OR Connection Magazine - Volume 4; Issue 3

9

TheAligning practice with policy to improve patient care

Volume 4, Issue 3

YouTubeSensation!

Peggy Fleming Comes to Congress

Positioningto Prevent

Injury

FREE CE!

Brand NewFire Prevention

Guidelines

Habits of VeryHappy PeopleDance

The Pink Glove

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OR ConnectionThe

Aligning practice with policy to improve patient care

Subscribing to The OR Connection guarantees that you’llcontinue to receive this info-packed magazine and won’t missout on our industry updates and articles addressing on-the-job issues and tips on caring for yourself!

To subscribe, simply go to www.medline.com/orconnection.You will need to provide:Your nameFacility and positionMailing addressE-mail address

Never miss an issue of The OR Connection!Subscriptions are free and signing up is a snap!

We also welcome any suggestions you might have on how we can continue to improveThe OR Connection! Love the content? Want to see something new? Just let us know!

Content KeyWe've coded the articles and information in this magazine to indicate which patientcare initiatives they pertain to. Throughout the publication, when you see these iconsyou'll know immediately that the subject matter on that page relates to one or more ofthe 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 toolsfor implementing their recommendations. For a summary of each of theinitiatives, see pages 6 and 7.

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Aligning practice with policy to improve patient care 3

PATIENT SAFETY

6 Three Important National Initiatives for Improving Patient Care8 New SCIP Measures for Normothermia, Urinary Catheters9 Delaware Hospitals Standardize Wristband Colors11 CDC to Fund State Infection Control Efforts12 State Reporting of Infections and Adverse Events20 Perioperative Positioning Injuries on the Rise: What to Do!

OR ISSUES

13 Revised Universal Protocol for 201033 Can a Rigid Container System Be Greener and Safer

at the Same Time?39 O.R. Fires: New Recommendations for Prevention45 Scoring Fire Risk for Surgical Patients48 Breaking Free From Our Cultural Chains

SPECIAL FEATURES

43 Mark Bruley Talks About New Surgical Fire PreventionGuidelines

56 Changing the Catheter Culture at Your Facility69 Peggy Fleming to Speak at Medline’s AORN Breast Cancer

Awareness Breakfast70 Medline’s Pink Glove Dance: A YouTube Sensation

CARING FOR YOURSELF

65 9 Habits of Very Happy People77 Healthy Eating: Cheesy Potatoes Recipe

FORMS & TOOLS

79 FAQs About Catheter-Associated Urinary Tract Infection80 Surgical Safety Team Communication81 Universal Protocol and Fire Risk Assessment84 Extinguishing a Surgical Fire85 Preventing Surgical Fires87 H1N1 Patient Handout: English89 H1N1 Patient Handout: Spanish

EditorSue MacInnes, RD, LD

Clinical EditorAlecia Cooper, RN, BS, MBA, CNOR

Senior WriterCarla Esser Lake

Creative DirectorMike Gotti

Clinical TeamJayne Barkman, RN, BSN, CNORRhonda J. Frick, RN, CNORAnita Gill, RNMegan Shramm, RN, CNOR, RNFAKimberly Haines, RN, Certified OR NurseJeanne Jones, RNFA, LNCCarla Nitz, RN, BSNConnie Sackett, RN, Nurse ConsultantClaudia Sanders, RN, CFAAngel Trichak, RN, BSN, CNOR

Perioperative Advisory Board

Larry Creech, RN, MBA, CDTCarilion Clinic, VirginiaSharon Danielewicz, MSN, BSN, RN, RNFASt. Lukeʼs The Woodlands, TexasTracy Diffenderfer, RN, MSNVanderbilt University Medical Center, TennesseeBarb Fahey RN, CNORCleveland Clinic, OhioSusan Garrett, RNHughston Hospital Inc., GeorgiaZaida I. Jacoby, RN, MA, M.EdNYU Medical Center, New YorkJackie Kraft, RN, CNORHuntsville Hospital, AlabamaTom McLarenFlorida Hospital, FloridaDonna A. Pritchard, RN, BSN, MA, CNOR, NE-BCKingsbrook Jewish Medical Center, New YorkDebbie Reeves, RN, CNOR, MSHutcheson Medical Center, GeorgiaDiane M. Strout, RN, BSN, CNORChesapeake Regional Medical Center, VirginiaMargery Woll, RN, MSN, CNORNorth Shore Shore University Health System, Illinois

About MedlineMedline, headquartered in Mundelein, IL, manufactures and distributes more than100,000 products to hospitals, extended care facilities, surgery centers, homecare dealers and agencies and other markets. Medline has more than 800 dedi-cated sales representatives nationwide to support its broad product line and costmanagement services.

Meeting the highest level of national and international quality standards, Medline isFDA QSR compliant and ISO 13485 registered. Medline serves on major industryquality committees to develop guidelines and standards for medical product use in-cluding the FDA Midwest Steering Committee, AAMI Sterilization and PackagingCommittee and various ASTM committees. For more information on Medline, visitour Web site, www.medline.com.

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©2010 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Page 45


Dear Reader,

2010 is going to be a great year … for you and for us.

I believe this because we witnessed 2009 become

one of the busiest and most productive years in the

last two decades, and I am convinced that 2009 was

just setting the momentum for what is coming in

2010. As we move into the New Year and this excit-

ing time, I want to thank a number of you for your con-

tinued support.

First, thank you to our advisory board, for the time you

spent with us deliberating over details, testing ideas

and working with us to help make these ideas a

reality. Your time is valuable, and we appreciate every

minute you gave to us.

I’d also like to thank the Medline Grant Committee for

the many hours you spent reviewing and scoring grant

applications. Because of your dedication, Medline

was able to award $685,000 in grant funding for

healthcare research. Close to 25 percent of those

grants were specifically OR-related. While I’m at it, I’d

like to thank all of you who are associated with peri-

operative activities in your facilities. You deserve a lot

of credit for all you do.

Thank you to the many, many healthcare workers who

have contributed suggestions that have led to our

developing innovative product solutions, unique pro-

grams and state-of-the-art educational offerings. Here

at Medline, we want to continue to lead the way in

developing cost-effective and practical solutions that

will make your jobs easier. That wouldn’t be possible

without your input.

Check out this month’s cover. The photo was shot in

the O.R. from the “now famous” YouTube video, the

“Pink Glove Dance,” filmed at Providence St. Vincent’s

Hospital in Portland, Ore. (To view the video, visit

youtube.com and type “pink glove dance” in the

search bar.) Who would have believed that an off-the-

cuff idea like this video would generate more than six

million hits to date … and still counting.

For the past five years Medline has been an active and

visible supporter of breast cancer awareness. Our first

Breast Cancer Awareness Breakfast was held at the

AORN Congress in Washington, DC. I remember hop-

ing you would show up for that event … and you did!

And every year since, many of you have joined us for

our annual Breast Cancer Awareness Breakfast at

Congress to support this important cause. The “Pink

Glove Dance” video is just our latest effort to engage

you in this effort. Since the posting on YouTube,

you’ve sent us hundreds of congratulatory e-mails and

letters. Thank you for your continued support.

Take care. I look forward to an action-packed year

in 2010.

Here’s to you!

Sue MacInnes, RD, LD

Editor

”“

4 The OR Connection

THE OR CONNECTION I Letter from the Editor

I am convinced that2009 was just settingthe momentum forwhat is coming in2010.

On the cover:Shelley Galvin (left) and Alana Ellerbroek (right) from the Car-diac Surgery department at Providence St. Vincent MedicalCenter in Portland, Ore. during the filming of the “Pink GloveDance” video. See page 70 for the full story.


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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. Here’s 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 2009Purpose: 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 requirementsand 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.

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 offersguidance 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.

Origin: Initiated in 2003 as a national partnership. Steering committee includes the followingorganizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and theJoint Commission

Purpose: To improve patient safety by reducing postoperative complicationsGoal: 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 andoutcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgicalcomplications annually (just in Medicare patients) by getting performance up to benchmark levels.

IHI Improvement Map1

Joint Commission 2010 National Patient Safety Goals2

Surgical Care Improvement Project (SCIP)3


IHI Improvement Map: 70 Processes to Transform Hospital Care

Surgical Care Improvement Project (SCIP): Target Areas

Joint Commission 2010 National Patient Safety Goals


Patient Safety

By the numbers:• 3,740 hospitals are submittingdata on SCIP measures, representing75 percent of all U.S. hospitals• Currently, SCIP has more than 36association and business partners

• Improve the accuracy of patient identification.• Improve the effectiveness of communicationamong caregivers.

• Improve the safety of using medications.• Reduce the risk of healthcare-associatedinfections.

• Accurately and completely reconcile medicationsacross the continuum of care.

• Reduce the risk of patient harm resulting from falls.• Prevent healthcare-associated pressure ulcers(decubitus ulcers).

• The organization identifies safety risks inherent inits patient population.

• Universal Protocol for Preventing Wrong Site,Wrong Procedure, and Wrong Person Surgery.™

No new NPSGs have been developed for 2010.Effective January 1, 2010, organizations are expectedto have fully implemented the requirements related tohealthcare-associated infections established in 2009.

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

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

To learn more about the IHI Improvement Map and the 70 processes to transform hospital care, go to www.ihi.org/imap/tool

1. Surgical infections* Antibiotics, blood sugar control, hair removal, perioperativetemperature management• Remove urinary catheter on POD 1 or 2

2. Perioperative cardiac events• Use of perioperative beta-blockers

3. Venous thromboembolism• Use of appropriate prophylaxis

Visit www.qualitynet.org

Top 5 Key Processes Viewed by Improvement Map Users1. Acute Myocardial Infarction (AMI) Core Processes2. Set Direction: Aims3. CA-UTI4. Communication and Teamwork5. Central Line Bundle

Top 5 Key Processes Shared by Improvement Map Users1. Central Line Bundle2. CA-UTI3. Anti-Biotic Stewardship4. Falls Prevention5. Heart Failure Core Processes


8 The OR Connection

As reported in the last issue of The OR Con-nection, the Surgical Care Improvement Project(SCIP) introduced two new performancemeasures effective October 1, 2009, in theareas of normothermia and urinary catheters.

To clarify, here are the key points toremember regarding each measure:

SCIP Infection Measure #9: Urinary catheter re-moved on Postoperative Day 1 (POD 1) or Postopera-tive Day 2 (POD 2) with day of surgery being day zero.

Rationale: It is well-established that the risk of catheter-associated urinary tract infection (UTI) increases withincreasing duration of indwelling urinary catheterization.Studies have shown the following:• Bacteriuria will develop in 26 percent of patientsafter two to 10 days of catheterization; 24 percentof those patients will develop symptomaticurinary tract infection and bacteremia willdevelop in 3.6 percent.

• Patients who had indwelling catheters for morethan two days postoperatively were 21 percentmore likely to develop a urinary tract infection;significantly less likely to be discharged to homeand had a significant increase in mortality at30 days.

Source: Specifications Manual for National Hospital Inpatient QualityMeasures. Available at http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228695698425.

SCIP Infection Measure #10: Surgery patients forwhom either active warming was used intraoperativelyfor the purpose of maintaining normothermia or whohad at least one body temperature equal to or greaterthan 96.8 degrees F/36 degrees C recorded withinthe 30 minutes immediately prior to AnesthesiaEnd Time or the 15 minutes immediately afterAnesthesia End time.

Rationale: Core temperatures outside the normal rangepose a risk in all patients undergoing surgery. Studieshave shown the following:• Impaired wound healing, adverse cardiac events,altered drug metabolism and coagulopathiesare associated with unplanned perioperativehypothermia.

• Incidence of surgical site infections among thosewith mild perioperative hypothermia was threetimes higher than with normothermic periopera-tive patients.

• Hypothermia is associated with a significantincrease in adverse outcomes, an increasedchance of blood products administration,myocardial infarction and mechanical ventilation.

• Adverse outcomes resulted in prolonged hospitalstays and increased healthcare expenditures.

KEY POINTS:New SCIP Measures for Normothermia, Urinary Catheters

Patient Safety


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In September 2009 Delaware joined the growing list ofstates that have standardized the use of color-codedhospital patient wristbands. In coordination with theDelaware Healthcare Association, all acute care generalhospitals in the state have voluntarily agreed to adopt thefollowing colors and meanings to convey specific patientinformation to healthcare professionals.1

Red = patient allergiesYellow = fall riskPurple = do not resuscitate

In addition to these three colors, some states use a pinkwristband to identify a restricted extremity and green tosymbolize a latex allergy.2

Movement toward a national standard of color-codedpatient wristbands gained momentum in 2005 after ahospital patient in Pennsylvania nearly died because anurse incorrectly used a yellow wristband, which shethought meant “restricted extremity,” as it did at anotherhospital where she worked. At this hospital, yellow meant“do not resuscitate,” and the patient was nearly notresuscitated.1

References1 Improving Patient Safety: Delaware Hospitals Adopt Common Color Wrist Bands.Delaware Healthcare Association. Press Release. September 14, 2009. Available at:http://www.deha.org/news.htm. Accessed September 30, 2009.2 State color-coded wristband standardization. Available at: http://www.patientidex-pert.com/material/us_colorcode_implementation.pdf. Accessed September 30, 2009.3 American Hospital Association. Hospitals in Pursuit of Excellence website. Available athttp://www.hpoe.org/hpoe/wristband-colors.shtml.

Delaware HospitalsStandardize Wristband Colors

States withStandardizedWristband Colors3

Patient Safety


Medline Industries, Inc. first introduced Arglaes® silverdressings in 1997, and we’ve continued to be a leaderin silver antimicrobial technology ever since.

Arglaes technology utilizes ionic silver to create anenvironment that is hostile to bacteria and fungi yetcompletely non-cytotoxic. Arglaes’ sustained-activityionic silver maintains full efficacy for up to seven days.

The Arglaes family of products has something for everywound: Arglaes Film is ideal for managing bacterialpenetration on post-op and line sites. Arglaes Island

features a calcium alginate pad for fluid managementin addition to controlled-release silver.

Arglaes Powder is perfect for difficult-to-dress woundsand can be easily combined with other dressings tocreate a system for antimicrobial protection.

To schedule a FREE demonstration of Arglaesin your OR, contact your Medline representative,call 1-800-MEDLINE or visit www.medline.com.

ARGLAES IN THE ORANTIMICROBIAL SILVER TECHNOLOGY


Use silver to fight bacteria.



CDC to FundState Infection

ControlEfforts

The Centers for Disease Control and Prevention (CDC)is set to distribute $40 million in federal funds to statehealth departments to help reduce healthcare-associ-ated infections.

The CDC’s funding focuses on controlling bloodstreaminfections (BSI), surgical site infections (SSI) and catheter-associated urinary tract infections (CAUTI). Specifically,the agency wants state health departments to increaseinvestments in the U.S. Department of Health and HumanServices’ HAI Action Plan, which is designed to create wide-spread infection prevention practices by coordinating theefforts of local public and private partners.

The $40million investment, funded by the American Recoveryand Reinvestment Act, marks the first time Congress hasallocated money to curb healthcare infection rates at thestate level. Part of the funding is earmarked to increasehealthcare facilities’ use of the CDC’s National HealthcareSafety Network, a surveillance system that tracks, analyzesand compares HAI data. Funds also will go toward hiringand training local public health staff to implement and coor-dinate national infection prevention efforts.

“We expect these programs to strengthen tracking andprevention of healthcare-associated infections, enhancefacility accountability, provide data for informed policy, andultimately save lives,” said CDC Director Thomas R.Frieden, MD, MPH. “Funding critical prevention efforts atstate and local levels represents a significant investmenttoward elimination of HAIs and improved patient safety.”

Outpatient Surgery Magazine. September 8, 2009. Available at:http://www.outpatientsurgery.net/newsletter/eweekly/2009/09/08.php


12 The OR Connection

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Hospital-specific public data

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System pending

Reprinted with permission from Hearst Newspapers. Hearst research byOlivia Andrzejczak. Graphic by Kyla Calvert. Template by Alberto Cuadra.Available at http://www.chron.com/deadbymistake/hospitals.

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Copyright 2008 – Association for Professionals in Infection Control andEpidemiology, Inc.Please contact [email protected] for reprint permission andupdate requests. Reprinted with permission.

HAI Reporting Laws and RegulationsNearly 56 percent of states currently require pub-lic reporting of hospital-acquired infections.

State Reporting of Infectionsand Adverse Events

**

State Reporting of Adverse EventsWith no national mandatory event reporting systemin place, the United States is blanketed by a patch-work of state reporting systems collecting a variety ofdata in different ways. The amount of informationavailable to the public also differs from state to state.

Patient Safety



Joint Commission UpdateRevised Universal Protocol for 2010:

What This Means for the OR Manager

One of themost challengingmanagement responsi-bilities in every operating room or procedure area iskeeping patients safe. There are several ways to ensurethis happens, but one way is to make sure practices areup-to-date and staff are fully aware of requirementsestablished by accrediting and regulatory bodies.Recently, The Joint Commission revised the UniversalProtocol for PreventingWrong Site, Wrong Procedure, andWrong Person Surgery.

Revisions were made in four areas to ensure that safe careis provided to every patient having a surgical or non-surgical invasive procedure. The changes apply to proce-dures performed in acute care and critical accesshospitals, ambulatory care and office-based surgeryprograms. The intent of the changes is to continue toaddress important patient safety issues while givingorganizations the flexibility needed to apply the require-ments in their own particular setting and also to be able toincorporate the changes into their unique work processes.

The purpose of this article is to summarize the changesso you can educate your staff and revise your practicesto meet the revised elements of performance (EP).

The highlights of the changes are summarized below:

Applicability: The Universal Protocol has been revised toapply to “all surgical and non-surgical invasive proce-dures.” In the past, the protocol applied to “all invasiveprocedures that put patients at more than minimal risk,regardless of the location within an organization.”

Pre-procedure verification (UP.01.01.01): As a man-ager, you know patient safety in the OR begins withensuring that the right procedure is performed on the rightpatient. The Universal Protocol has been revised toremove references to the location (pre-procedure area)and timing of the verification. In addition, the term checklisthas been replaced by reference to a standardized list thatcan be used in the verification process. The changesrecognize that the pre-procedure verification is an ongoingprocess of gathering and confirming information. Thepurpose of the pre-procedure verification is to ensure thatall relevant documentation, information and equipment areavailable prior to the start of the procedure. Staff also mustensure that all documents are correctly identified, labeledand matched to the patient’s identifiers. Anotherimportant aspect of this process is making sure thepatient understands what procedure will be performedand ensuring that all members of the operating or proce-dure area correctly identify the patient and the procedureto be performed.

by Connie Yuska, RN, MS

OR Issues



Joint Commission Update

The changes recognize that the pre-procedure verificationprocess may occur at more than one time and place beforethe procedure is performed. It is now up to the hospital todecide when this information is collected and who will collectit. Some possibilities for when and where to collect thisinformation include:

• When the procedure is scheduled• At the time of preadmission testing and assessment• At the time of admission or entry into the facility for

a procedure• Before the patient leaves the pre-procedure area

or enters the procedure room

What this means for youNow you have the opportunity to work with your colleagueswho lead your pre-anesthesia and same-day surgery ambu-latory areas to develop a staff protocol to ensure the pre-procedure verification process is completed in the area thatmakes the most sense based on practices related to howpatients come into your institution.

Site Marking (UP.01.02.01): Surgery performed on thewrong site should never, never happen. One way to makesure that everyone in the operating room or procedure areaknows the correct location of the surgery or other procedureis to clearly mark the site. Patient safety is enhanced whena consistent process is used throughout the hospital to markthe site. The revised Universal Protocol requires that the pro-

cedure site be marked by “a licensed independent practi-tioner who is ultimately accountable for the procedure andwill be present when the procedure is performed.” However,The Joint Commission recognized the complexity of workprocesses surrounding invasive procedures and changed thestandard so that site marking can now be delegated toanother individual in limited situations where the individual isfamiliar with the patient and involved in the procedure. Theydefine those individuals as:

• Individuals who are permitted through a residencyprogram to participate in the procedure

• A licensed individual who performs duties requiringcollaborative or supervisory agreements with alicensed independent practitioner. These individualsinclude advanced practice nurses (APRNs) andphysician assistants (PAs.)2

It is important to remember that the licensed independentpractitioner remains fully accountable for all aspects of theprocedure even when the marking of the site is delegated toanother practitioner.

What this means for youCheck the regulations in your state regarding the scope ofpractice for your advanced practice nurses and your physi-cian assistants to make sure this activity is consistent withthe state’s practice act. Discuss this change with the mem-bers of your healthcare team who are doing surgery or per-forming procedures. You’ll want to review your current

Site Marking (UP.01.02.01)

Continued on page 16


Designed to break down barriers to surgical safetycompliance by offering easy-to-use tools to help youreach your safety goals, Medline’s Gold StandardSafety Program offers four levels of safety options:

1. The Gold Standard Safety Bundle: Includessix products to serve as visual safety remindersto reduce needle sticks and wrong site surgery.

2. Innovative safety products: Surgical Time OutProcedure (S.T.O.P.™) Drape and Dual Tip Markerremind OR staff to take time to verify key informationbefore the first incision to reduce wrong site surgery.

3. Med-Pack™: Electronic pack audit and a reviewof safety components.

Visit www.medline.com/goldstandard for a quickvideo overview on how Medline’s Gold StandardSafety Program can help improve safety in your OR.


Medline’s Gold Standard Safety Program—a complete tool kit for surgical safety.

Settinga new

standardin patient

safety.



procedure and discuss situations in which exceptions to sitemarking may be allowed. Develop an alternative process ifthat meets your needs, but be sure to document the changeand educate all personnel who will interact with the patient.

Time-out (UP.01.03.01): The purpose of the time-out pro-cedure is to conduct a final check that the correct patient,site and procedure are identified. This is the final safety checkthat all systems are go! In the revised version of in the Uni-versal Protocol, all references to conducting the time-outbefore initiating anesthesia have been removed. The ration-ale states “a hospital may conduct the time-out before anes-thesia or may add another time-out at that time.”2 The list ofissues to be addressed during the time-out was shortened toenable healthcare team members to focus on the correctpatient, procedure and site.

What this means for youYou have the opportunity to meet with the surgeons andother members of your team to decide how you want tostructure the time-out procedure. When is the best time foryou to perform the time-out? Think about all the steps youtake to keep your patient safe and ask yourself what thepatient can contribute during the time-out. If you determinethat the patient can contribute to the safety aspect of theircare, then it would make sense to do the time-out prior to thestart of anesthesia. Remember to designate a member of theteam to initiate the time-out and include active communication

among all members of the procedure team. Time-outs havebeen found to be most effective when conducted consis-tently across the hospital, so the ORmanager often can takea leadership role in helping to establish protocols for otherambulatory procedure areas.

Keeping patients safe at all times when they are under ourcare is the goal of every healthcare provider. Your role inmaking your colleagues aware of these changes and invitingthem to actively participate in updating procedures at yourfacility will ensure that you meet that goal.

References1. Approved: revised Universal Protocol for 2010. The Joint Commission Perspectives.

2009;29(10):3. Available at: http://www.jointcommission.org/NR/rdonlyres/DFBF9FFD-AF97-4CA1-A9C8-8102C2D77AE0/0/JCP1009.pdf. Accessed October 28, 2009.

2. The Joint Commission. 2010 National Patient Safety Goals (NPSGs). Pre-publicationVersion of the 2010 National Patient Safety Goals (NPSGs) outlines and chapters forall applicable programs. Available at: http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/. Accessed November 24, 2009.

About the author

Connie Yuska, RN, MS began her ca-reer as a nurse in the specialty of otorhi-nolaryngology. Her clinical experienceincludes both inpatient and outpatient careof head and neck oncology patients, and sheis certified in otorhinolaryngology and head-neck nursing. She has held clinical managerand director of nursing positions in a large

academic medical center and also has experience in the homecare setting as the vice president of operations for a large aca-demically affiliated home care agency in the Chicago area. Con-nie later joined the executive suite as the chief nursing officer of alarge community hospital in Chicago, and she is currently a vicepresident of clinical services for Medline. In all of her leadershiproles, she has been responsible for ensuring the delivery of highquality, safe and cost-effective nursing care.

Connie is a 2003 graduate of the J&J/Wharton Nurse ExecutiveProgram. She is member of the Board of the Illinois Organizationof Nurse Leaders and a member of the American Organization ofNurse Executives. In 2005, she was inducted into the 100 WiseWomen Program sponsored by Deloitte & Touche. In addition, shehas published several articles and chapters in oncology journalsand textbooks.

Time-out (UP.01.03.01)


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PERIOPERATIVEPRESSURE ULCER EDUCATION

The AORN Seal of Recognition has been awarded to Pressure Ulcer Prevention for Perioperative Servicesin June 2009 and does not imply that AORN approves or endorses any product or service mentioned inany presentation, format or content. The AORN Recognition program is separate from the AORN, ANCCAccredited Provider Unit and therefore does not include any CE credit for programs.

©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.The AORN Seal of Recognition is a trademark of AORN, Inc., All rights reserved.

Medline’s Pressure Ulcer Prevention Program now has acomponent designed specifically for perioperative services.The easy-to-use interactive CD addresses the following:

• Hospital-acquired conditions

• CMS reimbursement changes

• Best practices for pressure ulcer prevention

• Perioperative assessment tools

• Critical patient and equipment risk factors

I have seen an increase in the number of legal issues

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, CWS, BCLNC, FAAN

To learn more about Medline’s Pressure UlcerPrevention Programs and FREE webinars foracute care and perioperative services, callyour Medline representative or visitwww.medline.com/pupp-webinar.

More important than ever before

“



Patient Safety


Back to Basics Eleventh in a Series


Perioperative PositioningInjuries on the Rise:

by Alecia Cooper, RN, BS, MBA, CNOR

Author’s note: In 2007, I wrote a “Back to Basics” article onthe principles of proper positioning and prevention of posi-tioning injuries. I listed many types of injuries that can occuras a result of improper positioning before, during and aftera surgical procedure. The content of that article still holdstrue, but when I went back to the topic recently in prepara-tion for a live presentation, I was alarmed to learn that theseinjuries were not on the decline, but rather on the rise. Andthat’s what prompted me to write this article as a refresheron positioning for perioperative professionals.

The importance of proper patient positioning must not beoverlooked. More and more studies are attributing hospital-acquired pressure ulcers to lack of proper positioning inperioperative services. In fact, AORN’s 2009 PerioperativeStandards and Recommended Practices states that theincidence of pressure ulcers occurring as a result of surgerymay be as high as 66 percent.1 In addition, more and morelawsuits are being filed due to positioning injuries, not onlybecause of avoidable pressure ulcers, but also physiologiccompromises and nerve damage. The incidence of nerveinjuries is unknown, however in the United States, nervedamage accounts for 15 percent of postoperative litigationclaims.2

Positioning for a surgical procedure depends on the sur-geon’s preference, the anesthesia provider’s needs, the pro-cedure being performed and the need for exposure of thesurgical site. Overall, positioning is recognized as a balancebetween the position a patient can physically assume andwhat can be physiologically tolerated, based on the patient’sage, height, weight and overall health. A patient’s body mustbe positioned adequately on an OR bed, and proper bodyalignment must be maintained to lessen the potential forinjuries.3

AssessmentProper patient positioning begins with an assessment beforethe patient ever arrives in the operating room. Elements toconsider include the patient’s pre-existing conditions, thetype and duration of the procedure and individual patientcharacteristics such as height, weight, age, skin condition,etc.1 Regardless of these factors, however, all surgical pa-tients should be considered at risk for pressure ulcers be-cause of the uncontrollable length of surgery and the effectsof anesthesia on the patient’s hemodynamic state, alongwith the use of vasoactive medications during surgery.3

What to Do!



Risk factors identified during the assessment can determinethe degree of pressure the patient can tolerate. The followingfactors affect the ability of the skin and supporting struc-tures to respond to pressure:3

• Vasoactive medications and steroids• Comorbid diseases, such as cancer,

cardiovascular and peripheral vasculardeficiencies, diabetes and neurologicalor respiratory disease

• Extracorporeal circulation• Impaired regulation in body temperature• Existing fractures• Low hemoglobin and hematocrit levels• Nutritional deficiencies• Obesity• Low serum protein (i.e., prealbumin

or total albumin plus globulin)• Smoking• Low blood pressure

Maintaining optimal physiological conditions lessens the riskfor complications both intraoperatively and postoperatively.When a patient has inadequate arterial blood flow, improperpositioning can cause complications with blood pressure,decrease tissue perfusion and venous return and causeblood clots.

Pre-existing conditions are important to assessbecause certain patients are especially vulnerableto pressure ulcers and/or nerve damage. Patients withvascular disease may have existing tissue ischemia andoften have additional risk factors such as age, nutritionaldeficits, obesity or diabetes.1 Interestingly, these are thesame patients who often undergo cardiovascular surgery,which already puts patients at higher risk for injury simplybecause the procedures typically last four hours or longer.In addition, patients who smoke often experience vaso-constriction, which contributes to pressure ulcer formation.1

Patients with respiratory, circulatory, neurologic or immuneconditions are also more vulnerable to injury, as are thosewith physical limitations such as back problems and pros-theses or implants, such as an artificial hip or knee.

Special considerations for avoiding eye injuries1

Patients are at increased risk of developing post-operativevision loss if they:• Are undergoing procedures lasting 6.5 hours or more• Have substantial blood loss• Are in a prone position

In general, direct pressure on the eye should be avoided toreduce the risk of central retinal artery occlusion and otherocular damage, including corneal abrasion. Assess eyesregularly, especially in long procedures and when thepatient is in the prone position.

The type of procedure dictates how the patient willbe positioned on the operating table and the typeof positioning equipment that will be required. Themost common surgical positions are supine, prone, lateraland lithotomy. Each position carries its own risks and safetyconsiderations, as shown in Table 1 on page 29.

The length of the procedure is another consideration.Often, the longer a patient is on the operating table, thegreater the risk for pressure ulcers. One study reported thatintraoperative pressure ulcers increased when the proce-dure time extended beyond three hours. Cardiac, general,thoracic, orthopedic and vascular procedures were re-ported to be the most common types of proceduresassociated with pressure ulcer formation.1

Specific factors such as age, weight and skincondition, among others, are also important toassess prior to surgery.1 Patients who are 65 years ofage or older experience the highest incidence of pressureulcer development.3 These patients also have less flexibilityand poorer peripheral circulation, making them more proneto skin- and nerve-related injury. The same holds true forobese patients.4 Of course, every individual is different,and your assessment will reflect this. A fit, healthy 82-year-old may be less vulnerable than an overweight 35-year-oldwith diabetes. Very young pediatric patients are also atgreater risk for surgical injuries, as are frail, malnourishedindividuals.



NO PRESSURE, JUST SUPPORT.

Recent studies have shown that pressure ulcers can startto form in as little as 20 minutes in the operating room.1

When every second counts, the surfaces used for positioningand transporting patients need to be chosen carefully.

Medline’s gel positioners are designed to help reducepressure while providing exceptional support during surgicalprocedures. They’re latex- and silicone-free, antimicrobial,antibacterial and radiolucent. They’re also reusable and caneasily be cleaned and disinfected with standard hospitaldisinfectants. Available in a wide variety of shapes and sizes.

Gel positioners are one of several products recommendedas part of Medline's Pressure Ulcer Prevention Program.This proven, systematic approach combines education,best-in-class products and dedicated program managementto reduce pressure ulcer incidence.

To sign up for a FREE webinar on perioperativepressure ulcer prevention, go towww.medline.com/pupp-webinar.

References1 Pressure ulcers hit a sore spot in the operating room. Healthcare Purchasing News. Available at:http://www.hpnonline.com/inside/2007-08/0708-OR-pressure.html. Accessed November 17, 2008.


Gel positioners ease pressure in the OR



Be sure to assess the patient’s skin before surgery,looking for dryness, skin tears and existing wounds,including pressure ulcers, and document your findingsin the medical record. This information will be critical forcomparing the condition of the patient’s skin after surgery todetermine any damage that may have occurred in the oper-ating room. Many pressure ulcers that originate during sur-gery do not appear until one to four days after an operation,some are mislabeled as burns and some are unexplainedbecause they appear and progress differently from thepressure ulcers seen in nonsurgical patients. OR-acquiredpressure ulcers initially have a distinctive purple appearance.5

Shearing movement should be avoided when transferringpatients onto the OR table, especially the elderly, whose frag-ile skin can tear more easily than the skin of younger patients.The overall goal of positioning elderly patients is to reducestress and pressure on the spine and skin. The circulatingnurse should be particularly vigilant about optimal body align-

ment and support of joints whenan older adult patient is positionedafter undergoing sedation. If notcontraindicated, the circulatingnurse should also place a pillowunder the patient’s knees to avoidpostoperative stiffness that maylimit early mobility. Heels are anoften overlooked but vulnerablearea than can benefit from addi-tional padding as well.6

PlanningAfter assessment, the next step isplanning. The nurse must anticipatethe proper positioning equipmentand supplies that will be neededbased on the knowledge acquiredduring the assessment. The nurseshould review the surgery schedulebefore the patient’s arrival – prefer-ably before the day of surgery – to

identify potential conflicts in the availability of positioningequipment.1

The nurse should also confirm that the room is set upappropriately for the planned procedure before the patientarrives. In addition, positioning and transporting equipmentshould be periodically inspected and maintained. Properlyfunctioning equipment contributes to patient safety andassists in providing adequate exposure of the surgical site.1

Even when you have a plan, observe the patient right beforesurgery to ensure that your positioning recommendations arestill correct. Also double check that all necessary positioningdevices and padding materials are in the operating roomprior to transporting the patient.

Tools for Proper PositioningThe goal is to use equipment that is designed to redistributepressure and decrease the risk for positioning injuries. An




References1Braden Scale for Predicting Pressure Sore Risk. Available at:www.bradenscale.com/braden.PDF. Accessed November 6, 2008.

2Recommended practices for positioning the patient in the perioperative practice setting. In:Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008.

KEEP YOUR SURGICALPATIENTS DESERT DRY.

Medline’s Sahara® Super Absorbent OR table sheetsare designed with your patients’ skin integrity in mind.

QuickSuite®OR Clean Up Kit

The Braden Scale tells us that moisture is one of themajor risk factors for developing a pressure ulcer.1 We alsoknow that as many as 66 percent of all hospital-acquiredpressure ulcers come out of the operating room.2

That’s why we developed the Sahara Super AbsorbentOR table sheet. The Sahara’s super-absorbent polymertechnology rapidly wicks moisture from the skin andlocks it away to help keep your patients dry.

Sahara OR table sheets are available on their own oras a component in our QuickSuite® OR Clean Up Kits,which were designed to help you dramatically improveyour OR turnover time and help reduce cross contamina-tion risk through a combination of disposable products.

To sign up for a FREE webinar on perioperativepressure ulcer prevention, go towww.medline.com/pupp-webinar.



Special considerations for avoidingnerve injuries1

Surgery-related nerve injuries most often are attributed tocareless positioning. The most common injury is to theulnar nerve, followed by the brachial plexus. To minimizethe risk of nerve injury, safety measures should include:

• Padded arm boards attached at less than a90-degree angle for the supine position

• Placing the patient’s hands palms up withfingers extended

• Keeping shoulder abduction and lateral rotationof the patient to a minimum

• Preventing the patient’s extremities from droppingbelow the level of the procedure bed.

• Placing the patient’s head in a neutral position,if not contraindicated by the surgical procedureor the patient’s physical limitations

• Adequate padding for the saphenous, sciatic andperoneal nerves, especially for patients in thelithotomy or lateral position

• Placing a well-padded perineal post against theperineum between the genitalia and the uninjuredleg when a patient is positioned on a fracture table

inverse relationship may exist between the duration andintensity of pressure. Low-intensity pressure over a longperiod can initiate tissue breakdown, as can high-intensitypressure for a short period of time.3

During the positioning procedure, it is the nurse’s respon-sibility to:1

• Restrict access to the operating room• Close all doors• Limit traffic within the operating room• Minimize exposure• Provide auditory privacy• Prohibit prejudicial behavior

Positioning devices. Safety is the primary concern whendetermining the adequate number of personnel and typeof devices to safely transfer and position the patient. Trans-ferring is accomplished with a lateral transfer device (e.g.,slide boards, air-assisted transfer devices) that reducesfriction and shear.3

One study involving the review of 16 perioperative incidentreports showed that in 63 percent of the cases, patientswere above the weight limit for the equipment. To avoid thissituation in your practice, ensure in advance that you will beusing a bed that is sufficiently sized for the patient, obtainpressure redistribution table pads and be sure that arm-boards are available.1

Use specific positioners for head and neck surgeries,extremities procedures and procedures performed onthe torso.

Support surfaces. Proper padding around the patient’sbody helps prevent skin breakdown, especially on high-riskareas where soft tissue is compressed between a bonyprominence and a hard surface, such as the OR table. Useof too many pads or blankets, however, can cause thecapillary pressure to rise over 32 mmHg, which increasesthe risk for poor tissue perfusion, causing the patient to beat risk for developing pressure ulcers.3

Pressure redistribution devices should be used to promotereduction of interface tissue pressure for patients at highrisk of developing pressure ulcers or nerve injuries. Several

types of pressure redistribution support surfaces are avail-able. One type is an overlay, which is placed directly on themattress or bed frame as a replacement for the standardfoam OR mattress.3

Foam, static-air and gel are common types of overlays.Static-air overlays allow air to exchange through multiplechambers when a patient lies on the overlay. This type ofoverlay must be reinflated periodically. Gel overlays preventshearing, support weight and prevent bottoming out. Onestudy found that gel overlays helped prevent skin changesand pressure ulcers in older adults, including those withchronic health comorbidities or vascular disease and thoseexperiencing extended surgical duration.3

Mackey reviewed three OR trials that indicated that the useof air and gel pressure overlays might be beneficial inreducing the incidence of pressure ulcers for high-risksurgical patients.3



According to research published by Reddy et al, mattressoverlays on the OR bed may decrease the incidence ofpostoperative pressure ulcers, along with adequate nutri-tion, moistening the skin and repositioning.3

Note: Rolled sheets and towels should not be usedbeneath the procedure bed mattress or overlay becausethey may negate the pressure-reducing effect of themattress or overlay.1

Position to protect and support1

• Pad bony prominences• Protect arms from nerve damage• Confirm finger locations• Carefully apply safety restraints to avoid

nerve damage• Ensure no body parts touch metal equipment• Elevate heels whenever possible• Align head and upper body with the hips• Keep legs parallel (do not cross ankles)• Position head in neutral position on a headrest• A pillow may be placed under the back of the

patient’s knees to relieve pressure on the lower back• If pregnant, insert a wedge under the right side• Do not tuck arms at patient’s sides unless

absolutely necessary

DocumentationHere’s a question. Should nurses document specificallywho does what when positioning a patient for a surgicalprocedure? According to legal experts, the nurse shoulddocument exactly who did what to make it easier to deter-mine liability in case of a lawsuit. Remember that everyonein the OR is responsible for their own actions.7 If the anes-thesia provider tucks the patient’s arm to the side, give thatperson the credit on the operative record. If the surgeonpositions the patient’s legs in stirrups, document that fact.Of course the nurse must always check to make sure allpressure points are padded or that pedal pulses are intactafter the legs are positioned.

It may be time-consuming and cumbersome to chart all ofthe specifics of positioning; however, it is advisable for thenurse’s protection. To simplify the task, a checklist couldbe developed, and the nurse could simply write the initialsof the responsible party next to each task performed.7

Documentation should include the following:1

• A written preoperative assessment, including askin assessment on arrival and discharge

• The type and location of positioning equipment• Names and titles of persons participating

in positioning• Position patient is placed in and new position if

repositioning occurs• Post-operative assessment for injury



If it’s not recorded, it didn’t happen5

A 60-year-old patient with multiple medical problemsunderwent 12-hour vascular reconstruction of the right leg.Sacral pressure ulcers were noted soon after, and despitetreatment, severe necrosis developed. The patient’s legwas amputated below the knee and the sacral ulcerrequired surgical debridement with grafting. The patientalleged negligence in positioning during surgery, whichresulted in severe sacral pressure ulcers that required pro-longed hospitalization and additional surgery. A review ofthe medical record revealed a lack of documentation by thesurgeon, anesthesiologist and the OR nursing staff regard-ing the patient’s increased risk for skin breakdown.Although serious skin breakdown may not have been pre-ventable, documentation of heightened awareness by staff,as well as preventive measures, and a description of thepatient’s skin after surgery, may have made it easier for thehospital to defend the case. The OR nursing documenta-tion lacked information on the condition of the patient’sskin, and the padding used to position the patient on theOR table. The patient received a $100,000 indemnity pay-ment and later sought additional compensation.

Thorough nursing documentation wins the case8

A patient sued her surgeon and the hospital over persist-ent numbness in her right hand, which she first noticedafter a total right hip replacement. Her lawsuit alleged thenumbness was an ulnar nerve injury from improper posi-tioning or the surgeon pressing against her arm or handduring surgery. All defendants were exonerated from blamedue to the effort made by the circulating nurse to docu-ment in precise detail how the patient had been positioned,stabilized and padded before surgery. Of special note wasthe nurse’s documentation of the steps taken to extend thepatient’s arms out of harm’s way and to pad her arms andhands to avoid injury due to positioning or pressure.

The court record reiterated the circulating nurse’s docu-mentation word-for-word: “6 table with safety strap in place2 in. above knees – supine with bean bag underneath pa-tient post induction & catheter insertion into the left side,with right side up, per __MD & __MD, - auxiliary roll in place(1000 cc bag IV fluid wrapped in muslin cover) – held inplace per surgeons until bean bag deflated with suction –pillow placed under right leg with left leg bent slightly – Udrape in place per surgeons pre-prep – left arm extendedon padded arm board - right arm placed on mayo tray thatis padded”

References1. Recommended practices for positioning the patient in the perioperative practice

setting. In: Perioperative Standards and Recommended Practices.Denver, Colo.:AORN, Inc. 2009.

2. Prevention of injuries in the anaesthetised patient. Available at: http://www.surgical-tutor.org.uk/core/preop1/perioperative_injuries.htm. Accessed October 23, 2009.

3. Walton-Geer PS. Prevention of pressure ulcers in the surgical patient. AORN Journal.2009;89(3):538-548.

4. Meltzer B. A guide to patient positioning. Outpatient Surgery. 2001;2(4). Available at:http://www.outpatientsurgery.net/issues/2001/04/a=guide-to-patient-positioning.Accessed December 3, 2009.

5. ECRI Institute website. Executive summary. Pressure ulcers. HRC.2006;3(4). Availableat: http://www.ecri.org/documents/patient_safety_center/pressureulcers.pdf.Accessed December 3, 2009.

6. Doerflinger DMC. Older adult surgical patients: presentation and challenges. AORNJournal. 2009;90(2):223-240.

7. For the nurse’s protection, it is advisable to document all specifics of positioning apatient for surgery. AORN Journal.1993;58(1):116.

8. Ulnar nerve injury alleged from surgery: hospital not liable – circulating nurse’sdocumentation of patient’s positioning carries the day. Legal Eagle Eye Newsletterfor the Nursing Profession. 1997;5(1):3. Available at: http://www.nursinglaw.com/ulnar.pdf. Accessed December 4, 2009.

Documentation Makes or Breaks the Case at Trial



Table 1Injury Risks and Safety Considerations When Positioning Patients1

Position Risk Safety Consideration

Supine

Prone

Lateral

Lithotomy

Pressure points, including occiput, scapulae,thoracic vertebrae, olecranon process,sacrum/coccyx, calcaneae, and knees.

Neural injuries of extremities, including brachialplexus and ulna, and pudendal nerves.

Head

Eyes

Nose

Chest compression, iliac crests

Breasts, male genitalia

Knees

Feet

Bony prominence and pressure points ondependent side

Spinal alignment

Hip and knee joint injuryLumbar and sacral pressureVascular congestion

Neuropathy of obturator nerves, saphenousnerves, femoral nerves, common peronealnerves, and ulnar nerves.

Restricted diaphragmatic movementPulmonary region

• Padding to heels, elbows, knees, spinalcolumn, and occiput alignment with hips,legs parallel and uncrossed ankles.

• Arm boards at less than 90-degree angleand level with floor.

• Head in neutral position.• Arm board pads level with table pads.

• Maintain cervical neck alignment.

• Protection for forehead, eyes, and chin.

• Padded headrest to provide airway access.

• Chest rolls (ie, clavicle to iliac crest) toallow chest movement and decreaseabdominal pressure.

• Breasts and male genitalia free from torsion.

• Knees padded with pillow to feet.

• Padded footboard.

• Axillary role for dependent axilla.• Lower leg flexed at hip.• Upper leg straight with pillow between legs.

• Maintain spinal alignment during turning.• Padded support to prevent lateral neckflexion.

• Place stirrups at even height.• Elevate and lower legs slowly andsimultaneously from stirrups.

• Maintain minimal external rotation of hips.• Pad lateral or posterior knees and ankles toprevent pressure and contact with metalsurface.

• Keep arms away from chest to facilitate respiration.• Arms on arm boards at less than 90-degreeangle or over abdomen.



True or False (circle one)

1. In the United States, nerve damage accounts for 15percent of postoperative litigation claims. T F

2. Patients who are 45 years of age and olderexperience the highest incidence of pressureulcer development. T F

3. Surgical documentation should include a writtenpreoperative assessment, including a skinassessment on arrival and discharge. T F

4. Patients are at increased risk of developingpost-operative vision loss if they are in a proneposition. T F

5. OR-acquired pressure ulcers initially have adistinctive greenish appearance. T F

Multiple Choice

6. The incidence of pressure ulcers occurring as aresult of surgery may be as high asa. 10 percentb. 82 percentc. 66 percentd. 38 percent

7. Which of the following affects the ability of the skinand supporting structures to respond to pressure?a. Obesityb. History of sleep apneac. Nutritional deficienciesd. Both a and c

8. Which of the following is an often overlookedbut vulnerable area that can benefit fromadditional padding?a. Calvesb. Heelsc. Nosed. None of the above

9. Use of too many pads or blankets can cause thecapillary pressure to rise overa. 19 mmHgb. 32 mmHgc. 76 mmHgd. 94 mmHg

10. The most common perioperative nerve injury isto thea. Lingual nerveb. Ulnar nervec. Brachial plexusd. Sciatic nerve

Back to Basics CE Questions

Submit your answers atwww.medlineuniversity.com

and receive 1 FREE CE credit

Perioperative Positioning Injuries on the Rise: What to Do!


TAKE THE PRESSURE OFFYOUR SURGICAL PATIENTS

It’s estimated that up to 66 percent of pressure ulcers occur as a result of

surgery.1 What can you do to help prevent your patients from becoming statistics?

Medline’s pressure redistribution OR table and stretcher pads can help

redistribute the pressure that can occur before surgery while lying on

stretchers, on the table during surgery and while being transported

to the postoperative care unit.

All of our OR table and stretcher pads are designed

with state-of-the-art materials to offer an

advanced level of pressure redistribution.

Each pad offers a different level of pressure

redistribution and can be custom-made

to fit any OR table. Finally — product

solutions to help you meet your pressure

ulcer prevention goals!

To sign up for a FREE webinar on perioperative pressureulcer prevention, go to www.medline.com/pupp-webinar.

Reference1 AORN. Recommended practices for positioning the patient in the perioperative practice setting. PerioperativeStandards and Recommended Practices. 2008 Edition. Denver, Colo.: AORN Publications; 2008.


Completely conformsto the body


PROTECTION, PERFORMANCE & COMFORT.

WITHOUT COMPROMISE

SensiCare® surgical gloves address a rising concern in the OR — latex allergies.

References:1American Latex Allergy Association. Latex Allergy Statistics. Available at: www.latexallergyresources.org/topics/LatexAllergyStatistics.cfm. Accessed November 5, 20082Phillips VL, Goodrich MA, Sullivan TJ. Health care worker disability due to latex allergy and asthma: a cost analysis. American Journal of Public Health. 1999:89(7):1024-28.©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

The American Latex Allergy Association estimates thatbetween 8 and 17 percent of all healthcare workers aresensitized to natural rubber latex.1 Studies have suggestedthat the costs of healthcare workers’ disability compensa-tion due to latex allergies justifies or significantly offsetsthe cost of conversion to a latex-free environment.2

Medline’s Sensicare® latex-free polyisoprene surgicalgloves are made from Isolex™ (synthetic polyisoprene) thathas a molecular structure that is virtually identical to natu-ral rubber latex.

In fact, it is softer, more elastic and more comfortable.So never compromise again. Choose the SensiCare®

glove that best fits your needs.

• SensiCare® with Aloe – standard thickness,smooth grip

• SensiCare® LT with Aloe – standard thickness,textured grip

• SensiCare® Green with Aloe – 10% thinnerfor enhanced tactile sensitivity

• SensiCare® Ortho – 40% thicker for extra protection

Get a FREE one-day supply of SensiCare surgicalgloves to try for yourself. To learn more, contactyour Medline representative, call 1-800-MEDLINE ore-mail [email protected].


Can a Rigid Container System BeGreener and Safer at the Same Time?

Unique rigid container benefits healthcare “greening” efforts

by Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT

Providing optimal safety for patients is a major responsibilityof any healthcare provider. One of the highest priorities shouldbe to promote patient safety by tackling problems and findingsolutions to known issues. In today’s healthcare environment,infection prevention plays a huge role in national initiatives toreduce healthcare-acquired infections (HAIs). This is particu-larly important for perioperative professionals in regard tosurgical site infections (SSI).

One critical way to minimize risks to surgical patients is topresent items that are sterile (free of contamination) at the timeof use. It is imperative that sterilization packaging systemsensure the integrity of the sterilized contents until opened foruse. The material or packaging device used for items to besterilized should provide a microbial barrier, protect packageintegrity, provide adequate seal integrity, allow for asepticpresentation and reduce the chance of contamination of thecontents once sterilized.1


OR Issues



Shelf lifeIt has been proven that sterility does not change over time,but is compromised by events that harm the integrity ofthe package and/or the environmental conditions. We referto the time that an item may remain on the shelf and stillmaintain sterility as shelf life.1,2,3

The integrity of sterile packaging can be compromised bymany things, such as poor package quality, improper stor-age conditions and excessive and/or abusive handling.2

Events that may lead to decreased package integrity andtherefore loss of sterility include:2

• Multiple handling• Moisture penetration• Exposure to environmental contaminants• Uncontrolled/unclean storage conditions• Improper type or configuration of packaging

materials used

Handling sterile suppliesAfter surgical instruments are sterilized and cooled, it isextremely important that they are handled carefully tomaintain sterility. “Care should be taken to avoid dragging,sliding, crushing, bending, compressing, or puncturing thepackaging or otherwise compromising the sterility of thecontents.”3

Sterile packages or trays must be handled several timeswhen they are placed on and pulled off storage shelves,placed on and off case carts, and then again when in theprocedure area or operating room. Due to the fast-pacedenvironment of the operating room, packages are notalways handled with the greatest of care and are some-times inadvertently subject to abuse (i.e., dropping). There-fore, we must place an increased importance on thehygienic security of sterilization packaging.

Package choicesThere are many available choices for sterilization packag-ing on the market today. A popular choice for numerousreasons is reusable rigid sterilization containers. Thesecontainers serve as packaging for surgical instrumentsbefore, during and after sterilization. Sterilization containersystems have been on the market for more than 25 yearsand vary in design, mechanics and construction materials.Reusable rigid sterilization containers require a barrier sys-tem (i.e., filters or valves) to maintain package integrity.4

Rigid container systems protect instruments, contain setsand help eliminate the chance of package compression,tears or holes that may be associated with other types ofpackaging, resulting in compromised package integrity.

Reusable containers are an environmentally friendly alter-native to disposable packaging. In the push for healthcare



1. Double LidSolid, double lid ensuresmaximum protection andcomplete hygienic security.Also allows safe transportationof soiled instruments aftera procedure.

2. Reusable ValvePatented, automaticvalve eliminates theneed for disposablefilters. It assuresreliable, cost-effective,maintenance-freesterilization.

3. ThermoLocPatented lockingsystem eliminatesthe need fordisposable,tamper-evidentlocks/arrows.

4. Condensate DrainTemperature-activateddrain removes excesscondensation fromcontainer.

facilities to become more “green,” reusable containersoffer an opportunity to reduce the carbon footprint.

A unique rigid container on the market is the Steriset con-tainer system manufactured in Germany by Wagner anddistributed by Medline®. Steriset does not require anydisposable filters or locks, which is an added benefit forour healthcare greening efforts.

According to the Sterilization Container Overview & Tech-nical Data sheet, Steriset containers are composed ofa completely closed double lid protection system that isexceptionally tamper proof and hygienically secure. Thecontainers are designed with a permanent reusable stain-less steel valve that opens and closes to allow steam to

enter and exit based on the steam pressure during thesterilization cycle. The containers are also equipped withreusable tamper-proof locks that are temperature-activated.5

Environmentally responsibleWith the national initiatives to reduce HAIs, healthcare pro-fessionals’ major concern is patient safety. Perioperativeprofessionals must do everything they can to helpdecrease the chances of surgical site infections. Steriliza-tion containers in themselves are much more environ-mentally friendly than sterilization wrap; however,eliminating the use of disposable filters or locks as wellmakes Steriset containers the “greenest” container ofthem all, thereby best meeting the need for both patientsafety and environmental responsibility.



These environmentally friendly containers are a betteralternative to those requiring disposable items, but do theyoffer any additional protection?

The container’s double lid is designed to provide completehygienic security, therefore adding an additional shieldfrom any external contaminants once sterilized. Further,with its permanent filter and lock features, Steriset requiresmuch less assembly time and significantly reduces thepossibility of user error during packaging – which can onlybenefit patient safety.

Does this design really help protect the con-tents against external contaminants while instorage? To validate the complete hygienic se-curity provided by Steriset against disposablefilters, an independent lab study was con-ducted by Q Laboratories Inc. in Cincinnati,Ohio.

Study design and methodologyA methylene blue strike-through test wasemployed to evaluate the rigid containers. Inthis analysis, tests were performed on emptycontainers. Two containers included the manu-facturer-recommended filter material assem-bled in the perforated lids and bottoms of thecontainers. The Steriset containers do notcontain any filters. A single sheet of wet facialtissue was placed over the bottom filters onthe inside of the two containers. A wet facialtissue was placed on the bottom of the Sterisetcontainer. After the lids were closed and latched, one tea-spoon of methylene blue dust was sprinkled on top of eachof the three containers.7

Each container was dropped three times onto a hard tablesurface from a height of 10 cm (3.9 inches). Following thedrop test, each container was placed into a closed cabinet,and the door was closed at normal force five times. Thenthe three types of container were again dropped threetimes onto a hard table surface from a height of 10 cm(3.9 inches). The lids were then carefully opened toobserve for any strike-through of the methylene blue onthe wet facial tissue inside of each container. In order toevaluate the degree of strike-through present, the lids and

filters were sprayed with distilled water. To obtain a thor-ough set of qualitative data, this entire procedure wasreplicated 10 times on each container. After each test,photos of the filters and moistened facial tissue were takenfor a visual comparison.7

Study purposeThe purpose of this study was to compare the Sterisetcontainer system with two other rigid container systemsthat use disposable filters and locks. The principle ideawas to evaluate the ability of each container to protect thecontents from environmental contaminants.6

Results of studyThe study results indicate that none of the Wagner Sterisetcontainers had any methylene blue strike-through residuepresent. The other two rigid sterilization containers hadstrike-through residue present at the conclusion of all 10trials tested. (See Table 1.)

Study conclusionWagner’s Steriset container is superior at eliminating thepossibility of external contaminants entering a closed con-tainer under storage and handling conditions. Steriset pro-vides extra protection because it is a closed designcontainer system with no pathway though the outer lid andinner valve, therefore bacteria cannot reach contentsunless opened.

Table 1. Test Results

SterisetContainer 1 Container 2 ContainerWith disposable With disposable No filtersfilter filter

Did the methylene blue strike through the filters?Trial No. 1 Yes Yes NoTrial No. 2 Yes Yes NoTrial No. 3 Yes Yes NoTrial No. 4 Yes Yes NoTrial No. 5 Yes Yes NoTrial No. 6 Yes Yes NoTrial No. 7 Yes Yes NoTrial No. 8 Yes Yes NoTrial No. 9 Yes Yes NoTrial No. 10 Yes Yes NoTotal number of strike-throughs

10 10 0



Other safety issuesBefore being opened, sterile packages should beinspected for package integrity. If the packaging is a rigidsterilization container system, the external latch, filters,valves and tamper-evident devices should be inspectedfor integrity. The lid should be inspected for the integrity ofthe filter or valve and the gasket.3 For disposable filters,this means the circulator must remove filter retentionplate(s) in order to do a complete inspection of the filterbefore the items are handled by the scrub person.

As mentioned earlier, Wagner’s Steriset container designhelps significantly reduce user errors that surrounddisposable filters and locks. Common errors include:• Forgetting to replace disposable filters before every use• Forgetting to inspect disposable filters for pinholesbefore every use

• Incorrectly replacing a disposable (i.e., not positioningit correctly)

• Forgetting to use disposable locks before sterilizingthe set

• Insufficiently securing disposable locks to ensure setit adequately sealed

All of the above insecurities are eliminated by the Sterisetcontainer design.

Event-related shelf life means dependence on the physicalintegrity of the sterile packaging. However, if dust is able tostrike through disposable filters in rigid containers; will theparticulates be visible to the naked eye?

SummaryAs choices continue to expand, perioperative nurses, aswell as sterile processing professionals, have an essentialrole in evaluating and selecting products that may affectthe quality of care and safety of the surgical patient whilebeing more ecologically responsible.8

When it comes to product selection, patient safety shouldbe the principal concern. In an effort to do all we can tohelp decrease the chance of surgical site infections in ourpatients, additional safety margins that help protect sterileinstruments from external contaminants are definitelyworth considering.

Steriset Sterilization Containers manufactured by Wagner are protected under UnitedStates Patent No: US 6,620,390.

Medline is a registered trademark of Medline Industries, Inc.Steriset is a registered trademark of Wagner GMBH Company

References1.Recommended practices for maintaining a sterile field. In: Standards,

Recommended Practices, & Guidelines. Denver, CO: AORN, Inc.;2009.2.Recommended practices for selection and use of packaging systems for sterilization.In: Standards, Recommended Practices, & Guidelines. Denver, CO:AORN,Inc.; 2009.

3.Comprehensive guide to steam sterilization and sterility assurance in health carefacilities. ANSI/AAMI ST79:2006, A1:2008 and A1:2009. Arlington, VA: Associationfor the Advancement of Medical Instrumentation; 2009.

4.Containment devices for reusable medical device sterilization. ANSI/AAMI ST77:2006.Arlington, VA: Association for the Advancement of Medical Instrumentation; 2006.

5.Medline Industries. Sterilization Container Overview & Technical Data page. Availableat: http://www.medline.com/products/centralsterile/steriset-sterilization-containers.asp.Accessed July 24, 2009.

6.Proposal for the evaluation of the methylene blue test for sterilization of containers.Q Laboratories, Inc., Cincinnati, OH. Aug. 14, 2008.

7.Crowley, E. Final report: an evaluation of sterilization containers using the methyleneblue test. Q Laboratories, Inc. Cincinnati, OH. September 2008.

8.Recommended practices for product selection in perioperative practice settings.In: Standards, Recommended Practices, & Guidelines. Denver, CO: AORN, Inc.;2009.

About the author

Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT,is president/CEO of Seavey Healthcare Consulting Inc., andformer director of the sterile processing department at TheChildren’s Hospital of Denver. Rose is an elected member of the2008-2010 Association of periOperative Registered Nurses(AORN) Board of Directors. She was honored with AORN’saward for Outstanding Achievement in Clinical Nurse Educationin 2001. She has authored many articles on various topicsrelating to perioperative services and sterile processing.


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For more information on the Pressure UlcerPrevention Program, contact your Medlinerepresentative, call 1-800-MEDLINE or visitwww.medline.com/pupp-webinar to registerfor a free informational webinar.

References1Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.


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O.R. FIRES

NEWRECOMMENDATIONS

FOR PREVENTIONAligning practice with policy to improve patient care 39

Although surgical fires are relatively rare, their effectsare almost always tragic. Healthcare professionals werereminded once again of this chilling fact when a 65-year-oldwoman died September 8, 2009, six days after being burnedin a flash fire during surgery at a Marion, Ill. hospital. Accord-ing to the medical examiner, the woman died from complica-tions of thermal burns. Further details have not been releasedpublicly.1

Virtually all operating room fires ignite on or in the patient,causing considerable injury or even death. The ECRI Institute,an independent not-for-profit organization that researchesapproaches to improving patient care, estimates that 550 to650 surgical fires occur among the 65 million surgical casesperformed in the United States each year. Of those fires,about 20 to 30 are serious, resulting in disfiguring or disablinginjuries. One or two result in patient deaths.2 The good newsis that similar to many other healthcare-related errors, surgicalfires are 100 percent preventable.3

The ECRI Institute released new surgical fire safety guidelinesin October 2009, which are based on their own research andinvestigations and collaboration with the Anesthesia PatientSafety Foundation (APSF) and the American Society of Anes-thesiologists (ASA) surgical fire task force. The primarychange in the new guidelines is the recommendation todiscontinue the traditional practice of open delivery of 100percent oxygen during surgery of the head, face, neck andupper chest. The purpose for this recommendation is toprevent the formation of oxygen-enriched atmospheres nearthe surgical site, reducing the likelihood of fires.2

The fire triangle4

Understanding the elements needed to create a fire is the firststep toward learning how to prevent a fire. Three basicelements – known as the fire triangle – are necessary toignite a fire and keep it burning. The elements are oxidizers,ignition sources and fuel. In the operating room, oxidizersinclude oxygen supplied for the patient, as well as nitrous

OR Issues



oxide. Examples of ignition sources are electrosurgical and elec-trocautery devices, heated probes, defibrillators, lasers andfiberoptic light sources and cables. Fuel sources include certainprepping agents and ointments, linens, dressings, the patient’shair and anesthesia components.

How to prevent surgical fires2

The most obvious and easiest method of fighting fires is toprevent them from starting, primarily by making sure the threeelements of the fire triangle never combine in the operating room(OR). This task is achieved by controlling ignition sources, man-aging fuels and minimizing oxygen concentration.

Similar to best practices for protecting patients from healthcare-acquired injury in the OR, fire prevention must be a team effort.For the most part, anesthesia professionals control oxidizers,surgeons control ignition sources and nurses control fuelsources. Each team member should understand the fire haz-ards associated with each side of the fire triangle and do theirbest to keep those elements apart.

Minimizing oxidizers. High oxygen concentration, includingthe oxygen contributed by nitrous oxide, enhances theignitability of most fuels. Conversely, minimizing the percentageof oxygen flowing around the patient will reduce the fire risk.

According to new guidelines, except for certain cases, thetraditional practice of open delivery of 100 percent oxygenshould be discontinued. In the majority of cases, room air or alow concentration of oxygen balanced by an inert gas (e.g.,nitrogen, helium) may be adequate for ventilation and thusreduce the fuel-ignition risk.

If supplemental oxygen is needed during surgery, the patient’sairway should be sealed using a tracheal tube or laryngeal mask.

Controlling ignition sources. Electrosurgical devices are themost common ignition source in surgical fires. These devicescan produce a high-temperature electric arc or incandescenceat the probe tip. Surgical fires also can start if electrosurgicalelectrode cables spark. This problem usually occurs with

Oxi

dize

rsIgnition

source

Fuel

The Surgical Fire Triangle

Oxidizers(Mainly controlled byanesthesia providers)- Air- Oxygen- Nitrous oxide

Fuel (Mainly controlled by nurses)- Prepping agents - Anesthesia components- Linens - Patient’s hair- Dressings - Tracheal tubes- Ointments - Intestinal gases

Ignition sources(Mainly controlled by surgeons)- Electrosurgical devices- Electrocautery devices- Lasers- Fiber optic light sources- Defibrillator paddle or pads


reusable monopolar cables that connect to an active electrode,such as those used in laparoscopy. (Note: The ECRI Institutereports that to their knowledge, there has never been a reportof a fire with bipolar electrosurgery; only monopolar.)

Sparking typically results from cable failure at the activeelectrode connector or at its strain relief. The cable’s internalconductor strands become severed over time from use andhandling during sterilization. A scheduled program of periodiccable replacement is one way to avoid this problem.

Managing fuels. Allotting sufficient time after patient preppingand before draping allows vapors and gases to dissipate. Wherevolatile liquid exists, so does the risk of fire. Volatile fuels, suchas alcohol, collodion and acetone, can take several minutes tofully vaporize, and a few minutes more to become diluted inroom air. Care should be taken to avoid or minimize pooling ofvolatile liquids – particularly under the patient, where they maynot be noticed. Taking the time to check that these volatile fuelshave fully evaporated on and under the point of application willprevent them from being ignited when electrosurgery or otherheat-producing devices are in use.

Developing a fire plan that includes fire drillsBeing prepared for a fire will minimize the cost in dollars, losttime, emotional shock and injury or death. Preparation involvesa number of steps—the most important of which is practicingfire drills that teach all staff about their responsibilities during afire. Having a predetermined method of fighting a surgical fireso that every team member knows what to do is criticallyimportant.2

A 2008 Practice Advisory published by the American Society ofAnesthesiologists notes that all team members should take ajoint and active role in agreeing on how a fire will be preventedand managed. Each team member should be assigned a spe-cific fire management task to perform in case of a fire. If a teammember completes a pre-assigned task, he or she should helpother team members perform their tasks.5

Practice drills for fires on and in the patient are especially crucialto ensure OR staff knows how to:• keep minor fires from getting out of control• manage fires that do get out of control• locate and properly use fire-fighting tools; medicalgas valves; heating, ventilation, and air-conditioning(HVAC) controls; and electrical supply switches

• operate the fire alarm and communication system

Although many facilities, in compliance with Joint Commissionrequirements, conduct drills for evacuating the OR in the eventof a major fire, drills for the surgical team for fighting firesinvolving the patient are rare—and should not be.

Operating Room Fire Equipment and Suppliesto Keep Immediately Available5

• Several containers of sterile saline• A CO2 fire extinguisher• Replacement tracheal tubes,guides, face masks

• Rigid laryngoscope blades; this mayinclude a rigid fiberoptic laryngoscope

• Replacement airway breathing circuitsand lines

• Replacement drapes, sponges

Note: Your operating room may benefit from assembling a portablecart containing equipment and supplies to expedite immediate responseto an operating room fire. The contents of this cart will vary dependingon your procedures and resources.

What to do if the patient is on fire2

Most fires in the OR will be either on or in the patient. In eithercase, quick action will avert a disaster. Smoke, the smell of fireor a flash of heat or flame should prompt a fast response. In30 seconds or so, a small fire can progress to a life-threateninglarge fire. During any fire, protecting the patient is the primaryresponsibility of the staff; self-protection is a secondaryconsideration.


The primary change in the new guidelines is the recommendation todiscontinue the traditional practice of open delivery of 100 percentoxygen during surgery of the head, face, neck and upper chest.



To contain the flames, the fire triangle must be disrupted bydiminishing or removing one or all of its sides. For example,a small area of burning drape or gown can be patted outeffectively and safely by hand; larger areas can be smotheredeffectively with a fire blanket or towel. Fires inside the patientare typically small, but can be deadly. Practicing for an airwayfire, such as from a burning tracheal tube, can develop thespeed that will minimize injury in a real emergency.

Closing thoughtsStopping small fires before they become big fires – orpreventing them altogether – requires a team effort. Goodcommunication among the surgical team can ensure fire-safepractices.

If a surgical fire occurs, the anesthesia provider should stopthe flow of gas; the surgeon should remove the burningmaterial and the nurses should extinguish the burning mate-rial. Once the fire has been extinguished, attention must beturned to the patient, resuming ventilation but using only airuntil it’s certain the fire is totally out, then resuming use ofoxygen appropriate to the patient’s needs; controlling bleeding;evacuating the patient (if in danger from smoke or fire) and thenexamining the patient for injuries.

References1 Suhr J. Woman catches fire during surgery. Associated Press. September 17, 2009.Available at: http://news.aol.com/article/woman-dies-after-catching-fire-during/675219?Accessed September 27, 2009.

2 New clinical guide to surgical fire prevention. Health Devices. 2009; 38(10):314-332.3 AORN guidance statement: fire prevention in the operating room. In: Standards,

Recommended Practices & Guidelines. Denver, Colo.: AORN, Inc.; 2009:171-179.4 Mathias, JM. Scoring fire risk for surgical patients. OR Manager. 2006;22(1).5 Practice advisory for the prevention and management of operating room fires.

Anesthesiology. 2008; 108(5):786-801. Available at: http://journals.lww.com/anesthesiol-ogy/Fulltext/2008/05000/Practice_Advisory_for_the_Prevention_and.6.aspx. AccessedSeptember 28, 2009.

All-new guidelines regarding open deliveryof oxygen in the operating room2

• Use only air (not oxygen) for open delivery to the face ifthe patient can maintain a safe blood oxygen saturationwithout supplemental oxygen.

• If the patient cannot maintain a safe blood oxygen saturationwithout extra oxygen, secure the airway with a laryngealmask airway or tracheal tube.

Exceptions: The following recommendations are for surgeryin which the patient’s verbal responses may be required – suchas carotid artery surgery, neurosurgery and pacemaker insertion– and where open oxygen delivery is required to keep thepatient safe. At all times, deliver the minimum oxygen concen-tration necessary for adequate oxygenation (as monitored witha pulse oximeter).• Begin with a 30 percent oxygen concentration andincrease as necessary.

• For unavoidable delivery above 30 percent, deliver fiveto 10 L/minute of air under drapes to wash out excessoxygen.

• Stop supplemental oxygen at least one minute beforeand during use of electrosurgery, electrocautery or laser,if possible. Surgical team communication is essential forthis recommendation.

• Use an adherent incise drape, if possible, to help isolatehead, face, neck and upper-chest incisions fromoxygen-enriched atmospheres and from flammablevapors beneath the drapes. The incise drape can helpprevent gas communication channels between theunder-drape space and the surgical site.

• Keep fenestration towel edges as far from the incisionas possible to prevent their ignition from electrosurgicalflames or sparks.

• Arrange drapes to minimize oxygen buildup underneath(such as from an uncuffed tracheal tube or a laryngealmask airway) and to direct gases away from theoperative site.

• Coat hair on head and face within the fenestrationwith water-soluble surgical lubricating jelly to make itnon-flammable.

• For coagulation, use bipolar electrosurgery, notmonopolar electrosurgery.


Mark Bruley Talks AboutNew Surgical FirePrevention Guidelines

Vice President,Accident andForensicInvestigation,ECRI Institute

The OR Connection had the opportunity to interview surgicalfire safety expert Mark Bruley in October 2009, shortly afterpublication of the new ECRI Institute surgical fire safety guide-lines, which he authored. As a forensic investigator for the ECRIInstitute for the past 30 years, Bruley has acquired a wealth ofknowledge and data through numerous on-site surgicalfire investigations and related research at the ECRI Institutelaboratories.

Bruley said that in terms of well-researched, evidence-basedrecommendations, the newly published surgical fire safetyguidelines are “at the pinnacle of recommendations. Theserecommendations are supported by the physics of fire and thephysics of anesthesia machinery.”

The new ECRI Institute guidelines came about coincident withBruley and his colleagues being approached by the AnesthesiaPatient Safety Foundation (APSF) – an affiliate of the AmericanSociety of Anesthesiologists (ASA) – to create an updatedsurgical fire safety educational video.

“As we began working on the video,” Bruley said, “we cameupon pragmatic problems regarding the exceptional surgicalcases that require open delivery of oxygen and the logistics ofhow to provide blended air and oxygen in the operating room.”Exceptional cases are those where a patient may need tospeak during the surgery.

As a traditional course of practice, the majority of surgeriesunder monitored anesthesia care (MAC) of the head, face,neck and upper chest have involved open delivery of 100 per-cent oxygen, however, the ECRI Institute’s years of surgical fireinvestigations have shown a strong correlation between surgicalfires and this practice. Therefore, they recommend avoidingthe use of open delivery of oxygen whenever possible anddelivering medical air instead. For patients who need extraoxygen, they recommend securing the airway with a trachealtube or laryngeal mask airway. That recommendation isendorsed by APSF.

For the exceptional cases when open delivery is necessary, theanesthesia provider should blend air and oxygen to provide alower percentage of oxygen. But because open delivery of oxygenhas been routine for so long, the prospect of changing thisclinical practice led to considerable debate among anesthesiaproviders and surgical fire prevention specialists.

In order to address these issues, the guidelines neededto explain how to provide a blended air and oxygen mixturein those exceptional cases when open delivery of oxygenwas required.

“The problem with open delivery of oxygen is that the oxygenwill exhaust at the patient’s head and neck, which presents aflash fire hazard,” Bruley said. To minimize this effect, the ECRI


Special Feature



Institute’s new guidelines recommend a variety of techniquesto use in those exceptional cases when the patient requiresopen delivery of oxygen, including:1

1. Delivery of the lowest percentage of oxygen possibleto maintain patient safety

2. Beginning with 30 percent delivered oxygenconcentration and increasing as necessary

3. Delivery of 5 to 10 L/min of air under drapes to washout excess O2

4. Stopping supplemental oxygen at least one minutebefore and during use of an ignition source suchas electrosurgery

According to Bruley, with oxygen levels at 30 percent or below,there is no flash fire hazard. ECRI Institute recommendsbeginning with 30 percent oxygen, and titrating up only if nec-essary to maintain the patient at a healthy oxygen level. “Flashfires, which begin in an instant, will occur during surgery onlywhen oxygen levels are between approximately 40 and 100percent,” Bruley said.

This new approach, however, of blending air and oxygen bringsabout a logistical dilemma. Not all anesthesia equipment isdesigned to deliver blended air and oxygen. So how can theblending be achieved?

According to the ECRI Institute’s 2009 guidelines, threeapproaches are recommended for blending oxygen:1

• Use an oxygen-air blender. This is the preferredand most reliable approach because it is the simplest.

• Use a three-gas (air, oxygen, N2O) anesthesiamachine that has a common gas outlet (CGO)and take the blended gas from the CGO.

• Use the breathing circuit wye on an anesthesiamachine that does not have an available CGO.Close the APL valve on the absorber for fasterchanges in the delivered oxygen concentration.

Regardless of how the oxygen-air mixture is obtained,monitoring of the delivered oxygen by the anesthesia provideris recommended to ensure that the gas mixture is as desired.

How to minimize riskwhen a surgical fire occurs2

In spite of taking precautions to prevent surgical fires, they canand do occur. If a fire or other serious incident ever takes placein your operating room, the ECRI Institute advises taking thefollowing steps immediately in order to minimize risk and pre-serve evidence for later forensic investigation.• Take emergency measures to minimize and care for injuryto, discomfort of, and threat to life of patients and staff.

• Take appropriate action to minimize damage to equipmentand the environment.

• Notify the attending clinician who has legal responsibilityfor the patient.

• Impound all equipment attached or contiguous to theinjured party in the same room or areas.

• Do not disconnect or change the relative physicalpositions of equipment or connecting cables, exceptas absolutely necessary to avoid further injury or damage.

• Retain and preserve any disposable products that mayhave been involved (e.g., drapes, electrodes), as wellas their packaging materials.

Free educational posters on surgical fire prevention and extin-guishment are available at ECRI Institute’s surgical fire websiteat www.ecri.org/surgical_fires. See also pages 84 – 85.

Locations of Surgical Fires1

On the patient

In the airway

On the head, neck, or upper chest

Elsewhere in the patient

Elsewhere on the patient

In the patient

44%

21%

8%

26%

Flash fires will occur during surgery only when oyxgenlevels are between approximately 40 and 100 percent“ ”

References1 New clinical guide to surgical fire prevention. Health Devices. 2009;38(10):314-332.2 Accidents happen – an immediate action plan. The ECRI Institute website. Available at:https://www.ecri.org/Products/PatientSafetyQualityRiskManagement/CustomizedSer-vices/Pages/Immediate_Action_Plan.aspx. Accessed November 2, 2009.



SCORING

FIRE RISKFires in the operating room are a risk that requires prevention,

vigilance, and quick action to prevent patient injury. To heighten

awareness, the Christiana Care Health System (CCHS) in Newark,

Del., added a Surgical Fire Risk Assessment Score to its

Patient Identification and Surgical Site documentation form.

FOR SURGICAL PATIENTS

OR Issues



“What brought this issue to our attention were two surgi-cal fires. One occurred in the electrophysiology lab andthe other in the OR with a patient having a carotidendarterectomy. Both cases involved a high concentrationof oxygen, surgery above the xiphoid, and a heat source,”Judith Townsley, RN, MSN, CPAN, director of clinicaloperations for perioperative services, told OR Manager.

The chairman of the anesthesiology department, KennethSilverstein, MD, developed the fire risk assessment scoreafter the fires were investigated by ECRI Institute(www.ecri.org), a not-for-profit organization thatresearches health services and technology, and RussellPhillips & Associates (www.phillipsllc.com), consultants infire, code compliance and emergency management.

Assigning a fire risk scoreThe fire risk assessment is performed by the entire surgicalteam (anesthesia provider, surgeon and nurse) before theincision is made and is documented by the circulatingnurse, noted Denise Dennison, RN, BSN, CNOR, staffdevelopment specialist.

The assessment requires the surgical team to identify thethree key elements that are necessary for a fire to start –the fire triangle:

• Heat• Fuel• Oxygen

In the OR, three key risks are:• Surgical site or incision above the xiphoid• Open oxygen source (i.e., patient receiving

supplemental oxygen via face mask or nasal cannula)• Available ignition source (i.e., electrosurgery unit, laser

or fiberoptic light source)

The surgical team at Christiana Care Health Services inNewark, Del., follows a surgical safety checklist as they per-form a pre-incision team briefing. The checklist is mounted onthe opposite wall and includes the components of the surgicaltime out and the fire risk assessment score. Pictured, left to right:scrub nurse Judy Saunders, CST; anesthesia provider RonCastaldo, CRNA; surgeon Mike Conway, MD; assistant PaulAguilon (medical student) and circulator Kelly Saunders, RN.

Score 3 = High risk.All three components of the fire triangle are present.

Score 2 = Low risk with potential to convertto high risk.

This score is given when the procedure is in thethoracic cavity, the ignition source is remote from anopen oxygen source, the ignition source is close toa closed oxygen source, or no supplemental oxygenis used.

Score 1 = Low risk.Only supplemental oxygen is being used.

Each risk score has a fire protocol assigned to maximizepatient safety. The documentation form allows the circu-lating nurse to indicate that the high-risk protocol wasinitiated. It also allows for documentation that sufficienttime was allowed for fumes to dissipate when an alcohol-based prep solution is used.



Fire Risk Protocols

Score 3 = High riskThe circulating nurse and anesthesia provider takethese precautions.

Circulating nurse• Verifies fire triangle, including verbal confirmationof the oxygen percentage

• Ensures appropriate draping techniques tominimize oxygen concentration under the drapes

• Minimizes ESU setting• Assesses that enough time has been allowedfor fumes of alcohol-based prep solutions todissipate (minimum of 3 minutes)

• Encourages use of wet sponges• Ensures a basin of sterile saline and bulb syringeare available for fire suppression

Anesthesia provider• Ensures that a syringe full of saline is in reach forprocedures conducted within the oral cavity

• Documents oxygen concentrations and flows• Uses the MAC circuit for oxygen administrationinitially at FiO2 of .30 using fresh gas flows of atleast 12 L/min.

Score 2 = Low risk with potential to convertto high riskStandard fire safety precautions are followed with thepotential to convert to high-risk precautions if necessary.

Standard precautions are to:• Observe alcohol-based prep drying times(minimum of 3 minutes)

• Protect heat sources (e.g., using the ESU pencilholster)

• Use standard draping procedure

Score 1 = Low riskStandard fire safety precautions are followed.

Communication heightens awarenessSince adding the fire risk assessment to the OR docu-mentation, communication among the surgical team mem-bers as well as identification of the fire risk triangle havevastly improved, noted Dennison.

“The secret to success of this process is that this formalcommunication and documentation makes everyoneinvolved aware of the potential risk of a fire,” Townsleysaid. “Enhancing communication between providers hasstrengthened our focus on providing clinical excellence forour patients.”

ReferencesBruley ME. Surgical fires: Perioperative communication is essential to prevent this rarebut devastating complication. Qual Saf Health Care. December 2004;13:467-471.Meltzer HS, Granville R, Aryan HE, et al. Gel-based surgical preparation resulting inan operating room fire during a neurosurgical procedure: Case report. Neurosurg.April 2005;102:347-349.Paugh DH, White KW. Fire in the operating room during tracheostomy: A case report.AANA J. April 2005;73:97-100.

Reprinted with permission from OR Manager, copyright ©2006.

The surgical site fire risk assessment guide(above) was developed by Kenneth Silverstein,MD, anesthesiologist and chair of theanesthesiology department at ChristianaCare Health Services. He developed theguide to help prevent surgical fires atthe hospital.



Breaking Free From Our Cultural Chains

Human beings rarely, if ever,succeed at accurately perceivingtheir own culture.

So deeply entrenched is culture that no one talks aboutit: the unspoken rules and behaviors (called norms) arenever written down, and yet everyone knows them. Welearn these norms the hard way through the process ofassimilation into a culture. For example, when Shelli wasa new scrub nurse with only six months’ experience,she failed to anticipate that the surgeon would need aparticular scalpel. Immediately, her experienced pre-ceptor deftly handed the correct blade to the im-patient surgeon with a glare in Shelli’s direction.At that moment, Shelli learned that if she was not on topof the surgeon’s needs, she would end up feelingembarrassed and looking incompetent. Shelli did notfind this information in her orientation manual.

Culture also determines what we see – and what wedon’t. Scrub nurses do not innately “know” which sur-geon tolerates technical questions or joking and whichones do not, or what subjects are acceptable to talkabout among their team. They figure this out. Humansquickly pick up on these subtle cues and then actaccordingly. Like any group, operating teams learnnorms by induction and trial and error because the needto belong is so strong. So without a conscious thought(whether scrub nurse, anesthesiologist, tech or surgeon),

By Kathleen Bartholomew, RN, RC, MN


we mimic the behaviors of those around us in order to beaccepted. After a while, no one even notices the subtle,unspoken rules. And why would they? Everyone exhibitsthe same behaviors. The norms are now downloaded intoour subconscious mind.

Culture even determines our perception of the scrubnurses’ work – much of which goes unnoticed. In a reviewof 13 papers looking at scrub nurse skills, there were nobehaviors that could be classified as leadership or decision-making.1 The vast amount of problem-solving, anticipationand critical decision-making that scrub nurses demonstrateconstantly during surgery is invisible.

In addition to operating room norms, each subgroup has itsown specific norms as well. For example, residents learnquickly that asking questions is a sign of vulnerability andweakness; and to protect each other no matter what.2

Scrub nurses learn to assess situations without interrupting,and they read surgeons’ demeanor to sense the appropriatetime to ask a question. This is known as “prudent silence.”3

Some group norms have to do with errors, i.e., “Don’t everspeak about a sentinel event outside these walls.” And forthose who break these unspoken rules, there are seriousrepercussions – the worst of which is being ostracized fromthe group. There is nothing more painful for any humanbeing, no matter the role or education level.

Group ThinkWhen individuals merge and form a group there are alwaysthings they can do, things they must do and things theycan never do. For example, healthcare workers do nottypically share their feelings in high-tech, high-pressureenvironments because feelings are perceived by thegeneral culture to be “soft stuff.” Ironically, this belief couldn’tbe further from the truth. Feelings not only matter, but areconveyed unconsciously, because 93 percent of allcommunication is non-verbal. If you think someone doesn’tlike you, they probably don’t. In a study of collaborationamong residents, nurses and physicians, the single mostimportant factor in producing positive collaborativeoutcomes turned out to be affect. Our bodies consistentlyexpress what we feel.4

Another overarching cultural imperative holds that in adangerous environment, the group must stay together inorder to stay safe. In one case, a surgeon accidentallybegan incising the wrong breast for a mastectomy proce-dure. The incision was only an inch long when the circulatorscreamed and the physician stopped, acknowledged themistake, and sewed up the cut. After the operation, thesurgeon called his team together in the room and said:“I need to know that you are with me on this one. There isabsolutely nothing to be gained by telling this patient whathappened. I’m asking for your support to tell her that theincision on her left breast was exploratory.”

This misuse of power tells us more about the culture thisphysician is ‘leading’ than any statistic ever could; and hisuse of coercion raises the impetus to be safe to a higherstatus than even ethics.



OR Issues


S.T.O.P.™ FOR SAFETY.

References1The Joint Commission. The Statistics page. Available at:http://www.jointcommission.org/NR/rdonlyres/D7836542-A372-4F93-8BD7-DDD11D43E484/0/SE_Stats_12_07.pdf. Accessed March 13, 2008.

* Patent pending


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In the operating room, each player has a specific role: sur-geon, scrub nurse, circulator, perfusion specialist, etc. Eachrole also comes with a set of expectations for behavior. Ontop of this, every operating room has its own unique culture.For example, scrub nurses in the United Kingdom perceivedtheir main responsibility was to not upset the surgeon andto keep the surgeon happy.1

Ignorance SquaredEducators often state that the worst knowledge deficit iswhen “You don’t know what you don’t know.” So if we areso deeply entrenched that we can’t perceive our own cul-ture, then how do we rationally and logically assess whetherour operating room is, for example, a just culture or a blameculture? A collegial interactive team or just a group of peo-ple working in the same place at the same time? We learnabout the culture by listening to their stories.

The Play of “Human Error”The drama in our worlds will tell us more about our culturethan anything else because it is riddled with feelings: anger,shame, embarrassment, hurt and grief. These are powerfulemotions felt at one time or another by every member of theteam simply because we are human beings working in acomplex, high-stress environment with the same peopleevery day. When humans work that closely and frequently,their relationships become the dominant value. Dana Jackcalls this “self silencing.”5 Healthcare workers silence them-selves because they value the relationship with their cowork-ers more than anything (even the patient) and fear reprisal.On a very primal level we are keenly aware that our survivaldepends on the group’s survival. A deeply worrisome ex-ample of this comes from a new study where 80 percent ofnurses demonstrated knowledge of best practice for oxy-tocin administration during delivery, yet only 22.5 percentwould actually implement the appropriate clinical action ifthe physician asked them to increase the dose.6 There isnothing stronger than culture – not even education. Notupsetting the physician even trumps best practice.

Groups quickly learn not to speak up about certain issues.One OR team feared they would be diminished in the eyesof their peers when a sentinel event wasmade public, missingentirely the opportunity to use their experience for teaching,improving the system and building a healthy culture aroundmistakes. Unknowingly, our well-intentioned but predictableresponses perpetuate the predominant culture. Humansunder stress will consistently default to previously learnedbehaviors and responses.

Standing up to the predominant culture is a monumentaltask. This quest is better undertaken as a team because ofthe critical amount of support that is needed in any organi-zation to produce adaptive change. For example, at Cincin-nati Children’s Hospital, every employee computer whenturned on displays an icon labeled “Patient Safety Tracker”in the upper right hand corner stating how long it has beensince harm has come to a child in their care. If an eventoccurs, you can then click on another box for details of theevent, which are general knowledge. The result: no oneloses focus. This admirable demonstration of transparencytakes phenomenal leadership and support from the bedsideto the boardroom.

In the healthcare culture, however, transparency and opendialogue are the exception rather than the rule. Instead ofthese healthy behaviors, several other survival behaviorshave been observed. Sometimes leaders inadvertently

The Behaviors We Can Expect• Human error - inadvertent action; inadvertentlydoing other than what should have been done;slip, lapse, mistake. CONSOLE

• At-risk behavior – behavioral choice thatincreases risk where risk is not recognized,or is mistakenly believed to be justified. COACH

• Reckless behavior - behavioral choice toconsciously disregard a substantial andunjustifiable risk. PUNISH




divert their group’s attention away from the real issuebecause it is too volatile, painful, or simply, unpredictable. Inthis way, the group is once again united – although dys-functionally. In one emergency room, for example, staff werefurious with the ICU and would complain incessantly abouthow poorly they were treated by this department. As Dr. Philwould say, “What’s this doing for you?” In this case, as inmany others, having a common enemy united the group.Another behavior that fuels an unhealthy culture occurswhen groups or individuals are at odds with each other.They never sit down at the same table face-to-face. If theydid, then the rumors and gossip might end the saga thatsustains them. The sad reality is that well-intentioned peopleare unaware of the strong emotional maneuvers designed ata very primal level to simply keep the group safe.

Emotions and the Blame CultureEmotional drama is more prevalent in a blame culture thana just culture because the ethos of a just culture re-focuseson the event as an opportunity to learn and share. When anevent is submerged, defensive emotions will emerge largerthan life every time. Another indication of a blame culture issecrecy. Members of the team being kept in the dark abouta serious incident is another indication of a blame culture.

In a healthy safety culture every surgeon, tech, scrub andcirculator would know about an error or near-miss as soonas possible in order to produce a heightened sense ofawareness and to decrease the chances of the same erroroccurring again. Clearly, these events are complicated, andit often takes time to gather information. But information isshared as it is gathered with the whole team. Unbelievableas it seems, this is just not happening at most healthcarefacilities, and our well-respected leaders fail to see their ownbehavior. For example, one day a surgeon shared the detailsof a disturbing sentinel event that happened to him just afew days earlier. Yet his colleague sat next to him obliviousand uninterested in his dilemma because, after all, it didn’thappen to him – even though they worked in the same OR!

The Second VictimIn every sentinel event, there is more than one victim. Thefirst is the patient – harm or vulnerability to harm is tangible,perceived and acknowledged. The victim’s emotional stateis tended to very carefully. We invest a great deal of time andemotional energy in understanding the impact of the erroron the individual and their family. Forms are filled out docu-menting the error and we work diligently through root causeanalysis to change our system and processes so that the

“The single greatest impediment to error prevention in the medicalindustry is that we punish people for making mistakes.”

– Dr. Lucian Leape



event never has the opportunity to occur again. But thereare other victims as well whose pain is not so visible.

In the healthcare culture, we seldom speak about the sec-ond victim – the scrub, tech or surgeon who assumeswhether rightly or not, that they could have anticipated orprevented the event; who beat themselves up and privatelygrieve their role in the play of “Human Error.” The impact ofmistakes on clinicians is devastating. Any healthcare workerwill confirm the difficult process of forgiving themselves –especially if the event results in harm or death. Unfortunately,the current system frequently does not provide the conso-lation and solace they so desperately need.

Blame vs. Just CultureThere is a movement in the healthcare industry to shift froma blame culture toward a just culture. This call to action isbeing heralded by concerned patient safety advocates. Ablame culture is characterized by secrecy, overt or covertpunishment for mistakes, ostracism and strong emotionalresponses such as blaming and shaming. Individuals areoften targeted (named) and the focus is “who did what?”rather than on system issues. This is “the way we’ve alwaysdone it.” A just culture is characterized by open dialoguesurrounding errors, inclusion of all involved, a clear under-standing of whether the error was human error, at-risk orreckless behavior and appropriate management response7

as well as a focus on processes, learning and sharing.

Research shows that the hospital culture in and of itself is agood indicator of whether a just or blame culture prevails.Some hospitals have a command and control-based

philosophy, whereas others are engaged in a commitment-driven philosophy. A consistent pattern emerged from theresearch: a blame culture is more likely to occur in hierar-chical organizations, and a just culture is more likely to occurin institutions that actively engage employees in thedecision-making process.8 In other words, the greater thenumber of hoops you have to jump through to get what youneed to do your job, the greater the hierarchy and thegreater the tendency toward a blame culture. Successfulpatient safety programs are not top-down driven initiatives.They are a core value.

ConclusionIn 1999 Dr. Lucian Leape, a professor at the Harvard Schoolof Public Health, briefed a congressional sub-committee onthe state of human error management in health care. Sadly,the statistics from a decade ago have not changed. Anestimated one million people are injured by treatment errorsat hospitals every year, resulting in an estimated 120,000deaths. But because of the punitive healthcare culture,Leape revealed that only two to three percent of majorerrors are actually reported through incident reportingsystems, mostly because “workers often report only whatthey cannot conceal.”9 Research specific to the operatingroom found that OR/PACU staff reported more frequentwitnessing of unsafe patient care.10 Our stories tell us thatin the healthcare culture we value the safety of our groupmore than the patient, ethics or even best practice. Howcan this change?

A culture does not change overnight. Nor will any culturesharply change direction as a group. Imagine an army of 12

What we know changes what we see.What we see changes what we know.”

– Piaget“



million healthcare workers marching shoulder-to-shoulder inone direction. It’s dangerous for a single individual to fall outof step. If we could only visualize the thousands of woundedand deceased in one place, then the entire army wouldimmediately about-face. But we can’t. And we don’t.

People die and are harmed from healthcare-related errorsone-by-one; and they will only be saved one-by one as eachindividual’s awareness rises above the group, and weconsciously and courageously decide to break the culturalchains that bind us to our old familiar ways.

References1. Mitchell L, Flin, R. Non-technical skills of the operating theatre scrub nurse: literature

review. Journal of Advanced Nursing. 2008;63(1):15-24.2. Maxfield D, Grenny J, McMillan R, Patterson K., Switzler A. Silence kills: the seven

crucial conversations for healthcare. VitalSmarts and the American Association ofCritical-Care Nurses. 2005.

3. Riley RG & Manias E. Governance in operating room nursing: nurses’ knowledge ofindividual surgeons. Social Science and Medicine. 2006;62(6):1541-1551.

4. McGrail KA, Morse DS, Glessner T, Gardner K. What is found there: qualitative analysisof physician-nurse collaboration stories. Journal of General Internal Medicine.2009;24(2):198-204.

5. Jack, D. Silencing the self: woman and depression. Harvard University Press. 1993.6. Simpson KR & Lyndon A. Clinical disagreements during labor and birth: how does

real life compare to best practice? The American Journal of Maternal/Child Nursing.2009;34(1):31-39.

7. The North Carolina Just Culture Journey [videotape]. North Carolina Board of Nursingand North Carolina Hospital Association. Available at: http://www.justculture.org.Accessed November 1, 2009.

8. Khatri N, Brown GD. From a blame culture to a just culture in health care. HealthManagement and Informatics, University of Missouri School of Medicine,Columbia. 2009.

9. Marx D. Patient safety and the “just culture”: a primer for health care executives insupport of Columbia University. Funded by a grant from the National Heart, Lung,and Blood Institute National Institutes of Health (Grant RO1 HL53772, Harold S.Kaplan, MD, Principal Investigator). 2001.

10. Kaafarani HM, Itani KM, Rosen AK, Zhao S, Hartmann CW, Gaba DM. How doespatient safety culture in the operating room and the post-anesthesia care unitcompare to the rest of the hospital? American Journal of Surgery.2009;98(1):70-75.

About the author

Kathleen Bartholomew, RN, RC, MN, hasbeen 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 tohealth care – specifically physician and nurserelationships. For her master’s thesis, she au-thored Speak Your Truth: Proven Stategies

for Effective Nurse-Physician Communication, which is the onlybook to date that addresses physician-nurse communication. Shealso wrote Stressed Out About Communication, a book designedfor new nurses. Save 20 percent by using source code MB84712Aat www.HCMarketplace.com or call customer service at (800) 650-6787. To increase performance with High Reliability Organizationmethods, Kathleen has now partnered with ConvergentHRS.

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Changing the

Catheter Culture

at Your Facility



Recently my husband was hospitalized following a10-foot fall at work. We were thankful his injuries werenot life-threatening, but he did have bilateral ankle and heelfractures. Given the immobility we knew was ahead, I wasdiscussing the treatment plan with a good friend who is anurse. One of her first questions was, “They are going toput in a catheter aren’t they?” My reply was, “I certainlyhope not. I don’t want him to get a catheter-associatedinfection. That is the last thing we need with everything elsethat’s going on!”

This conversation verified what I have experienced for themajority of my career both as a staff nurse and as a chiefnursing officer. More likely than not if a patient was inconti-nent or having difficulty getting to the bathroom, one of thefirst requests would be an order for a urinary catheter. Thenurses believed that their primary intervention of catheterinsertion would maximize the patient’s comfort and avoidskin breakdown. Today we know that urinary tract infectionis the most common healthcare-associated infection (HAI);80 percent of these infections are attributable to anindwelling urethral catheter.1 One in four patients receivesan indwelling urinary catheter at some point during theirhospital stay and up to 50 percent of these catheters areplaced unnecessarily.2,3

So, how do you change the culture at your facility if nursesstill want to place a catheter? We all know that changingan organization’s culture can feel like turning a cruise shiparound in a wild and stormy sea. The perception of nursestraditionally has been that putting a catheter in an inconti-nent patient is the best standard of care. We have tochange that perception. As we begin to collect data, theevidence is showing that avoiding catheterization protectsthe patient from acquiring a catheter-associated urinary

tract infection. And we know that too many indwellingurinary catheters are inserted. We also know that indwellingurinary catheters stay in too long.4

Components of Successful Culture ChangeSuccessful culture change consists of many components.The following are some key strategies you can try at yourfacility, including use of the new Guideline for Preventionof Catheter-Associated Urinary Tract Infections 2009,education and training, engaging front-line staff, a rewardprogram, and finally, being creative, having fun and trackingprogress.

The Centers for Disease Controland Prevention (CDC) GuidelineThe Healthcare Infection Control Practices AdvisoryCommittee (HICPAC) of the CDC recently published theGuideline for Prevention of Catheter-Associated UrinaryTract Infections 2009. This is an excellent reference toreview prior to initiating a catheter reduction program atyour facility. The document contains recommendations onappropriate urinary catheter use and proper techniques forurinary catheter insertion and maintenance. In addition, theguideline outlines strategies for quality improvement andsurveillance programs and summarizes recommendationsfor an administrative infrastructure to support a CAUTIprevention program.5

Education and trainingA logical place to start is by designing a comprehensiveeducation and training program. Having a program thatprovides the supporting framework for education also helpsto organize and publicize the initiative. Medline’s ERASECAUTI program will give you all the tools you will need.

Connie M. Yuska, RN, MS


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The ERASE CAUTI Program for nurses (RNs and LPNs) isa two-part educational program. Part One is a step-by-stepproduct training program on the ERASE CAUTI cathetertray and insertion methodology. Part Two includes thefollowing four modules:

Module 1: Indications and Alternatives to CatheterizationModule 2: Aseptic Technique and Proper Insertion of

a Foley CatheterModule 3: Care and Maintenance, Signs and Symptoms

of CAUTIModule 4: Competency Validation

In addition, current practice guidelines, sample policies andprocedures and competency validation tools are included.You have the opportunity to initiate the training at orientationwhen a new employee joins your organization. This “setsthe stage” for the catheter culture in your facility. You aresetting the expectation that your staff will keep an inconti-nent patient clean and dry without exposure to the unnec-essary risk of acquiring a catheter-related urinary tractinfection. Then during your annual competency reviews foryour staff, you can reinforce the training and the new“catheter culture.” This gives you a greater chance of hard-wiring the change into your culture and ensuring that yourstaff’s new viewpoint on catheterization is sustained.

Engaging front-line staffIt is also important to identify staff nurse champions atthe beginning of the program. Enlisting their help through aformalized assignment is one good way to generate enthu-siasm and support for the new program. Staff nurses havevery good ideas and usually know the best answer if weremember to include them! Getting them involved in theliterature review and in planning the staff education roll-outwill solidify their role as “champions.” They also can be thecheerleaders to encourage their peers to join the Race toERASE CAUTI!

Reward programIn sustaining any long-term change, it is extremely impor-tant to recognize achievement. Staff work very hard, and

Join the RACEto ERASE CAUTI



their efforts need to be recognized. Another part of theERASE CAUTI Program is a reward component. Everyonewho successfully completes the course and achieves atleast an 80% on the post test receives one CE credit, a cer-tificate of completion and a pin to display on their IDbadge or uniform. The pin recognizes individual achieve-ment and provides an opportunity for the staff to talkabout the program with patients, families and otherhealthcare professionals, keeping the program top-of-mind.

Being creative, having fun and tracking progressSince this is a Race to ERASE CAUTI, encourage your staffto post statistics regarding the decline in catheter- associatedinfections. Nursing units in hospitals or hospitals in systemscan make this a fun, competitive event that results inbetter patient care. Finally, celebrate when an individual orthe entire facility crosses the finish line of achieving zerocatheter-associated urinary tract infections.

A Happy EndingAlthough my husband did not have any incontinence,he was non-weight bearing and thankfully, none of thenurses actually asked that a catheter be placed prior to sur-gery. He did have a catheter placed during surgery, but itwas taken out within 24 hours! The hospital staff did followthe Guideline for Prevention of Catheter-Associated UrinaryTract Infections 2009, which states “for operative patientswho have an indication for an indwelling catheter, removethe catheter as soon as possible postoperatively, preferablywithin 24 hours, unless there are appropriate indications forcontinued use.”5

I am happy to report that my husband was discharged fromthe hospital to a rehabilitation facility, and he was able tocome home for Thanksgiving. This year I was very thankfulthat he was in a hospital with an up-to-date catheterculture, and he is on the road to recovery!

References1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA

practice recommendations: strategies to prevent catheter-associated urinary tractinfections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50.

2. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reducesurinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf.2005;31(8):455-462.

3. Stokowski, LA. Preventing catheter-associated urinary tract infections. MedscapeNursing Perspectives. February 3, 2009. Available at:http://www.medscape.com/viewarticle/587464-4. Accessed July 6, 2009.

4. Sulzback-Hoke, Linda M. “Ask the Experts.” Critical Care Nurse. 2002,22:84-87.Available at: http.//ccn.accnjournals.org/cgi/content/full/22/3/84. Accessed July 24, 2009.

5. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, HealthcareInfection Control Practices Advisory Committee, Centers for Disease Control. Availableat: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CAUTI_Guideline2009final.pdf.

About the author

Connie Yuska RN, MS began her career as a nurse in the spe-cialty of otorhinolaryngology. Her clinical experience includes bothinpatient and outpatient care of head and neck oncology patients,and she is certified in otorhinolaryngology and head-neck nursing. Shehas held clinical manager and director of nursing positions in alarge academic medical center and also has experience in thehome care setting as the vice president of operations for a largeacademically affiliated home care agency in the Chicago area.Connie later joined the executive suite as the chief nursing officerof a large community hospital in Chicago, and she is currently avice president of clinical services for Medline. In all of her leader-ship roles, she has been responsible for ensuring the delivery ofhigh quality, safe and cost-effective nursing care.

Connie is a 2003 graduate of the J&J/ Wharton Nurse ExecutiveProgram. She is member of the Board of the Illinois Organizationof Nurse Leaders and a member of the American Organization ofNurse Executives. In 2005, she was inducted into the 100 WiseWomen Program sponsored by Deloitte & Touche. In addition, shehas published several articles and chapters in oncology journalsand textbooks.



MEDLINE’S HAND HYGIENE COMPLIANCE PROGRAM

FOR ALL THE LIVES YOU TOUCH.

Now more than ever, hand hygiene compliance is crucial.As of October 1, 2008, the Centers for Medicare & MedicaidServices no longer reimburses hospitals for eight hospital-acquired conditions, including catheter-associated urinarytract infections, surgical site infections and bloodstreaminfections.1 We know that hand hygiene is the numberone line of defense against hospital-acquired infections.2

There’s no such thing as“overeducating” when it comesto hand hygiene. Enhance yourcurrent strategy with Medline’sHand Hygiene ComplianceProgram!

The Hand Hygiene Compliance Program includes:• An instructor’s manual that takes the guessworkout of planning lessons

• A customizable plug-and-play CD that containspresentations, posters and more

• Forms and tools to serve as reminders andreinforcements

• A cost calculator to help you determine the costof prevention vs. the cost of an infection

• A rewards program to recognize those whocomplete the course

• Patient and family education materials• CE-credit courses for staff• A how-to guide on enhancing your presentation skills

For an on-site presentation of the Hand HygieneCompliance Program and our Healthy HandsProduct Bundle, contact your Medline representativeor visit www.medline.com/handhygiene.

References1Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital inpa-tient prospective payment systems and fiscal year 2007 rates. Available at:www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf.Accessed November 20, 2007.

2 Davis D, Sosovec D. The value of products that improve hand hygiene and skin. HealthcarePurchasing News. Available at: http://www.hpnonline.com/inside/2003-11/1103hygiene.htm.Accessed November 20, 2007.


We didn’t just design anew tray, we designed away to make it hard forhealthcare workers to dothe wrong thing.The new ERASE CAUTI program combines design, educationand awareness to tackle catheter-associated urinary tractinfection – the number one hospital-acquired infection.1

DesignThe innovative one-layer tray design guides the clinician throughthe process of placing a catheter to ensure aseptic technique.

EducationThe acronym ERASE is easy to remember, remindingthe clinician to:

Evaluate indications – Does the patient really requirea catheter?

Read directions and tips – Follow evidence-basedinsertion techniques

Aseptic techniques – Key design solutions supportaseptic technique

Secure catheter – A properly secured catheter willreduce movement and urethral traction

Educate the patient – Printed materials tell the patienthow to reduce the likelihood of infection

AwarenessJoin the Race to ERASE CAUTI! The current state of healthcare demands that nurses play a leading role in identifying andimplementing CAUTI risk reduction strategies. Help us reach ourgoal to introduce 100,000 nurses to the ERASE CAUTI system.

To sign up for a FREE webinar, “Innovation in the Preven-

tion of CAUTI,” go to www.medline.com/erase/webinar.asp.

DesignOpen up the

innovative one-layercatheter tray andsee the intuitive

design foryourself.



EducationClick here for

details on nursingeducation materials

that promoteevidence-based

practice. AwarenessVisit this sectionto join 100,000nurses in the

Race to ERASECAUTI.

Reference1. Catheter-related UTIs: a disconnect in preventive strategies.

Physicians Weekly. 25(6), February 11, 2008.



9 Habits of Very Happy People

Economy sputtering; swine flu getting everyone upset;lots of changes at my facility, and you want me to behappy? You’re kidding, right?

Actually not! Because no matter how bad things seem to be,it’s important to remind ourselves that Abraham Lincoln wasabsolutely right when he said, “Most people are about ashappy as they make their minds up to be.” Happy people arenot happy because they are endowed with the happinessgene—although researchers tell us that accounts for abouthalf of one’s potential for happiness—happy people are happybecause they realize that happiness is something they controlby doing certain things every day. So here are nine things youcan do that will make you happier:

1. Love what you doI find it ironic that many people deny themselves the joy of theirwork. Somehow they assume that work is a dirty four letterword and that they must escape it as soon and as fast as pos-sible so that they can get home and plop down in front of theTV. (This by the way, is a great way to become more unhappyand depressed.) I suspect it is because they have not foundwhat they love to do. The key word here is love—not like—because once you find what you love to do you will not everhave to “work” another day in your life. (By the way, it took me36 years to find what I love to do, so don’t give up your search,because when you find your passion, the quality of your lifewill improve dramatically.) If you would like help with this, readmy book Make It a Winning Life: Success Strategies for Life,Love and Business.

By Wolf J. Rinke, PhD, RD, CSP

Caring for Yourself



2. Chase your dreamsHappiness is often a byproduct of something that we aregoing after—something that juices us. Think of children. Whenare they the happiest? About two weeks before the Christmasor Hanukkah holidays, or when they have ripped all the pres-ents open? Once we have clearly-defined, specific, fire-in-the-belly goals, we get turned on, and we become happy.In other words, if your goal is to be happy—that’s what manypeople in my seminars tell me—you won’t necessarily behappy. You get happy from traveling the journey or remindingyourself that you are doing something that improves the qualityof someone else’s life. Chasing your dreams cranks up yourinternal body chemistry to such an extent that it energizes youto achieve extraordinary results and may keep or may evenmake you healthy.

Want proof? A good example is Lance Armstrong, who afterbeing diagnosed in 1996 with an advanced form of testicularcancer that had metastasized to his brains and lungs, wasgiven only about a 50 percent chance of survival. Afterreceiving aggressive cancer therapy, including brain andtesticular surgery and extensive chemotherapy, he went on towin the Tour de France—cycling’s most prestigious andgrueling race—seven times in a row from 1999-2005. (Theprevious record was winning it five times.) And just wheneveryone thought he was down and out, he returned tocompetitive racing after four years of “retirement” to finish thirdin the 2009 Tour de France. Not bad for someone who atage 38 is considered old in the punishing sport of competi-tive cycling. 3. Nourish an attitude of gratitude

A difficulty for many successful people is that they perpetuallylook up the mountain, never down. To feel a sense of grati-tude you must have goals—look up the mountain—but alsotake the time to reflect on all that you have already achievedand accumulated—look down the mountain.

If you need a bit of help with this, take advantage of the nextholiday season. Instead of buying gifts for people who alreadyhave more than they will ever need, rally the whole family andserve a meal at a homeless shelter. Or visit a third world coun-try. For example, when I used to speak in the Pacific Rim, mysense of gratitude was always renewed. Typically the clientbooked me in a five-star hotel, which makes any of our fivestar hotels pale in comparison. One of the hotels in Jakartaeven had a marble driveway. Not concrete, not flagstones—marble. When I looked out of my 29th story window I sawmany other super-modern high-rise buildings. I also saw agarbage dump several blocks away swarming with people –people who were living on the dump in cardboard “houses”and foraging for scraps. Stop right now, and be grateful for allthe love and abundance that surrounds you.



4. Love someone deeplyBarbra Streisand was absolutelyright, “people who love peopleare the luckiest people in theworld.” Start by developing astrong bond and lifetime relation-ship with a significant other. Hav-ing been happily married to my“Superwoman” for 41 years, Ican attest that she by far ismy biggest source of joy andhappiness. (She got that name

because she is a one-in-a-million mate, mother, businesspartner and confidant.) If you don’t have such a relationship,make it one of your top three fire-in-the belly goals, becausesuch a partner becomes increasingly more important as youenter the later passages of your life. Extend that same love toyour family and your close friends. The greater your circle ofloving relationships, the greater your happiness.

5. Treat your “body-mind” like a templeNeuroscientist and pharmacolo-gist Dr. Candance Pert, who dis-covered the opiate receptor – thecellular binding site for endor-phins in the brain – calls our bodyand mind the “body-mind” be-cause her work has unequivo-cally demonstrated that the mindand the body are one. Her workalso shows that thoughts are

things – things that manifest themselves in the body and inyour life. So if you think “bad” or negative thoughts, then thatwill have a negative impact on your body. And of course thereverse is true. Since the mind can have only one thought ata time, get in the habit of monitoring your thoughts and self-talk by asking, “Is what I’m thinking about right now nega-tive?” (The worst is hate.) If it is, it will move you away fromhappiness and optimum health. On the other hand, positivethoughts, such as love, kindness and appreciation will moveyou in a positive direction. This is so powerful that we nowhave a whole science concerned with this phenomenon—

psychoneuroimmunology, or PNI for short. (Want to knowmore? Read Dr. Pert’s books: Molecules of Emotions: TheScience Behind Mind-Body Medicine and Everything YouNeed to Know to Feel Go(o)d.)

6. Laugh moreThat’s right – go ahead andlaugh right now. Can’t seem toget it going? Go to the bath-room, stick your tongue out,wiggle your nose and make thesilliest face you can possiblycome up with and get yourself tolaugh. If you need more help, joina laughter yoga club, popular-ized in India, and now availableall over the world including the

United States (http://www.laughteryoga.org). Or consult witha “certified laughter leader.” (Hey, I’m not making this stuff up!)A good way to nurture this is to laugh more at yourself. It willcause you to take yourself less serious—which is a great startbecause you are not nearly as important as you think you are.(I’m including myself in that statement; so don’t get bent outof shape). Laughter has innumerable benefits. It turns on yourendorphins and other internal “drugs” that are far more pow-erful than anything you can ingest—legal or illegal. In fact, it isso powerful that the late Norman Cousins used it as an “anes-thetic” to combat pain associated with his incurable disease.

7. Give more of whatyou wantA shortcut to happiness is mak-ing other people feel happy.Why? Because life is like a mir-ror—whatever you give—is whatyou get. Make people happy andyou will be happier. Hate peopleand you will live in a hateful world.Love people the way they are,and you will experience morelove. You catch my drift. Actually

you already knew that. And that’s why you are much moreanxious to give a gift than get one. Happiness certainly doesnot come from things. Otherwise the happiest people on



earth would be lottery winners. They are not. In fact lotterywinners often become discouraged and depressed becausethey become so obsessed with “stuff” that most are brokethree years after they have won the jackpot. “Superwoman”and I have come to the realization that less is more. That is tosay, the more stuff we have, the more problems and stress wehave. That’s why we evaluate every new opportunity by ask-ing ourselves whether taking advantage of the new opportu-nity will add to the quality of our lives. If the answer is yes, wego for it. If the answer is no, we don’t.

8. Develop a PositiveExplanatory StyleProfessor Marty Seligman, of theUniversity of Pennsylvania, whohas had a tremendous influenceon getting psychologists to focuson the good—what he hasdubbed “positive psychology”—wrote a number of powerfulbooks addressing this topic(http://www.authentichappi-

ness.sas.upenn.edu/seligman.aspx). His research hasdemonstrated that we can learn to be more optimistic by de-veloping a “positive explanatory style” (PES). The way you dothat is by focusing on the good stuff, especially when badthings happen to you. In other words you learn to fake it untilyou make it. Research has shown that people who have de-veloped PES, as opposed to a Negative Explanatory Style(NES) are able to evaluate “reality” more clearly—just theopposite of what most people assume. Process “bad” newsmore effectively, and you are more likely to accept what can’tbe changed and move on. In short, PES enables you toinoculate yourself against the negative attitude “virus” and hisbig cousin—depression.

9. Keep Hope AliveHope is an incredibly powerfulemotion. Without it not only doyou become unhappy—you die.No one has told that story morepowerfully than Dr. Victor Franklin his book Man’s Search forMeaning, in which he details therole of hope in surviving the Ger-man concentration camps. Sobe sure to never give up hope, nomatter how bleak it gets. And

even more important, be sure not to confuse inconvenienceswith problems. Because many of the “problems” that we getourselves all worked up about are inconveniences, nottragedies. When you are in the middle of one of these, a greatdiagnostic is to ask yourself: “How will I feel about this fiveyears from now?” And then act accordingly. To deal more ef-fectively with the real tragedies—which will come—turn to thesource of hope and inspiration that works for you. It may bereligion, spirituality, meditation or listening to a great motiva-tional speech. (Just had to sneak that in there.) It will help youkeep hope alive and make you more optimistic and happier.

© 2009 Wolf J. Rinke

Dr. Wolf J. Rinke, PhD, RD, CSP is a keynotespeaker, seminar leader, management con-sultant, executive coach and editor of the freeelectronic newsletters Make It a Winning Lifeand The Winning Manager. To subscribe goto www.WolfRinke.com. He is the authorof numerous books, CDs and DVDs includingMake it a Winning Life: Success Strategies forLife, Love and Business; Winning Manage-

ment: 6 Fail-Safe Strategies for Building High-Performance Organi-zations and Don’t Oil the Squeaky Wheel and 19 Other ContrarianWays to Improve Your Leadership Effectiveness. All are available atwww.WolfRinke.com. His company also produces a wide variety ofquality, pre-approved continuing professional education (CPE) self-study courses including Beat the Blues: How to Manage Stress andBalance Your Life, on which this article is based, available atwww.easyCPEcredits.com. Reach him at [email protected].

Be sure to never give up hope, no matter how bleakit gets. And even more important, be sure not toconfuse inconveniences with problems.


For the fifth year in a row,Medline will be hosting acomplimentary breast cancerawareness breakfast March 15,2010, during the Associationof periOperative RegisteredNurses (AORN) Congress in

Denver, Colo. Olympic gold medalist and breastcancer survivor Peggy Fleming will share storiesabout her personal experience with breast cancer.

Each year since 2006, breakfast participantshave been inspired by celebrities who have wonthe battle against breast cancer. In 2009 Medlinewas proud to host TV journalist Linda Ellerbee.Past speakers have included Dr. Marla Shapiro,Rue McClanahan and Ann Jillian.

Save the Date!Medline’s Breast CancerAwareness BreakfastMarch 15, 2010 – 5:45 to 7:30 a.mSpeaker Peggy Fleming presents“The Fight of a True Champion”

AORN CongressHyatt Regency at ColoradoConvention Center,Denver, Colo.

Olympic Figure Skater

Peggy Flemingto Speak at Medline’sAORN Breast CancerAwareness Breakfast

Attendance by invitationonly. Contact your Medlinesales representative formore information.




PINK GLOVEMEDLINE’S

Thank You!Providence St. Vincent

Medical Center

From the highest leve ls of yourorganization down through your entirestaff, we could not have picked a betterpartner for the “Pink Glove Dance,”video project.

Thank you for taking part in acause that touches us all.



DANCEA YouTube™ Sensation One early November morning, when the OR

staff of Providence St. Vincent Medical Centerwas approached by Medline to take part in a littlebreast cancer awareness video they were doing, littledid they know what an impact their participationwould soon make.

A little more than a month later, over six million peopleacross the globe have seen the “Pink Glove Dance” video.

The YouTube video phenomenon has been featured onCNN, ABC World News with Charles Gibson, Fox &Friends - Fox News Network’s national morning show,and literally more than 100 local TV newscasts acrossthe country.

News stories about the video also span the Internet, fromthe Huffington Post to the AOL home page. People can’tstop talking about this video, which showcases morethan 200 hospital workers from the medical center inPortland, OR. dancing in Medline’s pink gloves. Phonecalls, cards and e-mails are flooding both the hospitaland Medline. And more than 10,000 people have postedcomments about the video on YouTube. It has enter-tained and inspired laughter and, for many, it has evokedmemories of their own battle with breast cancer or bat-tles faced by loved ones.

One viewer wrote: “Wonderful! This brought tears tomy eyes as I am a survivor 13 years out and it remindedme of the wonderful staff at Yale Oncology unit. Thankyou to all in the medical field. Please be sure to sharethis with those who are going through treatments. I amsure this will be helpful.” – mamakawecki55

Another said: “Given the type of work that they do,it is good to see them having fun for a good cause.Remember they are the ones who care for those withcancer.” – seaglassfriends

Boosting Hearts, Mindsand Support for Breast

Cancer Awareness

Special Feature



Birth of an IdeaWhy would perfectly sane and incredibly busy hospitalworkers agree to dance in a YouTube video? The shortanswer is to get people talking about breast cancer. Butthere’s more to the story. It all began at Medline’s Corporateoffice when employees were brainstorming ideas to pro-mote their new Generation Pink™ glove (launched inOctober). To further support Medline’s ongoing breast cancerawareness campaign (visit www.medline.com/breast-can-cer-awareness for details), they had already implemented apromotion to donate $1 of every case purchased to theNational Breast Cancer Foundation to fund mammogramsfor individuals who cannot afford them.

But they needed a big idea to help spread the word. So,they asked, “What if we were to video healthcare workersdancing in pink gloves? Could we produce a viral video?”Little did they know. . .

The first step was finding the right hospital to partner withMedline to create the video. The Providence Health Sys-tem, a 26-hospital system in the northwest area of thecountry, proved to be the perfect choice. The health systemsuggested Medline work with Providence St. Vincent Med-ical Center in Portland, which not only was willing to give fullaccess to each area of the facility for the video shoot, butalso shared Medline’s passion for breast cancer awareness.

The next few days were a blur of action. The hospital sentout a call for employee volunteers to dance in the video.Back at Medline, the wheels were in motion. Jay Sean’s hitsong “Down” was selected for the video and discussionstook place to coordinate which areas of the hospital wouldbe filmed, the number of staff participating in each shot andthe overall plan of events.

The Making of the VideoA week later, Medline product manager Emily Somers wasat the hospital with a few boxes of pink gloves and the filmcrew. More than 200 employees of all ages, departmentsand skill levels answered the call to participate.

“We had so many people who said, ‘You know, thisdisease has touched my life. I want to be a part of it,’” said


“”

I am very honored that Medline andProvidence St. Vincent Medical Centerused my song “Down” to promote andsupport Breast Cancer Awareness.I like that such a fun and light heartedapproach was taken to create aware-ness for a serious disease that canbe cured if caught early.

– Jay Sean



Martie Moore, the chief nursing officer at ProvidenceSt. Vincent Medical Center.

The filming took two days and Emily taught the volunteersbasic dance moves to showcase the pink gloves. “In anenvironment filled with sickness and gloom, the caregiversbrought incredible energy to the making of the video,expressing their great heart and spirit,” Emily said. Fromlab technicians and the kitchen help to surgical teams, theyall let loose, dancing throughout the hospital.

Touching People Around the WorldThousands of people across the globe have posted inspiringcomments about the video — even singer Jay Seanresponded by posting a link to the video on his website.On his Facebook page he wrote, "The vid is awesome …medicine will always be close to my heart and this is sucha worthy and important cause. So maybe I could havebeen a doctor and a singer at the same time after all then?Just brilliant."

17,000 Screaming Pink-Gloved FansTo further spread the “Pink Glove Dance” message, morethan 17,000 passionate fans recently wore Medline’s pinkgloves at a live concert held in Chicago. With 34,000 pinkgloved hands swaying back and forth to a live performanceby Jay Sean singing his hit song “Down,” the arena took ona surreal appearance of a dense forest of pink trees wavingin the wind. It was an unbelievable sight that brought tearsto the eyes of many in the audience.

Emily Somers, Medline product manager – and the choreographerof the “Pink Glove Dance” – teaches the lab staff of ProvidenceSt. Vincent some dance moves during the shooting of the video.

Monte Crawford, “themop man,” has becomeone of the more popularfigures in the “Pink GloveDance” video.


A world without breast cancer is in our hands.

Medline’s Generation Pink latex-free, third-generation vinyl exam gloveshave the comfort, barrier protection and price you love.

Even better, when you choose Generation Pink gloves, you’re helpingMedline support the National Breast Cancer Foundation.

For more information on Medline’s exam gloves, please contact your

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

©2009 Medline Industries, Inc. The cross-fingered pink glove hand image is a trademark ofMedline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Watch the “Pink Glove Dance” video at:YouTube.com/watch?v=OEdvfyt-mLw

Other ways to show your support:

Become a Facebook fan at: facebook.com/medlinebreastcancerawareness

TM



Support The Cause. Help fund free mammograms!When you choose Generation Pink Gloves, a portion of the proceeds will be donated to theNational Breast Cancer Foundation to fund free mammograms for women who cannot afford them.

Depending on who you are (an individual or a facility), there are two sites to choose fromwhen ordering gloves.• Individuals visit www.scrubs123.com•Healthcare facilities visit www.medline.com/breast-cancer-awareness• If you wish to donate directly to the National Breast Cancer Foundation,visit the NBCF website www.nationalbreastcancer.org.

• Over 6 million views on YouTube• Over 10,000 comments on YouTube• More than 120 TV news storiesacross the country

• National news – ABC, CNN, FOX, MSNBC• 17,000 fans donning pink gloves duringa live performance of Jay Sean’s hitsong, “Down”

PinkGloveDanceVideoGoesViral!

“”



Healthy Eating

• 16 oz. bag frozen hash brown potatoes(cubed or shredded)• 16 oz. container sour cream• 1 can cream of chicken soup• ½ c. chopped onion• 8 oz. bag shredded cheddar cheese

Topping:• 2 c. corn flakes• ¾ stick melted butter or margarine

Directions:Mix together all ingredients and place in a baking dish. Top withcrushed corn flakes mixed with the melted butter. Cover withfoil and bake at 350 degrees F for 30 minutes. Remove the foiland bake an additional 20-30 minutes.

Hint: To cut down on salt and fat, use low-sodium soup and re-duced fat cheese and sour cream.

Shipping employee Dennis Shannon has worked at Medline’sAllentown, Penn. warehouse for 10 years. In his spare time, heenjoys cooking and entertaining. He said at his house, “I do thecooking and my wife does the baking, so it works out well.”

The Shannons regularly host parties at their home, where theyhave a fully outfitted game and entertainment room in the base-ment. Dennis said his cheesy potatoes dish is a big favoritewith guests. “It’s easy and inexpensive to make, and peoplereally like it.”

With football season in full swing, theShannons have been doing their usualentertaining, and Dennis offered anotherquick, easy and inexpensive recipe:Spread a thin layer of chive-flavoredcream cheese onto a flour tortilla andthen layer it with a slice of turkey breastlunch meat, a piece of red leaf lettuce

and pimentos. Roll it up and cut into slices for an attractive anddelicious snack.

Cheesy Potatoes (12 servings) NutritionInformation

Servings: 12Calories: 296Fat: 12.7 gSodium: 407.7 mgFiber: 1.2 g



Forms & Tools

The following pages contain practical tools for implementingpatient-focused care practices at your facility.

CAUTIFAQs about Catheter-Associated Urinary Tract Infection . . . . . . .79

Surgical Fire SafetySurgical Safety Team Communication . . . . . . . . . . . . . . . . . . . . .80Universal Protocol and Fire Risk Assessment . . . . . . . . . .81Extinguishing a Surgical Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84Preventing Surgical Fires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85

H1N1 (Swine Flu)H1N1 Patient Handout (English) . . . . . . . . . . . . . . . . . . . . . . . . . .87H1N1 Patient Handout (Spanish) . . . . . . . . . . . . . . . . . . . . . . . . .89


FAQs “Catheter-Associatedabout

system, which includes the bladder (which stores the urine) and the kid-neys (which filter the blood to make urine). Germs (for example, bacteriaor yeasts) do not normally live in these areas; but if germs are introduced,

If you have a urinary catheter, germs can travel along the catheter andca

What is a urinary catheter?

A urinary catheter is a thin tube placed in the bladder to drain urine.Urine drains through the tube into a bag that collects the urine. A urinarycatheter may be used: • If you are not able to urinate on your own • To measure the amount of urine that you make, for example, during

intensive care•• During some tests of the kidneys and bladder

urinary tr

germs tha -

there. Germs can enter the urinary tract when the catheter is being put inor while the catheter remains in the bladder.

• Burning or pain in the lower abdomen (that is, below the stomach)• Fever•

problems•

So

emoval or change of the catheter. Your doctor will deter-

What are some of the things that hospitals are doing to prevent catheter-

ac

o Catheters are put in only when necessary and they are removed assoon as possible.

o Only properly trained persons insert catheters using sterile (“clean”)technique.

o The skin in the area where the catheter will be inserted is cleanedbe

• External catheters in men (these look like condoms and are placed overthe penis rather than into the penis)

•aw

Catheter care

o Healthcare providers clean their hands by washing them with soapand watouching your catheter.

If you do not see your providers clean their hands, please ask them to do so.

-

o The catheter is secured to the leg to prevent pulling on the catheter.

o Keep the bag lower than the bladder to prevent urine from backflow-ing to the bladder.

o Empty the bag regularly. The drainage spout should not touch any-thing while emptying the bag.

if I have a catheter? •• Always keep your urine bag below the level of your bladder. • Do not tug or pull on the tubing. • Do not twist or kink the catheter tubing.•

What do I need to do when I go home from the hospital?• If you will be going home with a catheter, your doctor or nurse should

explain everything you need to know about taking care of the catheter.Make sure you understand how to care for it before you leave the hospital.

•as burning or pain in the lower abdomen, fever, or an increase in the

• Before you go home, make sure you know who to contact if you haveques

Co-sponsored by:

CAUTI-Patient Handout Forms & Tools


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Forms & Tools Universal Protocol and Fire Risk Assessment


Medline’s comprehensive line of facemaskswas designed to meet a variety of needs andpreferences, but all of our masks are unitedby a common trait—quality. Every mask wemanufacture—from our fluid-resistant masksto our spearmint-scented masks—is backedby Medline’s quality guarantee and designed toexceed expectations for comfort and protection.• Fluid resistant• Fog-free• Spearmint-scented• Chamber style• Isolation• Procedure• Face shield• Protective eyewear

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EMERGENCY PROCEDUREEXTINGUISHING A SURGICAL FIRE

Fighting Fires ON the Surgical PatientReview before every surgical procedure.

In the Event of Fire on the Patient: 1. Stop the flow of all airway gases to the patient.2. Immediately remove the burning materials and have another team member extinguish them.

If needed, use a CO2 fire extinguisher to put out a fire on the patient.3. Care for the patient:

—Resume patient ventilation.—Control bleeding.—Evacuate the patient if the room is dangerous from smoke or fire.—Examine the patient for injuries and treat accordingly.

4. If the fire is not quickly controlled:—Notify other operating room staff and the fire department that a fire has occurred.—Isolate the room to contain smoke and fire.

Save involved materials and devices for later investigation.

Extinguishing Airway FiresReview before every surgical intubation.

At the First Sign of an Airway or Breathing Circuit Fire, Immediately and Rapidly:1. Remove the tracheal tube, and have another team member extinguish it. Remove cuff-protective

devices and any segments of burned tube that may remain smoldering in the airway.2. Stop the flow of all gases to the airway.3. Pour saline or water into the airway.4. Care for the patient:

—Reestablish the airway, and resume ventilating with air until you are certain that nothing is left burning in the airway, then switch to 100% oxygen.

—Examine the airway to determine the extent of damage, and treat the patient accordingly.Save involved materials and devices for later investigation.

MS09

445_

1

Source: New Clinical Guide to Surgical Fire Prevention. Health Devices 2009 Oct;38(10):330. ©2009 ECRI InstituteMore information on surgical fire prevention is available at: www.ecri.org/surgical_fires


Forms & Tools Extinguishing a Surgical Fire



Source: New Clinical Guide to Surgical Fire Prevention. Health Devices 2009 Oct;38(10):319. ©2009 ECRI InstituteMore information on surgical fire prevention, including a downloadable copy of this poster, is available at www.ecri.org/surgical_fires

ONLY YOU CAN PREVENT SURGICAL FIRESSurgical Team Communication Is Essential

At the Start of Each Surgery: Enriched O2 and N2O atmospheres can vastly increase flammability of drapes, plastics, and hair. Be aware of possible

O2 enrichment under the drapes near the surgical site and in the fenestration, especially during head/face/neck/upper-chest surgery.

Do not apply drapes until all flammable preps have fully dried; soak up spilled or pooled agent.

Fiberoptic light sources can start fires: Complete all cable connections before activating the source. Place the source in standby mode when disconnecting cables.

Moisten sponges to make them ignition resistant in oropharyngeal and pulmonary surgery.

During Head, Face, Neck, and Upper-Chest Surgery: Use only air for open delivery to the face if the patient can maintain a safe blood O2 saturation without supplemental O2.

If the patient cannot maintain a safe blood O2 saturation without extra O2, secure the airway with a laryngeal mask airway or tracheal tube.

Exceptions: Where patient verbal responses may be required during surgery (e.g., carotid artery surgery, neurosurgery, pacemaker insertion) and where open O2 delivery is required to keep the patient safe: — At all times, deliver the minimum O2 concentration necessary for adequate oxygenation. — Begin with a 30% delivered O2 concentration and increase as necessary. — For unavoidable open O2 delivery above 30%, deliver 5 to 10 L/min of air under drapes to wash out excess O2.— Stop supplemental O2 at least one minute before and during use of electrosurgery, electrocautery, or laser, if

possible. Surgical team communication is essential for this recommendation. — Use an adherent incise drape, if possible, to help isolate the incision from possible O2-enriched atmospheres

beneath the drapes. — Keep fenestration towel edges as far from the incision as possible. — Arrange drapes to minimize O2 buildup underneath. — Coat head hair and facial hair (e.g., eyebrows, beard, moustache) within the fenestration with water-soluble surgical

lubricating jelly to make it nonflammable. — For coagulation, use bipolar electrosurgery, not monopolar electrosurgery.

During Oropharyngeal Surgery (e.g., tonsillectomy): Scavenge deep within the oropharynx with a metal suction cannula to catch leaking O2 and N2O. Moisten gauze or sponges and keep them moist, including those used with uncuffed tracheal tubes.

During Tracheostomy: Do not use electrosurgery to cut into the trachea.

During Bronchoscopic Surgery: If the patient requires supplemental O2, keep the delivered O2 below 30%. Use inhalation/exhalation gas monitoring

(e.g., with an O2 analyzer) to confirm the proper concentration.

When Using Electrosurgery, Electrocautery, or Laser: The surgeon should be made aware of open O2 use. Surgical team

discussion about preventive measures before use of electrosurgery, electrocautery, and laser is indicated.

Activate the unit only when the active tip is in view (especially if looking through a microscope or endoscope).

Deactivate the unit before the tip leaves the surgical site.

Place electrosurgical electrodes in a holster or another location off the patient when not in active use (i.e., when not needed within the next few moments).

Place lasers in standby mode when not in active use.

Do not place rubber catheter sleeves over electrosurgical electrodes.

The applicability of these recommendations must be considered individually for each patient.

MS09

445_

2Developed in collaboration with the Anesthesia Patient Safety Foundation.

®

Preventing Surgical Fires Forms & Tools


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

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

What are the symptoms of H1N1 flu?The symptoms of H1N1 flu include fever, cough, sore throat, runny or stuffy nose, bodyaches, headache, chills and fatigue. Diarrhea and vomiting may also be associated withH1N1 flu. Most people with the virus have recovered without needing treatment, but hospitalizations and deaths have occurred.

What should I do if I think I have H1N1 flu?If you have flu symptoms, stay home and avoid contact with other people to avoid spreading your illness. It is recommended that you stay home for at least 24 hours afteryour fever is gone, or if possible, until your cough is gone. If you have severe illness or you are at high risk for flu complications, contact your health care provider. He or she will determine whether testing or treatment is needed.

Seek emergency medical care for any of the following warning signs:

In children:• Fast breathing or trouble breathing • Bluish skin color • Not drinking enough fluids • Not waking up or not interacting • Being so irritable that the child does not want to be held • Flu-like symptoms improve but then return with

fever and worse cough • Severe or persistent vomiting

In adults: • Difficulty breathing

or shortness of breath • Pain or pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting • Flu-like symptoms improve but then return with

fever and worse cough

• Headache

• Fever

• Fatigue

• Chills

• Runny or

stuffy nose

• Sore throat

• Cough

• Body aches

H1N1 Symptoms

Page1 5mcc.comnursingcenter.com anatomical.comText courtesy of NursingCenter.com. Images courtesy of Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.

Forms & Tools H1N1 Patient Handout



How is H1N1 flu treated?The CDC recommends the use of oseltamivir (brandname Tamiflu) or zanamivir (brand name Relenza) totreat and/or prevent swine influenza. These antiviralmedications may also prevent serious complications. For treatment, antiviral drugs work best if started within 2 days of symptoms.

• Coughing or sneezing into your arm; avoiding close contact with people who haverespiratory symptoms such ascoughing or sneezing

• Staying home when you're sick and getting as much rest as possible

• Washing your hands often with soap and water for 15-20 seconds; using alcohol-based hand cleansersis also acceptable

• Not touching your eyes, nose, ormouth because this is how germsget into your body

• Keeping surfaces and objects(especially tables, counters, door-knobs, toys) that can be exposedto the virus clean

• Practicing other good health habits,including getting plenty of sleep,staying active, drinking plenty offluids, and eating healthy foods

What can I do to prevent H1N1 flu?You can reduce your risk of contracting and spreading swine influenza and other influenza viruses by:

Lisa Morris Bonsall, MSN, RN, CRNP

Check with your healthcareprovider to see if the H1N1 vaccine is right for you.

Text courtesy of NursingCenter.com. Images courtesy of Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.

5mcc.comnursingcenter.com anatomical.com


Forms & Tools H1N1 Patient Handout


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

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

¿Cuáles son los síntomas de la gripe por H1N1?Los síntomas de la gripe por H1N1 incluyen fiebre, tos, dolor de garganta, nariz conmucosidad o tupida; dolor en el cuerpo, dolor de cabeza, escalofríos y fatiga. La mayoríade las personas que han tenido el virus se han recuperado sin necesitar tratamiento, peroha habido otras que han necesitado hospitalización, y también otras que han muerto.

¿Qué debo hacer si pienso que tengo gripe por H1N1?Si usted piensa que tiene síntomas de gripe quédese en casa y evite entrar en contacto conotras personas para no propagar la enfermedad. Es recomendable quedarse en casa por lomenos durante 24 horas después de que le haya pasado la fiebre, o si es posible, después de que le haya pasado la tos. Si está gravemente enfermo, o si pertenece a un grupo de alto riesgo para desarrollar complicaciones, entre en contacto con su proveedor de atención médica. Él determinará si es necesario que le hagan análisis o que tome tratamiento.

Busque atención médica de urgencias si presenta cualquiera de los siguientes signos (señas) de alarma:

• Dolor de cabeza

• Fiebre

• Fatiga

• Escalofríos

• Nariz con

mucosidad o tupida

• Dolor de garganta

• Tos

• Dolores corporales

Síntomas de A(H1N1)

Página1 5mcc.comnursingcenter.com anatomical.comTexto por cortesía del centro NursingCenter.com. Imágenes por cortesía de Anatomical Chart Company.Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.

En niños:• Respiración acelerada o dificultad para respirar• Tonalidad morada en la piel• No está tomando suficientes líquidos• No se despierta o no responde a las acciones• Está tan irritable que no quiere que lo alcen• Los síntomas como de gripe mejoran pero

luego reaparecen con fiebre y tos más fuerte.• Vómito intenso o persistente

En adultos:• Dificultad para respirar o sensación de «falta de aire»• Dolor o sensación de presión en el pecho o en

el abdomen• Mareo súbito• Confusión • Vómito intenso o persistente• Los síntomas como de gripe mejoran pero luego

reaparecen con fiebre y tos más fuerte.

H1N1 Español por los Pacientes Forms & Tools



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

• Tosiendo o estornudando sobre su brazo y evitando el contactocercano con personas que presentan síntomas respiratoriostales como tos o estornudos.

• Quedándose en casa cuando estáenfermo y descansando el mayor tiempo que pueda.

• Lavándose las manos con frecuencia con agua y jabóndurante 15 a 20 segundos ousando un limpiador para lasmanos con base en alcohol.

• No tocándose los ojos, nariz oboca, pues ésta es la maneracomo los gérmenes llegan hastanuestro cuerpo.

• Manteniendo limpias las superficiesy objetos (especialmente mesas,mesones, cerraduras de puertas)que puedan estar expuestos al virus.

• Practicando otros hábitos saludables;incluso dormir bastante, mantenerseactivo, tomar líquidos en cantidad ycomer alimentos saludables.

¿Qué puedo hacer para prevenir la gripe por A(H1N1)?Usted puede disminuir su riesgo de contraer gripe por A(H1N1) y de propagarotros virus de la influenza de la siguiente manera:

Escrito por Lisa Morris Bonsall, MSN, RN, CRNPTraducido por Marcela D. Pinilla, M.H.E., M.T. (ASCP)

Verifique con su proveedor de atención médica paradeterminar si la vacuna contra el virus de la influenza A(H1N1) es adecuada para usted.

Texto por cortesía del centro NursingCenter.com. Imágenes por cortesía de Anatomical Chart Company.Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.

5mcc.comnursingcenter.com anatomical.com


Forms & Tools H1N1 Español por los Pacientes


FREE MEDICLIP® TRIAL!

Why choose MediClip?Clippers can help you avoid nicking or cutting the patient’s skin during preoperative hair removal,helping to reduce the patient’s risk for surgical site infections. MediClip is designed to be held at a30-degree angle to prevent the cutting blades from ever coming in contact with the patient’s skin.

Other reasons to try MediClip• User instructions are right on the handle for ease of use• Ergonomic handle design provides a comfortable grip• Hands-free blade disposal protects the user• Clean-up is easy with the sealed, waterproof handle• Smooth surface has no screws, crevices or engraving to trap dirt and debris

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and up to five cases of MediClip blades.



PERIOPERATIVE PRESSURE ULCER PREVENTION

J A N U A R Y5th 1:00 - 2:00 pm20th 12:00 - 1:00 pm29th 11:00 - 12:00 pm

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A P R I L6th 1:00 - 2:00 pm15th 12:00 - 1:00 pm27th 11:00 - 12:00 pm

Learn about pressure ulcer prevention in the perioperative arena and the implicationsof the 2008 CMS inpatient hospital care “Present on Admission (POA)” indicator.

INNOVATION IN THE PREVENTION OF CAUTI

J A N U A R Y7th 11:00 - 12:00 pm12th 12:00 - 1:00 pm14th 2:00 - 3:00 pm22nd 12:00 - 1:00 pm25th 2:00 - 3:00 pm27th 11:00 - 12:00 pm

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A P R I L6th 2:00 - 3:00 pm8th 11:00 - 12:00 pm13th 12:00 - 1:00 pm15th 2:00 - 3:00 pm26th 12:00 - 1:00 pm28th 11:00 - 12:00 pm

Join your colleagues from around the country to learn more about strategies to preventcatheter-acquired urinary tract infections as well as Medline’s ERASE CAUTI system.

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Free WebinarsNew Techniques for Pressure Ulcer Prevention,

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MKT210020/LIT570R/22M/JBK5©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

J A N U A R Y15th 12:00 - 1:00 pm29th 12:00 - 1:00 pm

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A P R I L2nd 11:00 - 12:00 pm23rd 11:00 - 12:00 pm

As the number one defense against healthcare-acquired conditions, hand hygiene playsan important role in the prevention of infections. Learn how hospitals and healthcarefacilities are combining best-in-class products and education to achieve hand hygienecompliance while dramatically improving the skin condition of healthcare workers.

HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES


OR Connection Magazine - Volume 4; Issue 3

Documents

Transcript of OR Connection Magazine - Volume 4; Issue 3