.5
The first report of hernia repair with laparoscopy was made by
Ralph Ger in 1982.7 To perform laparoscopic hernia surgery, a
laparoscope connected to a special camera is inserted into
the body after making a small (1/4 inch) hole in the abdomen,
allowing the surgeon to view the hernia and surrounding tissue
on a video screen.
Two other holes are also made, which allow the surgeon to
work inside the body. A small piece of surgical mesh is inserted
through the surgical hole and placed either outside or inside
the hernia defect and held in place with sutures, staples or
surgical tacks.
Surgical mesh
An ideal surgical mesh is strong, pliable, non-allergenic and
non-biodegradable. It should also stimulate tissue growth for
optimum assimilation into the body. Although there are more
than 80 different prosthetic biomaterials that can be used to
repair inguinal and incisional hernias,7 they are all somewhat
similar.
The most significant difference is whether or not the mesh is
designed to be used inside the peritoneum, the body’s natu-
ral barrier to adhesion formation. This peritoneum is more or
less a slippery sack that gives the internal organs position and
allows them to move freely past one another. Mesh used
inside the peritoneum must have an anti-adhesive nature. This
is achieved by making the mesh out of materials that are anti-
adhesive themselves (polytetrafluoroethylene [PTFE]) or coat-
ing the mesh with an anti-adhesive film (caprolactone-coated
polypropylene [PP] or cellulose-coated polyethylene tereph-
thalate [PET]). Outside the peritoneum, this factor is less
important. Common materials are PP and PET because they
have good mechanical properties at an economic price point.
44 The OR Connection
are afflicted with this complaint; – the
great variety of forms in which it appears;
– the fatality which results from its
improper treatment, and the ample
resources of surgery in preventing its
evil consequences, are circumstances
which combine to render the investiga-
tion of hernia peculiarly interesting.
John Syng Dorsey, 18185
All types of flat mesh are available in a variety of sizes and can
”
be cut to cover over any size hernia. The main difference
between the materials is the tightness of the weave, the vari-
ation in the weave, and the thickness, suppleness, pliability
and weight of the mesh.7
The other large differentiation for types of mesh is the shape.
Many mesh products are simple flat mesh. However, there are
a few techniques like the Lichtenstein repair that incorporate
mesh that with a unique three-dimensional shape. These
shapes work in concert with the local anatomy. As a result,
many surgeons use these products and feel they lead to a
lower recurrence rate for their hernia repairs.
References
1 Lau WY. History of treatment of groin hernia. World Journal of Surgery. 2002;
26(6):748-759.
2 Read RC. Herniology: past, present, and future. Hernia. 2009; 13(6):577-580.
3 Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J.
Long-term follow-up of a randomized controlled trial of suture versus mesh repair
of incisional hernia. Annuals of Surgery. 2004;240(4):578-585.
4 Encyclopedia and Dictionary of Medicine, Nursing and Allied Health. 4th ed.
Benjamin F. Miller and Claire Brackman Keane. W.B. Saunders Company.
Philadelphia. 1987. pp. 570-572.
5 Lowenfels AB. Managing inguinal hernias. Medscape General Surgery.
6 Patient Information for Laparoscopic Inguinal Hernia Repair from SAGES. Society
of American Gastrointestinal and Endoscopic Surgeons (SAGES). March 2004.
7 Kingsnorth A & LeBlanc K. Hernias: inguinal and incisional. The Lancet. 2003;
362(9395):1561-1571.
 Medline Suction
Canisters and
Liqui-Loc™
Solidifiers
Easy, convenient fluid
management for the OR

Introducing a fluid management system that saves

time, adds convenience and reduces waste.

Medline Suction Canister with patent

pending all-in-one tank turret lid
• No more elbows to lose or misplace
• Shorter OR setup times (less time
spent looking for lost parts)
• Designed and tested with
help from our customers
• FREE accessory program!
Eligible customers may
receive free suction canister
carriers and holders.

Medline advanced
Liqui-Loc solidifiers
Dissolvable PVA packs are:
• Safer - Add solidifier before
the procedure, maintaining
a closed system
• Environmentally friendly -
Eliminate bottle disposal
• More convenient -
Save time setting
up and cleaning
the OR

To request a sample of the advanced Liqui-Loc

Solidifier in the PVA pack, send an e-mail to
Dynacorsamples@medline.com.
©2011 Medline Industries, Inc. Medline is a registered trademark
and Liqui-Loc is a trademark of Medline Industries, Inc.
 The final piece
to complete the
latex-free puzzle
in your OR

SensiCare® Surgical Gloves

The protection, performance and comfort of latex – without the latex.
Most supplies in the OR are latex-free these days, but for • SensiCare® with Aloe – standard thickness,
many operating rooms, surgical gloves remain the last smooth grip
piece of the latex-free puzzle. Transitioning to latex-free • SensiCare® LT with Aloe – standard thickness,
surgical gloves has been challenging because historically, textured grip
the latex-free gloves available have offered inferior fit and
• SensiCare® Green with Aloe – Dark green color,
feel compared to natural rubber latex.
10% thinner for enhanced tactile sensitivity
Medline's SensiCare latex-free surgical gloves are different • SensiCare® Ortho – 40% thicker for
because they are made from Isolex, our self-manufactured extra protection
synthetic polyisoprene. SensiCare is actually softer and • SensiCare® SLT – 5% thinner, textured grip
more elastic than latex. Choose the SensiCare glove
option that best fits your needs.

Participate in a BE FREE Day at your facility. Medline will

provide a day’s worth of SensiCare latex-free surgical
gloves to trial at no cost. Call 1-800-MEDLINE or e-mail
glovedivision@medline.com to get started.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
The Quest to Improve
Staff and Patient Safety:
How one health district converted
to latex-free surgical gloves
by Heather Francis RN MBA, Cindy Fulmore RN BN CPN(c), Deborah Garnier RN MN CPN(c)

Who is Capital Health?

Healthcare Group: Capital District Health Authority (CDHA) is the largest integrated academic health dis-
Capital District trict in Atlantic Canada. It provides tertiary health services to Atlantic Canadians and to
Health Authority 40 percent of Nova Scotia’s population. Capital Health consists of nine facilities with
11,000 employees, physicians, learners and volunteers providing medical and surgical
Location: care, mental health care, community health programs, addiction prevention and treat-
Nova Scotia, Canada ment and environmental health services. There are 38 operating rooms across the
district, performing approximately 33,845 operations per year.
Size:
Nine facilities with As an academic district, CDHA helps educate tomorrow's healthcare providers and ad-
11,000 employees ministrators and engages in research on new treatments, cures, processes and prac-
tices. With an operating budget of almost $800 million, CDHA serves the 400,000
Challenge:
residents of the district and provides specialist services to the rest of Nova Scotia and
Move the operating room
Atlantic Canada.
staff, including surgeons, to
latex-free surgical gloves

Aligning practice with policy to improve patient care 47


Victoria General Hospital, Halifax, Nova Scotia
Our Challenge
Capital Health is on a journey to become a world-leading haven
for people-centered health, healing and learning.
For the last several years, CDHA has implemented a proactive
latex-free glove program aimed at protecting its staff and pa-
tients from the complications caused by allergic reactions to
latex. The serious consequence of latex allergies for patients
and staff are well-documented, including the costs associated
with staff disability, teardown of surgical sets, worker’s com-
pensation claims and adverse events of patients.
Recent technological advancements have enabled most prod-
ucts previously made with latex to now be manufactured using
non-latex materials that look, feel and perform like the latex ver-
sion – only safer. A good example of where this has occurred is
with exam gloves. As a result of new technologies and materi-
als improving the properties of latex-free exam gloves, by the
end of 2006, all CDHA sites had converted to the latex-free ver-
sion. Staff had shown broad acceptance for this new glove and
continue to do so more than three years after the conversion.
Moving the operating room staff, including surgeons, to latex-
free surgical gloves – one of the last and most important pieces
of the latex-free glove puzzle – would prove to be more chal-
lenging. The desire to change existed on the part of the surgi-
cal team, but not everyone had the information about the
improved quality of latex-free gloves.
Latex-free gloves, to this point, were used on a limited basis for
cases known to involve a latex-sensitive patient or OR staff
member. There were many reasons for this, including the fact
that the fit, feel and performance of latex-free gloves had his-
torically been unacceptable to most clinicians and surgeons.
The initial products tore easily, rolled down in the cuffs and did
48 The OR Connection
“For the last several years, CDHA
has implemented a proactive
latex-free glove program aimed at
protecting its staff and patients from
the complications caused by allergic
reactions to latex.”
not have the tactile sensitivity of the latex version. This resulted
in the staff and surgeons having to compromise the fit, feel and
protection of the latex gloves.
Surgeon preference was expected to be a barrier to overcome,
as gloves can be a very personal item for most doctors. The
overwhelming choice for many was latex gloves because they
liked the fit and feel of latex. Convincing them to change was
going to be a challenge.
Cost was also a factor, as latex-free gloves cost more than the
latex version. While the impact to our glove budget was signifi-
cant, (approximately double the cost), the overall OR supply
cost increase was only going to be approximately less than one
half of a percent (0.4%) or about $5.00 per procedure if we to-
tally converted to latex-free gloves.
For us to change, we needed a supply partner who not only
had the right products, but also the staff to provide education
and clinical resources to execute a successful evaluation – and
ultimately – a conversion to latex-free gloves.
The Solution
In 2006, the glove contract with the current supplier was expir-
ing. This provided an opportunity for further exploration of pow-
der-free, latex-free gloves, as a change was going to occur
anyway. At that time CDHA joined a group purchasing organi-
zation. Medline Industries, Inc., a major manufacturer and dis-
tributor of healthcare supplies, had won the surgical gloves
contract with this purchasing organization. Medline was the
North American market leader in many product categories,
including exam gloves, and was rapidly growing within the sur-
gical glove market.

We determined that gaining approval for latex-free
gloves from the surgical team required the following
key strategies:
• Have the surgical chief of staff and surgical department
heads support a trial and get them involved in the
selection process. Without acceptance by senior
OR leadership, convincing the rest of the OR staff to
trial the gloves would be extremely challenging.
• Do not dictate the team to go latex free. If there was
pressure to accept the change, staff may resist the
process. It would be key to provide choices, so the
end users feel empowered to choose a glove that
suits them personally.
• Prior to a switch, educate staff on the properties of
latex and latex-free gloves, as well as benefits of
latex-free, powder-free gloves.
• Share with staff the support of occupational health
and risk management and share personal examples
of latex reactions.
Aligning practice with policy to improve patient care 49
Key players at CDHA, including management, clinical educa-
tors and supply management, were convinced with education
and existing information regarding latex reactions, that moving
to latex-free surgical gloves was the right thing to do. At a min-
imum it was agreed there would be a conversion to powder-
free gloves with the goal of moving to a latex-safe environment.
The initial plan was to convert to powder-free, latex gloves to re-
duce exposure to latex proteins by staff and to prevent
aerosolization of the latex proteins in the OR environment while
keeping the look and feel of latex. This would significantly
reduce the risk of a latex reaction for staff and patients. At this
time, 78% of surgical gloves being used were powdered latex
and 22% were powder-free latex.
Medline introduced its new powder-free, latex-free surgical
glove manufactured with a state-of-the-art polyisoprene syn-
thetic formula, which was well-received by the perioperative
leadership group. This glove appeared to have the look and feel
of a latex glove, but contained no latex. They also introduced a
neoprene latex-free glove. The decision was made by materials
management, purchasing and OR executives to introduce these
latex-free options to staff and to have three powder-free latex
gloves as alternatives. This became the idea for a “Be Free Day”
during which latex-free gloves could be evaluated.
Continued on Page 51
 FREE
Informational
Webinars

Now Available
On Demand 24/7!
Click on the links below to participate in a webinar any time.

Perioperative Pressure Ulcer Prevention

www.medline.com/PUPP-webinar
Hand Hygiene Compliance Improvement Strategies
www.medline.com/handhygiene
Innovation in the Prevention of CAUTI
www.medline.com/erase/webinar.asp
Prior to the “Be Free Day,” a glove provider representative was
a constant presence to provide support and education sessions
and tirelessly meet with many of the surgical staff to talk about
the differences between latex and latex-free gloves, all in an
effort to garner support for the new gloves. As in any large
hospital group, there were a few surgeons that would be a
challenge to convert, and convincing this group required
addressing them in a more personalized manner. The glove rep-
resentative met separately with the surgical chief in each spe-
cialty to explain the gloves, and the process of changing to
latex-free. She found out from the chiefs who would be the
‘challenging’ surgeons to convince. She then met with them
individually over several months to ensure as many end users as
possible were on board with the move to latex-free. Each chief
also sent emails to the respective surgical specialties to ensure
all end users were reached. Communication and choice would
prove to be key in a successful conversion to latex-free. In ad-
dition, a poster campaign was launched to introduce the
concept of the “Be Free Day.”
Be Free
Day
Phase I – “Be Free Day”
“Be Free Day,” Phase I of the latex-free surgical glove process,
took place on June 25, 2007. It was a chance to try/evaluate
the latex-free gloves with each surgeon’s group at all OR sites
in CDHA. The purpose of the exercise was to gauge the
response of the OR staff toward the gloves. The glove provider
Aligning practice with policy to improve patient care 51
brought in clinical support for the day to answer questions and
provide information on the latex-free gloves. Tables were set up
near the ORs where clinicians and surgeons could try on the
gloves, test them and ask questions in a casual atmosphere.
Staff members who wanted to try the gloves during surgery
were encouraged to do so. It was clear to the staff that they
were not being forced to go latex-free. There were no pressure
tactics involved. Each person was asked to complete a simple
form indicating if the new glove was “better than/ equal to/or
worse than” their current latex glove. To encourage participa-
tion, each form was entered into a prize drawing.
The results from the “Be Free Day” were very positive:
90% answered “better than” or “equal to”
10% answered “worse than”
Based on the success of “Be Free Day,” CDHA investigated the
cost implications of a primarily latex-free surgical glove choice.
Cost was going to increase (see page 2), but not enough to pre-
vent the switch, as executives were convinced it was the right
thing for patient and staff safety. The conversion also gave us
the opportunity to standardize the number of different glove
types in the organization, which would reduce our inventory
and costs associated with inventory management. At this
point, the organization was using nine different glove types
from different glove vendors. The goal was to standardize to
three or four glove types.
Phase II – Two-week Evaluation
Based on the acceptance from “Be Free Day,” a two-week eval-
uation period started the week of October 15, 2007. All of the
old gloves were removed from every area during the evaluation
period so staff did not have the option of reverting to the old
gloves. The glove supplier provided a clinical support team at
each site to work with individual staff members to determine the
right glove based on their specialty, glove practices, sensitivi-
ties and other considerations.
Staff members wore gloves in their surgical cases to determine
which glove was most appropriate for them. After wearing the
gloves for several days, staff members filled out an evaluation
form indicating if the gloves were “acceptable” or “unaccept-
able.” If a glove was “unacceptable,” the staff member worked
with the glove provider’s clinical expert to find a glove with an
acceptable fit and feel. Ongoing information-sharing was also
“Based on the acceptance
available from the glove supplier’s on-premise representatives.
Key to the evaluation phase was for the glove supplier to work
rate during the trial and the
closely with materials management to ensure an adequate sup-
ply of all gloves were on hand throughout the entire evaluation
overall cost justification, the
period. If we ran out of gloves, it would negatively impact the OR leadership team and
entire process.
materials management
The results of the evaluation were overwhelmingly
positive. The acceptance rate was 96.4%. decided to officially move
A sampling of staff comments and/or
observations from the evaluations included: forward with a conversion.”
“I love the zero latex concept. Thanks”
“Happy! Happy! Happy!”
“Feels good, fits well”
“The best I’ve ever tried”
“I actually like them”
“I like the fit and feel. Very comfortable”

Phase III - Conversion

Based on the acceptance rate during the trial and the overall
cost justification, the OR leadership team and materials man-
agement decided to officially move forward with a conversion.

The implementation phase was expedited as it was thought a

conversion would go smoother for surgical teams if they began
using the new gloves they tried during the evaluation immedi-
ately, rather than switching back to old gloves while the deci-
sion-making occurred.

This also eliminated stocking challenges for supply staff, as they

did not have to pull evaluation gloves from the stock shelves and
reintroduce them at a later date. The glove provider and our
distributor ensured order numbers were provided to the supply
staff and that the initial implementation order was distributed to
all appropriate areas. Staff responsible for picking case carts
were engaged at this time and introduced to the new product.

Implementation was facilitated by the extensive preliminary

work/education provided by the glove provider, which also
ensured that our OR staff members were engaged in the process.

Continued on Page 54

52 The OR Connection
 Finally!
A way to know
when the catheter
was placed

MEDLINE’S FOLEY INSERTAG™

This easy documentation tool lets you know
exactly when your patient’s catheter was placed
Foley
InserTag
Despite SCIP Measure #9 recommending removal of
urinary catheters in surgical patients by postoperative day
one or two,1 and CDC guidelines advising prompt removal
of catheters,2 74 percent of hospitals do not keep track of
how long patients have catheters in place.3

Medline’s Foley InserTag is a sticker to be placed on each

catheter bag as part of the insertion procedure. It has
space to write when the catheter was placed in order
to minimize duration and encourage timely removal. The
InserTag is included with each Medline ERASE CAUTI tray.
To learn more about Medline’s Foley InserTag and
Medline’s Foley InserTag. The one little sticker that can the ERASE CAUTI program, attend an informational
make all the difference. webinar at www. medline.com/erase/webinar.asp.

Reference
1 Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces urinary catheterization in
hospitalized patients. Jt Comm J Quality Patient Saf. 2005; 31(8): 455-462
2 Patient Safety Quality Measures for the Surgical Care Improvement Project (SCIP). Health Services Advisory Group.
Available at: http://qualitymeasures.ahrq.gov/content.aspx?f=rss&id=16275. Accessed December 7, 2010.
3 Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. Centers for Disease Control and Prevention.
Available at: http://www.cdc.gov/hicpac/cauti/001_cauti.html. Accessed December 7, 2010.

©2011 Medline Industries, Inc. Medline is a registered trademark and InserTag is a trademark of Medline Industries, Inc.
 1
8 Steps to a Successful Glove Conversion

Engage key decision makers

2 Ask risk management and

occupational health to provide
evidence on the hazards of latex

3 Educate, educate, educate

4 Be transparent and facilitate

ongoing communication

5 Provide choices and options

6 Consider cost, but not as the

only deciding factor

7 Make sure product is available

to ensure a successful trial and
evaluation

8 Ask glove supplier to provide

on-site experts to support all
staff, including the supply team,
surgeons, nursing and sterile
processing

54 The OR Connection
Current Status
We are a little more than two years into the conversion to the
latex-free surgeon’s gloves, and the acceptance and satisfac-
tion rates among the OR staff continue to be high. At one site,
“We are a little more
the number of glove types have been reduced to four from nine
at the time of conversion.
than two years into the
conversion to the latex-free
Next steps
There are a still a few staff members from the original conversion surgeon’s gloves, and the
who have not found a glove with the fit or durability they
enjoyed with their latex glove. Since the original conversion, acceptance and satisfaction
Medline has developed four new latex-free gloves, including a
latex-free orthopedic glove. These new options should provide rates among the OR staff
more acceptable choices for those staff members who were not
satisfied with the initial latex-free gloves.
continue to be high.”

About the Authors

Heather Francis, RN BN MBA – Heather was the Health Service Director for Perioperative Services for
eight years until fall 2009. She has 15 years of perioperative experience. She is currently the Health
Services Director of Dartmouth General Hospital. She graduated from St. Rita's School of Nursing
and earned her Bachelor of Nursing and Master of Business from Dalhousie University.

Cynthia Fulmore RN BN CPN(c) – Cindy has been the clinical educator for the operating rooms at
Victoria General Hospital in Halifax for the past seven years. She is a graduate of Dalhousie University
Halifax. She is certified in perioperative nursing (Canada), and has 20 years perioperative experience.

Deborah Garnier RN MN CPN(c) – Deborah has been the Health Service Manager for the operating
rooms at Victoria General Hospital in Halifax for the past four years. Previously she held positions as
OR supervisor, perioperative educator and perioperative staff nurse. She is a graduate of SA Grace
General Hospital School of Nursing, St. Johns NL, St. Francis Xavier University, Antigonish NS and
Athabasca University, Athabasca, Alberta. She is a certified perioperative nurse (Canada) with over
20 years of perioperative experience.

Aligning practice with policy to improve patient care 55

 Special Feature

Patient experience is #1
Nurse leaders rank priorities in national survey

According to the newly

released HealthLeaders
Media Industry Survey 73%
of nurse leaders said
2011, nurse leaders are
their organization plans to
most concerned about encourage more nurses
1. Patient experience/ to pursue bachelor’s de-
patient satisfaction grees over the next three
years; 18 percent plan to
2. Quality/patient safety encourage
3. Cost reduction nurses to pursue
master’s degrees.

With the advent of the of nurse leaders

HCAHPs (Hospital Care
Quality Information from the
Consumer Perspective)
survey and more government
39% say that nursing
research is
being effectively
translated into
pay-for-performance practice at the
requirements, nurses are bedside.
making the connection that
reimbursement will be tied
to patient satisfaction and When ranking the most important
quality of care, and patient factors for providing high-quality
safety beginning next year. patient care, nurse leaders reported:

#
Regarding hand 1 MOST IMPORTANT
hygiene compliance, Nurse-to-patient staffing ratio

48%
of nurse leaders agreed that
53%
of nurse leaders confirmed
#

#
2 MOST IMPORTANT
Nurse experience level

that their organization will

3 MOST IMPORTANT
the primary reason behind
be part of an accountable Nurse education/certification level
failure to achieve hand-washing
compliance is lack of spine care organization within
to self-police and report the next five years.
colleagues’ violations.

Source: HealthLeaders Media Industry Survey 2011: Nurse Leaders. Available at: www.healthleadersmedia.com/intelligence

56 The OR Connection
BioCon™- 500
Bladder Scanner
Safely Measures
Bladder Volume
Minimize unnecessary catheterization
Research has shown that 80 percent of urinary tract
infections acquired at healthcare facilities are associated
with an indwelling urethral catheter.1 This type of infection
is known as CAUTI, or catheter-associated urinary tract
infection. What’s more, Medicare no longer reimburses
for treatment of CAUTI if it happens while a patient is
hospitalized, giving hospitals a major incentive to prevent it. But
how?

Avoiding unnecessary catheter use is a primary strategy

for preventing CAUTI, and clinical guidelines recommend
the consideration of alternatives to catheterization.2
Bladder scanners can be used in place of a urinary
catheter to assess bladder volumes, and many
catheterizations can be avoided.3

To learn more about CAUTI

prevention and the BioCon-500, visit
www.erasecauti.com/alternatives.asp
or contact your Medline
sales representative.

1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA

practice recommendation: strategies to prevent catheter-associated urinary tract
infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50.
2. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape
Nursing Perspectives. February 3, 2009.
3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Med/Surg
Nursing. 2005; 14(4):249-253.

©2010 Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc.
BioCon-500 is a trademark of Mcube Technology Co., Ltd.
 What did we do after
designing a revolutionary
new catheter tray system?

We found THREE more ways

to make it even better.
We’re obsessed with engineering new and better
technology for healthcare workers. So after we
revolutionized the outdated Foley catheter tray with
a unique, one-layer system design, we immediately
turned our attention to addressing how we could
make it even easier to use. We studied how the
tray was being used in the field. The result was
three more great improvements.
Combined with the previous innovative tray redesign
and comprehensive ERASE education, these three
new features help to improve patient safety and quality,
while reducing avoidable costs associated with waste
and urinary tract infections.
To learn about the ERASE CAUTI system, as well as
other strategies for minimizing the risk of CAUTI, sign
up for a free Innovation in the Prevention of CAUTI
webinar at www.medline.com/erase/webinar.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
1 Real photography on the outside –
so you know exactly what’s inside
A photo on the package helps identify the
contents of the kit, serves as an educational
tool for the clinician and can be used to
discuss the procedure with the patient.
Also, the label opens up to a booklet
with step-by-step instructions and
helpful tips for the clinician.

2 A revised checklist for the

medical record
The reformatted checklist is smaller,
making it easier to place in the paper chart
or attach to the electronic medical record.

3 Education you’ll want to present

to your patient
There’s nothing like the new Patient
Education Care Card. Designed to look
and feel like a “Get Well Soon” card, it
tells patients about catheterization so
they know you are providing them the
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 OR Issues

Unity Hospital: Utilizing Medline’s ERASE CAUTI®

Program to Reduce Hospital Acquired Infections
in the Delivery of Safe, Quality Care
By Erica Perez BSN, RN, Clinical Educator, Unity Hospital

Quality Improvement Goal

Hospital: Unity Hospital continuously monitors for hospital-acquired infections (HAIs),
Unity Hospital including catheter-associated urinary tract infections (CAUTI). Through data
monitoring of infection markers, Unity Health System has identified areas for
Location: improvement to reduce urine Nosocomial Infection Markers (NIMs), and reduce
Rochester, NY the number of CAUTIs to enhance outcomes. Opportunities identified include:
increasing nurse/provider communication/collaboration; educating nurses
Size: regarding best practice techniques for catheter insertion; empowering nurses to
340-bed actively evaluate clinical indications or need for catheter insertion, along with
early Foley discontinuation; and reinforcing patient education. By focusing on
Challenge: these initiatives, Unity Health System is able to provide safe, quality care and
To develope a proactive approach to infection reduce the risk of HAIs. The reduction of urine NIMs not only enhances patient
prevention and to raise awareness of the outcomes but also promotes organizational efficiency. With the implementation
significance of hospital-acquired infections of the Value Based Purchasing (VBP) program by Centers for Medicare &
on our patients and the facility. Medicaid Services (CMS), reimbursement is directly linked to quality outcomes
and efficiency. Many organizations, including Unity Health System, continue to
Results:
strive for best quality and care outcomes.
Decreased urine NIMs by 32% demonstrating:
Facility Demographics
• Significant cost-avoidance of $3,637 per
Unity Hospital is a 340-bed, nonprofit hospital. It is accredited by The Joint
urine NIM
Commission, and the hospital’s intensive care unit ranks in the Top 100 in the
• Reduced risk of patients developing a
United States. In 2009 Unity Hospital had 14,687 discharges and a total of
catheter-associated urinary tract infection
147,265 patient days.
(CAUTI)
• Improved standard of care for patients
receiving a Foley catheter

Aligning practice with policy to improve patient care 61

 “The ERASE CAUTI program ties education, nursing
power and industry product to promote best processes
and decrease the opportunity for a CAUTI to develop.”
Unity Health System offers a wide range of services including:
• Emergency center
• Endoscopy unit
• Family birth place
• Intensive care unit
• Joint replacement center
• Spine center with pain management
• Residency program
• Stroke center
• Surgical center
• Vascular center
Unity Hospital strives to offer the latest advancements in
treatment while giving the personal attention patients expect
and deserve from a community health system. Not only are
the physicians able to provide high quality medical services,
clinical staff also provides compassionate care to make the
patient feel as comfortable as possible.
The Challenge
Unity closely monitors HAIs, including catheter-associated
urinary tract infections (CAUTI). Instances in which a CAUTI
developed, data was evaluated to determine the cause of
the infection. While examining the cause of the infection in
retrospect was valuable, a more proactive approach in
infection prevention was imperative. It was essential to raise
awareness of CAUTI and the significance of HAIs within the
facility, but more importantly the outcomes these have on our
patients.
Throughout this process, we identified gaps in standardization
and knowledge regarding the proper insertion technique and
clinical indications of a Foley catheter. The decision to insert a
Foley involves collaboration between medical and nursing
staff; however, nurses must possess a sense a responsibility
for ensuring the appropriate clinical decision. In addition, the
nurses sought to feel more empowered to monitor a patient’s
ongoing need for a Foley, ensuring its timely removal.
62 The OR Connection
Inconsistencies were observed in the technique nurses used
to insert Foley catheters. This was due to:
1. Variance in how nurses were initially taught the procedure;
2. Differing protocols at previous facilities where nurses
have practiced;
3. Different types of Foley trays nurses have used in the past.
Given these challenges, Unity Hospital established the following
new goals:
• Raise awareness of CAUTI prevention;
• Reduce catheter utilization;
• Provide clinical education for proper Foley
insertion techniques;
• Enhance patient education;
• Reduce urine NIMs and overall CAUTI rate.
The Solution
Medline’s ERASE CAUTI Foley catheter management program
was introduced to Unity Hospital in April, 2010. The ERASE
CAUTI program ties education, nursing power and industry
product to promote best processes and decrease the
opportunity for a CAUTI to develop.
The Medline program offered the tools to reduce the
inconsistencies identified.
1.The one-layer tray presents the procedure components in an
intuitive manner, guiding the nurse through the procedure from
left to right. It is also more efficient to handle all the
components in one layer, making it easier to maintain aseptic
technique. The one layer tray is a neatly packaged clinical
solution, not just a supply solution.
2.The accompanying education program is provided online
through the e-learning site, Medline University. The education
encompasses a video overview, three learning modules, and
an interactive competency that the clinician uses to
demonstrate knowledge of proper foley insertion.
3. Awareness tools are also included in the program to
communicate program goals engaging the nurses in the
education process, and to encourage the participation in the
facility-wide effort to reduce CAUTI.
4. The patient education card resembles a greeting card, which
every nurse reviews with their patients before insertion. This
allows the patients to become an active participant in their
care. The card, included in the tray, helps to bridge the
knowledge gap for patients caring for their catheter once it
is in place.
Awareness tools, education, and the tray design all emphasize
evidence- based techniques that standardize practices for Foley
catheters. The checklist on the front of the tray also serves as
a useful tool that guides nurse’s practice when a Foley insertion
is necessary.
Execution
After learning more about the program and demonstrating its
capabilities to a group of staff members and nurse leaders,
Unity Hospital decided to trial the program in June 2010.
Step 1- Process Improvement Plan
The organization’s first step was to create an overall process
improvement plan. Team leaders, staff champions, directors and
the Infection Prevention team collaborated to draft the plan.
Meetings were held to discuss all components of the program
including: steps of implementation, necessary tasks to complete,
delegation of tasks, and the estimated date of completion for
each task. The plan was communicated to all staff involved in the
project and updated to reflect the current status of each step.
Step 2- Education
The team worked to educate the end user clinical staff
regarding the ERASE CAUTI program by utilizing the tools
available on Medline’s e-learning site: Medline University. The
program was rolled out to nurses and the education classes
Aligning practice with policy to improve patient care 63
were conducted for two weeks. These online modules have
since been added to clinical orientation as a mandatory core
competency for new nursing staff. To date, over 500 nurses
have completed the education classes online.
It’s essential to note that because the education is web-based,
it was critical to evaluate the technical standards of the work
station computers, as well as the facility network capability. When
we experienced initial usability issues, Medline worked with the
information technology (IT) department to make adjustments to
the facility firewall and other technical concerns.
Step 3- Trial the Tray
Following the completion of the competency, four units - - (the
Emergency Department (ED), the Operating Room (OR), and
medical surgical units 2300 and 2400) - - trialed the ERASE
CAUTI Foley catheter tray for three weeks. As a supplement to
the online education program, Medline support staff was
available to demonstrate the
components of the tray to all nurses in the participating units.
Medline staff was on site throughout the trial process to support
clinical staff, ensure communication and documentation of
feedback. The outcomes of the trial were monitored and
hospital- wide implementation was discussed.
Step 4- Implementation
Following a successful trial period, the program was rolled out
facility- wide to all acute units in August 2010. Medline provided
product support staff to assist during distribution and rollout.
Educators demonstrated the product design and layout to
familiarize the nursing staff with the new product. The
mandatory online education and interactive competency taught
the indications and alternatives to catheterization, aseptic
technique and proper insertion of a Foley catheter, care and
maintenance, signs and symptoms of CAUTI and timely
removal. Ensuring proper education is a crucial step in the
ongoing sustainability and success of the program.

Results
Unity Hospital was satisfied with the results experienced within
one month of implementing Medline’s ERASE CAUTI program.
Data collected from the same time period one year prior to
implementation (August 2009) revealed a marked reduction in
urine NIMs.
Reduction in urine NIMs:
Unity Hospital uses a data surveillance system to track NIMs.
This data collection system increases efficiency for reporting
and internal process improvements by prescreening likely
causes of HAIs. During the implementation of Medline’s ERASE
CAUTI program, the rate of urine NIMs was closely monitored.
Compared to the control period of August 2009, Unity Hospital
observed a decrease in urine NIMs of 32% in August 2010. The
data surveillance provider that Unity utilizes calculates a dollar
amount associated with each NIM identified. The associated
cost for each urine NIM is $3,637, which demonstrates a
significant cost-avoidance based on the reduction in urine NIMs
after the ERASE CAUTI Program implementation. This reduction
in urine NIMs indicates fewer patients may be at risk for
developing a CAUTI. Unity Hospital is very proud to share this
demonstration of reduction in urine NIMs.
Reduction in CAUTI:
Although Unity Hospital experienced a very low rate of CAUTI in
2009, after implementing the ERASE CAUTI Program rates
continue to trend downward. Because Unity Hospital had few
incidences of CAUTI prior to implementation, success has been
measured by demonstrating a decrease in NIMs post
implementation of this program.
64 The OR Connection
“This decrease in urine NIMs
demonstrates safe care delivery
and a significant cost-avoidance
for Unity Hospital.”
Summary of Clinical Outcomes
Standardization of Foley insertion technique, increased
education, nurse/physician communication and collaboration,
along with overall awareness of proper indications for use
contributed to a 32% decrease in urine NIMs. This decrease in
urine NIMs demonstrates safe care delivery and a significant
cost-avoidance for Unity Hospital. Achieving these outcomes
was possible thanks to Medline University’s online ERASE
CAUTI education and competency course that simulates
proper insertion technique. The education combined with a
single layer tray design that follows the Center for Disease
Control (CDC) Guidelines, plus the dedication and commitment
to clinical excellence demonstrated by the clinical care team at
Unity has made this initiative a success.
As a result, Unity has improved the standard of care for patients
receiving a Foley catheter and has reduced the risk of CAUTI.
Through continued use of the online education program for new
clinical nurses, enhanced patient education and sustained use
of the ERASE CAUTI tray, Unity anticipates continued clinical
excellence and safe patient care delivery to better serve our
community and our patients.
About the author
Erica Perez is the Clinical Educator at Unity Hospital in Rochester,
New York. In this position, Erica has the responsibility of overseeing
clinical education in the acute inpatient areas, developing and
delivering inservices on new products, communicating updates of
hospital policy and procedures and serves as the Infection Control
liaison. Erica brings 18 years of nursing experience to this position
with a specialty in Emergency Medicine and serves as a member of
the New York State Emergency Nurses Association Genesee Valley
Chapter. Serving the past roles of CNA, LPN, RN and BSN
throughout her career allows Erica to effectively implement education
programs while remaining sensitive to the participation of all roles in
nursing practice. Most recently Erica has earned her Masters of
Science in Nursing from Roberts Wesleyan College.
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68 The OR Connection

12
Ways to
Reduce Hospital
Readmissions
By Cheryl Clark
for HealthLeaders Media
December 27, 2010
Time flies. In just 21 months, the federal government will start
penalizing hospitals with higher than expected readmission rates.
And even though much about the regulations-to come remains
unclear, clinicians along the care continuum are scrambling to
get ready.
Or they should be. It’s not just important for a hospital’s bottom
line. It’s important for the patient.
We’ve been talking with some of the nation’s experts on the sub-
ject, including Stephen F. Jencks, M.D., whose April 2009 article
in the New England Journal of Medicine set the tone for today’s
readmission prevention energy. His review of nearly 12 million
beneficiaries discharged from hospitals between 2003 and 2004
found that nearly 21 percent, or one in five, were re-hospitalized
within 30 days and 34 percent were readmitted within 90 days.
Aligning practice with policy to improve patient care 69
Special Feature
We also spoke with Amy Boutwell, MD, an internist at Newton-
Wellesley Hospital in Newton, MA and Director of Health Policy
Strategy for the Institute for Healthcare Improvement; Timothy
Ferris, MD, medical director of the Massachusetts General Physi-
cians Organization, and Estee Neuhirth, director of field studies
at Kaiser Permanente in California.
Some of these strategies aren’t yet proven to work in all settings,
of course. And many are still in the demonstrations phase. But
with national readmission rates as high one in five, and higher for
certain diseases, many providers are trying anything that sounds
plausible.
Here are some of the prevention strategies that these and other
experts think might be worth a shot. Many involve—to a greater
or lesser degree —following the patient out of the hospital,
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either in-person, electronically, or by phone, but others involve
upside-down introspection and re-evaluation by providers along
the care continuum.
1. Discharge Summaries
Dictate discharge summaries within 24 hours of discharge.
Boutwell says that standard practice and policy at most hospi-
tals is that discharge summaries are completed within 30 days
of the discharge. “I was trained that the summary is a retro-
spective report of what happened in hospitalization. But what we
need today is anticipatory guidance. Patients get discharged and
go home. They can’t fill their meds, insurance doesn’t cover the
med or they have questions. They’re nervous and worried. They
call their primary care provider, who didn’t even know they were
admitted.
Boutwell says that 30-day-discharge summary policies “might
have sufficed in a time gone by. But that doesn’t work anymore.
Information needs to be available at the time of discharge.
There’s a growing recognition of this need, but staff bylaws
haven’t changed.”
2. Lengthen the Handoff Process
At every juncture in patient care process, especially discharge,
have teams talk to each other about the patient. And by the way,
don’t call them discharges. Call them “transitions.” Standardize
them for a variety of providers, from hospital to rehabilitation
facility to skilled nursing facility to home and back.
Boutwell says that “taking this person-centered approach shifts
the concept from discharge, which is a moment in time and
you’re done with it, to a transition—a shared accountability. We
need to make sure the receiving providers understand who this
patient is, with a 360-degree view.
Aligning practice with policy to improve patient care 71
Jencks adds that “senders and receivers, for example hospital
discharge planners and skilled nursing facility staff and home
health” meet often enough so they can learn about the realities
of the transitions they initiate and receive.
3. Provide Medication on Discharge
Send the patient home with a 30-day medication supply,
wrapped in packaging that clearly explains timing, dosage,
frequency, etc. Some health centers with Medicaid patients may
be trying this strategy, which is difficult for hospitals to do with
Medicare patients because of distinctions between Part A and
Part B payment. Still, for some high-risk populations, such as
patients with congestive heart failure and those who have been
readmitted before, it might be worth it for the hospital to absorb
the cost.
4. Make a Follow-up Plan Before Discharge
Have hospital staff make follow-up appointments with patient’s
physician and don’t discharge patient until this schedule is set
up. A key is to make sure the patient has transportation to the
physician’s office, understands the importance of meeting that
time frame, and following up with a phone call to the physician
to assure that the visit was completed.
5. Telehealth
We couldn’t find anyone using video monitors to communicate
on a daily basis with the use of such software as Skype, for
example, but some readmission experts say it’s an interesting
approach to keep up visual as well as verbal communication with
patients, especially those that are high risk for readmission.
On a more practical scale, Home Healthcare Partners in Dallas
uses health coaches, intensive care clinicians, and wireless tech-
nology to record vital signs on a daily basis for about 2,100
discharged Medicare fee-for-service beneficiaries for between
 60 to 120 days. So far, they have done this for about 7,000
unduplicated patients in the last two years, for several hundred
hospitals in Dallas and Louisiana, says HHP’s CEO, Wayne Bazzle.
The target population for intense monitoring includes those with
four or five co-morbidities and who have a primary diagnosis of
congestive heart failure, chronic obstructive pulmonary disease,
diabetes, Alzheimer’s and hypertension.
Bazzle says that the effort involves phone calls of between five
and 15 minutes, and is frequent enough with the same team “so
we have their trust. We can help them stay out of the hospital if
they'’re more truthful with us about what’s going on, and if we
see some deterioration, we can help them cope. Normally it’s a
medication management issue, or they’ve become a little too
relaxed with their diet.”
6. Identify Frequent Flyers
Customize your hospita’s admission and re-admission rates for
demographic and disease characteristics to identify those at
highest risk, and expend extra resources on their care needs.
This may involve special programs for homeless patients, such
as the one effort by a cohort of Los Angeles hospitals who grap-
pled with how to safely discharge homeless patients without
violating city laws.
The Los Angeles project now discharges homeless patients who
meet certain criteria to a half-way type of house in nearby Bell,
and saved $3 million for hospitals in its first few months. Expan-
sions in other parts of Southern California are underway.
Many strategies involve—to a greater or lesser
degree —following the patient out of the hospital,
either in-person, electronically, or by phone.
72 The OR Connection
7. Understand What's Happening After Discharge
Kaiser Permanente is using video cameras to chronicle home
settings and the entire care process to determine what’s
happening to the patient after discharge that provoked a
readmission.
The team is also using video of the care team, from the phar-
macist, home care providers, nurses, and physicians about their
care of that patient, to highlight wrinkles and cracks in the
system that brought the patient back to the hospital.
So far, Kaiser officials say that the video project has contributed
to a reduction in readmission rates at some hospitals where it
has been tried, such as from 15.7 percent to 9 percent at
Kaiser’s South Bay Medical Center near Los Angeles, because
it gave the team information to streamline care, says Kaiser’s
Neuwirth.
8. Provide Home Care on Wheels
Just like Meals-on-Wheels can be scheduled in advance, so can
case management, housekeeping services, transportation to the
pharmacy and physician’s office. At Piedmont Hospital in Atlanta,
in collaboration with the Area Agency on Aging, patients having
elective knee surgery get coupons and prescheduling, “so that
by the time you get out of the hospital, it’s waiting there for you,”
Boutwell says. She adds that this kind of a pre-arrangement for
post-transition care is “spreading like wildfire” among a number
of hospitals, but so far it’s mainly being tried with elective
patients.
Continued on Page 74
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 9. Consider Physician Medication Reconciliation For surgical patients, those with vascular surgery had the high-
A recent paper in the New England Journal of Medicine by Yut- est readmission rate, 23.9 percent, followed by those with hip or
ing Zhang of the University of Pittsburgh noted the wide geo- femur surgery, 17.9 percent. Perhaps these are the places where
graphic variation among physicians’ prescribing practices with readmissions can be most quickly reduced.
medications that should be avoided in patients over age 65. She
also noted variation in prescribing practices for drugs that have States with the Highest Hospital Readmission Rates
a high risk for negative drug-disease interaction. Washington, D.C. 23.2%
Maryland 22%
Jencks says that Zhang and colleagues “are pointing us to a Louisiana 21.9%
rather important gap in the most common thinking about transi-
New Jersey 21.9%
tions—that we are to make sure that patients are able to get and
Illinois 21.7%
take medications, get recommended follow-up, and generally do
West Virginia 21.3%
as they are told. But we know that medication plans can be in
Kentucky 21.2%
life-threatening error, that physicians often recommend a time-to-
Mississippi 21.1%
follow-up that is too long, that discharge plans are often written
in ignorance of the patient’s pre-admission history and experi- Missouri 20.8%
ence. In general, we need to be much more critical of the plans New York 20.7%
patients get.” Massachusetts 20.2%
Oklahoma 20.1%
10. Make Sure Patients Understand
Patients may nod, and say they understand what they’re sup-
posed to do after they leave the hospital. But “teach back,” in 12. Listen to the Patient
which they and their caregivers repeat back those instructions, Involve the emergency room, hospice or home health providers
even to more than one hospital caregiver, needs to be constantly to make sure patients don’t come to the emergency room for
reinforced, readmission experts say. Jencks says that caregivers non-emergent end-of-life care issues. Providing patients and
need to understand that their patients are often heavily med- their family members with informed choices, opportunities for
icated, stressed, groggy and confused. And that their disease advance directives, and counseling in the emergency room setting
state may impair their ability to understand what they are being may avert painful, unnecessary admissions. Look for this to be
told, much less remember it two days later. a major expansion of palliative care professionals inside the ED.

11. Focus on Highest-risk Patients
Examine the readmission patterns at your hospital and see which
patients, with which conditions, diseases or procedures, have
the most readmissions. If resources are limited as they are at
most hospitals, push them toward a select group of patients in
a more intense way to see if increased effort makes a difference.
For example, in his New England Journal of Medicine paper,
Jencks showed that for certain diseases or conditions, and in
certain parts of the country, readmission rates are even higher
than the national average of one in five. For example, for med-
ical patients, the readmission rate for heart failure patients was
27 percent; for those with psychoses, 24.6 percent; chronic
obstructive pulmonary disease, 22.6 percent. Patients with
pneumonia and gastrointestinal problems were re-hospitalized
at rates of 21 percent and 19.2 percent respectively.
“There really needs to be a care plan that reflects the patient’s
wishes,” Jencks says. “This is quite different from either a med-
ical power of attorney or what is often called a living will because
it lays out the goals of treatment.
“Cure? Palliation? Functional independence? Playing dominoes
with friends? Hospice? This kind of plan has little relevance to
persons without substantial chronic conditions, but it is totally
relevant to a patient with one or more chronic conditions that
have required hospitalization. With such a plan, one can often
avoid readmissions that really do not serve the patient’s needs or
values. What is, after all, worse than a readmission? Readmission
of a patient who does not want to be readmitted,” Jencks says.
Reprinted with permission from HCPro, Inc. (February 2011) Copyright
HCPro, Marblehead, MA. For more information, call 800/639-7477 or visit
www.HealthLeadersMedia.com.

74 The OR Connection
Still Pouring Salt
on the Wound?

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To place an order, call 1-800-MEDLINE.

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innovation and ongoing clinical research guide the development of IrriMax products. U.S. Patent No. 5,830,197; 6,468,253; 7,662,125; D588,692; and D556,595. Additional U.S. and Foreign Patents Pending. ©2010 IrriMax Corporation, All Rights Reserved.
Aligning practice with policy to improve patient care 75
IrriSept®, IrriRinse™, SplatterGuard™ and Splatter Matters™ are trademarks of Innovation Technologies, Inc. *Laboratory Testing Records per USP <51>, Antimicrobial Effectiveness Testing, on file at IRRIMAX Corporation
 Medline natural OR towels

A LITTLE CHANGE

A LOT OF DIFFERENCE
The greensmart™ collection of OR products helps
reduce your impact on the environment.
• Natural OR towels are dye-free and bleach-free. They produce less lint and
are more absorbent than traditional blue towels.
• The typical 10-OR suite that switches from blue OR towels to natural OR
towels could save up to one half ton of dye, bleach and other chemicals
from polluting the environment every year.
• 100% biodegradable trays are made of compressed paper with an
eco-friendly, water-resistant coating.
• The revolutionary EcoDrapeTM has all the features and protection you expect.
It breaks down in landfills in about two to five months.

To learn more about Medline’s green products, visit

www.medline.com/greensmart or www.medline.com/
green-initiatives/pdf/medline_eco_product_guide.pdf.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. greensmart and EcoDrape are trademarks of Medline Industries, Inc.
 Medline Joins
Greening the
Operating Room
Initiative

Medline has joined a group of corporate sponsors to support The following are the GOR areas for “green” interventions in the
Practice Greenhealth’s Greening the Operating Room (GOR) operating room:
initiative. This initiative to green the nation’s operating rooms was • Single-Use Device (SUD) Reprocessing
launched in 2010 to reduce the environmental footprint of oper- • Reusables v. Disposables: Gowns, Surgical Drapes, Basins
ating rooms in U.S. hospitals. Hospital operating rooms contribute and Other Reusables
between 20 and 30 percent of the hospital’s total waste.1 • OR Kit Formulation
• Waste Anesthetic Gas Scavenging Systems
Medline will join the collaborative effort of hospitals, manufactur- • Fluid Waste Management Systems
ers and related stakeholders to develop guidance documents for • Energy Use/Lighting & Thermal Comfort
helping reduce the environmental impact of the nation’s operating • Regulated Medical Waste (RMW)
rooms and potentially reduce cost, increase quality and improve Minimization/Segregation
worker or patient safety. • Substitution of Reusable Hard Cases for Blue Sterile Wrap
• Recycling of Medical Plastics
• Laser Safety/Smoke Evacuation
• Green Cleaning/Proper Disinfection in a Surgical Setting
• Medical Equipment and Supplies Donation

To learn more about Practice Greenhealth’s Greening the OR initiative visit www.greeningtheor.org.
Reference
1. Esaki RK & Macario A. Wastage of supplies and drugs in the operating room. Medscape Anesthesiology.

Aligning practice with policy to improve patient care 77

 Medline Launches
Sustainability Program
Healthcare facilities, which generate an estimated 6,600
tons of waste per day, are almost the largest generator of
waste in the country, second only to the food industry.
That translates to the equivalent of 5,110 pounds of waste
per patient bed annually. Medline is addressing this
industry-wide concern through their Sustainability Pro-
gram, which will include hospital management consulting,
staff education, and facility-wide awareness campaigns.
For more information on Medline’s Sustainability Program,
contact Francesca Olivier at 847-643-3821.

Hospital operating rooms contribute between 20 and 30

percent of the hospital’s total waste. Medline is a co-sponsor
of Practice Greenhealth’s Greening the Operating Room™
initiative, a collaborative effort of hospitals, manufacturers
and related stakeholders to develop guidance docu-
ments to reduce the environmental impact of the nation’s
operating rooms.

Practice Greenhealth’s vision for this initiative is to help

every provider in the country offer the best available
patient care in operating rooms that utilize product and
practices that are patient-, worker-, and environmentally
safe while minimizing costs.

Nearly 100 hospitals have already pledged their participa-

tion by completing the Participation Commitment Form,
which is included on the next page. The Commitment
allows hospitals to participate in whichever way is best for
their needs. Resources and educational materials for hos-
pitals can be found at www.practicegreenhealth.org or by
calling 502-727-8658.

78 The OR Connection
 Green Facts

Upcoming
Green Events An avera
of
g
percent e of 24
86%
of total hospital
waste is medical
cla
as hazard ssified costs are
CleanMed 2011 ous a
regulate nd attributed to
d
Medline will be an exhibitor at CleanMed 2011, a conference
this waste
that brings together leaders in environmentally sustainable
healthcare and features topics from environmentally preferable
products and purchasing, to green building design. Medline will
exhibiting our greensmart products such as the EcoDrape, Nat- 90% of red bag waste does not actually meet
ural OR Towels and Pigment-Free Plastics. The conference is in criteria for red-bag waste
Phoenix, Arizona April 6-8, 2011.

Webinars By switching to reusable

To register for these events go to surgical gowns, one
http://www.practicegreenhealth.org/tools/webinars/calendar hospital saved $60,000
per year

Apr 12 Climate Change and the Role of the Health Care By switching from blue wrap
Free Professional: Education, Mitigation and Adaptation storage to hard cases, a hospital
saved $26,000 per year
Apr 14 Climate Change and the Role of the Health Care
Free Clinician: Education, Mitigation and Adaptation

40
Percent of red-bagged medical waste
Apr 27 Green Design & Construction Series:
from ORs that is actually just packaging
$150 Regulatory Impact on Healthcare Greening
material (Another 40% is suction
May 05 Introduction to Greenhealth Tracker canister waste)
Free

25
Percent estimated portion of hospital
May 10 Getting Started with PGH - Intro for New Members operating costs that are consumed
Free by energy use

May 11 Green Operations Series: Community Organizing

Source: Kwakye G, Brat GA, Makary, MA Arch Surg.
$150 101: How a Corner Office Can Cultivate a 2011;146(2):131-136.
Sustainable Local Food Program for Patient
Health, Healing and Wellness.

May 19 Greening the OR: Energy Efficiency in the OR 121 ft

Free per day
Amount of material the average
May 25 Green Design & Construction Series:
$150 10-OR Suite could save if they
Greening the Community Hospital:
Re-scaling the Management of Benefits and Costs replaced half of their full-size
vier at 847-643-3821. natural OR towels with the slightly
smaller natural OR hand towel

Medline Industries, Inc. Data on file.

Aligning practice with policy to improve patient care 79

The OR Goes Green
– the only TRULY eco-friendly surgical drape
Medline’s new patent-pending EcoDrape is the only Composition Comparison
dye-free eco-friendly surgical drape available today. EcoDrape SMS

Made of more than 96% wood pulp, EcoDrape will Fibers More than 96% No wood
wood pulp pulp
biodegrade in only two to five months in a landfill –
Petrochemical 0% 100% PP
polypropylene drapes take hundreds of years to break ingredients (plastics)
down. EcoDrape has all the same great features and Additives Bio-based Fluorine
performance as other Medline drapes, including
hook-and-loop line holders, large reinforcement
zones, and premium tape and incise film flush to For a quick online video demonstration,
the fenestration. visit www.medline.com/ecodrape

Try the new EcoDrape and take your OR to the next

level of green!

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
EcoDrape and greensmart are trademarks of Medline Industries, Inc.
 !
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N-($J! !

!
Please feel free to call or write with any questions, comments or suggestions you might have.

Thank you so much for your support and we look forward to working with you as a pioneer in this
extraordinarily important undertaking!

Go to www.practicegreenhealth.org for an electronic copy of this form.

Aligning practice with policy to improve patient care 81

!
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Introducing New
Continuing Education
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 Study of
Breast Biopsies
Finds Surgery
Used Too
Extensively
Too many women with abnormal mammograms or other breast prob-
lems are undergoing surgical biopsies when they should be having
needle biopsies, which are safer, less invasive and cheaper, new
research shows.

A study in Florida found that 30 percent of the breast biopsies there

from 2003 to 2008 were surgical. The rate should be 10 percent or
less, according to medical guidelines.

The figures in the rest of the country are likely to be similar to

Florida’s, researchers say, which would translate to more than
300,000 women a year having unnecessary surgery, at a cost of hun-
dreds of millions of dollars. Many of these women do not even have
cancer: about 80 percent of breast biopsies are benign. For women
who do have cancer, a surgical biopsy means two operations instead
of one, and may make the cancer surgery more difficult than it
would have been if a needle biopsy had been done.

Dr. Stephen R. Grobmyer, the senior author of the Florida study, said
he and his colleagues started their research because they kept see-
ing patients referred from other hospitals who had undergone surgi-
cal biopsies (also called open biopsies) when a needle should have
been used.

By Denise Grady

84 The OR Connection

Hospitals charge $5,000 to $6,000 for a needle biopsy,
and double that for an open biopsy,
“After a while you keep seeing this, you say something’s
going on here,” said Dr. Grobmyer, who is director of the
breast cancer program at the University of Florida in
Gainesville.
The reason for the overuse of open biopsies is not known.
Researchers say the problem may occur because not all
doctors keep up with medical advances and guidelines. But
they also say that some surgeons keep doing open biopsies
because needle biopsies are usually performed by radiolo-
gists. The surgeon would have to refer the patient to a radi-
ologist, and lose the biopsy fee.
A surgical biopsy requires an inchlong incision, stitches and
sometimes sedation or general anesthesia. It leaves a scar.
A needle biopsy requires only numbing with a local anes-
thetic, uses a tiny incision and no stitches and carries less
risk of infection and scarring.
If the abnormality in the breast is too small to be felt and has
been detected by a mammogram or other imaging method,
the needle biopsy must also be guided by imaging — mam-
mography, ultrasound or M.R.I. — and will often have to be
performed by a radiologist. If a lump can be felt, imaging is not
needed to guide the needle, and a surgeon can perform it.
“Surgeons really have to let go of the patient when they have
an image abnormality,” said Dr. I. Michael Leitman, the chief
of general surgery at Beth Israel Medical Center in Manhat-
tan. “They are giving away a potential surgery. But the stan-
dards require it. And I’m a surgeon.”
Dr. Grobmyer’s study, published by The American Journal of
Surgery, is based on 172,342 biopsies entered into a state
database in Florida. It is the largest study of open biopsy
rates in the United States, and the first to include patients
with and without cancer.
Aligning practice with policy to improve patient care 85
OR Issues
About 1.6 million breast biopsies a year are performed in the
United States. But in 2010, only about 261,000 found can-
cer (207,000 women had invasive breast cancer, and another
54,000 had a condition called ductal carcinoma in situ, in
which cancer cells have not invaded the surrounding tissue).
Hospitals charge $5,000 to $6,000 for a needle biopsy, and
double that for an open biopsy, according to Dr. Grobmyer’s
article. Doctors’ fees for an open biopsy range from $1,500
to $2,500, he said, and $750 to $1,500 for a needle biopsy.
A surgeon who was not part of Dr. Grobmyer’s study said
she often encountered patients referred from other hospitals
whose open biopsies should have been done with a needle.
“I see it all the time,” said the surgeon, Dr. Elisa R. Port, the
chief of breast surgery at Mount Sinai Medical Center in
Manhattan. “People are causing harm and should be held
accountable.”
Dr. Melvin J. Silverstein, a breast cancer surgeon at Hoag
Memorial Hospital Presbyterian in Newport Beach, Calif., and
a clinical professor of surgery at the University of Southern
California, said it was “outrageous” that 30 percent of breast
biopsies were done by surgery.
He said some of the unnecessary procedures were being
performed by surgeons who did not want to lose biopsy fees
by sending patients to a radiologist.
“I hate to even say that,” Dr. Silverstein said. “But I don’t
know how else to explain these numbers.”
A study at Beth Israel Medical Center in Manhattan (Dr. Leit-
man was an author), published in 2009, found that the rate
of open breast biopsies in 2007 varied with the type of
surgeon.
 One way for hospitals to stop excess open biopsies is to ban
them, Dr. Silverstein said, unless they are truly necessary, as in
uncommon cases in which a needle cannot reach the spot.
Breast surgeons employed by the hospital and involved in
teaching had a 10 percent rate. Breast surgeons in private
practice who operated at Beth Israel had a 35 percent rate.
Among general surgeons, who do not specialize in breast
surgery (some who were on staff at the hospital and some
who were not), the rate was 37 percent. All the doctors earn
biopsy fees, so they all had the same incentive.
The lead author of the study, Dr. Susan K. Boolbol, chief of
breast surgery at Beth Israel, said the difference could be
explained, in part, by training. She said the academic breast
surgeons on the hospital staff were more likely than the others
to keep up with new developments in the field and to work
closely with radiologists. As for the idea that the motivation
was money, she said, “A huge part of me doesn’t want to
believe it’s true.”
She said that when she asked surgeons in the study why
they were doing open biopsies, many said patients wanted
them. “My comeback was, ‘Do you think you had an inher-
ent bias in the way you explained it?’ ” In the past seven
years, she said she had only one patient choose an open
biopsy over a needle biopsy.
Dr. Boolbol says some patients fear that sticking a needle
into a cancer will cause it to spread, and she spends a lot of
time explaining that it is not true. She said that open biopsy
rates declined among surgeons at Beth Israel who were told
about her study’s findings, but newcomers still tended to
have higher rates.
“This is a constant education process for surgeons,” she
said.
86 The OR Connection
One way for hospitals to stop excess open biopsies is to ban
them, Dr. Silverstein said, unless they are truly necessary, as
in uncommon cases in which a needle cannot reach the
spot.
“We made a rule,” he said. “If it can be done with a needle,
it has to be. We embarrass you if you do an open biopsy. We
bring you before a tumor board to explain.”
Dr. Silverstein says that when he lectures and asks how
many surgeons in the audience perform open biopsies, no
hands go up. “Nobody will admit it,” he said.
He said there is more to be gained by taking his message
straight to the patients. He and other doctors say that any
woman who is told that she needs a surgical biopsy should
ask why, and consider a second opinion.
“Maybe we have to get patients to say, ‘This guy took a big
chunk out of me and I didn’t even have cancer, and now I’m
deformed,’ ” Dr. Silverstein said. “Who just overthrew
Mubarak? The people. This is exactly the same thing.”
From The New york Times, February 19, 2011. © 2011 The New york
Times All rights reserved. used by permission and protected by the
Copyright laws of the united States. The printing, copying, redistribution,
or retransmission of the Material without express written permission
is prohibited.
ARGLAES® IN THE OR
ANTIMICROBIAL SILVER TECHNOLOGY

Use silver to fight bacteria and surgical site infections

Arglaes provides: The Arglaes family of products has something
for every incision:
• Antimicrobial protection for up to 7 days
• Moist wound healing • Arglaes Film is ideal for managing bacterial penetration
• Fewer dressing changes on post-op incision and line sites.
• Non-attaining assay • Arglaes Island features a calcium alginate pad for fluid
• Transparency for wound monitoring management in addition to controlled-release silver.

To schedule a FREE demonstration of Arglaes

in your OR, contact your Medline representative,
call 1-800-MEDLINE or visit www.medline.com.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Arglaes is a registered trademark of Giltech Limited Corporation.
 Special Feature

Celebrating Six Since 2006, Medline has been hosting “Together We Can
Save Lives Through Early Detection” breast cancer awareness
breakfast forums at the Association of PeriOperative Regis-
Years of Spreading tered Nurses (AORN) Annual Congress as part of the com-
pany’s efforts to raise breast cancer awareness and share the

Breast Cancer importance of early detection.

Awareness to Spreading this message to nursing professionals is a key goal

of Medline’s campaign. Nurses are not only caregivers, but

Healthcare major influencers of women when it comes to early detection.

Every year, Medline invites a celebrity breast cancer survivor to

Professionals share her survival story and her own inspirational message
of hope at the breakfast. Past keynote speakers include Ann

Across the Nation Jillian, the late Rue McClanahan, Dr. Marla Shapiro, Linda
Ellerbee and Peggy Fleming.

2011
Breakfast Forum at the AORN 58th Congress – Philadelphia, Pennsylvania

This year, Medline’s 6th annual breakfast, held in conjunction

with the AORN 58th Congress in Philadelphia, Pennsylvania,
features Jill Eikenberry, a breast cancer survivor, and her hus-
band Michael Tucker. Eikenberry and Tucker are veteran
stage, film and television actors, perhaps best known for their
portrayals of Ann Kelsy and Stuart Markowitz on the long-run-
ning hit television series l.A. law.

88 The OR Connection
 A look back at the breakfast forums
over the past five years

2010
Breakfast Forum at the AORN 57th Congress – Denver, Colorado

An audience of more than 1,200 operating room nurses, the largest yet, gathered
to hear Olympic gold medalist Peggy Fleming talk about her skating career and battle
with breast cancer. She did not disappoint the early morning crowd, who were
also treated to a surprise appearance by several other celebrities of sorts – the
staff members from Providence St. Vincent Medical Center in Portland, Oregon,
who starred in the “Pink Glove Dance,” a YouTube video sensation that has more
than 13.1 million views to date.

AORN breakfast participants are inspired by Peggy Fleming’s story about her battle with breast cancer

Aligning practice with policy to improve patient care 89

 2009
Breakfast Forum at the AORN 56th Congress – Chicago, Illinois

One of the funniest, frankest and most distinctive journalists to ever appear on television,
keynote speaker Linda Ellerbee touched and inspired the crowd of 1,000 with her candid
talk about her treatment and recovery. A 17-year breast cancer survivor, she said she was
lucky because her training as a journalist taught her to ask questions.

Photo by Gordon Munro

2008
Breakfast Forum at the AORN 55th Congress – Anaheim, California

Dr. Marla Shapiro, author of life in the Balance: My Journey with Breast Cancer, a renowned
Canadian on-air medical expert and a physician with a thriving medical practice, delivered
a dynamic presentation on coping with stress, balancing life and battling breast cancer. She
candidly told the audience that on August 13, 2004, she went from being a doctor to a
patient in a matter of moments. And that despite her medical training, she was not fully
prepared for the path her life would take.

2007
Breakfast Forum at the AORN 54th Congress – Orlando, Florida

The late Rue McClanahan, an award-winning actress who played Blanche Devereaux on
the hit TV series Golden Girls, filled the room with laughter as the keynote speaker of
Medline’s 2nd annual breast cancer awareness breakfast forum. She was diagnosed with
breast cancer in 1997 and was treated successfully. Janelle Hail, president of the National
Breast Cancer Foundation (NBCF) also spoke, reminding everyone that each day is a gift.

2006
Breakfast Forum at the AORN 53rd Congress – Washington, D.C.

Medline held its first “Together We Can Save Lives Through Early Detection” breakfast forum
during the AORN 53rd Congress in Washington, D.C. Attendees were inspired by the words
of Ann Jillian, actress, singer and breast cancer survivor. At 35 years old, the actress made
headlines when she was diagnosed with breast cancer and she became a vocal advocate
for cancer research and prevention.

To see more photos from the breakfast forums visit medline.com/breast-cancer-awareness.

90 The OR Connection

A World
Without Breast
Cancer Is in
Our Hands™
Healthcare Sites Appearing in the
Pink Glove Dance Sequel
Providence St. Vincent Medical Center, Portland, Oregon
University of Minnesota Medical Center, Fairview, Minneapolis, Minnesota
Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana
Tallahassee Memorial Healthcare, Inc., Tallahassee, Florida
Saint Michael’s Medical Center, Newark, New Jersey
The Medical Center of Plano, Plano, Texas
HCA Johnston-Willis Hospital, Richmond, Virginia
Sky Ridge Medical Center, Lone Tree, Colorado
Thibodaux Regional Medical Center, Thibodaux, Louisiana
Capital Health, Halifax, Nova Scotia
Burgess Square Healthcare and Rehab Centre, Westmont, Illinois
Isabella Geriatric Center, New York, New York
Lorien Health Systems, Ellicot City, Maryland
Scripps Memorial Hospital La Jolla,
La Jolla, California
Medline started the Generation Pink movement with a single
vision: A World Without Breast Cancer Is in Our Hands. It’s
now the largest philanthropic cause in the company, where
Medline partners with the National Breast Cancer Foundation
(NBCF) to support free mammograms for underserved women,
build awareness at forums for nurses and other healthcare
workers, and even spread awareness virally through social
media and events such as The Pink Glove Dance.™
Pink ribbon products, including pink gloves, help Medline sup-
port the National Breast Cancer Foundation. Medline donates
a portion of the proceeds to the NBCF: more than $800,000
to date. Their mission of awareness, early detection and pre-
vention lines up perfectly with Medline’s: A World Without
Breast Cancer Is in Our Hands.™
The Dance Goes
On and On…
Seen over 13 million times since it went viral in
2009, the Pink Glove Dance kicked off a huge
wave of awareness, joy and caring. The
2010 sequel features more than 4,000 health-
care workers and breast cancer survivors from
14 separate facilities all over the United States
and Canada. Visit pinkglovedance.com
 Straight From the Heart
Quotes about the Pink Glove Dance

“ Watching this video is the first time I’ve cried over my

breast cancer. I hadn’t realized how alone I felt, even
though surrounded by caring family and friends. The fact
that so many healthcare workers were donning gloves
“
and dancing to show that I am not alone touched me
deeply. Thank you from my heart for this video.
Jenny W.
Ft. Collins, Colo.

“ I have just watched these videos for the 5th time. Each
time tears stream down my face. I have shared these
with my family and work family to help them realize just
how important breast cancer awareness is. It saved my
life not once, but twice. Let’s hear it for all those great
“
people dancing all over the United States … THANKS
from the bottom of my heart.
Louise C.
Haverhill, Mass.

92 The OR Connection
 Caring For Yourself

Medline Breast Cancer Awareness By the Numbers

$809,606 Dollars Medline has donated to the

National Breast Cancer Foundation to date.
4,000 Healthcare workers and breast cancer
survivors participated in the Pink Glove
Dance sequel.
6 Number of breast cancer awareness
breakfast forums Medline has hosted in
conjunction with AORN Congress.
13,178,145 Views of the Pink Glove Dance and
Pink Glove Dance Sequel on YouTube.
5,700 Healthcare workers who have attended
Medline breast cancer awareness breakfast
forums since 2006.
14 Facilities that participated in the Pink Glove
Dance Sequel.
4,567 People that like Medline’s Breast Cancer
Awareness Facebook page.

Aligning practice with policy to improve patient care 93

Yes, They’re Genuine.
Only Medline’s Pink Pearl™ gloves combine
aloe, nitrile and breast cancer awareness.

For more information,

contact your Medline
representative, call
1-800-MEDLINE or
visit www.medline.com.

©2011 Medline Industries, Inc.

Medline is a registered trademark
and Pink Pearl is a trademark of
Medline Industries, Inc.
 Special Feature

Beyond a Reasonable Doubt:

Open Communication Helps Jill Eikenberry
Raise the Bar for Breast Cancer Awareness

Aligning practice with policy to improve patient care 95

 Most everyone has heard the saying “your life
can change in an instant.” Actress Jill Eikenberry
is one who can definitely appreciate it
After struggling for more than a decade on the New
York City stage, Eikenberry and her husband Michael
Tucker finally felt they’d made it when, in 1986, they
landed regular roles on a new television show called L.A.
Law. Their son was starting kindergarten. She was cele-
brating her thirteenth wedding anniversary.
“We were going to get the fame and fortune we thought
we always wanted,” says Eikenberry.
And then in a moment, everything changed. She found a
tiny lump in her right breast. It would later test malignant.
The diagnosis was breast cancer.
“I didn’t know anybody who’d survived breast cancer,”
she recalls. “And I thought I was going to die for sure.”But
while breast cancer is one of society’s common denom-
inators, so fortunately, are hope and survival. All it took
was a chance meeting with a woman who had survived
– with her breast intact – to provide Eikenberry with a
belief in both.
Eikenberry’s breast cancer story began as she and
Tucker were packing up their lives and children in New
York to move to the West Coast. They had finished
shooting the pilot for L.A. Law and were heading to Los
Angeles for the rest of the series.
“I reached up while driving and felt something, and
instantly when I felt this thing I knew that something was
wrong. This wasn’t what was supposed to be there,” said
96 The OR Connection
Eikenberry. “I had never checked myself before. I don’t
know what made me do it, but I think somehow we
know. We have some sort of intuitive feelings sometimes.”
She called her gynecologist, who acknowledged that she
had felt something during Eikenberry’s last exam and
had, in fact, already scheduled a mammogram without
telling her. At age 39, it would be her first. The result
wasn’t good: the lump was malignant.
“I was terrified. In those days, no one was talking about
surviving breast cancer,” she said. “The only person that
I knew that had had it was the woman that lived upstairs
from us in our New York apartment. She had died the
year before, leaving three children.”
Eikenberry and Tucker consulted a breast surgeon, who
recommended either a lumpectomy or a mastectomy.
The surgeon leaned toward a mastectomy. Eikenberry’s
first panicky impulse was to agree.
“I said ‘Whatever you have to do get it out of here – get
it off.’ And we went home in despair.”
It wasn’t until a couple of days later – “I sort of laid on the
bed and cried, didn’t want to tell anybody” – that she
decided to attend a screening of a movie she had
recently completed called The Manhattan Project. The
cast included her friends John Lithgow and Cynthia
Nixon.
 While Eikenberry has a long list of theater,
film and television credits, she is perhaps
best known for her portrayal of L.A.
Law’s Ann Kelsey

She walked into the lobby of the movie theater, deter-
mined not to tell anybody about her situation. However,
“Cynthia took one look at me and said ‘what happened
to you?’ And I poured the whole story out.”
Nixon brought Eikenberry into the audience to see her
mother, Ann. Nixon’s mother then took her hand and
dragged her up the aisle into the ladies room.
at Barnard College in New York. In her second year, how-
ever, she auditioned for and was accepted into the Yale
School of Drama in New Haven, Connecticut.
She met Tucker while the two of them were performing at
the Arena Stage in Washington, D.C. They were later cast
in the play Moonchildren, which eventually took them to
Broadway in 1972. They married the following year.

“Ann hiked up her blouse and said, ‘You see this little scar While Eikenberry has a long list of theater, film and tele-
on my right breast? That’s all I have to remind me of my vision credits, she is perhaps best known for her portrayal
breast cancer 11 years ago.’ And all of a sudden, I felt of L.A. Law’s Ann Kelsey alongside Tucker’s Stuart
hope,” said Eikenberry. Markowitz. Over the course of the series’ long-run, she
received four Emmy nominations, two Golden Globe
That hope persuaded Eikenberry to seek a second opin- nominations and a Golden Globe Award.
ion. The news was better this time as her doctor said she
was a perfect candidate for a lumpectomy. “I saved my One of the most decorated dramas in television history,
breast,” she said. “It was amazing what Ann Nixon did the show followed a group of lawyers at the fictitious law
for me.” firm McKenzie, Brackman, Chaney and Kuzak. In its
prime, blessed with a plumb Thursday time slot behind
Amazing is a descrip- “Cosby” and “Cheers,” the series regularly finished in the
tion that Eikenberry top 15. Its legal cases covered big issues of the day, such
herself has heard over as the outing of prominent gays and the morality of the
the years in reference death penalty, as well as unusual ones like dwarf tossing
to her stellar career and the culpability of a Jewish mohel sued for snipping a
and odds-defying, bit too much at a circumcision ceremony.
long-term Hollywood
marriage to Tucker. The compelling stories would often intermix with the
lawyers’ sexy personal entanglements – including the
Born in New Haven, famous storyline where Tucker employs a secret sexual
Connecticut, she was technique called the “Venus Butterfly” to win the hand of
raised in Madison, Eikenberry. The episode was one of the most talked
Wisconsin before about of the entire season, and although the “V.B.” was
moving to Missouri. a fictional figment of a writer’s fertile imagination, hordes
She began her college of viewers wrote the show asking what the ancient sex-
studying anthropology ual practice was.

Aligning practice with policy to improve patient care 97

 The chemistry between Eikenberry and Tucker made
them instantly identifiable as a TV couple, and a hit show
put them squarely in the public eye. The fame would
make it challenging for Eikenberry, who by now had
undergone surgery at Mt. Sinai in New York, to keep her
ensuing radiation therapy treatments a secret. That pri-
vacy was very important to Eikenberry, as she was very
concerned about the word getting out and people think-
ing of her as “the actress with cancer.”

“After the surgery Steven Bochco, who was producing

L.A. Law, called a friend at UCLA who agreed to admin-
ister my radiation therapy in private so nobody would
know,” she recalled. “So every night we would have to
get off the set without anybody noticing and sneak over
to UCLA and have my radiation treatments.”

However, despite being able to keep the treatments from
the public, she wasn’t, by her own admission, dealing
very well with the up-and-down emotions she was expe-
riencing.
Eikenberry was among the first to be
installed into the Cancer Survivors Hall
of Fame in October 2000.

“On one hand, I think that it was really good for me to

play that character because Ann Kelsey was a fighter.
She could walk into a room filled with men, CEOs, and
level the room. She was really tough. I think for me it was
the most positive thing to play somebody that tough
when I was feeling as vulnerable as I was,” she said. “But
I wasn’t really talking to myself about my fears. I was just
trying to bury them in the character and work the char-
acter and be famous instead of being the person with
cancer.”
Tucker was having a hard time as well.
“My focus was on Jill – helping her and making her feel
confident. I completely forgot about myself,” said Tucker.
“Because of that fear of loss, I went into a phase of
denial for two years. It wasn’t until later that the penny
dropped and I realized that I was going through some-
thing too.”
Things began to change when Eikenberry was
approached by Linda Otto, a documentary film maker
who also had breast cancer. She had an idea for a new
documentary film based on interviews with women who
have survived the disease. Her pitch resonated with
Eikenberry: “I don’t think anyone knows you can survive.
I think that if people know there is a good chance of sur-
vival, especially if you catch it early, people would be less
afraid to check themselves and to get their mammograms.”
Even so, Eikenberry was very reluctant at first to do it.
“I thought there was going to be a terrible stigma if I went
on television and said I have breast cancer,” she said. “I
was a celebrity now. I had done L.A. Law for a couple of
years and I was terrified of what people would think.”

98 The OR Connection
 Eikenberry received four
Emmy nominations for
playing lawyer
Ann Kelsey, noting that
“She was a fighter.
I think for me it was
the most positive thing
to play somebody that
tough when I was
feeling as vulnerable
as I was.”
But in her car after meeting with Otto, she thought about
her own initial reaction to her diagnosis and her subse-
quent encounter with Ann Nixon – and tearfully decided
that it was time to go public.
“I knew that I had to talk about it because it had been so
important to me when somebody talked about it.”
Eikenberry not only agreed to participate, but also
became the interviewer for the project. The result became
the 1988 NBC special Destined to Live: 100 Roads to
Recovery, with subjects ranging from Gloria Steinem and
Nancy Reagan to a gruff-talking female deputy sheriff and
a woman whose supportive husband bought her a Fred-
erick’s of Hollywood negligee after her breast surgery.
“It was very important for me to do this documentary,”
said Eikenberry in an interview with the Los Angeles
Times. “On a personal level I have a tendency, because
I’m optimistic, to put it away and pretend it didn’t hap-
pen. But being able to face one’s own mortality does give
one a new lease on life.”
The Los Angeles Times praised the special, noting that
“the candor is remarkable considering society’s lingering
Aligning practice with policy to improve patient care 99
anti-cancer bias, and their forthrightness becoming the
program’s spiny strength as it helps to further lift the
stigma from a disease that was once considered
unmentionable.”
When the documentary went on the air it was a revelation
for Eikenberry.
“I thought there would be a stigma, when in fact it was
the beginning for a whole new career for me really be-
cause people had felt as alone as I had. When they saw
the documentary they were given hope. It was just this
amazing thing to realize that I had friends everywhere
who were so grateful to be able to share their story once
they heard all the stories we told on the show.”
The success of Destined to Live: 100 Roads to Recovery
led to Eikenberry receiving the Vital Options Vital Spirit
Award 1991. At the awards ceremony, emcee Meryl
Streep praised “the ease with which the information was
given” within the documentary, noting that Eikenberry “re-
ally got the women to talk about it. It was moving and
heartening. It made you understand what they went
through.”
 “I think that the most important thing that I have learned
is that silence is not golden in this situation,” said Eiken-
berry. “The more that we are able to try and understand
what we are feeling and communicate it, the better we
feel and the more we are able to go into the experience
and be present and make our own decisions. It’s just so
important to be open with ourselves and other people.
It’s a very different environment now. People are not feel-
ing the way they were feeling back then.”
“Each of us has changed a lot and grown a lot,” said
Eikenberry. “And I think the main thing is that we allowed
the change in the other person and did not try to keep
things in a status quo situation. I think that’s big. We’re
very good communicators. We make a point of it.”
It’s also why both Eikenberry and Tucker continue to
travel the country, telling their story. It’s not only cathartic,
it makes them stronger and feel more connected.

Eikenberry witnessed the difference first hand, because in “Every time I go out and talk about the cancer, even
February of 2009 she faced what every breast cancer though it is difficult to say the words, it ends up eliciting
survivor fears most – a check-up mammogram that all kinds of responses in people out there in the audience
detected a recurrence. – the nods, the compassionate faces. And I feel suddenly
that I am so not alone. Everyone should know that feeling.”
“My mammogram discovered another tiny tumor in
exactly the same spot as my old one,” she said. “But this
time was so different. There’s a lot more people vocal
about their breast cancer now. My radiologist said to me
on the phone when she gave me the news, ‘you have
nothing to worry about.’ They would have newer said that
to me in 1986.”

Another big change noted by Eikenberry: the communi-

cation between her caregivers and herself.

“I had so much communication with everybody all along

the way this time and last time I felt completely in the
dark,” she says. “This time I didn’t have to have chemo
or radiation; I was able to have a lumpectomy again in
the same spot. But I felt like it was my choice every step
of the way, and that I was being part of the experience
instead of the victim of the experience.”

And like he has for more than four decades, Tucker was
there to help her through it.

“My husband was able to be so present with me because

he wasn’t afraid the same way as last time,” she said.
“We were really able to have our eyes open and talk
about it every step of the way instead of feeling like we Eikenberry originally was very
had to push it all down. And that was just really an eye
opener in many respects. The medical profession has
concerned with word getting out
changed and I have changed a lot for the better.” that she had breast cancer, and
was “terrified that people would
It’s open communication that has kept Eikenberry and think of me as the actress
Tucker – or Tuckerberry as they refer to themselves – to-
gether both personally and professionally since 1970.
with cancer.”

100 The OR Connection

OR Issues
Less Invasive
Surgery Just as
Effective for Some
Breast Cancer Patients
by Allison Bierly, PhD
When breast cancer has spread to nearby lymph nodes, many
doctors believe that removing several more nodes provides
better treatment. But a new study suggests otherwise. The find-
ing may change the way early-stage breast cancer is treated in
some patients.
Doctors often begin with sentinel lymph node dissection
(SLND)—only removing one or two lymph nodes—to determine
if cancer has spread. If these sentinel nodes don’t contain tumor
cells, no more surgery is performed. However, if the sentinel
nodes do contain tumor cells, the next step is to perform axillary
lymph node dissection (ALND)—removing at least 10 nodes.
ALND can lead to a number of side effects, including seromas
(swelling due to clear fluid pockets), tingling sensations and
buildup of lymph fluid called lymphedema. Moreover, studies
haven’t definitively shown whether ALND improves survival or
staves off reoccurrence of the disease compared to SLND alone.
Dr. Armando Giuliano of the St. John’s Health Center in Santa
Monica, California, and his colleagues set out to investigate.
Complication rates following lymph node removal
25 %
complications
70 %
complications
axillary lymph sentinel lymph
node dissection node dissection
Aligning practice with policy to improve patient care 101
The team recruited almost 900 patients from 115 different treat-
ment centers. All had tumor cells in 1 or 2 sentinel lymph nodes.
Patients were randomly divided into 2 groups. One underwent
ALND while the other did not. All the patients received radiation
therapy. The study, which was funded by NIH’s National Cancer
Institute (NCI), appeared in the February 9, 2011, issue of the
Journal of the American Medical Association.
Overall, an average of 17 lymph nodes per patient was removed
from the ALND group, while just 2 were removed from patients
who underwent SLND alone. Strikingly, 5 years after surgery,
the research team saw no difference between the 2 groups in
the percentage of patients who survived or who remained
disease-free.
The team also compared how many patients in each group had
complications from surgery, including wound infection, seromas
and tingling sensations. In the group that received SLND alone,
only 25 percent suffered from these complications, while 70
percent of the ALND group experienced them.
These results show that SLND is no less effective than ALND at
preventing death or reoccurrence of disease after 5 years, while
dramatically reducing the risk of side effects from surgery.
Giuliano notes that several treatment centers—including
St. John’s Health Center and the Memorial Sloan-Kettering
Cancer Center—are already using the findings to make treat-
ment decisions for early metastatic breast cancer. “It’s ready to
go for these patients,” he says.
Source: National Institutes of Health http://www.nih.gov/researchmatters/
february2011/02282011surgery.htm
 How to
ENERGIZE
102 The OR Connection
 by Wolf J. Rinke, PhD, RD, CSP

YOUR TEAM
Aligning practice with policy to improve patient care 103
 ...the fastest way to achieve peak
performance is to treat all employees
as if they were volunteers
Let’s face it—health care is a team “sport.” No matter what your
current role, sooner or later you’ll end up being a team leader.
And when that happens, your success depends on your team
members’ willingness to go the extra mile. (Hint: if you are not
yet a team leader, read this anyway because the time to
practice is now.) Here are six strategies to keep your team
members “juiced.”
1. Treat all team members as if they are volunteers.
I refer to this as the most important leadership principle of all
time. I discovered it while I was a Board member of one of my
professional associations and the Chair for the Council on
Education. In that role the Board looked to me to implement
new Standards of Education, which had been in limbo for
countless years. A team of 12 professionals was on my com-
mittee. All highly educated, all volunteers, all having their own
agenda. I quickly became aware that all the “crutches” that I
relied on during my “day job” did not work. For example, one of
my committee members, let’s call her Julie, was really gung-ho.
Any time there was a project to be done she was the first one
to volunteer. There was only one problem—Julie seldom deliv-
ered. Forget delivering on time, she just did not deliver. At work,
when any of my team members did that, I could counsel them
and if that did not work I could use the ultimate “crutch”—
I could fire them. Trying that with Julie, however, produced just
the opposite results. Her response: “Hey I don’t need this; I’m
outta here—more time with the family.”
After banging my head against the proverbial brick wall several
times I finally figured out that my autocratic strategies simply
did not work with volunteers. I had to develop an entirely different
skill set to motivate these people. And after I had mastered
them, I transferred these new strategies to my “day job.” For
me this was a defining moment that enabled me to transform
myself from an autocratic manager to a highly effective leader.
What was that concept? Are you ready for it? This is BIG! Drum
roll please! Treat all employees as if they are volunteers.
Now, stop and think, what would you say to your team mem-
bers if indeed they were volunteers? How about: "Please."
"Thank you!" "Can I count on you?" "I need your help." "I really
appreciate what you’ve done." "Thanks for being on my team!"
"Thanks for showing up." And now the one that blows the
autocratic managers away: "Could you do me a favor?" That
one just doesn’t sit well with lots of managers. Here are some
of the things they’ve said to me: "What are you talking about?
You’re paying them; they owe you a good job." Or "You’ve got
to be nuts. They are not doing you any favor, it’s their job," and
so on. All really good arguments, and all really, really incorrect.
(If you agree with any of these, it’s time to wake up and smell the
coffee. Because the only thing pay will do is get team members
to show up, and stay with you. (Not bad, but certainly not peak
performance.) And the fastest way to achieve peak perform-
ance is to treat all employees as if they are volunteers.
2. Catch team members doing things almost right!
Most of us were taught to supervise team members by catch-
ing them making mistakes. Someone even gave it a name:
management by exception. Unfortunately most team members
will live up or in this case down, to your expectation. To reverse
this, you will need to learn to catch team members doing things
right. No wait, let me modify that, catch team members doing
things almost right! The problem is that if you are a perfection-
ist some of your team members just have a tough time getting
it right, especially if right is defined as the way you would have
done it. Then you must compliment or recognize that positive
performance in some way. In other words, you must learn to
Continued on page 106
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 I learned a long
time ago that if it’s
fun, it gets done.
practice management by appreciation (MBA). Although difficult
to master, this is a more powerful strategy than you will ever
learn in any university MBA program. Catching team members
doing things almost right means you use your abundant men-
tal energy to look for your team members moving in the right di-
rection, instead of using the same amount of energy to catch
them messing up. If you look hard enough, you will find that
most team members do several things each day that they feel
really great about. Find it, and then be sure to make a big deal
about it, ideally in public. If you still find yourself slipping back
into old habits use the 10 penny system. Put 10 pennies in your
left pocket or in case you don’t have pockets, the left side of
your desk. Every time you catch one of your team members
doing something almost right and let them know about it, trans-
fer one penny from your left pocket to your right pocket. On the
other hand if you provide negative reinforcement to one of your
team members, reverse the process; but this time move three
pennies back to the left pocket. Your goal is to have all pennies
in your right pocket at the end of each day.
106 The OR Connection
3. Make work fun.
I learned a long time ago that if it’s fun, it gets done. So ask
yourself, are your team members having fun? Better yet ask
them. It’s very hard to be motivated and energized if work is a
big pain. In fact Sigmund Freud got this right when he identified
the Pleasure Principle, which basically says that all human
beings move themselves in the direction of pleasure and move
themselves away from pain. So if you have a high turnover rate,
have team members who abuse sick leave or have trouble get-
ting team members to show up for work on time, you can be
sure that working for you is painful. What to do? Ask five of your
team members to serve on a “Celebration or Fun Team.” Give
them a budget. If you don’t have one, suggest that they con-
tact local merchants who’d love to achieve greater visibility in
your organization. Suggest that they ask those merchants to
make donations to your Celebration Team. Example: movie tick-
ets, a weekend for two at a local resort, etc., etc. Just be sure
to give those who donate lots of visibility. Now ask the Cele-
bration Team to get together to identify specific things they are
planning to do each month that make work fun. Tell them any-
thing goes, provided that they stay within their allocated budget
and it does not violate any laws, rules or regulations.
4. Be positive and energetic
Attitudes, just like colds are
catching. Positive attitudes are
caught just as easily as negative
attitudes. The only problem is
that negative attitudes suck the
energy out of your team mem-
bers like a giant sponge—some-
thing your peak performers are
just not going to put up with. On
the other hand, positive attitudes
are like the little Energizer bunny.
They will keep your team mem-
Continued on page 108
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 Recognize that positive
language energizes you.
bers going, and going, and going (well, you get it.) To build a
positive attitude, become aware of your conversations including
the ones that you have inside of your head. Recognize that pos-
itive language energizes you, and negative, cynical, “stinking
thinking” conversations de-energize you and your team mem-
bers. Make it a practice to say positive things, especially about
other people, or say nothing at all. Also recognize that your
mind can hold only one thought at a time. It can either be pos-
itive or negative, it is your choice! So when you catch yourself
thinking positive thoughts, congratulate yourself. On the other
hand when you are thinking negative thoughts, catch yourself,
change those thoughts, then give yourself credit. Remember
because of “mirror neurons” your team members take their cue
from you! You must be the role model for the kind of behaviors
you want them to exhibit. (For in-depth strategies of how to
make this happen read Make It a Winning Life--Success
Strategies for Life, Love and Business available at http://wol-
frinke.com/miwlbook.html.)
5. Build on team members' strengths.
Statistics tell us that 25% of the US population hates what they
do, another 56% could take it or leave it, and only 19% love
what they do. Typically team members who love what they do
are in jobs that let them build on their strengths. So find out
what your team members love to do and do everything in your
power to assign them to those projects or place them in those
positions. What if you end up losing them? Think about it: would
you rather have team members who love what they do and
hence are peak performers, or those who stick with you
because they can’t get a job anywhere? Even your most dedi-
cated team members are going to get burnt out really fast if
they are not building on their strengths. So you would be much
better served to get team members in positions or projects that
enable them to build on their strengths even if you lose them.
Just remember that whoever inherits one of your team mem-
bers will be much more likely to reciprocate in the future. Plus
the team member who has left you will become an "ambas-
sador of goodwill" for you. And in today's competitive health
care industry, good will is a very valuable commodity when you
need to fill your next vacancy.
108 The OR Connection
6. Get team members to listen to motivational
audio programs.
Mary Kay sales associates, or for that matter all highly suc-
cessful sales professionals, have this figured out. You must pro-
vide team members with external motivation if you want them
to consistently perform at peak performance. So start building
an audio-program library. Suggest to your team members that
they listen to a program every day on their way to work. Meet
in brief weekly meetings and have team members share one
powerful principle they learned from each program. That way
everyone can learn from everyone else, and energize each other
at the same time. Supplement these activities by showing a mo-
tivational program during your next in-service. (Aren’t your team
members getting tired of the same mandatory training?) Or bet-
ter yet hire a motivational speaker to energize your next "all
hands" team meeting. Your team members will be positively
surprised, feel honored and energized. And when they are
energized everyone’s job will be much more enjoyable, and to
top it all off, your patients will be less grumpy and may even get
better faster.
© 2011 Wolf J. Rinke
Dr. Wolf J. Rinke, RD, CSP is a keynote
speaker, seminar leader, management con-
sultant, executive coach and editor of the free
electronic newsletter Read and Grow Rich,
available at www.easyCPEcredits.com. In ad-
dition he has authored numerous CDs, DVDs
and books including Make It a Winning Life:
Success Strategies for Life, Love and Busi-
ness, Winning Management: 6 Fail-Safe Strategies for Building
High-Performance Organizations and Don’t Oil the Squeaky Wheel
and 19 Other Contrarian Ways to Improve Your Leadership Effec-
tiveness; available at www.WolfRinke.com. His company also pro-
duces a wide variety of quality pre-approved continuing
professional education (CPE) self-study courses, available at
www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.
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 Healthy Eating

Nutrition
Information
Servings: 9
Calories: 166
Fat: 15.6 g
Sodium: 159 mg
Fiber: 0.1 g

Aunt Judy’s
Tortilla Roll-Ups
1 cup finely shredded cheddar cheese
½ cup sour cream
8 oz. cream cheese, softened
1 pkg. taco seasoning
12 green olives or green chiles/pimentos
3 large tortillas

Directions: This recipe is Judy’s favorite appetizer, which she inherited from
Mix ingredients together, and spread onto the tortillas. Roll up her Aunt Judy a year ago. It’s a highly requested dish at the
tortillas. Place into a zip lock bag and chill. When ready to serve, many events Judy attends.
slice and serve with salsa.
Judy was also involved in creating Medline’s first and second
Hint: Healthier alternative ~ low fat cheese and low fat sour edition cookbooks, which feature recipes from Medline employ-
cream and whole wheat tortillas may be used. ees. The latest edition is available for purchase, and the pro-
ceeds go to Medline’s Spirit of Giving fund, which helps support
Judy DeSalvo, Marketing Business Manager – Mundelein Medline employees in times of need.
Judy DeSalvo has been working at Medline for nine years. She
basically “does it all” to keep the Marketing Department running
The Medline employee cookbook
efficiently. Judy sees print projects through to completion, mak-
is $10. To purchase your own
ing sure vendor estimates are correct on
copy, please e-mail Judy at
invoices, all the way down to ensuring
jdesalvo@medline.com.
marketing materials arrive on time and in 

the right location at trade shows and

meetings. She’s often been sighted mov-
ing boxes of brochures and Medline dolls,
and she’s even been known to wield a
screwdriver to repair a piece of office
equipment in a pinch so coworkers can
get their jobs done.

110 The OR Connection

 Forms & Tools

The following pages contain

practical tools for implementing
patient-focused care practices
at your facility.

Surgical Attire
Highlights of AORN’s Revised Recommended
Practices for Surgical Attire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

Hand Hygiene
CDC Clean Hands Poster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120

Pressure Ulcer Prevention

How Well Do You Know Pressure Points? . . . . . . . . . . . . . . . . . .121

Aligning practice with policy to improve patient care 111

 KEEP YOUR SURGICAL
PATIENTS DESERT DRY.
Medline’s Sahara® Super Absorbent OR table sheets
are designed with your patients’ skin integrity in mind. QuickSuite®
OR Clean Up Kit
The Braden Scale tells us that moisture is one of the
major risk factors for developing a pressure ulcer.1 We also
know that as many as 66 percent of all hospital-acquired
pressure ulcers come out of the operating room.2

That’s why we developed the Sahara Super Absorbent

OR table sheet. The Sahara’s super-absorbent polymer
technology rapidly wicks moisture from the skin and
locks it away to help keep your patients dry.

Sahara OR table sheets are available on their own or

as a component in our QuickSuite® OR Clean Up Kits,
which were designed to help you dramatically improve
your OR turnover time and help reduce cross contamina-
tion risk through a combination of disposable products. To sign up for a FREE webinar on perioperative
pressure ulcer prevention, go to
www.medline.com/pupp-webinar.
References
1
Braden Scale for Predicting Pressure Sore Risk. Available at:
www.bradenscale.com/braden.PDF. Accessed November 6, 2008.
2
Recommended practices for positioning the patient in the perioperative practice setting. In:
Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008.

©2010 Medline Industries, Inc. Medline, QuickSuite and Sahara are registered trademarks of Medline Industries, Inc.
 AORN’s Recommended Practices Forms & Tools

Highlights of AORN’s
Revised Recommended Practices
for Surgical Attire

November 2010

Highlights of
AORN’s Revised
Recommended
Practices for
Surgical Attire

The following report includes excerpts from AORN’s “Recommended

Practices for Surgical Attire.” For a complete copy, refer to AORN’s 2011
Perioperative Standards and Recommended Practices.

Aligning practice with policy to improve patient care 113

 Forms & Tools AORN’s Recommended Practices

Italicized wording throughout the document represents language quoted

directly from AORN’s Recommended Practices for Surgical Attire.

AORN recently revised its Recommended Practices for Surgical Attire to include stronger
recommendations for donning safe surgical attire, based on emerging evidence showing a
connection between attire and possible risk of infection.

The following are some of the major changes:

• The biggest change: All recommendations for home laundering of
surgical attire have been removed. AORN recommends that surgical
attire should be laundered in a health care-accredited laundry facility
• New information on characteristics of safe surgical attire fabrics, including
recommendations that fabrics should be low linting, tightly woven, stain
resistant and durable, and that 100% cotton fleece should not be worn
• A new recommendation that cover apparel (lab coat, cover gown)
should be laundered daily
• A new recommendation that nonscrubbed personnel in the semirestricted
and restricted areas should wear a freshly laundered or single-use long
sleeve warm-up jacket
• A new recommendation on quality assurance monitoring of laundering processes

Recommendation I
Surgical attire should be made of low-linting material, contain skin
squames, provide comfort, and promote a professional appearance.

Researchers have found that tightly woven and/or synthetic surgical attire helps contain bacterial
shedding and promotes environmental control. The design of the surgical attire is not as important
as the material from which it is made.

I.a. Surgical attire fabrics should be:

• Tightly woven
• Stain resistant
• Durable
• Comfortable in terms of design, fit,
breathability and weight of the fabric

I.b. Surgical attire made of 100% cotton fleece should not be worn. Some fabrics made
of cotton fleece collect and shed lint. Lint may harbor microbial-laden dust, skin squames,
and respiratory droplets.
114 The OR Connection
 AORN’s Recommended Practices Forms & Tools

Recommendation II
Clean surgical attire, including shoes, head covering, masks, jackets,
and identification badges should be worn in the semirestricted and
restricted areas of the surgical or invasive procedure setting.

Clean attire minimizes the introduction of microorganisms and lint from health care personnel
to clean items and the environment.

II.a.2. When wearing a two-piece scrub suit, the top of the scrub suit should be secured
at the waist, tucked into the pants, or fit close to the body.

II.a.3 Health care personnel should change into street clothes whenever they leave the health
care facility or when traveling between buildings located on separate campuses.

II.e. Identification badges should be worn by all personnel authorized to enter the
perioperative setting. Health care personnel as well as patients should be able
to identify caregivers.

II.e.1. Identification badges should be secured on the surgical attire top, be visible, and
be cleaned if they become soiled.

II.f.1 Cover apparel should be laundered daily in a health care-approved or accredited

laundry facility (See Recommendation V.)

In one study of cover coats worn by 100 physicians, Staphylococcus aureus was isolated
from 25 of the cover coats. The cuffs and pockets of the coats were the most contaminated.

Aligning practice with policy to improve patient care 115

 Forms & Tools AORN’s Recommended Practices

Recommendation III
All individuals who enter the semirestricted and restricted areas
should wear freshly laundered surgical attire that is laundered
at a health care-accredited laundry facility or disposable surgical
attire provided by the facility and intended for use within the
perioperative setting.

III.a. Surgical attire should be changed daily or at the end of the shift.

Surgical attire may have bacterial colony counts that are higher when scrub clothing
is removed, stored in a locker, and used again.

III.a.1. Reusable or single-use contaminated attire should be placed in appropriately

designated containers after use. Worn reusable surgical attire should be left at
the health care facility for laundering.

III.a.2. Surgical attire that has been penetrated by blood or other potentially infectious materials
should be removed immediately or as soon as possible and replaced with freshly
laundered, clean surgical attire. When extensive contamination of the body occurs,
a shower or bath should be taken before donning fresh attire.

III.a.3. Wet or contaminated surgical attire should not be rinsed or sorted in the location of use.

III.a.4. Surgical attire contaminated with visible blood or body fluids must remain at the health
care facility for laundering or be sent to an accredited laundry facility contracted by the
health care organization.

III.b. When in the semirestricted or restricted areas, all nonscrubbed

personnel should wear a freshly laundered or single-use long
sleeved warm-up jacket snapped closed with cuffs down to the wrists.

III.b.1. All personal clothing should be completely covered by the surgical

attire. Undergarments such as T-shirts with a V-neck, which can
be contained underneath the scrub top may be worn; personal
clothing that extends above the scrub top neckline or below the
sleeve of the surgical attire should not be worn.

Personal clothing is not laundered by a health care-accredited laundry.

Appropriate surgical attire,
including warm-up
jacket, for semirestricted
and restricted areas.
116 The OR Connection
 AORN’s Recommended Practices Forms & Tools
Recommendation V
Surgical attire should be laundered in a health care-accredited
laundry facility.

Accredited health care laundering facilities provide a monitored laundering process and must
adhere to established standards set forth by the Healthcare Laundry Accreditation Council (HLAC).
These standards require that facilities demonstrate regulated practices for every step of the
laundering process, from transferring soiled laundry, to sorting it, washing with specified wash
formulas, time and temperature according to manufacturer guidelines, drying, pressing, packing and
transporting clean laundry. The new AORN Recommended Practices for Surgical Attire cites many
studies showing the ineffectiveness of home laundering in removing infectious bacteria from fabrics.

Surgical attire; street clothing; PPE; and other hospital textiles (e.g., bed linens, towels, privacy
curtains, washcloths) may become contaminated by bacteria and fungi during wear or use.
In one study, researchers found that microbes can survive on hospital textiles for extended
periods of time. These textiles included:
• 100% cotton clothing
• 60% cotton/40% polyester blends (e.g., scrub suits, lab coats)
• 100% polyester clothing; and
• polyethylene plastic aprons

The shortest time for enterococci survival on textiles was 11 days.1,2 It has been postulated that
these fabrics can become vectors for fungi.2

Health care-accredited laundry facilities are preferred because they follow industry standards.

V.a. Laundered surgical attire should be protected during transport to the practice
setting to prevent contamination.

V.a.1. Surgical attire should be transported in a clean vehicle and enclosed

carts or containers.

V.b. Clean surgical attire should be stored in a clean, enclosed cart or cabinet.

V.b.1 Surgical attire may be stored in a dispensing machine. Dispensing machines

should be routinely emptied and cleaned according to the manufacturer’s directions.

1. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and plastic. J Clin Microbiol. 2001;38(2):724-726.
2. Neely AN, Orloff MM. Survival of some medically important fungi on hospital fabrics and plastics. J Clin Microbiol. 2001;39(9):3360-3361.

Aligning practice with policy to improve patient care 117

 Forms & Tools AORN’s Recommended Practices

Recommendation VII
Health care personnel should receive initial and ongoing education
and demonstrate competency on appropriate surgical attire.

Competency assessment verifies that health care personnel have an understanding

of the articles and purpose of surgical attire. This knowledge is essential for reducing
the risk of health care-associated infections.

Recommendation IX
The health care organization’s quality management program
should evaluate compliance with surgical attire policies and
identify and respond to opportunities for improvement.

IX.a.1. Quality indicators for surgical attire may include, but are not limited to,
• head coverings completely cover the hair and scalp;
• warm-up jackets with wrist-length sleeves are worn and are snapped;
• identification badges are worn, visible, and clean;
• shoes are clean and protect health care personnel’s feet;
• visibly soiled or wet surgical attire is removed and cleaned at an
accredited health care laundry facility;
• masks, when worn, are tied securely and are discarded after each
procedure; and
• cover apparel, if worn, is laundered daily at the organization
or an accredited laundry facility.

118 The OR Connection

 AORN’s Recommended Practices Forms & Tools

These recommended practices are intended as guidelines adaptable to various practice settings,
including traditional operating rooms (ORs), ambulatory surgery centers, physicians’ offices,
cardiac catheterization laboratories, endoscopy suites, radiology departments and all other areas
where surgery and other invasive procedures may be performed.

GLOSSARY
Restricted Area: Includes the OR and procedure room, the clean core, and scrub sink
areas. People in this area are required to wear full surgical attire and cover all head and
facial hair, including sideburns, beards and necklines.

Semirestricted Areas: Includes the peripheral support areas of the surgical suite and
has storage areas for sterile and clean supplies, work areas for storage and processing
instruments, and corridors leading to the restricted areas of the surgical suite.

Surgical Attire: Nonsterile apparel designated for the OR practice setting that includes
two-piece pantsuits, cover jackets, head coverings, shoes, masks, protective eyewear,
and other protective barriers.

Aligning practice with policy to improve patient care 119

120
CLEAN HANDS SAVE LIVES
Forms & Tools

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION
Protect patients, protect yourself

The OR Connection
Candida
Staphylococcus

Influenza

RSV
Hand Hygiene Poster

Klebsiella Pseudomonas

Enterococcus
Alcohol-rub or wash
before and after EVERY contact.
www.cdc.gov/handhygiene
 Pressure Point Quiz Forms & Tools

How well do you know

Pressure Points?
Feel free to use this quiz for skill 6
fairs, training and in-services. 7
1
Choose from (some may be used twice)
Dorsal thoracic area
Ear
Elbow
5
Foot 2 4
Greater trochanter 3
Heel
Ischial tuberosity 10
Lateral aspect of foot
Lateral aspect of knee
Lateral malleolus
Medial aspect of ankle
Medial malleolus
Occiput 8 12
Posterior knee 9 11 13
Ribs
Sacrum/Coccyx
Shoulder
Shoulder blade
19
1. _____________________
2. _____________________
3. _____________________
14 20
4. _____________________
5. _____________________
6. _____________________
7. _____________________
8. _____________________
9. _____________________ 15
10. _____________________
11. _____________________
12. _____________________
13. _____________________
14. _____________________ Answer key to
16 quiz on page 123
15. _____________________
16. _____________________
17. _____________________
18. _____________________
19. _____________________ 17 18
20. _____________________

Aligning practice with policy to improve patient care 121

 “Just
what
I was “
looking
for.

NEW CE Courses
for Surgical Techs!
Medline University continues to build its curriculum with
another group of NEW Surgical Tech courses, available at
www.medlineuniversity.com

Visit today to earn free CE credits with the following courses:

• The Different Types of Wounds
• Debridement
• Using DIMES to Your Advantage
• Infection Prevention
• Wound and Skin Care Education
• Hand Hygiene Improvement Strategies

Access courses on your computer, iPhone or iPad.

Follow us
Be the first to know when we
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. add new courses and content.
* Courses are approved for continuing education credit by the
Association of Surgical Technologists.
Pressure point answers
From page 121

1. Lateral malleolus
2. Lateral aspect of foot
3. Lateral aspect of knee
4. Greater trochanter
5. Ribs
6. Shoulder
7. Ear
8. Occiput
PERIOPERATIVE PRESSURE
9. Ear
ULCER EDUCATION.
10. Elbow
11. Dorsal thoracic area
MORE IMPORTANT
THAN EVER BEFORE
12. Sacrum/Coccyx
13. Heel
14. Shoulder blade
15. Sacrum/Coccyx
16. Ischial tuberosity
17. Posterior knee
18. Foot
“ I have seen an increase in
the number of legal issues
linking facility-acquired pressure
ulcers to post-surgical patients.
A pressure ulcer program for the
OR is more critical than ever.”
Diane Krasner, PhD, RN, CWCN,
19. Medial malleolus CWS, BCLNC, FAAN
20. Lateral malleolus
Medline’s Pressure Ulcer Prevention Program now has a
component designed specifically for the perioperative services.
The easy-to-use interactive CD addresses the following:
• Hospital-acquired conditions
• CMS reimbursement changes
• Best practices for pressure ulcer prevention
• Perioperative assessment tools
• Critical patient and equipment risk factors

To learn more about Medline’s Pressure

Ulcer Prevention Programs for long-term
care, acute care and perioperative
services, call your Medline representative
or visit www.medline.com/pupp-webinar.

©2011 Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc.

Aligning practice with policy to improve patient care 123

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