OR Connection Magazine - Volume 4; Issue 2
Transcript of OR Connection Magazine - Volume 4; Issue 2
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8/9/2019 OR Connection Magazine - Volume 4; Issue 2
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TheAligning practice with policy to improve patient care
Volume 4, Issue 2
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OR ConnectionThe
Aligning practice with policy to improve patient care
Subscribing to The OR Connectionguarantees that
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articles addressing on-the-job issues and tips oncaring for yourself!
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Content KeyWe've coded the articles and information in this magazine to indicate which patient
care initiatives they pertain to. Throughout the publication, when you see these
icons you'll know immediately that the subject matter on that page relates to one
or more of the following national initiatives:
IHI's Improvement Map
Joint Commission 2009 National Patient Safety Goals
Surgical Care Improvement Project (SCIP)
We've tried to include content that clarifies the initiatives or gives you ideas and
tools for implementing their recommendations. For a summary of each of the
initiatives, see pages 6 and 7.
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Aligning practice with policy to improve patient care
PATIENT SAFETY
6 Three Important National Initiatives for Improving Patient Care
20 Patient Safety Initiatives Across the United States
30 CAUTI Prevention: How Do You Rate?31 Back to Basics: Tell Me Again Why This Patient Needs
a Catheter?
51 Clean Up Your Act!
OR ISSUES
8 Breaking News
22 The Silent Treatment
42 Playing Traffic Control in the OR
SPECIAL FEATURES
10 Comparative Effectiveness Research
12 Prevention Above All Conference
13 Celebrating Nurses Accomplishments
14 OR Nurses Set Sail for Surgery
40 A Cost-Effective Alternative to Urinary Catheterization
46 Legal Issues in the Care of Pressure Ulcer Patients
CARING FOR YOURSELF
56 How to Communicate Effectively
65 Breast Cancer Awareness68 Recipe: 24-Hour Dill Pickles
FORMS & TOOLS
71 SCIP Prophylactic Antibiotic Regimen Selection for Surgery
73 VTE Prophylaxis Options for Surgery
75 What You Need to Know About Infections AfterSurgery: English
77 What You Need to Know About Infections AfterSurgery: Spanish
79 How to Handrub?81 CATS Decrease Surgical Site Infections: English82 CATS Decrease Surgical Site Infections: Spanish
Editor
Sue MacInnes, RD, LD
Clinical Editor
Alecia Cooper, RN, BS, MBA, CNOR
Senior Writer
Carla Esser Lake
Art Director
Mike Gotti
Clinical Team
Jayne Barkman, RN, BSN, CNOR
Rhonda J. Frick, RN, CNOR
Anita Gill, RN
Megan Shramm, RN, CNOR, RNFA
Kimberly Haines, RN, Certified OR Nurse
Jeanne Jones, RNFA, LNC
Carla Nitz, RN, BSNConnie Sackett, RN, Nurse Consultant
Claudia Sanders, RN, CFA
Angel Trichak, RN, BSN, CNOR
Perioperative Advisory Board
Larry Creech, RN, MBA, CDT
Carilion Clinic, Virginia
Sharon Danielewicz, RN, MSN, BSN, RNFA
St. Lukes The Woodlands, Texas
Barb Fahey RN, CNOR
Cleveland Clinic, Ohio
Susan Garrett, RN
Hughston Hospital Inc., Georgia
Zaida I. Jacoby, RN., M.A., M.EdNYU Medical Center, New York
Jackie Kraft, RN, CNOR
Huntsville Hospital, Alabama
Audrey Kuntz, EdD, MSN, RN
Vanderbilt University Medical Center, Tennessee
Tom McLaren, RN, BSN, MBA, CNOR
Florida Hospital
Donna A. Pritchard, RN, BSN, MA, CNOR, NE-BC
Kingsbrook Jewish Medical Center, New York
Debbie Reeves, RN, CNOR, MS
Hutcheson Medical Center, Georgia
Diane M. Strout, RN, BSN, CNOR
Chesapeake Regional Medical Center, Virginia
Margery Woll, RN, MSN, CNOR
North Shore University Health System, Illinois
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 dedi-
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Meeting the highest level of national and international quality standards, Medline is
FDA QSR compliant and ISO 13485 registered. Medline serves on major industry
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cluding the FDA Midwest Steering Committee, AAMI Sterilization and Packaging
Committee and various ASTM committees. For more information on Medline, visit
our Web site, www.medline.com.
Page 14
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2009 Medline Industries, Inc. The OR Connectionis published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
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Dear Reader,
As the summer of 2009 comes to a close, my
youngest child, Molly will be going to college. She is
the youngest of three so, my husband and I are now
officially empty nesters. I dont usually discuss mywork at home. By the time I get home, work is the last
thing I want to rehash, but Molly has had it in her head
for quite a while now that she wants to be a surgeon.
I havent said much to discourage or encourage her,
but earlier in the summer, I thought to myself, does
she have any idea what that means? And so, in typical
motherly fashion, I asked her if she wanted to watch
an actual surgery. My thinking was, if she is going to
commit the time and money into becoming a surgeon,
shed better make sure that is what she wants to do.
I dont know many eighteen-year-olds who are more
psyched about scrubbing in on a surgery than goingto Six Flags but Molly is one. I had promised to look
into it; the summer was flying by and every day Molly
would ask me if I had made any arrangements. I really
didnt think she would hold me to this. I was wrong.
My first dilemma was finding a mentor, someone who
would embrace the curiosity and naivet of youth and
allow Molly to watch a surgery. I contacted Margery
Woll, Director of Perioperative Services at North Shore
University Health System in Skokie, Ill., to ask her
advice and to see if this was even possible. Margery
embraced the project and invited Molly to her OR.
And that was that. All I really knew before the event
was that Molly had to get up much earlier than usual.
She had gotten directions to the hospital and was told
who to report to. I didnt hear anything until she was
on her way home.
That afternoon I received a call at the office. Molly said
it was the greatest day of her life! She spoke so fast
and so full of excitement I couldnt understand every-
thing she was saying. She said that surgery was a
marriage between art and science, and she felt she
could be good at both, so that is why this was meant
for her. She said the doctors told her she had great
hands. Celia (Celia Arrogante, RN, BSN, Clinical Nurse
Manager, Perioperative Services) and the nurses
treated her like she was one of them. She said it was
so cool because the surgeons were listening to music
from their iPods. She stood 18 inches from the
surgery. Her favorite part was the first cut. She saw 3
different surgeries starting with a breast biopsy, and
then proceeded to a total knee. She said that the total
knee was messy, but really cool. And, finally she saw
a total hip. The surgery team was so nice to her, they
told her what was going on and the chief of surgery
told her she could shadow him any time. Molly said,
Mom how many kids my age get a chance to actu-
ally go into surgery? I was right there. And, I was
invited back to see a heart.
Later Margery e-mailed me about the day. She said,
Dr. Velasco (Juan Velasco, MD, Vice Chairman of
Surgery) was so impressed with Mollys interest and
discipline in watching the cases. She continued, It
was a good day for Dr. Raab (David Raab, MD,
Orthopedic Surgeon), he taught both of us. He was so
honored
So, at a time that is so critical in health care, with
healthcare reform, patient safety initiatives at the fore-
front of every hospitals agenda and new guidelinesand evidence directing our actions, I have to stop and
say you make a difference. I got to experience
vicariously the love you have for what you do, the pas-
sion and teamwork you express at every opportunity.
Thank you. Youve just recruited another potential
surgeon who is telling all of her friends that they
simply have to work in the OR (and this kid has a lot
of friends).
Heres to you!
Sue MacInnes, RD, LD
Editor
4 The OR Connection
THE OR CONNECTION I Letter from the Editor
I got to experience
vicariously the love
you have for what you
do, the passion and
teamwork you expressat every opportunity.
Thank you.
(Left to right): Scott Pittman, MD, Anesthesiologist; Margery Woll,
RN, MSN, CNOR, Director of Perioperative Services and Molly
MacInnes at North Shore University Health System in Skokie, Ill.
Before observing three surgeries at the hospital, Molly said she
hadnt realized what a major role nurses play in the OR. The nurses
do so much. Nothing would happen without them, she said.
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6 The OR Connection
Three Important National Initiativesfor Improving Patient Care
Achieving better outcomes starts with an understanding of currentpatient-care initiatives. Heres what you need to know about national
projects and policies that are driving changes in care.
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 will cover the entire landscape of outstanding hospital care, keeping the 12 changes from
the 100,000 Lives and 5 Million Lives Campaigns and expanding the agenda with three new interventions.
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 2010; however, revisions to the NPSGs will be effective in 2010.
Crucial to understanding the 2009 NPSGs is a new method of numbering the goals, for which the Joint Commission has
created a crosswalk available at www.jointcommission.org.
Origin: Initiated in 2003 as a national partnership. Steering committee includes the followingorganizations: 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.
IHI Improvement Map1
Joint Commission 2009 National Patient Safety Goals2
Surgical Care Improvement Project (SCIP)3
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IHI Improvement Map: 12 Existing Interventions + Three New Ones
Surgical Care Improvement Project (SCIP): Target Areas
Joint Commission 2009 National Patient Safety Goals
Aligning practice with policy to improve patient care
Patient Safety
By the numbers:
3,740 hospitals are submitting
data on SCIP measures, representing
75 percent of all U.S. hospitals
Currently, SCIP has more than 36
association and business partners
There are six new requirements for 2009:
Elimination of transfusion errors that are related
to misidentification of patients
Prevention of healthcare-associated infections
resulting from multiple drug-resistant organisms
(MDRO) using evidence-based practices
(one-year phase-in period applies)
Prevention of central line-associated bloodstream
infections using evidence-based practices (one-year
phase-in period applies) Prevention of surgical site infections using best
practices (one-year phase-in period applies)
When a patient leaves a facility, the patient and his
or her family receives a complete list of the patients
medications with an explanation of that list
In settings in which medications are prescribed
minimally or for a short time, modified medication
reconciliation processes are carried out
In addition to the new requirements, some of the NPSGs
already in place have been modified. Extensive changesalso have been made to the Universal Protocol (UP).
To learn more about the 2009 National Patient Safety Goals, go to www.jointcommission.org.
The Improvement Map is chartered with the following 15 interventions, and IHI will continue to add interventions
over time, clustering them by care setting and content area, and will help hospitals identify where they should
focus to maximize impact.
To learn more, turn to Page 8!
1. Surgical-site infections Antibiotics, blood sugar control, hair removal, normothermia
2. Perioperative cardiac events Use of perioperative beta-blockers
3. Venous thromboembolism Use of appropriate prophylaxis
SCIP is targeting two new measures for October 2009:
Removal of urinary catheters within 48 hours post surgery
A new, updated normothermia measureVisit www.qualitynet.org
1. Prevent pressure ulcers
2. Reduce methicillin-resistant staphylococcus aureus
(MRSA) infection
3. Prevent harm from high-alert medications
4. Reduce surgical complications
5. Deliver evidence-based care for congestive heart failure
6. Get boards on board
7. Deploy rapid response teams
8. Prevent adverse drug events (ADEs)
9. Deliver evidence-based care for acute myocardial infarction
10. Prevent surgical-site infections
11. Prevent central-line infections
12. Prevent ventilator-associated pneumonia
13. WHO Surgical Safety Checklist
14. Prevent catheter-associated urinary tract infections (CAUTI)
15. Link quality and financial management engage the chief
financial officer and provide value for patients
To learn more, visit www.ihi.org
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8 The OR Connection
SCIP Adds Two New Measures
Effective October 1
Urinary catheter removal, normothermia
As part of its Surgical Care Improvement Project (SCIP), theCenters for Medicare & Medicaid Services (CMS) will begin
requiring hospitals to report quality data on two new meas-
ures effective October 1, 2009. The measures relate to
removal of urinary catheters and the documentation and reg-
ulation of patient body temperature.
SCIP Measure 9: Removal of urinary catheters
This new measure states that urinary catheters are to be
removed during the first or second day after surgery. The risk
of urinary tract infection and bacteremia increase when a
catheter remains in place for more than two days. Although
this measure pertains primarily to inpatient cases, surgerydepartments will need to establish protocols for a physician
order and a method of documenting catheter removals.
SCIP Measure 10: Normothermia requirements
This new measure requires the recording and reporting of
patient temperatures, documenting whether temperatures
dropped below 96.8 degrees F from 30 minutes before surgery
to 15 minutes after anesthesia ends. It also must be noted
whether forced-air or warmed-water patient warming devices
or garments were used. The measure applies to procedures
that last 60 minutes or longer, and employ general anesthesia
or neuroaxial blocks.
For more details on all of the SCIP measures,
visit www.qualitynet.org.
AORN Revises Hand Hygiene
Recommendations to Include
Use of Surgical Scrub Agent
Revised terminology in Recommended Practices for Hand
Hygiene in the Perioperative Setting, which was recently pub-lished by the Association of periOperative Registered Nurses
(AORN), advises use of a surgical hand scrub before donning
gloves for a surgical procedure. AORN recommends using an
antimicrobial or alcohol-based surgical hand rub product.
The following terminology was submitted
and approved by AORNs board of directors
on July 17, 2009:
A surgical hand scrub should be performed by health care
personnel before donning sterile gloves for surgical or other
invasive procedures. Use of either an antimicrobial surgical
scrub agent intended for surgical hand antisepsis or analcohol-based antiseptic surgical hand rub with documented per-
sistent and cumulative activity that has met US Food and Drug
(FDA) regulatory requirements for surgical hand antisepsis is
acceptable.
These changes will be made to the Recommended Practices
for Hand Hygiene in the Perioperative Setting, which is cur-
rently available electronically. AORNs electronic recom-
mended practices are available through AORNs new
eSubscription (www.aorn.org/eSubscription) and through
a pay-per-document platform (www.aorn.org/PracticeRe-
sourcees/AORNStandardsandRecommendedPractices/EDocuments/).
Reference
AORN board revises hand hygiene recommended practice. News Release. July
22, 2009. Available at http://www.aorn.org/docs/assets/A36FA8F4-046B-197F-
81B585C4FB6DF06E/HandHygieneAnnct.pdf. Accessed July 29, 2009.
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Sterillium Rubs high alcohol content delivers a
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Sterillium Rubs balanced emollient blend leaves hands feeling soft and smooth,
never greasy or sticky, and makes gloving a breeze. But that doesnt mean that
Sterillium Rub makes any sacrifices in efficacy. In fact, it meets FDA requirements
for efficacy specifications. Its also CHG, latex and non-latex glove compatible.
We know that comfort drives compliance. When you choose Sterillium Rub,
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www.medline.com2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
For more information on Sterillium Rub, contact your Medline sales
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10 The OR Connection
Patient-centered researchTherefore, the healthcare research conducted under this
initiative will be patient-centered and apply to the real
world in order to help patients, clinicians and other deci-
sion makers assess the relative benefits and harms ofstrategies to prevent, diagnose, treat, manage or monitor
health conditions.1
In addition, the research should consider and include a
variety of patient populations (e.g., people with disabilities
and chronic illnesses, and different racial and ethnic back-
grounds) for the program to be effective.2
Federal Coordinating Council for ComparativeEffectiveness Research
The first step in the comparative effectiveness initiative wasto appoint a management council in March 2009. The Federal
Coordinating Council for Comparative Effectiveness
Research (the Council) is composed of 15 distinguished
leaders from key government healthcare-related agencies,
including the Veterans Health Administration (VHA), Centers
for Disease Control and Prevention (CDC), Centers for
Medicare & Medicaid Services (CMS) and the HHS, among
others.2 The Councils purpose is to coordinate compara-
tive effectiveness research and related health services
research across the federal government with the intent of
reducing duplication and encouraging the complementary
use of resources.1
The Council will oversee the $1.1 billion in funding, of which
$300 million is allocated to the Agency for Healthcare
Research and Quality (AHRQ), $400 million to the National
Institutes of Health (NIH) and $400 million to the Office of
the Secretary.1
Goals of Comparative Effectiveness Research
Reduce healthcare costs2
Build public interest2
Improve patient care2
Encourage development and use of clinical registries
and data networks1
Increase consistency of treatment provided in different
geographic regions1
Greater ability to tailor interventions to treat patients
specific needs1
Care based on evidence and best practices1
Legislators in the Senate and House have been busy
this year preparing and debating their versions of a
healthcare reform bill. Perhaps one of the bills, or a
hybrid, will be passed by the end of 2009. In the interim,
the launch of a new federally funded healthcare program on
comparative effectiveness research is well underway.
The American Recovery and Reinvestment Act of 2009allocated $1.1 billion to the U.S. Department of Health and
Human Services (HHS) for this initiative. What is compara-
tive effectiveness? The Institute of Medicine (IOM) defines it
as the extent to which a specific intervention, procedure,
regimen or service does what it is intended to do under real
world circumstances.1As HHS describes it, comparative
effectiveness research provides information on the relative
strengths and weaknesses of various medical interventions,
including drugs, devices and procedures.2
Comparative Effectiveness Research:
What It Is and How
It Can Help You andYour Patients
Whats Happening in Healthcare Reform
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Aligning prac tice with po licy to imp rove pa tie nt ca re 1
High-Priority Topics for Federally FundedComparative Effectiveness Research3
The American Recovery and Reinvestment Act of 2009
called on the Institute of Medicine to recommend a list of
priority topics to be the initial focus of a new nationalinvestment in comparative effectiveness research.
The complete list contains 100 topics, prioritized into four
groups of 25 each. The following is a sampling of topics that
relate to surgical professionals. They are listed in order from
highest to lowest priority, as indicated by the Institute of
Medicine:
Compare the effectiveness oftreatment strategies for
atrial fibrillation, including surgery, catheter ablation
and pharmacologic treatment.
Compare the effectiveness of various screening,
prophylaxis, and treatment interventions in eradicating
methicillin-resistant Staphylococcus aureus
(MRSA) in communities, institutions and hospitals.
Compare the effectiveness ofstrategies (e.g.,
bio-patches, reducing central line entry, chlorhexidine
for all line entries, antibiotic-impregnated catheters,
treating all line entries via a sterile field) for reducing
healthcare-associated infections (HAI), including
catheter-associated bloodstream infection, ventilator-associated pneumonia and surgical site infections in
adults and children.
Compare the effectiveness ofrobotic assistance
surgeryand conventional surgery for common
operations, such as prostatectomies.
References
1. U.S. Department of Health and Human Services. Federal Coordinating Council
for Comparative Effectiveness Research: Report to the President and Congress,June 30, 2009. Available at http://www.hhs.gov/recovery/programs/cer/cerannu-
alrpt.pdf. Accessed August 3, 2009.
2. Zigmond, J. Healthy choices: industry wonders how $1.1 billion for comparative-
effectiveness research will be applied. Modern Healthcare. March 30, 2009:
6-7,16.
3. Institute of Medicine. 100 Initial Priority Topics for Comparative Effectiveness
Research. Available at http://www.iom.edu/?id=71032. Accessed August 3, 2009.
Brian Lee Morrison earned his registered nurse degree in
May 2009 from St. Petersburg College School of Nursingin St. Petersburg, Fla. He (and Medline nurse doll Alice)
graduated with honors. Brian is continuing at St. Peters-
burg College to complete a bachelors degree in nursing.
He currently works in the OR at St. Josephs Hospital in
Tampa. Before earning his RN, he had been a surgical
technologist and certified first assistant.
Graduation Day for Two!
Easier navigation to find
what you need faster.
Visit the redesignedwww
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what you think!
www.medline.com
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All continuing education
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12 The OR Connection
Prevention Above All Conference,Washington, DC, August 16-18, 2009
Chief nursing officers, chief medical officers, directors of nursing
and other clinical executives from hospitals across the country
gathered in Washington, DC, August 16-18, 2009, for Medlines
popular Prevention Above All Conference. They learned new
strategies for delivering cost-effective, high-quality health care
and evidence-based solutions for improving patient care.
An impressive agenda
Tying in all that is top-of-mind on Capitol Hill these days, former
senator Tom Daschle opened the conference by discussing hisbook on healthcare reform and the delivery of cost-effective
health care. Following Daschle was Institute of Medicine President
Dr. Harvey Fineberg, who addressed the impact of comparative
effectiveness research on delivering cost-effective, evidence-
based health care. (See article on page 10 to learn more about
comparative effectiveness research.)
Emphasis on patient safety
As always, patient safety was a major focus, and world
renowned experts shared the latest innovations and evidence-
based practices in the prevention of catheter-associated urinary
tract infections (CAUTI), hand hygiene and pressure ulcerprevention.
CAUTI. Medline introduced its new evidence-based system
to help prevent CAUTI. The ERASE CAUTI program combines
innovative design, education and awareness to tackle catheter-
associated urinary tract infection the number one hospital-
acquired infection.
Hand hygiene. Internationally renowned professor and
epidemiologist Didier Pittet, of Switzerland, shared the latest
hand hygiene improvement strategies. Dr. Pittet is lead of the
World Health Organization (WHO) World Alliance for Patient
Safety and a member of the advisory board for the WHOsFirst Global Patient Safety Challenge, Clean Care Is Safe Care.
In addition, German epidemiologist Gunter Kampf presented
new discoveries and considerations in hand sanitizing tech-
niques. He is the author of 119 scientific papers published
in national and international infection control journals.
Pressure ulcers. Wound care expert Elizabeth Ayello provided
insight on CMS present on admission (POA) indicators as they
relate to hospital administrators and clinicians.
PREVENTIONABOVE ALL
TARTGETED INTERVENTIONS PRACTICAL SOLUTIONS
Also, two experts in wound care and healthcare law, who arealso members of the International Expert Wound Care Advisory
Panel, addressed the legal implications of caring for patients with
pressure ulcers, sharing ways healthcare professionals can pro-
tect themselves from litigation. Turn to page 46 for excerpts from
their new white paper, Legal Issues in the Care of Pressure
Ulcer Patients: Key Concepts for Healthcare Providers.
SCIP. The Surgical Care Improvement Project continues to
evolve, with two new measures coming in October. Highly
regarded quality improvement specialist Dale Bratzler, DO, MPH,
medical director of SCIP, discussed patient safety in the context
of SCIP and expanded on new and revised SCIP measures.
Prevention Above All Discoveries Grant recipients
Dr. Andrew Kramer announced the names of Prevention Above
All (PAA) Discoveries Grant award winners. Dr. Kramer, professor
of medicine at the University of Colorado, served as chair of the
PAA Discoveries Grant Review Committee. The committee also
included Dale Bratzler, DO, MPH, medical director of SCIP; Diane
Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN, wound & skin
care consultant; Michael Raymond, MD, chief medical officer,
North Shore University Health System and Heidi Wald, MD,
MPH, professor of medicine, University of Colorado. All grant
applications and proposals were independently reviewed and
approved by this committee. Watch for more information on therecipients and their research topics in upcoming issues of The
OR Connection.
Unable to attend the Prevention Above All Conference?
Visit medline.com for highlights from the meeting, including video
clips from the presentations.
Critical: What We Can Do About the
Health-Care Crisis, authored by for-
mer senator Tom Daschle, outlines the
healthcare reform strategies that are
the foundation of President Obamas
healthcare initiative. Evaluating where
p re v io u s a t te mp ts a t n a tional
healthcare coverage have succeeded,
and where they have gone wrong,
Daschle explains the complex social,
economic and medical issues involved in reform and sets
forth his vision for change. The book is available for purchase
at leading retail bookstores and online outlets.
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Aligning practice with policy to improve patient care 1
OSF St. Joseph Medical Center
Achieves Magnet Recognition
OSF St. Joseph Medical Center in Bloomington, Ill.,
recently achieved Magnet Recognition for excellence in
nursing services by the American Nurses Credentialing
Center (ANCC).
The Magnet Recognition Program recognizes healthcare
organizations that demonstrate excellence in nursing prac-
tice and adherence to national standards for the organi-
zation and delivery of nursing services. The ANCCs
Commission on Magnet made a unanimous decision to
make OSF St. Joseph Medical Center a Magnet hospital.
Magnet applicants undergo a rigorous evaluation process,
including written documentation of 14 specific areas of
nursing practice called Forces of Magnetism. Hospitals
also participate in extensive interviews and an on-site
review of nursing services. OSF St. Joseph began work-
ing toward Magnet Recognition in 2004.
A magnet steering committee
was formed to create a docu-
ment proving that OSF St.
Joseph Medical Center met or
exceeded the 164 standards
that are part of the Forces of
Magnetism.
Each committee member was responsible for finding
sources of evidence to support the standards within one
force. Committee chair Sandra Scheidenhelm encouraged
all members to stay on task until the final documentation
was turned in all 15 volumes of it!
The committees hard work and dedication paid off.
OSF St. Joseph was awarded Magnet Recognition in
December 2008.
The OR ConnectionCelebrates
Nurses Accomplishments
OSF St. Joseph Medical Center CEO Ken Natzke presents
the ANCC Magnet Recognition obelisk to Chief Nursing
Officer Deb Smith.
OSF St. Joseph Medical Center Magnet Steering Committee.
Back row (left to right): Marcia Laesch, Dixie Reynolds,
Sue Herriott, Pat ODell, Barb Stevig. Front row (left to right):
Mark Dabbs, Deb Smith, Sandi Scheidenhelm, Phyllis McNeil.
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14 The OR Connection
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OR NURSES SET SAILFOR SURGERY ONBOARD
MERCYSHIPS
Aligning practice with policy to improve patient care 1
Excellent nursing care for the underprivileged
Mercy Ships is a global charity
that has operated hospital ships
in developing nations since
1978. Mercy Ships brings hope
and healing to the forgotten poor
by mobilizing people and re-
sources worldwide and serving allpeople without regard for race,
gender or religion. Recently, a
partnership was formed between
AORN and Mercy Ships with the goal of increasing
awareness of the opportunities available to operating
room nurses wanting to serve the suffering poor.
The Africa Mercy is the worlds largest non-governmental
hospital ship. An entire deck functions as a complete
hospital with five wards, an intensive care unit, medical
lab, CT scanner and six operating rooms. There are 450crew members, and 130 are healthcare staff. Each year,
Mercy Ships welcomes more than 1,200 long-term
volunteers from over 40 nations and 2,000 short-term
volunteers.
Onboard the Africa Mercy, 12 surgeries, on average, are
completed each day, including maxillofacial, plastics,
general, orthopaedic, and vesicovaginal fistula (VVF). An
additional average of 30 cataract
removals and other eye-related
surgeries also take place daily. Tu-
mors are removed, burn contrac-
tures are released, limbs are
straightened, deformities are cor-
rected, sight is restored and,above all, dignity and hope are
given to thousands of previously
suffering individuals.
The work of highly skilled surgeons from around the
world allows for such tremendous healing to take place.
However, without the help of the operating room (OR)
nursing staff, none of it would be possible.
There are currently 15 OR nurses serving onboard the
Africa Mercy. Some have been onboard for more thantwo years (long-term); others will serve short-term for two
weeks or more. Both long-term and short-term commit-
ments are important and greatly appreciated. The dura-
tion of commitment may vary, but the standard of work
and care provided by all of the nurses is impeccable.
OR nurses from all walks of life serve with Mercy Ships
even those with families of their own. Before Jenny Rol-
Special Feature
by Mila Hightower
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land, along with her husband and three children, joined Mercy Ships,
she worked as an OR nurse in the United States for 14 years, spe-
cializing in otolaryngology, ophthalmolics and plastics. She now
works as the assistant OR supervisor onboard the Africa Mercy. She
manages the daily surgery schedule, acts as a liaison between the
wards and the ORs, and provides orientation and assistance for new
nurses.
Apart from the factthat it is located on a ship, the
Africa Mercys OR is almost identical to the OR of a
regular hospital.
Remarkably, this hospital is very similar, Rolland said. Its encour-
aging to have short-term nurses who know how an OR functions,
and all they really need to know is where the supplies are kept. Then
they can do what they know how to do. Thats the beauty of it.
Every weekday morning, the OR staff meets at 7:30 a.m. for devo-
tions and a time of prayer. This is followed by a short briefing on the
days schedule. Thereafter, surgeries begin. Though it changes every
day, the OR usually doesnt end surgeries until around 6:00 p.m.
During nights and weekends, the OR is closed, although a weekly
team of three is on call in case of an emergency.
16 The OR Connection
MERCYSHIPS
Melissa Brown of the USA is
currently serving with Mercy
Ships as an OR nurse for 3
months. An AORN member,Brown has found the
management and efficiency
of the Africa Mercys onboard
hospital similar to that of a First
World hospital.
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Of course, running a First World facility in a Third World
environment has its challenges. As a not-for-profit organi-
zation, Mercy Ships resources are sometimes limited.
Surgical instruments and equipment have to be used more
than once. Effective methods of sterilization and a subse-
quently low infection rate make this feasible.
With an international staff represented by more than six
countries, language and communication can be problem-
atic. Theres a language that one has to get used to when
there are four different names for one instrument, Rolland
said. Thankfully the OR is sort of a universal environment.
A broad spectrum of nationalities and cultures also has its
benefits. Rolland explained, I think being able to work with
an international staff is very enlightening because there are
ways that people from different parts of the world do
things. Its nice to have that added to what we do.
Sometimes there might be a way that is more efficient.
Melissa Brown recently joined Mercy Ships as a short-term
OR nurse. My experience so far has been great! My first day
in the OR everyone was very welcoming, and they helped
me fit right in by explaining the procedures, she said.
Brown is a registered nurse and a member of AORN with
CNOR and first assistant certifications. She worked as a
travel nurse in the United States before joining the Africa
Mercy as an OR nurse for three months during the summer.
I have never been able to combine missions with my OR
nursing career, she said. Here with Mercy Ships is my first
opportunity to be able to do that, and that is very special to
me, Brown said.
Although the Africa Mercy is currently stationed in the West
African nation of Benin, the onboard hospital continues
to operate effectively. Its staff finds the conditions famil-
iar and comfortable.
Aligning practice with policy to improve patient care 1
Continued on Page 19
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2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Medlines Gold Standard Safety Program is designed
to break down barriers to surgical safety complianceby offering easy-to-use tools to help you reach your
safety goals.
The program offers four levels of safety options:
1. The Gold Standard Safety Bundle: Includes six
products to serve as visual safety reminders to reduce
needle sticks and wrong site surgery.
2. Innovative safety products: Surgical Time Out
Procedure (S.T.O.P.) Flag and Drape remind OR
staff to take time to verify key information before
the first incision.
3. AORN Checklist: Wrong site, wrong procedure,
wrong patient surgery prevention.4. Med-Pack: Electronic pack audit and a review
of safety components.
To learn more about the Gold Standard Safety
Program, contact your Medline sales representative,
call us at 1-800-MEDLINE or visit www.medline.com.
www.medline.com
Weresetting
a newstandardin patient
safety.
G O L D S T A N D A R D S A F E T Y P R O G R A M
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Aligning practice with policy to improve patient care 1
I worked a day shift at home so the hours here are very
similar, explained Brown. As far as how the OR is run and
the management and efficiency of things, I think its very
similar to a First World OR.
Although she is currently assisting with eye surgeries,
Brown will get the opportunity to work in all the surgical
specialties performed onboard the Mercy Ship.
Alison Green is a long-term volunteer who joined Mercy
Ships shortly after completing four years of nursing school
in Tyler, Texas. Although she has only been onboard theAfrica Mercy for a few months, she has already gained a
wealth of experience that will undoubtedly further her pro-
fessional career as an OR nurse.
Its great to see what I was a part of and
how Ive made a difference in their lives.
Ive found that Ive learned more here in five months than
I did in three years back home, Green said. Many of the
procedures and surgeries we do here are not normally done
back home because the cases are so unique. I have
learned so much as a scrub nurse. I get to be more
involved in assisting the surgeons, whereas back home I
had to do more paperwork.
Because Green has made a long-term commitment to
Mercy Ships, she is being trained in all the specialties. She
is currently undergoing six weeks of VVF scrub nurse train-
ing and has already completed training in ophthalmolics,
general and maxillofacial surgery.
In the United States I found surgeries were all about time
and getting things done, but here the surgeons are willing
to teach you more so that you are able to take better care
of the patients. They are humble and willing, she explained.
Green finds that a notable and positive difference is the
opportunity to spend more time with patients. I think that
here we get more connected with our patients. We have an
opportunity to pray with them, get to meet them face-to-face before surgery, see them afterwards in the ward and
watch how they heal, she explained. Its great to see what
I was a part of and how Ive made a difference in their lives.
Life here is very fast-paced and very busy, but at the same
time, its rewarding and life-changing. This work really
reminds me about why I became an OR nurse. I can see
the hope and healing brought to the patient firsthand. I think
if nurses are rundown and have forgotten why they are
doing what they are doing, they will be inspired if they come
here, Green said.
If you would like to be a part of bringing hope and healing
to the worlds poor, please visit www.mercyships.org or
contact the Mercy Ships human resources department at
(903) 939-7045. Mercy Ships headquarters is located in
Lindale, Texas.
MERCYSHIPS
Jenny Rolland of the USA lives onboard the Africa Mercy with
her husband and three children. With 14 years of experience,
she now works as the Assistant OR Supervisor for Mercy Ships.
Taking time for a little fun.
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20 The OR Connection
Rhode Island adopts protocol to
prevent wrong site surgery
Program implemented July 1, 2009
All 12 hospitals and 21 surgical centers in
Rhode Island have agreed to adopt a sur-
gical safety protocol designed to reduce
the risk of wrong site surgeries. According to the Hospital Associ-
ation of Rhode Island, the state is the first in the nation to have all
surgical providers voluntarily adopt the same safety protocol.1
The term wrong site surgery applies if the wrong procedure is per-formed or if a procedure is performed on the wrong person or the
wrong body part.
Rhode Islands protocol was developed over a period of 18 months
by state hospital and healthcare leaders in cooperation with the
Joint Commission.2 It is similar to surgical safety checklists created
by the World Health Organization and The Joint Commission.
With an emphasis on clear communication among surgeons, staff
and patients, the protocol is designed to prevent errors but also to
avoid the confusion that sometimes occurs when practitioners split
their time between facilities with different policies.
They have steps built into their protocol that allow all team mem-
bers to be accountable and responsible for speaking up if they
believe that something doesnt look right, said Mark Crafton,
the Joint Commissions executive director for state and external
relations.1
Four key features of the protocol include:2
Three-way pre-op consult. The surgeon, one other licensed
practitioner (such as a registered nurse) and the patient or patients
guardian all confirm the surgical site together before it is marked
with the surgeons initials.
OR team briefing.All team members introduce themselves and
their roles. The surgeon then briefs the team, identifying the patient,
procedure and site, and explaining plans for the surgery, including
any medications, documentation and equipment needed.
Time out. Led by the surgeon, all team members verify the
patient, procedure and site and confirm that the site marking is
visible after prepping and draping.
Post-op de-briefing.The surgeon leads a discussion of the post-operative plan of care and a review of how the surgery went and
what could have been done differently.
William Cioffi, MD, surgeon-in-chief at Rhode Island Hospital, said
that safety efforts must walk a fine line, requiring accountability with-
out overemphasizing blame; each member of the surgical team has
responsibilities to meet but also must feel free to acknowledge and
report errors.1
Cioffi added that the hospitals will train staff through lectures and a
video and also will devise ways to make sure the protocol is prop-
erly and uniformly adopted around the state. This is a great first
step. Its not the end of the process.1
Providers began implementing the protocol July 1, but it could be
as long as one year before staff at all facilities have received train-
ing on the new rules.1
Earlier this year, the federal government took steps toward pre-
venting wrong site surgery. As of January 15, 2009, the Centers
for Medicare and Medicaid Services (CMS) no longer reimburse
hospitals or surgery centers for wrong site surgery.3,4,5
Patient Safety Initiatives Across the United States
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Aligning practice with policy to improve patient care 2
Near zero incidence of HAIs at
Monroe Hospital in Indiana
How do they do it?
Monroe Hospital in Bloomington, Ind. has
a near zero rate (0.06 percent) of hospital-
acquired infections among the more than
2,800 inpatients treated since the hospital opened in 2006.6 The
national average of healthcare-acquired infections in U.S. hospitals
is assumed to be five percent.7
So, how does Monroe Hospital stave off healthcare-acquired
infections? The following is a list of infection control measures used
at the hospital:6
1. Frequent handwashing with alternating products. Doctors
and staff are encouraged to wash their hands frequently particu-larly after having contact with a patient and before and after eating
or using the restroom. They are instructed to use three different
products soap and water, an alcohol-based hand foam and
an ammonia-based hand sanitizer on an alternating basis; each
one third of the time.
Hospital officials say this combination of products keeps the hands
clean, but also soft and pliable. Individuals with dry, cracked skin on
their hands tend to wash them less often.
2.A clean environment. Cleaning of all surfaces takes place
daily. Environmental services staff wipes down door handles, light
switches, patient beds, countertops and computer keyboards.
Deep cleaning, which includes cleaning behind computers and
under keyboards, occurs every Friday.
3. Isolation procedures. Patients with a history of MRSA are iso-
lated, and staff must wear gloves and protective gowns when they
come in contact with these patients. The patients remain in isola-
tion their entire hospital stay, regardless of subsequent negative
MRSA cultures.
4. Hospital-laundered scrubs.The hospital launders all doctors
and staff scrubs to make sure they are cleaned properly to remove
bacteria. No staff member enters or leaves the hospital wearingscrubs.
For further discussion on how scrubs may spread infection, turn to
page 51.
New Hampshire first state to
adopt surgical safety checklist
NH hospitals, ASCs lead the nation
in infection control
New Hampshire hospitals and ambulatory
surgery centers have voluntarily adopted
a safety checklist for surgeries and all other invasive procedures.
The protocol is based on a checklist developed by the World Health
Organization (WHO), which identifies three phases of a procedure
for which medical team members confirm appropriate tasks have
been completed. New Hampshire Gov. John Lynch applauded the
statewide collaboration, noting that reducing errors and infections
and improving quality all help in controlling the cost of health care.8
New Hampshire hospitals perform better than the national average
in each of the five Surgical Care Improvement Project (SCIP) meas-ures related to surgical care.9
Surgical Care Improvement Project (SCIP)
NH Nat. Avg.
Prophylactic Antibiotic Received Within One 96% 94%
Hour Prior To Surgery
Prophylactic Antibiotic Selection 98% 97%
Prophylactic Antibiotic Discontinued Within 94% 90%
24 Hours After Surgery
Recommended VTE Prophylaxis Ordered 94% 93%
Recommended VTE Prophylaxis Received 92% 90%
Controlled 6 am Postop Serum Glucose 91% 90%
Appropriate Hair Removal 99% 98%
References
1. Freyer FJ. R.I. hospitals agree on safety protocol for surgeries. The Providence Journal.
July 1, 2009. Available at
http://www.projo.com/health/conteent/SURGICAL_SAFETY_PROTOCOL_07-01-
09_QLETDSU_v10.3dce7cb.html. Accessed July 8, 2009.
2. Tsikitas I. R.I. adopts uniform surgery safety protocol. Outpatient Surgery Magazine.
Available at http://www.outpatientsurgery.net/news/2009/07/2.php. Accessed July 8, 2009.
3. Decision Memo for Wrong Surgery Performed on a Patient (CAG-00401N). Centers for
Medicare and Medicaid Services Web site. http://www.cms.hhs.gov/mcd/viewdecision-
memo.asp?id=223. Accessed July 8, 2009.
4. Decision Memo for Surgery on the Wrong Body Part (CAG-00402N). Centers for Medicare
and Medicaid Services Web site.
http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=222. Accessed July 8, 2009.
5. Surgery on the Wrong Patient (CAG-00403N). Centers for Medicare and Medicaid Services
Web site.
http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=221. Accessed July 8, 2009.
6. Denny D. Monroe Hospitals low infection rates draw national interest. Bloomington Herald
Times. January 19, 2009. Available at http://www.heraldtimeson-
line.com/stories/2009/01/19/news.qp-7992582.sto?1242057521. Accessed May 11, 2009.
7. Wenzel R, Edmond MB. The impact of hospital-acquired blood stream infections. Emerg Inf
Dis. 2001;7(2):174-177.
8. NH Health Care Quality Assurance Commission issues 4th annual report. News from the
Foundation for Healthy Communities. July 2009. Available at http://www.healthynh.com/
fhc/about/newsletter/FHCNewsletterJul09.pdf. Accessed July 21, 2009.
9. NH Quality Care Reports. New Hampshire Surgical Care Improvement Project (SCIP).
Available at http://nhqualitycare.org/reports.php?id=sip. Accessed July 22, 2009.
Patient Safety
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22 The OR Connection
THESILENTTREATMENT
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Aligning practice with policy to improve patient care 2
Recently, a highly accomplished orthopedic sur-geon was scheduled to work on three consecutive
cases with his OR team. The operating rooms were
state of the art within the medical centers newly con-
structed orthopedic hospital, which had not yet cele-
brated its first birthday. A system of time outs including
use of the World Health Organization (WHO) surgical
checklist had been in place at the medical center for al-
most three years now, with multiple checklists for patient
identif ication, pre-op procedures and instrumentation.
The surgeon was scrubbing in for his second case when the
charge nurse approached him from behind and quietly
said, Doctor, I have something to tell you. The instru-
ments that you used for the first case were not sterilized.
With the second patient already under anesthesia, there
was no time for the surgeon to discuss the small bomb-
shell that had just been lobbed in his direction, but his
thoughts couldnt let it go: Wheres the checklist for whenthings go wrong? he thought sarcastically to himself,
having seen system error after system error despite the
apparent adaptation of techniques used by high reliability
organizations. Sharply, he gave an order for Gentamycin
for his first patient and turned his attention, as best he
could, to his next case. He dreaded the moment when he
would have to tell his patient a man who trusted him
implicitly for a second knee replacement. But things just
got worse.
His second case was a lawyer who had a long history of
surgeries due to rheumatoid arthritis. The physician had
literally spent hours selecting the best implants for this
complicated revision, talking to vendors at great length to
ensure the compatibility of the various systems and care-
fully relaying his recommendations to the patient, who
was extremely involved after five surgeries.
by Kathleen Bartholomew, RN, RC, MN
and John J. Nance, JD
OR Issues
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24 The OR Connection
Socket, he said at the appropriate moment with hand
extended, eyes still fixated on the open wound.
Socket, he said again, irritated after nothing had landed
in his hand.
From his peripheral vision he picked up on commotion. He
turned and looked up at the circulating nurse who quietly
said, Its not here doctor. Fully focused on getting the
piece he needed STAT, the surgeon immediately got on
the phone to the vendor, trying to negotiate the use of
another implant despite his careful planning.
Shes under a spinal it will be wearing off. I cant wait
that long why isnt it here? he said loudly over the phone.
Finally, after half an hour, the vendor arrived with the implant.
Both relieved and frustrated, the surgeon closed and turned
to his third case, which was uneventful and painfully, as
silent as the second case. In fact, despite the two major
mistakes of the day, not a single person in the operatingroom had mentioned either event.
The saddest thing was that no one said a word, the sur-
geon said soberly. I work with these people all the time and
you think someone could have at least said, Im sorry that
happened, or something like that. But instead, there was
nothing but this awkward silence. More than anything, Im
still bothered by the silence.
As well he should have been.
As noted communication expert Susan Scott says, The
conversation isnt about the relationship. It is the relation-
ship.1This orthopedic surgeon is an outstanding physician,
known and respected for his skill and compassion the
only surgeon who would actually drive to a patients house.
Yet, he could not communicate his disappointment to his
team and his team refused to reach out to him; or vocalize
any concerted team effort to make sure these errors would
never happen again. Despite the very best of intentions and
the adoption of standardized checklists and procedures,
this team has a long way to go. The level of trust and feel-
ings of personal safety in the group simply arent high
enough for anyone to risk being vulnerable and actually
address a painful truth that as a team they had systemi-
cally screwed up.
Worse, violating every premise of regarding mistakes as
important messages from the underlying system, they were
willing to squander and discard the obvious opportunity to
improve their own techniques, not to mention the opportu-
nity to share what had happened (and how to fix it) with
other surgical teams. Patient safety can only be enhanced
when bad experiences are shared, probed, understood,
and procedures changed. In fact, collegial interactive teams
groups of professionals dedicated to a common goal and
willing to care about each other and trust each other
enough to honestly report and evaluate any failure never
hesitate to put a failure on the table for discussion. Andnever never does an effective collegial team care so lit-
tle for their own that they permit silence to shroud the
human pathways of interaction between them.2
Three powerful forces impede communication in health
care: time pressures, knowledge and culture. Understand-
ing their impact is the first step to creating collegial and
effective teams in which relationships go deeper than the
mask of composure. Honest and meaningful relationships
can only happen if we are free to speak our truth at all times.
Culture the undertow of health care
There is no force more powerful in an organization than cul-
ture. As all business experts counsel: Culture kills the best
of strategies. In fact, the phrase and the concept of This
is the way weve always done it! is the mindless battle cry
of culture-resisting change. Culture is never written down
or spoken but known by everyone.
Three powerful forces impede
communication in health care: time
pressures, knowledge and culture.
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Aligning practice with policy to improve patient care 2
For decades, operating room nurses were raised to be
humble; to care not only for the patient, but also for the sur-
geon. They monitored his/her moods and wondered if
he/she had gotten enough sleep. If necessary, they stroked
egos or took the blame for mistakes all for the sake of an
uneventful surgery. This is how many nurses were trained.
Instructors were often heard to say: If you want to work in
the OR, you better have thick skin. There were valid rea-
sons why a warning accompanied an invitation to work in
the OR.
Physicians were trained to lead in a hierarchical system and
taught to act and think as if their very education meant that
they were more important than any other member of the
team.3 Certainly they were, and are, more vulnerable. If the
patient died, the surgeon was faulted. And when all the
responsibility and liability is yours, then you had better have
total control over the situation.
In essence, this is the same drive for absolute physicianautonomy that according to healthcare governance expert
Jaime Orlikoff, originated about four thousand years ago
with the Code of Hammurabi, which decreed amputation of
a physicians fingers if his patient died after surgery. The
physician response, even in ancient Babylonia, was very
understandable: If I have total accountability, I demand total
autonomy in making decisions for my patients.4 In all the
millennia since, weve simply reinforced autonomy in our
medical culture. And that drive alone is frankly one of the
principal stumbling blocks in creating true collegial teams
in the OR rather than an iron-willed, all-knowing leaderand obedient followers (the old model).
Instructors were often heard to say,
If you want to work in the OR, you
better have thick skin.
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26 The OR Connection
Today, the massive profession-wide push for major improve-
ments in patient safety includes considerable pressure on
doctors to step away from the old model and shoulder theresponsibility of being an effective leader in building mean-
ingful, collegial relationships. But even the best leaders cant
lead if the members of the would-be team refuse to shoulder
their reciprocal responsibilities to be receptive and commu-
nicative and trusting. Thats what happened to the unhappy
orthopod left wondering why he got the silent treatment.
Whatever culpability he, as the surgeon, might have had for
not breaking the silence, his team also has a vital role.
The responsibility for a true team is a shared responsibility.
Start the conversation. What is the current culture of yourOR? Can you speak up at any time to ask a question or
stop the line? The culture of the operating room in the pre-
vious case was to lay low when things go wrong. No
member of the team ever acknowledged this, or said these
words out loud. As a team, they learned over the years to
hibernate until the storm passed. But until someone steps
forth and starts acting differently, nothing will change. Only
the courage to act differently over a long period of time,
even without the support of the group, can move cultural
inertia. If you can do this, you are a true leader regardless
of your position.
What is the single most important thing you can do
to impact culture on an individual level? Speak your
truth. But how?
Knowledge is power
Communication classes are noticeably absent from both
medical and nursing school curricula. Yet the number one
cause of adverse outcomes in a study of 2,400 sentinel
events by The Joint Commission was communica-
tion errors.
Communication omissions happen frequently. The operat-
ing room coordinator didnt know the bowel resection was
going to be lappy because nobody told him. The tech
didnt know that the surgeon switched systems for his
lumbar fusions because nobody told her. Likewise, the
orthopedic surgeon didnt know that his team cared, and
that they were just as upset as he was about the events of
the day, because nobody said anything. In the Silence Kills
study,5
fewer than 10 percent of physicians, registerednurses and clinical staff could directly confront their col-
leagues about their concerns. Why arent people talking?
A recent study of over 2,500 hospital nurses gives us some
answers.6 Nurses were asked to identify a conversation that
they needed to have in order to create a healthy
work environment.
When asked why they had avoided the crucial
conversation, they responded:
Fear of retribution Fear of retaliation (unfair assignment or schedule,
refusing to help, refusing a vacation)
Fear of being isolated or excluded from the group
Fear of being gossiped or talked about
Fear of being wrong
No time
Fear of upsetting the status quo; rocking the boat
Why bother? Nothing will change; its no use
The primary denominator here is fear. As long as we live in
fear, nothing will change. Healthcare workers share a pas-
sive-aggressive style of communication. They say why they
are upset to everyone in the department except the
person they are angry with. In addition, the most common
Continued on Page 28
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28 The OR Connection
way nurses deal with confrontation is avoidance. Nothing is
worth upsetting the relationship. Noting this, it is imper-
ative that leaders teach assertive communication and
confrontation skills in the workplace.
One very simple model is called the D-E-S-C Communica-
tion Model. It provides a great framework for organizing your
thoughts and feelings.7
D - Describe the behavior
E - Explain the effect of the behavior
S - State the desired outcome
C - Say what happens if the behavior continues
For example, the physician could haveapproached the team this way afterthe surgeries:
DESCRIBE - I want to talk to all of you about the silence in
the operating room today. No one said a word all day.
EXPLAIN - The silence is what upset me the most. Having
to explain the unsterile instruments to my patient was
extremely upsetting; as was not having the right implant.
But the silence made me feel like I was alone, or surrounded
by strangers.
STATE - When something happens that is not normal
(unanticipated event or error), I would appreciate your
support or acknowledgement of what happened. I want to
create an atmosphere where every member feels sup-
ported, and today, I certainly did not.
CONSEQUENCE - If we continue to ignore issues as a
team, then we are not a team.
Time is money AND
For every good idea to improve patient safety and clinical
quality there is a voice reminding us that time is money.
Money governs healthcare in America. No surgeon, OR
scheduler, or CEO can refuse to be concerned about how
efficiently an OR can be used. Pressures have become so
intrusive on the surgical team that beepers and Blackber-
ries now provide a constant opportunity for interruption and
distraction that few patients on the table would appreciate
if awake. While only preliminary data is emerging to validate
what we already intuitively know, the fact is, the higher the
pressure on time, and the higher the level of distraction in an
OR, the less concentration on the procedure. To the extent
that a surgical team is constantly disrupted by mid-proce-
dure personnel substitutions, thoughtless intrusions, and
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Aligning prac tice with po licy to imp rove pa tie nt ca re 2
highly distracting communications, patient safety is com-
promised. Time pressures drive distractions that fragment
and fracture teamwork and the ability of a surgical team to
stay focused and supportive of each other.
How does the leader of a would-be collegial interactive
team respond to such pressures? By taking the time to
discuss issues outside the OR, tracking outcomes and
reviewing all outliers. A team cannot coordinate their
actions or responses if they dont make the time to come
together before the fact and at least go over the basics of
what theyre about to do; as well as openly discuss unin-
tended outcomes.2
Example: During a bariatric surgery the surgeon asked theanesthesiologist, Is the stomach clear? and the anesthe-
siologist answered Yes. And so the surgeon stapled the
stomach to the tube. For when the surgeon asked if the
stomach was clear, the anesthesiologist thought he meant
clear of fluids - and not the tube they had inserted for
decompression. After the event, the checklist was revised
to include teaching and now reads: Before stapling, I will
specifically ask, Is the stomach clear of the tube because
before I staple, I need the tube to be pulled. Respond clear
when the tube is pulled.
SCOAP (Surgical Care and Outcomes Assessment Pro-
gram) is the future of surgical quality improvement. It is a
physician-led voluntary collaborative creating an aviation-
like surveillance and response system for surgical quality.
SCOAP's goal is to improve quality by reducing variation in
process of care and outcomes at more than 40 hospitals in
the state of Washington. SCOAP is an engaged community
of clinicians working to build a safer, higher quality,
an d mo re cost-effective surgical healthcare system.
http://www.scoap.org/index.html.
Find your voice
In the opening case scenario, every team member failed to
communicate. The truth is that neither checklists, nor pro-
cedures, or process improvement will work in the absence
of meaningful, collegial relationships in which every member
of the team feels comfortable communicating what they
see, feel and know at all times. Silent cultures never change.
Find the courage. Find your voice.
References
1. Scott, S. (2004). Fierce Conversations. New York: The Berkley Publishing
Company.
2. Nance, J. (2008). Why hospitals should fly. Second River Healthcare Press,
Bozeman, MT.
3. Bartholomew, K. (2007). Stressed Out About Communication Skills,Marblehead, MA
4. Orlikoff, J. (2008). IHI Conference: From the top: the role of the board in quality
and safety, November 6-7, Boston, MA.
5. Silence Kills: The Seven Crucial Conversations for Healthcare study by
VitalSmarts available at www.silencekills.com.
6. Bartholomew, K. Presentation for Sigma Theta Tau International: Using a
communication model to identify barriers and increase self esteem November
2, 2009, Indianapolis, IN
7. Cox, S. (2007) Cox & Associates, Brentwood, TN.
Kathleen Bartholomew, RN, RC, MN, has
been a national speaker for the nursing pro-
fession for the past seven years. Her back-
ground in sociology laid the foundation forcorrectly identifying the norms particular to
health care specifically physician and
nurse relationships. For her masters thesis,
she authored Speak Your Truth: Proven
Stategies for Effective Nurse-Physician
Communication, which is the only book to date that addresses
physician-nurse communication. Stressed Out About Communi-
cation is a book designed for new nurses. Save 20 percent by
using source code MB84712A at www.HCMarketplace.com
or call customer service at (800) 650-6787.
John J. Nance, JD, author of the American
College of Healthcare Executive's 2009
Book of the Year, Why Hospitals Should Fly
(2008, Second River Healthcare Press,
Bozeman, MT), has been a dedicated mem-
ber of the healthcare profession for the past
20 years and an acknowledged leader in
adapting the most effective methods of
transforming human systems to high relia-
bility status. One of the founding board members of the National
Patient Safety Foundation, John is a licensed attorney, a 13-thou-
sand hour veteran airline captain, and an Air Force Reserve Lt.
Colonel, as well as the author of 19 best-selling books. He also
serves as the aviation analyst for ABC World News and the avi-ation editor for Good Morning America. Why Hospitals Should
Flycan be purchased online at www.whyhospitalsshouldfly.com.
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QUIZ YOURSELF!
CAUTI Prevention: How Do You Rate?
1. At my facility, we remove urinary catheters
within 48 hours after surgery.
a. Always
b. Sometimesc. Never
2. I follow strict aseptic technique when
inserting a catheter.
a. Always
b. Sometimes
c. Never
3. At my facility, we educate catheterized
patients about urinary tract infections.
a. Always
b. Sometimes
c. Never
4. At my facility, we keep track of how long
catheters are kept in patients.
a. Always
b. Sometimesc. Never
5. Before placing a catheter, I assess whether
the patient really needs it, and I document
the assessment in the chart.
a. Always
b. Sometimes
c. Never
30 The OR Connection
Whats your score?
a _____ x 5 = _______
b _____ x 3 = _______
c _____ x 0 = _______
TOTAL _______
How do you rate?
25 Perfect score! Keep up the great work and educate others.
17 23 Great job. Read below for more helpful tips.
8 14 Youre doing OK. Turn to page 31 to find out more about CAUTI prevention AND earn a free CE!
0 5 Lots of opportunity to improve practices at your facility. Medline can help! Also review the strategies below.
We invite you to join the Race to ERASE CAUTI! With 100,000 nurses working together, we can do it!
CAUTI FACTS Evidence-Based Prevention Strategies The MOST effective way to prevent CAUTI is to AVOID inappropriate catheterization.1
Greater attention is REQUIRED to avoid inserting catheters in patients unnecessarily.2
Limiting urinary catheter use and, when a catheter is indicated, minimizing the duration the catheter remains
in place, are primary strategies for CAUTI prevention.3
Alternatives to catheterization should be considered.3
Documentation must include: indications for catheter insertion, date and time of catheter insertion,
individual who inserted catheter, date and time of catheter removal.3
Insertion using aseptic techniques and sterile equipment.4
Handwashing is the FIRST and most important preventive measure.5
Education must include appropriate indications for catheter placement and the possible alternatives to
indwelling catheters.5
Educating the patient can reduce readmissions6
and help to achieve higher patient satisfaction scores. SHEA/IDSA guidelines suggest that some common practices SHOULD NOT be used routinely to prevent
CAUTI including: Routine use of silver-coated or antibacterial urinary catheters.3, 4
References
1. Expert discusses strategies to prevent CAUTIs. Infection Control Today Web site. June 1, 2005. Available at http://www.infectionacontroltoday.com/articles/402/402_561feat2.html.
Accessed July 10, 2009.
2. Catheter-related UTIs: a disconnect in preventive strategies. Physicians Weekly. 25(6), February 11, 2008.
3. 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:S41S50.
4. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008. Draft. Centers for Disease Control
and Prevention. Available at http://www.cdc.gov/ncidod/dhqp/pdf/pc/cauti_GuidelineApx_June09.pdf. Accessed July 10, 2009.
5. Gokula RM, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004;32:196-199.
6. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at
http://www.medscape.com/viewarticle/587464_4. Accessed July 6, 2009.
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Aligning practice with policy to improve patient care 3
Back to Basics Tenth in a Series
by Alecia Cooper, RN, BS, MBA, CNOR
Insertion of an indwelling urinary catheter is a common
procedure within perioperative services. In fact, as many
as 86 percent of patients undergoing surgery have urinary
catheters.1 In addition, 50 percent of these catheters remain in
place for more than two days.1 Have you ever thought about or
questioned if the catheter you were inserting was really neces-
sary and clinically indicated for your surgical patient? It has
become critically important that we evaluate the need for
urinary catheterization and no longer insert catheters for con-
venience or because there is a preference card telling us toinsert a catheter. Whats more, did you know that requests from
nurses to place a urinary catheter for nursing convenience are
not uncommon?2
New guidelines and recommendations tell us that we should
determine if there is an approved medical indication for
catheterization. This means that we evaluate and reconsider a
common practice occurring pre-, intra-, or postoperatively
insertion of an indwelling catheter prior to a certain surgical pro-
cedures. This evaluation may change how we have always
done things.
The Centers for Medicare & Medicaid Services (CMS),
as a result of the Medicare Modernization Act of 2003
and the Deficit Reduction Act of 2005, has identi-
fied catheter-associated urinary tract infec-
tion (CAUTI) as a healthcare-associated
infection (HAI) that can reasonably be
prevented through the application of
Tell Me Again Why This PatientNeeds a Catheter?
Patient Safety
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32 The OR Connection
evidence-based practice. CMS reported in the 2008 Fed-
eral Register that in 2007 there were 12,185 CAUTIs, costing
$44,043 per hospital stay.2 CAUTI is one of 10 hospital-
acquired conditions (HACs) for which CMS will no longer
provide reimbursement if it occurs during hospitalization.3
Brand-new CAUTI prevention guidelinesCAUTI is the number one healthcare-associated infection
(HAI), accounting for 40 percent of all hospital-acquired
infections.4 One in four patients receives an indwelling
urinary catheter at some point during their hospital stay.5
As a result of this data, leading industry experts, including
the Association for Professionals in Infection Control and
Epidemiology (APIC), the Society for Healthcare Epidemiol-
ogy (SHEA), the Centers for Disease Control and Prevention
(CDC), the Joint Commission and many others have joined
together to outline strategies and guidelines to prevent
catheter-associated urinary tract infections in acute care
hospitals.6 The CDCs Draft Guideline for Prevention of
Catheter-Associated Urinary Tract Infections 2008 (released
in June 2009) identifies new guidelines and recommenda-
tions to prevent CAUTI.
Barriers to CAUTI preventionThree distinct barriers to the prevention of CAUTI become
evident when analyzing the problem. In the perioperative
environment it is hard to imagine that there are errors in
aseptic technique because we are acutely aware of proper
technique. But remember that most nurses outside of the
perioperative environment do not routinely perform aseptic
technique and may not be aware when contamination
occurs. In fact, during most observations of nurses outsideof the perioperative environment, we have seen inconsis-
tent practice in setting up a sterile field and inserting
indwelling catheters aseptically. It is perfectly clear that in
perioperative services, two of the three barriers occur rou-
tinely too many catheters are inserted and catheters stay
in too long.
CAUTI incidence outside theperioperative environment
To help you further realize the magnitude and role of
perioperative services in preventing CAUTI, lets look at
additional statistics from outside the perioperative environ-
ment. Did you know that the emergency department (ED)
has the highest percentage of catheter placements?7 In the
ED, as well as in perioperative services, documentation of
the reason for catheter placement is poor and a written
physician order is frequently lacking. Without a physician
order, physicians are unaware that the patient has a
catheter.5 When physicians do not know that a catheter has
been inserted, it is no wonder that an order for timely
removal is lacking, and catheters stay in longer than med-
ically necessary.
Common catheter practices in perioperative servicesAdding to the problem, inappropriately placed catheters are
more often forgotten about.5 In 56 percent of hospitals there
is no system to keep track of which patients have catheters,
and 74 percent of hospitals do not keep track of how long
the catheter is in place.8 Shocking as this may be, lets
assess common practice in perioperative services and see
if any of these common occurrences occur at your facility.
1. Do you have preference cards that tell you to insert
an indwelling catheter for a specific procedures
performed by a particular surgeon?
2. Do you assess patients to determine if the standing
order to insert an indwelling catheter is medically
indicated?
3. When a patient comes to the OR with an
indwelling urinary catheter or when you insert oneintraoperatively, do you evaluate the need to keep
the catheter in place at the end of the surgical
procedure before transporting the patient to the
post anesthesia care unit (PACU)