OR Connection Magazine - Volume 3; Issue 3

TheAligning practice with policy to improve patient care

Volume 3, Issue 3

FREECE!

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OR Pressure UlcerRisk AssessmentBack to Basics:Hand-Off Communication

Find Out How to Go Latex-Freewith Surgical GlovesAPIC’sTargeting Zero

Newfo

r 2009! Preventio

n Above All

6 Targeted HealthcareSolutions

OR ConnectionThe

Aligning practice with policy to improve patient care

Subscribing to The OR Connection guarantees thatyouʼll continue to receive this info-packed magazineand wonʼt miss out on our industry updates, articlesaddressing on-the-job issues and tips on caringfor yourself!

To subscribe, simply go to www.medline.com/orconnection. You will need to provide:Your nameFacility and positionMailing addressEmail 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 theseicons you'll know immediately that the subject matter on that page relates to oneor more of the following national initiatives:

• IHI's 5 Million Lives Campaign• Joint Commission 2009 National Patient Safety Goals• Surgical Care Improvement Project (SCIP)

We've tried to include content that clarifies the initiatives or gives you ideas andtools for implementing their recommendations. For a summary of each of the aboveinitiatives, see pages 6 and 7.

Aligning practice with policy to improve patient care 3

PATIENT SAFETY

6 Three Important National Initiatives for Improving Patient Care9 A Focus on Prevention

18 Back to Basics: Applying Evidence-Based Information toImprove Hand-Off Communication in Perioperative Services

30 Patient Safety in Surgery32 A Spotlight on “Never Events”50 Why Is Pressure Ulcer Risk Assessment So Important?

OR ISSUES

15 Targeting Zero Healthcare-Associated Infections26 Care Bundle for Surgical Site Preparation33 A Latex-Free Victory!42 Supply Management for Perioperative Services44 A New Way to “Pack” It All In58 Fluid Flow Disruption?

SPECIAL FEATURES

14 Prevention Above All Discoveries Grants28 Measuring What You Manage36 Organ Donation62 Why Can’t We All Just Get Along?77 Mark Your Calendar: Linda Ellerbee91 Ami Lends a Hand

CARING FOR YOURSELF

66 Hot to Set Priorities and Get the Job Done68 Conquer Stress During Tough Economic Times78 Recipe: Bruschetta Delizioso

FORMS & TOOLS

80 Summary of SCIP Measure Changes82 Hand-Off Communication in the Perioperative Setting85 SBAR Hand-Off Communication89 Pressure Ulcer Prevention Checklist: Perioperative Services

EditorSue MacInnes, RD, LDClinical EditorAlecia Cooper, RN, BS, MBA, CNORContributing EditorAndy J. Mills, MBAArt DirectorMike GottiCopy EditorLaura KuhnClinical TeamJayne Barkman, RN, BSN, CNORRhonda J. Frick, RN, CNORAnita Gill, RNMegan Giovinco, RN, CNOR, RNFAKimberly Haines, RN, Certified OR NurseJeanne Jones, RNFA, LNCCarla Nitz, RN, BSNConnie Sackett, RN, Nurse ConsultantClaudia Sanders, RN, CFAAngel Trichak, RN, BSN, CNORPerioperative Advisory BoardGail Avigne, RNShands Teaching Hospital (UFL), FloridaCaroline Copeland, RN MPHSouthern Hills Hospital & Medical CenterCathy Crandall, RNHealthTrust Purchasing Organization, TennesseeLarry Creech, RN, MBA, CDTCarilion Health System, VirginiaPat DʼErrico, RN, CNORMedical Center of Central Georgia, GeorgiaBarbara Fahey, RN CNORCleveland Clinic, OhioZaida Jacoby, RN, MA, M.EdNYU Medical Center, New YorkSherron Kurtz, RN, MSA, MSN, CNOR, CNAAWellstar Kennestone Hospital, GeorgiaWayne Malone, RNPhysicians Hospital, TexasLynda Mansfield, RN, CNOROrange County Memorial, CaliforniaJackie Minor, RN CNORHuntsville Hospital, AlabamaJennifer Misajet, BSN, MHA, CNORExempla St. Joseph Hospital, ColoradoPricilla Ranseur, RN, MSN, CNORDuke University Hospital, North CarolinaMargie Voyles, RN, MS, CNORLakeland Regional Medical Center, FloridaMargery Woll, RN, MSN, CNORRush North Shore, 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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© 2008 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Dear Reader,October 1, 2008, seems like the distant past as webreak open the New Year with a new president, newregulations, new goals and many new processes.Many of you are addressing the 11 hospital-acquiredconditions that will no longer trigger higher DRGpayments if they are acquired during the hospitalstay. Those conditions include:

1. Objects left in surgery2. Blood incompatibility3. Air embolism4. Catheter-associated urinary tract infections5. Pressure ulcers6. Vascular catheter-associated infections7. Falls and trauma (including burns)8. Surgical site infections – mediastinitis

after CABG9. Surgical site infections following certain

elective surgeries10. Certain manifestations of poor control of

blood sugar levels11. Deep vein thrombosis of pulmonary

embolism following total knee replacement/hipreplacement procedure

Patient safety is not a trend, but a part of our dailyactivities. 2009 will be a springboard for change asmore and more hospitals embrace the inevitable.This edition of The OR Connection is all about pro-viding solutions to help reduce hospital-acquiredconditions.

In reviewing Medlineʼs Prevention Above All cam-paign (Pages 9-14), you will find one solution afteranother on ways to reduce infections, programs toreduce pressure ulcers and products to assist in the

detection of foreign bodies left during surgery, toname a few. Look on Page 32 for an index of arti-cles offering solutions that will address many of the11 conditions.

The best solutions come from those of you who arein the trenches. For that reason, Medline wants tosupport and encourage these great ideas throughthe Prevention Above All Discoveries Grant Pro-gram. Medline will be awarding $1 million in grantmoney over several years. These awards are de-signed to assist healthcare providers in developingand testing creative solutions or interventions for re-ducing or preventing hospital-acquired harms. Formore information on the Discoveries Grants, seePage 14.

Finally, STOP and take time for yourself. Destressand refocus. Read how you can communicatepeacefully with other departments, set priorities andconquer stress. Let 2009 be the start of a great year!

Best Regards,

Sue MacInnes RD, LD

P.S. Take a look below at the Reader Question forthis edition. The winning response will receive acopy of Take Big Bites by Linda Ellerbee, ourkeynote speaker at our breast cancer awarenessbreakfast at AORN Congress in March.

“

4 The OR Connection

THE OR CONNECTION I Letter from the Editor

This edition ofThe OR Connectionis all about providingsolutions to helpreduce hospital-acquired conditions.”

This Edit ionʼs Quest ionWhat have you done

to improve patient safetyin your operating room?

Please submit your response to [email protected]. Eachissue will feature a new question of the month and a winner will bechosen for the best submission. Please submit early and often asthe best solutions are created by those who deliver patient careevery day!

DNV Joins Joint Commission and AOAfor Accreditation for CMS PaymentThe Centers for Medicare & Medicaid Services (CMS)has approved the first new hospital accreditation organi-zation in more than 40 years, giving hospitals anotherchoice when seeking to participate in Medicare or Medi-caid. The approval by Det Norske Veritas Healthcare Inc.for conferring deemed status on hospitals adds toaccreditation programs by the Joint Commission and theAmerican Osteopathic Association, or certification by astate survey agency.

To learn more about DNV go to:http://www.dnv.com/news_events/index.asp

Older Blood Raises Infection RiskA study conducted at Cooper University Hospital, Cam-den, NJ, and presented at the annual scientific meetingof American College of Chest Physicians in late Octo-ber, found that those who received a transfusion ofblood stored for 29 days or longer were twice aslikely to develop pneumonia, sepsis and other seriousinfections compared with those who received storedblood kept for 28 days or less. Additional studies areneeded to determine the optimal storage period for blood toprevent infections. Rules currently permit blood to bestored for 42 days.

To learn more about this study, go to:http://www.chestnet.org/about/press/releases/2008/CHEST/PDF/BloodStorage.pdf?zbrandid=3032&zid-Type =CH&zid=1342800&zsubscriberId=751519175

UCLA study reveals smoking's effecton nurses' health, death ratesA new UCLA School of Nursing study is the first to revealthe devastating consequences of smoking on the nursingprofession. Published in the November- December editionof the journal Nursing Research, the findings describesmoking trends and death rates among U.S. nurses andemphasize the importance of supporting smoking cessationprograms in the nursing field.

The current UCLA research explored changes in smokingtrends and death rates among female nurses enrolled in theNurses' Health Study between 1976 and 2003, a span of27 years.

According to the most recent data, the smokingrate among registered nurses nationwide isnearly 12 percent.

The rate of smoking among women in the Nurses' HealthStudy declined from 33.2 percent in 1976 to 8.4 percent in2003. The number of cigarettes smoked per day alsodropped. However, the daily number among currentsmokers still averaged more than 15 cigarettes, or over halfa pack.

The entire story can be found at:http://newsroom.ucla.edu/portal/ucla/new-ucla-study-reveals-smoking-71590.aspx?link_page_rss=71590

News Flash


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 December of 2006Purpose: To prevent unintended physical injury resulting from or contributed to by medical care that requires

additional monitoring, treatment or hospitalization, or that results in deathGoal: To prevent five million incidents of medical harm over the next two years and to enroll more than

4,000 hospitals and their communities in the project.

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

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

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

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

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

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.

5 Million Lives Campaign1

Joint Commission 2008 National Patient Safety Goals2

Surgical Care Improvement Project (SCIP)3


1. Prevent pressure ulcers2. Reduce methicillin-resistant staphylococcus

aureus (MRSA) infection3. Prevent harm from high-alert medications4. Reduce surgical complications5. Deliver evidence-based care for congestive heart failure6. Get boards on board7. Deploy rapid response teams8. Prevent adverse drug events (ADEs)

9. Deliver evidence–based care for acutemyocardial infarction

10.Prevent surgical-site infections11.Prevent central-line infections12.Prevent ventilator-associated pneumonia

By the numbers:• Over 4,000 hospitals currently enrolled• The Top 4 Interventions:

1. Adverse Drug Events (ADEs) – 3,1522. Surgical Site Infection (SSI) – 3,0473. Acute Myocardial Infarction (AMI) – 3,0164. Rapid Response Teams – 2,853

1. Surgical-site infections• Antibiotics, blood sugar control, hair removal, normothermia

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

3. Venous thromboembolism• Use of appropriate prophylaxis

SCIP is targeting two new measures for October 2009:• Removal of urinary catheters within 48 hours post surgery• A new, updated normothermia measure

To learn more, go to Page 9.Visit www.qualitynet.org

Patient Safety

5 Million Lives Campaign: Twelve Interventions

Joint Commission 2009 National Patient Safety Goals

Surgical Care Improvement Project (SCIP): Target Areas

By the numbers:• 3,740 hospitals are submitting

data on SCIP measures, representing75 percent of all U.S. hospitals

• Currently, SCIP has more than 36association and business partners

An IHI forum, “Celebrating 20 Years: The Futureof Health Care is Ours to Imagine,” was held inNashville on December 8-11, 2008. www.ihi.org

• Improve accuracy of patient identification• Improve effectiveness of communication

among caregivers• Improve medication safety• Reduce risk of healthcare-associated infections

(Expanded in 2008 to include either WHOor CDC Hand Hygiene Guidelines)

• Reduce risk of patient harm from falls• Reduce risk of influenza and pneumoccocal

disease through immunization

• Reduce risk of surgical fires• Encourage patientʼs active involvement in their care• Prevent healthcare-associated pressure ulcers

(decubitus ulcers)• Identify safety risks inherent in patient population

(suicide, home fires)• Improve recognition and response to changes in a

patients condition• Implementation of Universal Protocol for preventing

wrong-site, wrong-person, wrong-procedure surgery

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


A Focus on PreventionHighlights from the Prevention Above All Forum

At the Prevention Above All Forum in August, nearly 100chief nursing officers, chief medical officers and healthcarequality executives from across the U.S. came to Chicago tohear some of health careʼs top thought leaders discusspolicy changes, patient safety strategies and targeted,evidence-based solutions for improving patient outcomes.There was a lot of information and excitement around thenew reimbursement regulations that CMS put into practiceOctober 1, as well as the patient safety themes that thequality improvement organizations are working on.

If you didn't get a chance to attend this yearʼs meeting, hereare five key things that you missed hearing about:

The key to cultural change:mutual cooperation built on realmutual respectWith CMS revamping reimbursementfor hospital-acquired conditions (HACs)and expanding implementation of theQuality Indicator Survey for long-termcare facilities into more states, it wasnʼt

too surprising to hear Keynote Speaker John J. Nance, JDopen the Prevention Above All Forum by saying “the coreculture of medical practice has to be drastically changed.”

Nance, founding member of the National Patient SafetyFoundation and author of Why Hospitals Should Fly: TheUltimate Flight Plan to Patient Safety and Quality Care,touched on how the October 1 CMS reimbursement mile-stone for HACs provides the opportunity for healthcareproviders to “re-commit” to improving patient safety bybecoming engaged professionals dedicated to barrierlesscommunication.

“Youʼre not only going to solve the CMS problems (of HACprevention),” said Nance. “But you are going to get to thepoint of asking doctors ʻWhy donʼt we have 100 percentcompliance on handwashing?ʼ and ʻIs it okay if my nursesremind you?ʼ That consistent cross-checking of each other,completely devoid of professional defensiveness, and a realcaring for each other as full members of a team dedicated tothe patientʼs best interests, is the key to safe practice.

Why Hospitals Should Fly by John Nance is available atwww.whyhospitalsshouldfly.com.

“This conference was absolutely terrific,My knowledge has been increasedgreatly. Our ‘assigned row rep’ wasterrific, very helpful, anticipated ourneeds before we knew them and wasoverall great!”Karin L. Boylard, Clinical Nurse EducatorJohnson Memorial Hospital

CMSʼ new community approachto pressure ulcersIn terms of healthcare policy changesand their implications for care, one withan astounding impact discussed at theforum was CMSʼs new communityapproach to pressure ulcer preventionand care as outlined in the 9th Scope

of Work. Dale Bratlzer, DO, MPH, Med-ical Director of the Oklahoma Foundation for Medical Qual-ity, provided some early information on how the epidemic ofthe “ambulance acquired” pressure ulcer will be somethingof the past and how this is the number one initiative for theQuality Improvement Organizations (QIOs) right now.

Previously, CMSreviewed cap-tured MDS datato help identifynursing homesthat have highrates of pressureulcers. With theCMS 9th Scopeof Work, whichtook effect on

August 1, CMS now directs QIOs to focus not only on nurs-ing homes with a high incidence of pressure ulcers, but totake a closer look at hospitals in the same county and holdthem accountable as well. So the QIOs are tasked withgoing in and working with both the hospital and the nurs-ing home to reduce the rates of pressure ulcers. Youcan learn more about the 9th Scope of Work by visitingwww.providers.ipro.org/index/9SOW_summaries - 39k.

Nance

Bratzler

Be sure to visit the Prevention Above All Website at www.medline.com/special/PAA/ forcontinued updates and additional resources.

10 The OR Connection

According to Bratzler, CMS is actively working on buildingperformance measures that will publicly report hospital pres-sure ulcer rates, and once they complete that there will bea strong incentive for nursing homes and hospitals to worktogether to figure out the best way to prevent pressureulcers. This new community focus represents how CMS isstarting to look at data outside of the hospital to see what ishappening in the hospital. For example, they are looking atthings that happen in surgery and the effects 30 days and 60later, so the tracking systems from whether you are in theacute care setting or leave is going to ultimately look atevery setting of healthcare not just one.

Learn more about Medlineʼs Pressure Ulcer PreventionProgram on Page 13.

“I want to take the [Medline] pressureulcer program to our executive nursingteam – this program would be excellentin helping us to prevent pressure ulcersand to improve our overall patient caredelivery.”Debra Williams, Vice President/CNOGarden City Hospital

Implications of the CMS Guide-lines on pressure ulcer preventionand treatmentThereʼs a great variability in termsof how organizations prepared for theOctober 1 deadline and where they areat on that continuum of preparation.According to Diane Krasner, PhD, RN,

CWCN, CWS, BCLNC, FAAN, Wound and Skin Care Con-sultant. A lot of that preparedness comes down to education.

“If you just look at the pressure ulcer part of the CMS ruling,thereʼs a high training and education component that eachfacility is going to have to grapple with,” said Krasner.Krasnerʼs presentation highlighted the need for nursesto receive more education on:

• Risk assessment (interpretation of Braden Scale)• Pressure ulcer staging• Proper positioning (including bed and chair)• Effects of moisture on the skin (including incontinence,

humidity and maceration)

• Pressure-relieving products• Proper application and usage of prevention products

The following documents – currently in use at Krasnerʼsfacility, Rest Haven-York – are also available:

• Pressure Ulcer Protocol• Pressure Ulcer Protocol – Avoidable versus

Unavoidable Pressure Ulcers• Pressure Ulcer Notification Fax• Pressure Ulcer Risk Factors tracking chart• Wound Photo Documentation

If you are interested in receiving any of these documents,please email us at [email protected].

“This was the ultimate forum,unsurpassed, professional, phenomenalspeakers with the most up-to-date reliableeducation with statistical evidence. Kudosto Medline.”Charles Gizara, Director, Clinical OperationsAtlantic General Hospital

A proposed new SCIP measurefor October 2009 on timelycatheter removal.The proposed performance measurefocuses specifically on whether thehealthcare provider attempted toremove the catheter by the secondpost operative day (with surgery beingday zero). This important performance

measure that is now National Quality Forum endorsed willbe rolling out in October of 2009. A main driver behind thismeasure was a study led by Heidi Wald, MD, MPH, whodiscussed the connection.

Wald, along with her co-authors of the study “IndwellingUrinary Catheter Use in the Postoperative Period,” revieweddata from 35,904 Medicare patients at 2,965 acute care hos-pitals across the United States to determine the relationshipbetween catheter use and postoperative outcomes. Fromthat large number of patients that were operated on, theyfound that 86% of the patients had been catheterized, andthat half of them had their catheter for more than two days –

A Focus on PreventionHighlights from the Prevention Above All Forum

Krasner

Wald


a concern since patients whose catheters are in for a long pe-riod of time post-operatively are at an increased risk of infection.

Previously research had already demonstrated the doublingof mortality rate with something as simple as a urinary tract in-fection, but Dr. Wald and her colleagues were able to confirmthat indwelling urinary catheters that are left in place for longerthan two days postoperatively may result in catheter-acquiredurinary tract infections (CAUTI) as well as an increase in 30-day mortality and an increased length of stay (to view thestudy, please visit http://archsurg.ama-assn.org/cgi/content/short/143/6/551).

How big of an issue is this? There are an estimated 26-36 mil-lion operations performed in the United States each year andBratzler notes that every single study looking at patients withsimilar risks, having the same operation, shows the mortalityrate doubling if they get a surgical infection. And in fact, a Uni-versity of Pennsylvania study reviewing a large number ofoperations performed demonstrated that when a patient hasa major complication of surgery, the risk of death isincreased by threefold within the next 60 days.

“I didn’t know Medline had these types ofproducts. And the supportive evidence wasexcellent, how can we work together?”Mary R. Lopez, Vice President, Quality InitiativesHospital Council Northern & Central California

APIC: Spreading knowledge,preventing infectionSometimes a few changes need to bemade in order to clarify goals and con-tinue to move toward them. Kathy Warye,CEO of the Association for Professionalsin Infection Control and Epidemiology,Inc. (APIC) shared the associationʼs rec-

ommendation of changing the title of Infection Control Pro-fessional to Infection Preventionist with PreventionAbove All forum attendees.

“Language creates culture, and if the goal is around prevention,then our name needs to incorporate prevention,” Warye said.

Warye distributed copies of APICʼs MRSA guidelines and aDVD on hand hygiene geared toward patients. To download acopy of the DVD video, please visit www.cdc.gov/handhy-giene. For more APIC resources, please visit www.apic.org.

Warye

MedlinePresidentAndy Millsconfers withpresenterDea Kent

Guests get involved at the Prevention AboveAll Presentation

A sampling of the items presented at the forum

Medlineʼs six practical and targeted interventionsto help improve outcomes.There is compelling evidence that many hospital-acquired con-ditions (HACs), specifically those targeted by CMS as “neverevents,” are preventable. And there are plenty of great prod-ucts and evidenced-based solutions available. The challengeis implementing these solutions. There is a need to educatecaregivers, organize data and assist the healthcare providerwith process improvement.

Combining innovative products with evidence-based solutions,Medline strategically integrated a portfolio of focused andachievable evidence-based solutions designed to fit into theeveryday processes and systems most healthcare providersalready have in place. The six conditions targeted by Preven-tion Above All and their complementary Medline product andprogram solutions are:

Target: Catheter-AssociatedUrinary Tract Infection (CAUTIs)The Prevention Above AllIntervention: Silvertouch CathetersA bundled solution of advanced silver technology withMedlineʼs Silvertouch™ Foley catheters and educationaltraining to reduce CAUTIs.

Silvertouch Foley catheters incorporate the power of silverthrough a patented process that binds silver ions to thecatheterʼs lubricious coating, delaying the onset of biofilm for-mation. Educational materials provide summarizations of themajor recommendations from the CDC, SHEA, APIC and othersprovide a policy and procedure template guide for propercatheterization. Also included are validation tools that can beutilized during training or re-education classes, and a trou-bleshooting guide book and a poster to help caregivers workthrough issues.

Target: Harm Avoidanceand Patient SatisfactionThe Prevention Above All Inter-vention: Educational PackagingTo help reduce medical errors, Medline redesigned itsAdvancedWound Care packaging in a format that allows each packageto serve as a 2-minute course on advanced wound care.

The innovative packaging design is an improved delivery andcommunication system to help healthcare professionals betterunderstand and more easily deliver wound care at the patient'sbedside. It replaces confusion with clear, step-by-stepinformation, eliminating the clutter and highlightingcritical information.

Target: Objectsretained after surgeryThe Prevention Above AllIntervention: RF DetectRF system designed to alert the OR nurse when a RF-taggedsurgical item remains in the patient before closing the procedure.This provides an added level of safety and an adjunct to thecounting procedure.

The system consists of three components: a micro RF tagembedded in gauze, sponges and towels and a sterile hand-held wand that is connected to the third component, an easy-to-use, self-calibrating console. By passing the wand back andforth and side to side over the patient, hospital personnel will beable to accurately detect, within seconds, retained surgicaldisposables before site closure and rectify incorrect counts.

Target: Hospital-Acquired InfectionsThe Prevention AboveAll Intervention: HandHygiene Compliance ProgramA program of products that stresses appropriate applicationtechniques and education to achieve hand hygiene compli-ance while dramatically improving the skin condition of health-care workers.

The Hand Hygiene Compliance Program contains threeproducts – Sterillium Comfort Gel™, Medline Remedy™ SkinRepair Cream and Aloetouch® exam gloves – clinically provento nourish dry skin. The program includes an intensive edu-cational module developed by an expert panel of infectioncontrol professionals. Healthcare workers can earn up to fourcontinuing education credits by completing the training program.Additional components include testing for skill and competencyvalidation through the use of Visirub and a UV light box. Pa-tient education pamphlets, facility posters and a rewards pro-gram are also included to reinforce positive behavior change.


Prevention Above AllTargeted interventions, practical solutions


Target: Pressure UlcersThe Prevention AboveAll Intervention: PressureUlcer Prevention ProgramMedline offers a Pressure Ulcer Prevention Program to fitall disciplines, from physicians and OR nurses to CNAs,RNs and LPNs. A program of products, tools andresources to implement an effective prevention programand immediately begin reducing the incidence of pres-sure ulcers.

The Pressure Ulcer Prevention Program is a strategic prod-uct bundle to assist in reducing or preventing pressure ul-cers and incontinence-associated skin conditions, whichmay include dermatitis and skin tears. Products includeRemedy™ Advanced Skin Care Products, Ultrasorbs® APDry Pads, Restore®/Remedy™ Adult Brief, and Supra DPSalternating pressure and low-air-loss mattresses.

The Perioperative Pressure Ulcer Prevention Program in-cludes an educational DVD addressing pressure ulcer riskassessment and prevention methods and strategies. Its ac-companying product bundle includes Sahara OR TableSheets, Medline Gel Positioners and Pressure Redistribu-tion Table Pads.

The comprehensive program also packages together edu-cation and training tools so a healthcare team can implementan effective pressure ulcer prevention program and immedi-ately begin reducing the incidence of healthcare-acquiredpressure ulcers. Included are workbooks, patient andfamily education brochures and a rewards program.

Wayne Brannock,vice president ofclinical servicesfor Lorien HealthSystems inMaryland asksa question duringa session.

Attendees review MedlineʼsPressure Ulcer PreventionProgram materials.

Dr. Andrew Kramerspeaks to attendeesabout patient safety.

Medline Chief Marketing Officer Sue MacInnes addresses attendees during thePrevention Above all Forum.

Target: Wrong Site SurgeryThe Prevention Above AllIntervention: S.T.O.P. DrapeA surgical drape that incorpo-

rates a “Time Out” sticker stripthat must be removed prior to the surgical case and provided tothe circulating nurse to be placed on the patientʼs chart.

The Medline S.T.O.P drape has a sticker in the shape of a redstop sign and tells the staff to stop, forcing them to rememberto perform the time-out procedure required prior to beginningsurgery. The sticker provides a location to write and confirm thepatientʼs name, procedure, site and side, date, time andsurgeonʼs initials. By requiring the surgeon to initial the sticker,the surgical team is again reminded to perform the time-outimmediately prior to the incision.

Special Feature

Medline is committing up to $1 million in over several yearsto stimulate the gathering of solid evidence that supports theadoption of solutions into clinical practice. A review panel, whosemembers represent a breadth of research and practice knowl-edge, will select grant recipients to be awarded up to $25,000each for pilot studies or $100,000 each for empirical studies.

ObjectivesTo stimulate research that will lead to the development of newtargeted interventions aimed at reducing medical risks andharms associated with hospital-acquired conditions (identifiedby CMS in 2008 IPPS final rule).• To test the costs and effectiveness of interventions and

programs designed to reduce the incidence of hospital-acquired conditions.

• To disseminate practical, evidence-based solutionswithin and across hospitals, leading to a reduction inhospital-acquired conditions.

These awards are designed to assist healthcare providers indeveloping and testing creative solutions or interventions forreducing or preventing hospital-acquired conditions. Recipientsof grant awards will be paired with a research mentor/consul-tant through the grant program to develop methods and guidethe conduct of the study, ensuring that a rigorous researchprocess is followed. These studies can be small pilot studiesaimed at developing and testing the feasibility of new solutionsor larger evaluation studies to more fully test the costs, effec-tiveness or dissemination of evidence-based solutions.

Award Process1. In response to our request for applications (RFA),

providers will submit a 2-3 page letter of intent providingthe following information:

• The HAC(s) that the study will address• Whether the letter is for a pilot or

empirical study• The proposed solution• The objective of the study• The proposed approach in as much detail as

you have thought it through at this point• Expected output of the study• Brief biography about the individuals involved,

including any experience in the area of focus• Budget estimate, including the major expenditure

categories

2. The review committee will review letters of intent on arolling basis (see list of review committee members).Acceptable letters will be assigned to the most appro-priate research mentor, who will contact the applicantand work with him/her to develop the letter into a fullproposal of 5-7 pages in length, including a completebudget. Proposal and budget guidelines will be sentafter approval of letter of intent.

3. The review committee will review full proposals andbudgets on a rolling basis. Most of the projects that arechosen for full proposal submission will be funded;however, this process may involve a subsequentresubmission of a revised proposal so that the fundedresearch plan is clear.

4. Pilot studies will generally be up to six months in durationwith a budget of about $25,000. Empirical studies canbe up to $100,000 and last up to a year or more in duration.Pilot study grantees can go on to submit an empiricalstudy proposal at the successful conclusion of the pilot project,or applicants can apply for a full empirical study grantbased on their initial letter of intent if they have anexisting practice with evidence that they wish to evaluate.

5. The final report for a pilot grant study should be a briefpaper written for a Medline publication (Healthy Skin,The OR Connection or Infection Prevention Now)whether the grant is successful or not. The final reportfor an empirical study is a paper to be submitted forpublication in a peer-reviewed journal.

GRANT PROGRAM SCHEDULENov. 15 to Jan. 31, 2009Accept and review letters of intent on a rolling basis

Dec. 1 to Feb. 28, 2009Notification of acceptance and authorization to begin fullproposal (due one month after notification of letter of intent)

Jan. 1, 2009 to Apr. 30, 2009Full proposals funded and projects started withintwo months of proposal submission

PREVENTION ABOVE ALL DISCOVERIES GRANTS:Supporting the adoption of solutions

into everyday clinical practice

Targeting

ZEROHealthcare-Associated Infections

An exclusive report from APICBy Kathy Warye, APIC executive director

In January of 2006, the Association for Professionalsin Infection Control and Epidemiology published APICVision 2012, a strategic approach to the future of thepractice and profession. The first goal of the plan statedthat APIC will “promote prevention and zero tolerance forhealthcare-associated infections (HAIs).”1 Since that time,APICʼs approach has evolved and focused instead on pro-moting a culture where targeting zero healthcare-associatedinfections is fully embraced.

Insertion of the word “culture” was an important addition, asAPICʼs intent is to promote a cultural change within healthcare wherein providers strive to eliminate preventable HAIs.

While few organizations in the early 2006 time frame werecontemplating the possibility of reaching zero HAIs, zerotolerance first emerged in 2000 when Julie Gerberding,director of the CDC, introduced the concept. She noted that,over time, the goal of elimination had been applied to otherpublic health concerns, such as TB and polio. Eliminationmight not have occurred, but ambitious goals drove positivechange and dramatic reductions.

Making prevention a priorityAs APICʼs strategic plan was taking shape, a small butinfluential group of healthcare organizations were discoveringthat many more infections are preventable than previously

OR Issues


thought. They were setting goals to reduce HAIs significantlybelow previously accepted benchmarks, reaching and sus-taining them. With a declining arsenal of antibiotics to treatinfections, it was increasingly clear that the traditionalorientation toward control of HAIs needed to shift to onewhere preventing the occurrence was the priority throughoutthe institution. APIC was hearing from leaders across thespectrum of health care, from providers to patients andpatient safety advocates. It was in this context that APICʼsleaders agreed that the Association should be at the fore-front in promoting significant and sustained reductions inpreventable healthcare-associated infections.

Since that time, APIC has moved forward to promote pre-vention and provided members with a host of resources tohelp them set and reach ambitious goals for the reduction ofHAIs. Targeting Zero encourages all organizations to set thegoal of elimination rather than remain comfortable whenlocal or national averages or benchmarks are met. Everysingle HAI impacts the life of a patient and family – even oneshould feel like too many.

“Zero tolerance” explainedAPIC also believes that willful non-adherence by healthcareworkers with proven infection prevention and control measuresshould be unacceptable. References to “zero tolerance”today are generally intended as a response to unsafebehaviors and practices that place patients and healthcareworkers at risk. In the context of HAIs, zero tolerance doesnʼtmean that people or organizations should be penalized forinfections that might not be preventable, but this languagemay be used to stress the need for accountability and a cul-ture built on inquiry and learning as opposed to punishment.

A culture of targeting zero healthcare-associated infectionsand zero tolerance for unsafe practices is characterized bythe following:• Setting the theoretical goal of elimination of HAIs;• An expectation that infection prevention and control (IPC)

measures will be applied consistently by all healthcareworkers, 100 percent of the time;

• A safe environment for healthcare workers to pursue 100percent adherence, where they are empowered to holdeach other accountable for infection prevention;

• Systems and administrative support that provide thefoundation to successfully perform IPC measures;

• Transparency and continuous learning where mistakesand/or poor systems and processes can be openlydiscussed without fear of penalty;

• Prompt investigation of HAIs of greatest concern to theorganization and/or community and

• Focus on providing real-time data to front line staff forthe purpose of driving improvements.

Culture change in the ORCreating the culture change required to eliminate surgicalsite and other infections that begin in the OR will requirecommitment on the part of the entire OR team, fromsurgeons and anesthesiologists to operating room man-agers, nurses and technicians. The institutionʼs infectionprevention experts can assist in the provision of real-timedata, application of performance improvement concepts(such as root cause analysis) and ongoing education andtraining for OR staff in the consistent application of keyinfection prevention measures.

New technologies and procedures, more virulent pathogensand increasing resistance will continue to challenge thehealthcare community in its efforts to reduce HAIs. Becauseof this, even where large-scale cultural change and consis-tent application of IPC measures exists – even when nobreak in practice can be identified – healthcare-associatedinfections will still occur. However, where the goal of zerohas been set and the culture is consistent with this goal,APIC is confident that new approaches will emerge to bet-ter protect patients from healthcare-associated infections.

To view APICʼs evidence-based guides on the eliminationof infection, archived webinars and other resources in theTargeting Zero program, please visit www.apic.org.

1 Association for Professionals in Infection Control and Epidemiology, Inc. APIC Vision2012. Available at: http://www.apic.org/AM/Template.cfm?Section=About_APIC&Tem-plate=/CM/ContentDisplay.cfm&ContentFileID=4688. Accessed October 31, 2008.

About the authorKathy Warye is the executive director of the Association forProfessionals in Infection Control and Epidemiology, Inc., (APIC),a worldwide membership association providing 11,500 infectionprevention professionals legislative and/or public relations strategieson issues impacting the infection prevention and control profession.APIC advances its mission through education, research, collabo-ration, practice guidance, public policy and credentialing.

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There are three very significant hand-offs that occur inperioperative services for each patient who undergoes asurgical procedure. The first one is from the pre-operativepatient care area to the holding room staff. The second one isfrom the OR team to OR team members. The third one is fromthe OR team to the post-anesthesia care team.

There are also additional hand-offs that result for data gatheredwithin each unit or area, depending upon information gath-ered during assessment periods. There can be hand-offs fromholding room staff to anesthesia and the assigned circulatoras well as from circulator to circulator when being relieved forbreaks, lunch and at shift change. The last hand-off occurswhen the PACU nurse hands off to the post-op caregiver.

Obviously, there are many opportunities to gather andcommunicate critical information that can affect and improvepatient care, prevent injuries and medical errors and ensurethat your patient has the safest and highest-quality surgi-cal outcomes.

Adverse events during surgeryThe list of what can go wrong during a surgical experience islong and intimidating. Foreign bodies, mislabeled pathologyspecimens, operative fires, transfusion and medication errorsand wrong site, wrong procedure, wrong person surgery arejust some of the preventable hazards associated with surgery.1Adverse events occur more often in surgery than in any otherspecialty, and disproportionately greater harm results fromsurgical errors.2

In the surgical setting, a premium is placed on efficiency.There are strict schedules that must be kept despite constant

Applying Evidence-Based Informationto Improve Hand-Off Communication

in Perioperative Services

By Alecia Cooper, RN, BS, MBA, CNOR

Back to Basics Ninth in a Series


Patient Safety

interruptions from emergencies, add-ons, delays and compli-cations. Time becomes a barrier to communication.2 Rushingthe hand-off can lead to small, yet critical mistakes that canultimately harm patients.2

Example: A patient who has been in an accident and requiressurgery also has a severe shoulder sprain. However, the staffmembers who transfer the patient to preoperative holdingforget to mention this, so no one else – including the OR,anesthesia, PACU or the floor – is aware of the shouldersprain. Throughout the care, nurses repeatedly manipulatethe patientʼs arm during repositioning, causing distress to thepatient and worsening the patientʼs injury.2

National Patient Safety Goal 2EAccording to the Joint Commission, communication issues arethe leading factor in root causes of sentinel events.3 For thisreason, the National Patient Safety Goal 2E (NPSG.02.05.01)was added in 2006. This goal reads as follows: “The [organi-zation] implements a standardized approach to hand-off com-munications, including an opportunity to ask and respond toquestions.”3 The elements of performance that are measuredby the Joint Commission in an organizationʼs hand-offprocess include3:

1. Interactive communication that allows for the opportunityfor questioning between the giver and receiver ofpatient information.

2. Up-to-date information regarding the patientʼs condition,care, treatment, medications, services and any recentor anticipated changes.

3. A method to verify the received information, includingrepeat-back or read-back techniques.

4. An opportunity for the receiver of the hand-off informationto review relevant patient historical data, which may includeprevious care, treatment or services.

5. Interruptions during hand-offs are limited to minimizethe possibility that information fails to be conveyed oris forgotten.

The goal further states that an organization should implementa standardized approach to hand-off communication. Is yourprocess standardized?

Standardizing hand-off communicationHand-off communication is defined as the “transfer of infor-mation (along with authority and responsibility) during transi-tions in care across the continuum for the purpose of ensuringthe continuity and safety of the patientʼs care.”4 It is the inter-active delivery of accurate and current information about apatient exchanged from one provider/caregiver to another. Toimprove the reliability of workflows accomplishing their desiredgoals, and to reduce the risk to patient safety, researchers


recommend structured communications and clear agree-ments about roles and responsibilities in a hand-off.5

A clear barrier to hand-off communication is the sheer numberof individuals involved in the care of surgical patients. In arecent study, it was revealed that the typical surgical patientsees an average of 26.6 health professionals during theirhospital stay, compared with the mean of 17.8 health profes-sionals seen by medical patients.2 Therefore a standardizedprocess for hand-off communication becomes critical in peri-operative services to ensure that communication is thoroughand complete among all of the perioperative team members.

Choosing a standardized hand-off method and toolHealthcare providers have looked at other high-risk, high-stakes industries such as aviation, aerospace, nuclear powerand the military for new approaches that can be applied tohealthcare hand-offs.2 Organizations have also used the SixSigma methodology framework to try and better understandthe process for hand-off communication.6 The developmentof a standardized hand-off communications tool is a dynamicprocess that allows continued opportunities for improving thedelivery of patient care.4 AORN has developed a Perioperative

Patient “Hand-Off” Tool Kit that includes nine recommenda-tions for standardized hand-off policy development.4

Popular hand-off communication systemsHere are four widely used hand-off communication systems:• “I PASS the BATON” (Introduction, Patient, Assessment,

Situation, Safety Concerns, Background, Actions, Timing,Ownership, Next)

• “I-SBAR” (Introduction, Situation, Background, Assessment,Recommendation)

• “PACE” (Patient/Problem, Assessment/Actions, Continuing[treatments]/Changes, Evaluation)

• “Five Ps” (Patient, Plan, Purpose, Problem, Precautions,Physician [assigned to coordinate])

All four systems are effective as long as there is adherenceto the following rules4:1. Conduct the hand-off face-to-face.2. Be certain that the hand-off is two-way, with both participants

taking joint responsibility for ensuring accuratecommunication.

3. Use verbal and written means of communication.4. Give as much time as necessary to ensure accurate

communication.

Recommendation OneLeadership should respond to the Joint Commission man-date to improve hand-offs by initiating a program within eachfacility, setting the priority and identifying the timeline.

Recommendation TwoConsider using structured tools that can facilitate consis-tency in communication exchanges. Examples include, butare not limited to, the “I PASS THE BATON,” “I-SBAR,”“PACE” or the “Five Ps.” Each mnemonic is developed toguide medical hand-offs and optimize information transfer.

Recommendation ThreeWhen implementing training and process changes, use abroad definition for hand-offs to include most care transitionsand information handling across the continuum of care.

Recommendation FourUse a system, checklist, template or mnemonic that includesupdated information, recent changes in condition or circum-stances and any anticipated changes or aspects of care thatneed to be observed or watched closely.

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

Recommendation SixDesign methods that facilitate instruction on and implemen-tation of effective communication and teamwork skills, asprovided in TeamSTEPPS, which verify information transferwith closed-loop communication tools (including check-back,read-back, call-out, etc.) for transferring important informa-tion, such as critical actions, medication doses and urgentactions.

Recommendation SevenTo meet this requirement, charts, written information andreports/results should be available for review (as appropri-ate) by the oncoming provider(s).

Recommendation EightWhile developing hand-off policies and protocols, include aclear statement of how and when responsibility is transferredduring healthcare transitions.

Recommendation NineTeach and practice communication using established clear,common language among care providers during hand-offs.

AORNʼs nine recommendations for standardized hand-off policy development4


TeamSTEPPSTeamSTEPPS (Team Strategies and Tools to Enhance Per-formance and Patient Safety) is an evidence-based team-training curriculum used by the Department of Defense (DoD).It was developed by the Agency for Healthcare Research andQuality (AHRQ).

The DoD Patient Safety Program extended permission toAORN to customize its existing materials with a focus onperioperative settings. This is what was used in the develop-ment of AORNʼs tool kit. The TeamSTEPPS program is an op-portunity for the surgical team to diminish the risk of error andimprove patient outcomes by creating a structure to supportstandardized hand-offs and improve communications duringcare transistions.4 Within this kit are numerous tools,mnemonics and strategies to be used as templates. TheAORN tool kit is available for free and can be downloadedfrom www.aorn.org.

One healthcare organization utilizing the TeamSTEPPScurriculum developed a team hand-off model. To minimizeinterruptions and distractions during the hand-off process, thisorganization modified a concept championed by the aviationindustry – the “sterile cockpit.” In response to the increasingnumber of commercial airline accidents involving the cockpit

crewʼs attention being diverted from more critical tasks, theFederal Aviation Administration enacted regulations to prohibitcrew members from performing nonessential duties or activities(including conversation) while the aircraft is involved in thephases of flight most commonly associated with error: taxi,takeoff and landing.6

This healthcare organization interpreted the sterile cockpitconcept for the clinical setting during the verbal transfer ofpatient information. Specifically, only patient-specific conver-sation or urgent clinical interruptions were permitted to occurduring the hand-off process. They measured their perform-ance improvement after implementing the system and foundthey were able to reduce hand-off turnaround time from 15.3minutes to 9.6 minutes.

Formula 1 hand-offsAnother healthcare organization has initiated a new hand-offprocess modeled after routine pit stops in racing, which typicallytake less than 10 seconds. Each crew member has a specificjob that they know very well. The crew is prepared down tothe smallest detail. Safety is the number one concern becausethe consequences of errors can be life-threatening for bothdriver and crew. In contrast to pit stops, hand-offs can bechaotic events involving multiple simultaneous conversations.

10 barriers to effective hand-offs1. Lack of education at nursing and medical schools2. Healthcare system that historically has supported

individual autonomy and performance3. Lack of engagement of patients and families in the

care process4. Resistance to change among staff5. Lack of time for providers to devote to handoffs6. Problems in the physical setting, including

background noise and interruptions7. Language barriers between clinicians and between

the clinician and the patient. Itʼs also important forclinicians to avoid abbreviations and ambiguousterminology

8. Failures in mode of communication, such as faxmachine or email or the inability to locate thepatient record

9. Lack of definitive scientific research and data toidentify accepted hand-off best practices

10. Lack of financial resources to implementstandardized hand-off processes

10 tips for effective hand-offs1. Allow for face-to-face hand-offs whenever possible.2. Ensure two-way communication during the

hand-off process.3. Allow as much time as necessary for hand-offs.4. Use both verbal and written means

of communication.5. Conduct hand-offs at the patient bedside whenever

possible. Involve patients and families in the hand-offprocess. Provide clear information at discharge.

6. Involve staff in the development of hand-offstandards.

7. Incorporate communication techniques, such asSBAR, in the handoff process Require a verificationprocess to ensure that information is both receivedand understood.

8. In addition to information exchange, hand-offs shouldclearly outline the transfer of patient responsibilityfrom one provider to another.

9. Use available technology, such as the electronicmedical record, to streamline the exchange of timely,accurate information.

10. Monitor use and effectiveness of the hand-off.Seek feedback from staff.

Continued on Page 23

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Reference1. Popovic JR, Hall MJ. 1999 National Hospital Discharge Survey. Advance data from vital and healthstatistics. No. 319. Hyattsville, Md.: National Center for Health Statistics, 2001. (DHHS publication no.(PHS) 2001-1250 1-0287.).

a


This organization utilized a human factors expert along withmembers of the medical staff to study the unique maneuversof Formula 1 pit crews. They witnessed many behaviors thatthey then applied to patient hand-offs following surgery. Beforethe hand-off, the surgical team notifies the receiving care-givers of any specific equipment that the patient will need sothat there is no scrambling to get it set up. The equipment canbe ready and waiting upon arrival.

When the patient arrives, there is a routine process that isstandardized and takes place in the same order every time.First, all lines and tubes are untangled and reconnected qui-etly and efficiently. Then, the team ensures that the patientʼscondition is stable before the report begins. The final phase isthe report, which utilizes a handover checklist and surgeonʼssummary. This occurs without distraction from transfer activi-ties or competing conversations because the receiving teamis able to give their full attention to the transferring team asthe report is given. The hand-off is smooth, efficient and –most important – safe.2

Battling lost data in nursing hand-offsIn a study done by Pothier, Monteiro et al, the hand-off of 12simulated patients was observed over five consecutive hand-off cycles. Three hand-off styles were used and the amount ofdata loss was recorded for each style. The purely verbal hand-off style resulted in the loss of all data after three cycles. Anote-taking style resulted in only 31 percent of data beingtransferred correctly after five cycles. When a printed formwas included with the verbal hand-off, data loss was minimal.The authors recommend that nursing and medical staffinclude a printed data sheet as part of the hand-off process.4

AORN describes the preoperative brief as a powerful tool to“bring the entire OR team onto the same page”; removeincorrect assumptions; clarify the intended plan and contin-gency plans; obtain key information from surgeons, anesthe-sia providers, circulating nurses and surgical technologists orscrub nurses that enhances patient care safety and qualityand develop counter-strategies for avoiding common pitfalls,errors and complications.4

AORN recommends using four differenthand-off briefs, the Pre-Op Brief, Hand-Off Briefs for Continuity, Post-Op Briefand Discharge Brief. The diagram to theright displays the operating room briefsfrom the OR to discharge home.

Forms and checklistsTo facilitate an individualʼs comprehen-sion of what is communicated, informa-tion must be organized in a format that

Pre-Operative Intra-Operative Post-Operative Discharge Brief/HomePre-Op Brief Hand-Off Post-Op Discharge

Briefs for Brief BriefContinuity

“Bring the ORteam onto thesame page” bystating the plan

Nurse-nurseAnesth-anesthTech-tech

Anesth toPACU nurseto inpatientprovider

To the patient andfamily for homecare or homehealth nurse withclear diagnosisand post-op plan

the recipient is prepared to mentally process. Because of this,many organizations have developed structured communica-tion techniques such as checklists and read-back techniques.6The use of a checklist serves two purposes. It ensures thatcritical information necessary for patient care is not over-looked and it provides a consistent order in which infor-mation is communicated.

These tools serve to address those unique issues or criticalpieces of information related to continuity of patient carebetween specialty areas.4 The hand-off checklist or docu-mentation tool will help ensure a standardized method foreveryone to use. Although checklists can enhance memory,longer lists might not be as effective. A checklistʼs content anddesign must be prudent and strategic to gain its desired results.

When providing the hand-off communication, remember theseimportant communication techniques to ensure that there istwo-way interaction:• Get the personʼs attention• Make eye contact• Face the person• Use the personʼs name• Express concern• Use a standardized communication technique• Use a standardized communication tool/checklist• Re-assert as necessary• Escalate if necessary

Transitions in care are prime targets for improved patientsafety efforts. There are several strategies that have beendeveloped in high-reliability organizations that can be appliedto health care and have been successfully implemented withpositive results. For a sample hand-off policy and procedureas well as checklists and other tools from Trinity MedicalCenter in Rock Island, IL, please refer to Pages 82-83and 85-86 in the Forms & Tools section. Trinity has beenrecognized by the Joint Commission as a model forhand-off communication.

Anesthesia provider may report:• Patient name, gender, age, procedure, physician• History of present illness• History of chronic illness• Relevant pre-op lab tests• Type of anesthesia administered• Patient response to anesthesia agents• Duration of anesthesia• Reversal agents• Narcotics• Antibiotics• Fluid replacement and type (I & O)• Invasive monitoring line• Vital signs• Allergies• Other conditions• Medications given• Complications related to the procedure• Orders

Surgeon may report:• Immediate orders• Diagnostic tests for PACU• Interventions needed in PACU

Perioperative nurse may report:• Baseline patient assessment• Positioning during procedure• Skin prep• ESU pad placement and removal assessment• Use of special equipment (laser, endoscope)• Intraoperative irrigation fluids• Administration of medications or dyes from

surgical field• Implants, transplants, explants• Dressing• Drains, stents, catheters• Sensory or motor limitations• Prosthesis presence• Pressure ulcer risk assessment• Other pertinent patient information• Information about the family or others waiting

for the patient

Topics for hand-off checklists

References1 Makary M, Sexton J, Freischlag J. et al. Patient safety in surgery. Ann Surg.2006;243: 628-635.2 Stokowski L. Perioperative Nurses: Dedicated to Safe Surgical Care. Available at:http://www.medscape.com/viewarticle/562998. Accessed November 4, 2008.3 The Joint Commission. National Patient Safety Goals: History Tracking Report 2009-2008. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafe-tyGoals/09_hap_npsgs.htm. Accessed November 4, 2008.4 AORN. Perioperative Patient “Hand-Off” Tool Kit. AORN. Available at:http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/. Accessed No-vember 4, 2008.5 Agency for Healthcare Research and Quality. Patient Safety and Quality: An Evi-dence-Based Handbook for Nurses. AHRQ Publication No. 08-0043. April 2008.6 Mistry K, Jaggers J, Lodge A et al. Using Six Sigma® Methodology to Improve Hand-off Communication in High-Risk Patients. Available at: http://www.ahrq.gov/down-loads/pub/advances2/vol3/advances-mistry_114.pdf. Accessed November 4, 2008


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Applying Evidence-Based Informationto Improve Hand-Off Communication

in Perioperative Services

www.medlineuniversity.com1. Register (free) or log in2. Click Free Courses tab3. Locate the puzzle and click Learn

More, then Begin Course4. Certificates are available online

after puzzle completion

Back to Basics Crossword Puzzle


Across1 Consider using structured _____ that can facilitate

consistency in communication exchanges.5 When providing the hand-off communication,

express _____.7 Teach and practice communication using

established clear, common _____ among careproviders during hand-offs.

9 According to the Joint Commission, communicationissues are the _____ factor in root causes ofsentinel events.

12 _____ the hand-off can lead to small, yet criticalmistakes that can ultimately harm patients.

13 A clear _____ to hand-off communication is thesheer number of individuals involved in the care ofsurgical patients.

16 The National Patient Safety Goal 2E states that anorganization should implement a _____ approachto hand-off communication.

18 Redesign the hand-off and shift change processesto protect against unnecessary interruptions, andallocate sufficient time to the process.

21 Give as much _____ as necessary for the hand-offto ensure accurate communication.

22 Time becomes a barrier to _____.23 In the surgical setting, a premium is placed on _____.24 A healthcare organization initiated the sterile _____

concept for the clinical setting during the verbaltransfer of patient information.

27 _____ must be organized in a format that therecipient is prepared to mentally process.

31 _____ should respond to the Joint Commissionmandate to improve hand-offs by initiating aprogram within each facility.

32 When providing the hand-off communication, make_____ contact.

33 Adverse events occur more often in _____ than inany other specialty, and disproportionately greaterharm results from surgical errors.

34 A checklistʼs content and design must be prudentand strategic to gain its desired _____.

Down1 A standardized process for hand-off communication

becomes critical in perioperative services to assurethat communication is _____.

2 Be certain that the hand-off is two-way, with bothparticipants taking _____ responsibility for ensuringaccurate communication.

3 When providing the hand-off communication,_____ the person.

4 _____ in care are prime targets for improvedpatient safety efforts.

6 When providing the hand-off communication,use a standardized communication _____.

8 Healthcare providers have looked at otherhigh-risk, high-stakes industries such as _____ fornew approaches that can be applied to hand-offs.

10 The use of a checklist ensures that criticalinformation necessary for patient care is not _____.

11 The _____ brief brings the OR team on to the samepage by stating the plan.

14 When providing the hand-off communication, getthe other personʼs _____.

15 “I-SBAR” stands for introduction, _____,background, assessment, recommendation.

17 While developing hand-off policies and protocols,include a clear statement of how and when _____is transferred during healthcare transitions.

19 TeamSTEPPS is an evidence-based team-training_____ used by the Department of Defense.

20 Another healthcare organization has initiated a newhand-off process modeled after routine _____ stopsin racing.

25 Researchers recommend _____ communicationsand clear agreements about roles andresponsibilities in a hand-off.

26 There are _____ very significant hand-offs thatoccur in perioperative services for each patientwho undergoes a surgical procedure.

28 The use of a checklist ensures a consistent_____ for information.

29 When providing the hand-off communication,use the personʼs _____.

30 _____ communication is defined as the “transferof information during transitions in care acrossthe continuum.”

To receive one hour of CE credit, enter your answersonline at www.medlineuniversity.com


We have all heard the old adage “If you canʼt measureit, you canʼt manage it.” Most folks in health carestrongly believe in this concept. So it will come as no sur-prise to you that when I speak to healthcare executivesabout the work of LifeWings, I am always asked, “How doyou measure this?”

I think what they are really asking is, “What are the resultswe can expect to see?” and “How can you documentthat?” Consequently, we spend quite a bit of time and efforthelping hospital executive teams create realistic datacollection and analysis plans to help them paint the“before” and “after” pictures for their teamwork-basedpatient safety initiatives. Of course, by gathering andanalyzing data that builds the “after” picture, the client cansee in their measurement tool if the steps they are takingare actually changing anything – are they hitting theirgoal(s)? If not, they can take management action andchange or adjust the methodology to reach their goal(s).

Teamwork: the key to patient satisfactionOne common goal of most hospitals today is getting greatHCAHPS scores. CMS now publishes the results of thesepatient satisfaction survey scores on their Web site. Whatpatients think about the care they received in your hospitalis now available for the whole world to see on the Internet.

So, the goal of the facility is great patient satisfaction.The measurement tool is the satisfaction survey.

Based upon recent research from a large hospital in themid-South, if your goal is to improve patient satisfaction,the management action should be to improve the team-work of the healthcare team.

What management action should an institution take if thesatisfaction score is not where theyʼd like it to be? Byadding a question to their satisfaction survey asking thepatient to rate the level of teamwork they experienced dur-ing their stay, the hospital mentioned above was able toanalyze the results of almost 30,000 surveys to discovera .97 correlation between the “teamwork” rating and thepatientʼs willingness to give a “Would Recommend” andan “Overall Excellent” rating on their survey responses.

MeasuringWhatYou

Manage

Whether your goal is reduced mortality,to eliminate bloodstream infections or toimprove patient satisfaction, providingyour caregivers with excellent teamworkskills should play an important part inyour improvement equation.


Patients may not be expertly trained teamwork assessors,but they seem to know good teamwork when they see it.When your caregiversʼ teamwork is first rate, your patientsare going to give you an “Overall Excellent” rating and“Recommend” your facility to their friends and family.

Using teamwork to improve your mortality rateThis same research also showed a correlation between apatientʼs “teamwork” rating and the mortality rate of thehospital. The teamwork of the facilityʼs caregivers, asrated by the patient, controls approximately one third ofthe variation in mortality in that institution. If your goal isto provide better care and one of the measurement toolsfor that goal is your mortality rate, then one of the man-agement actions you should take to help reach that goalis to improve your providersʼ teamwork skills.

Hereʼs one more example of these principles. The state ofMichigan began a state-wide initiative called the KeystoneProject to reduce or eliminate bloodstream infections inpatients in their hospitalʼs ICUs. To achieve this, one ofthe tactics the facilities adopted was the use of a standardprotocol, accomplished with the aid of a checklist, to inserta central line. The checklist and the training process onhow to use it were pretty near identical for every institu-tion. Yet despite the similarity in protocol, process andtraining, ICUs saw variability in their results.

What causes the variability? Further analysis revealed themost successful ICUs were those with a better safety cul-ture as evidenced by a greater willingness to cross checkone another and to speak up to hold one another account-able to abide by the protocol. In short, better teamwork.If your goal is fewer bloodstream infections, and yourmeasurement tools are the level of compliance with theprotocol and the number of infections, the managementaction you should take to help reach your goal is toimprove the teamwork of the folks in the ICU.

One of my favorite quotes about measurement is from theauthor Robert Heinlein. He says, “If it canʼt be expressedin figures, it is not science; it is opinion.” One thing weknow about teamwork is there is a “science” to it. Team-work has been clearly shown, by expression in “figures”(or numbers), to improve outcomes in health care.

Whether your goal is reduced mortality, to eliminate blood-stream infections or to improve patient satisfaction, providingyour caregivers with excellent teamwork skills should playan important part in your improvement equation.

About the authorStephen W. Harden is President of LifeWings Partners LLC andco-founder of Crew Training International, Inc. (CTI), the parentcompany of LifeWings. Prior to his position at LifeWings, he wasthe principal courseware designer of CTIʼs Crew Resource Man-agement (CRM) training for the U.S. Air Combat Command, AirNational Guard, Air Force Reserve Command, Italian Air Force,Swiss Air Force, Belgian Air Force, domestic and commercialairlines, construction crews and hospital surgical teams.

Based upon recent researchfrom a large hospital in themid-South, if your goalis to improve patientsatisfaction, the managementaction should be to improvethe teamwork of thehealthcare team.

Special Feature

The first fatal airplane crash in history occurred exactly 100years ago, on September 17, 1908, when Army lieutenantThomas Selfridge died in a failed flight attempt with theaviation pioneer Orville Wright. Since that time, aviation safetystandards have significantly improved. Currently, the risk for anAmerican dying in an airplane crash is about 1:500,000, com-

pared to a 1:20,000 chance of dying in a car accident. Inthe field of medicine, it was not until the shock-

ing report by the Institute of Medicine in1999 revealed that 100,000's of pa-

tients die in the United States every year as a consequence ofmedical errors [1], when we began to realize that there is some-thing "wrong with the system". While this unacceptably highnumber has been chronically underrated in public recogni-tion, an extrapolation of these statistics to professional aviationequals to about 200 jumbo jet crashes per year, or one 747crash every other day. This dramatic insightled to the design of the "100,000 livescampaign" by the Institute forHealthcare Improvement in

Patient Safety in SurgeryLearning from aviation safety:

a call for formal "readbacks" in surgery

By Philip F. Stahel


Patient Safety

2004 [2]. By 2006, the campaign had surpassed its initial goal bysaving more than 120,000 lives through the implementation ofincreased patient safety standards and algorithms [2]. Theseinclude the recent implementation of a standardized surgical"time-out" to ensure the correct patient identity and correct pro-cedure performed at the correct surgical site [3]. In addition,the implementation of formal, structured perioperative briefingsin the operating room have been shown to significantly reducethe incidence of wrong site surgeries [4].Despite those recent improvements, the analysis of the Ameri-can College of Surgeons' closed claims study revealed that abreakdown in communication before, during, or after surgery stillrepresents a significant source of errors which lead to patient

complications [5]. Of these, 85% of adverse events related tocommunication breakdown occurred by verbal communication,while only 4% were attributed to communication in written form[5]. This notion provides the basis for a call for written checklistsand formal verbal "readback" orders among healthcare profes-sionals who care for surgical patients, in order to avoid orreduce the high incidence of perioperative complications relatedto a breakdown in communication. Interestingly, pilot readbacksrepresent a hallmark safety concept in professional aviation.While the current debate in aviation safety is related to optimiz-ing and correcting the modality of readbacks [6,7], this crucialform of communication is still virtually nonexistent among sur-geons. Dr. Eddie Hoover has characterized the issue to thepoint, in a recent editorial: "Getting surgeons to readback ordersand instructions will age you 10 years, yet the Navies of theworld have demonstrated for eons that it improves efficiency,promotes safety, and saves lives." [8].



I wish to emphasize that the implementation of verbal read-back orders represents the 2nd National Patient Safety Goal(NPSG) for 2009, as defined by the Joint Commission [9]. TheNPSG #02.01.01, aimed at improving the effectiveness ofcommunication among caregivers, is defined as such: "Forverbal or telephone orders or for telephone reporting of criticaltest results, the individual giving the order or test result verifiesthe complete order or test result by having the person receiv-ing the information record and 'read back' the complete orderor test result." [9].

In conclusion, I urge all healthcare professionals involved inthe care of surgical patients to contribute to improved patientsafety and reduced complications and sentinel events in 2009by addressing the most frequent root cause for adverse out-come in surgery: Ineffective communication. The implemen-tation of formal standardized "readbacks" is a promising start.

Competing interestsThe author declares that he has no competing interests.

AcknowledgementsI would like to thank Ms. Jan Minifie, Dr. Ted Clarke, and Dr.Kagan Ozer for helpful discussions related to this editorial.

References1. Institute of Medicine: To Err is Human: Building a Safer Health System. NationalAcademy Press, Washington D.C.; 1999.2. Wachter RM, Pronovost PJ: The 100,000 lives campaign: a scientific and policyreview. Jt Comm J Qual Patient Saf 2006, 32(11):621-627.3. Michaels RK, Makary MA, Dahab Y, Frassica FJ, Heitmiller E, Rowen LC, CrotreauR, Brem H, Pronovost PJ: Achieving the National Quality Forum's "never events":prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg2007, 245:526-32.4. Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E, RowenL, Behrens DC, Marohn M, Pronovost PJ: Operating room briefings and wrong sitesurgery. J Am Coll Surg 2007, 204:236-43.5. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, ZinnerMJ, Gawande AA: Patterns of communication breakdowns resulting in injury to sur-gical patients. J Am Coll Surg 2007, 204:533-40.6. Anderson DZ: Correcting readbacks. Aviation Safety 2008, 28(3):3.7. Correcting readbacks – letters to the editor. Aviation Safety 2008, 28(4):.8. Hoover EL: Patient safety and surgeons – why the resistance? Arch Surg 2007,142:1127-8.9. [http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/].

Published: 17 September 2008

Patient Safety in Surgery 2008, 2:21 doi:10.1186/1754-9493-2-21

This article is available from: http://www.pssjournal.com/content/2/1/21

© 2008 Stahel; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Com-mons Attribution License (http://creativecommons.org/licenses/by/2.0),which permits unrestricted use, distribution, and reproduction in any medium, pro-vided the original work is properly cited.

Address: Department of Orthopaedic Surgery, Denver Health Medical Center,University of Colorado School of Medicine, 777 Bannock Street,Denver, CO 80204, USA

Email: Philip F Stahel - [email protected]

A Spotlighton “Never Events”

As you know, as of October 1, 2008, CMS is no longerreimbursing at a higher DRG for 11 conditions deemed“never events.” Those conditions are listed below, alongwith articles in this magazine that relate to them. We hopethey help you enhance your facilityʼs prevention measures!

1. Retained foreign object after surgery“A Focus on Prevention” ..............................................Page 9

2. Air embolism

3. Blood incompatibility“Organ Donation”........................................................Page 36

4. Stage III and IV pressure ulcers“A Focus on Prevention” ..............................................Page 9“Why Is Pressure Ulcer Risk AssessmentSo Important?” ..................................................................Page 50“Fluid Flow Disruption?” ....................................................Page 58“Pressure Ulcer Prevention Checklist” ......................Page 89

5. Falls and trauma (fractures, dislocations, intracranialinjuries, crushing injuries, burns)

6. Catheter-associated urinary tract infections“A Focus on Prevention” ..............................................Page 9“Targeting Zero” ..........................................................Page 15

7. Vascular catheter-associated infections“Targeting Zero” ..........................................................Page 15“Care Bundle for Surgical Site Preparation” ...............Page 26

8. Surgical site infection – mediastinitis after coronaryartery bypass graft (CABG)“Targeting Zero” ..........................................................Page 15“Care Bundle for Surgical Site Preparation” ...............Page 26“SCIP Fact Sheet” ......................................................Page 80

9. Surgical site infections following certain electiveprocedures, including certain orthopedic surgeries,and bariatric surgery for obesity“Targeting Zero” ..........................................................Page 15“Care Bundle for Surgical Site Preparation” ...............Page 26“SCIP Fact Sheet” ......................................................Page 80

10. Certain manifestations of poor control of bloodsugar levels

11. Deep vein thrombosis or pulmonary embolismfollowing total knee replacement and hipreplacement procedures

“SCIP Fact Sheet” ......................................................Page 80

A Latex-Free Victory!One OR’s success

Kim Gordon, RN, BSN, CNOR, is the products nurseat River Oaks Hospital, a 14-room OR in Jackson,Mississippi. In her role, Kim was constantly orderingreplacement gloves for all of the services and special needsof the medical and surgical staffs. She was responsible forthe inventory of approximately 12 different types of glovesin sizes 5 ½ to 9.

At best, it was a difficult task. Kim knewthat her facility needed to standard-ize glove types and reduce theirinventory. At the same time, she sawan opportunity for the hospital to ad-dress a rising concern in the OR com-munity – latex allergies.

Latex allergies amonghealthcare workersThe American Latex Allergy Associationestimates that between 8 and 17 percent ofall healthcare workers are sensitized to naturalrubber latex.1 Studies have suggested that thecosts of healthcare workersʼ disability compen-sation due to latex allergies justifies or signif-icantly offsets the cost of conversion to alatex-free environment.2

When facilities contemplate where to start combating latexintolerance, one of their most frequently ordered commoditiespops into mind: gloves. Latex gloves have the highest con-centration levels of allergenic proteins and therefore are thegreatest threat to staff members and patients who are intol-erant to latex.3

What worked atRiver OaksTo help consolidate gloves and convert River Oaksʼ OR to alatex-free environment, Kim asked product representatives toinitiate a glove trial. When selecting new gloves, it is impor-

tant to establish criteria for thedecision. Examples includeproduct availability, viral pen-etration test results, color, tex-ture, finish, length, primary

material, pinhole levels andelongation levels.4

Kimʼs product representativeset up a station in a high-trafficarea and asked the medical andsurgical staff to try on latex-free

polyisoprene gloves with andwithout an interior aloe vera coating.

An interview with members of the River Oaks Hospital OR Team


OR Issues


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

The evaluations were tallied and the majority of the surgicalstaff approved the conversion and 100 percent are now usinglatex-free gloves. Through the conversion, Kim reduced hermassive inventory to four types of gloves – two types of latex-free gloves and two gloves that a handful of surgeons re-quire.

Addressing cost concernsFacilities have a tendency to believe that synthetic gloves arenot cost effective. However, conversion and simplification canlead to cost savings through inventory management. Kim wasable to demonstrate this by minimizing her glove stock from12 to four different types of gloves. Although Kimʼs gloveusage did not decrease, she was able to minimize waste andincrease efficiency.

Kim summarizes the overall impact ofconverting to latex free gloves to be:

1. “We improved our patient care by providing a safer,latex-free environment without increasing costs.”

2. “The conversion has created new, much needed spacefor us. Eliminating so many different kinds of gloves freedup three storage system carts in our central supply area.”

3. “The majority of our staff has been pleased with theconversion. It has certainly cut down on confusion.There is a comfort in knowing that there are two typesof gloves to choose from in our OR and both willprovide safe care for our patients.”

Other latex-free optionsGloves are not the only items purchased by medical facilitiesthat contain latex. Some hospitals are beginning to purchaselatex-free surgical packs. Other facilities have created a latex-safe unit or latex-safe rooms. This does not mean, however,that these rooms are 100 percent latex-free because there arestill some products on the market without a latex-free option.The “latex-safe” designation simply means that there is aseverely limited or small amount of latex that is kept or allowed toenter into the room. At River Oaks, Kim also focused on convert-ing to latex-free Foley trays, tubing and arthroscopic cannulas.

Another option for assisting patients with latex sensitivity is cre-ating a latex-free cart. This cart could be easily transported topatients with latex allergies without having to convert and en-tire room or unit to a latex-free environment. Medical staff willthen only be permitted use the latex-free supplies on the cartwhile working with the patient.

References1 American Latex Allergy Association. Latex Allergy Statistics. Available at:http://www.latexallergyresources.org/topics/LatexAllergyStatistics.cfm. AccessedNovember 5, 2008.2 Phillips VL, Goodrich MA, Sullivan TJ. Health care worker disability due to latexallergy and asthma: a cost analysis. American Journal of Public Health.1999;89(7):1024-28.3 Lenehan GP. Latex allergy: separating fact from fiction. Nursing. 2004Feb;Suppl:12-7; quiz 17-8.4 Lillis K. Hospitalʼs latex-free program fits like a glove – what works. HealthcarePurchasing News. 2002 Sept.5 Dyck RJ. Historical development of latex allergy. AORN Journal. 2000Jul;72(1):27-9, 32-3, 35-40.6 MayoClinic.com. Latex allergy. Available at: http://www.mayoclinic.com/health/latex-allergy/DS00621. Accessed November 5, 2008.7 Stout G. Creating a latex-safe environment. Infection Control Today Magazine.Available at: http://www.infectioncontroltoday.com/articles/051feat2.html. AccessedNovember 5, 2008.

Left to right: Doug Morrison, Sharon Grisham, Kim Gordon and DwayneBraxton – members of the Surgical Services Team at River OaksHospital who assisted with the latex-free conversion.

What is a latex allergy?It is estimated that more than three million people inthe United States suffer from a latex allergy.5 TheMayo Clinic defines “latex allergy” as “a reaction tocertain proteins found in natural rubber latex, a prod-uct manufactured from a milky fluid derived from therubber tree (Hevea brasiliensis) found in Africa andSoutheast Asia.”6 When people have latex allergies,their bodies mistake latex for a harmful substance.6

Milder reactions to latex include skin redness, rash,itching and hives. More serious reactions include sneez-ing, itchy eyes, scratchy throat and asthma. In severecases, sinusitis, rhinoconjunctivitis, anaphylaxis and gas-trointestinal problems can also occur.7

Sterillium® Rub’s high alcohol content delivers a devastating

blow to microorganisms—not your skin.

Sterillium® Rub’s balanced emollient blend leaves hands feeling

soft and smooth, never greasy or sticky, and makes gloving a

breeze. But that doesn’t mean that Sterillium® Rub makes any

sacrifices in efficacy. In fact, it meets FDA requirements for effi-

cacy specifications. It’s also CHG, latex and non-latex glove

compatible.

We know that comfort drives compliance. When you choose

Sterillium® Rub, you have an ally that’s tough on bacteria but

a real softie on your skin.

For more information on Sterillium® Rub, contact yourMedline sales representative, call 1-800-MEDLINE orvisit www.medline.com/sterilliumrub. Also be sure toask about our Hand Hygiene Compliance Program!

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

Sterillium® Rub with touchlessdispenser pictured.

Increased efficacy.Incredible comfort.Improved compliance.Sterillium Rub.

You have too much on your hands...to worry about bacteria.


Special Feature

As nurses, we know firsthand that when you arein the emergency room and a massive injurycomes through those doors, a multitude ofdecisions are being made very quickly. One of theimportant decisions is often organ donation andunfortunately, many of our patients have not madetheir wishes known beforehand. Organ donation isimportant for obvious reasons, and millions of peoplebelieve in its value. However, problems can crop upwhen itʼs actually time for the donation.

Victims of trauma were not planning on dying – andthey might have very strong feelings on whether theywant to participate in this final act. But, unless theyinform their family members of their wishes, thedecision-making quest can be terrible.

A personal experienceMy niece, Diane, lost her husband, Joe, two yearsago after battling the waiting list. For patients toreceive a transplant, they must be “sick enough” butnot “too sick” to receive a healthy organ. Every timeJoe was on the list, we prayed for a match. Everytime he was too sick, we prayed that modern medicinecould buy us more time. Joe and Dianeʼs childrenalways said things like, “When Daddy gets his trans-plant, we can go to Disney” or “When Daddy gets histransplant, we can do the things we used to do.” Joenever got that organ and their lives have changedmore than any of us could imagine.

Diane and her two children have joined forces withJoeʼs parents and siblings to educate everyone theycan on the value of this potentially life-saving decision.

Overcoming obstacles and objectionsOrgan Donation

By Jeanne M. Jones, RN



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

It could be the differencebetween life and death.Wrong site surgery has recently moved into the

number one position as the most frequentlyreported hospital error.1

This is despite a conscientious effort to eliminate thisproblem before it occurs. What is needed is another layerof safety...something that will improve our chances ofcorrecting the mistake before it happens.

Enter S.T.O.P. Surgical Drapes* from Medline.We just made a good idea even better. S.T.O.P. (SurgicalTime Out Procedure) drapes are available in a variety ofconfigurations, and include a “S.T.O.P.” strip across thefenestration. As a result, you can’t forget to take a timeout to verify the correct patient, procedure, side and site.Then all that is left is to hand the sticker off to the circulatingnurse to include in the medical record, documenting thatthe verification process was completed.

If you would like to receive a free sampleof the S.T.O.P. Drape system to evaluate foryourself, ask your Medline representative orcall us at 1-800-MEDLINE.

www.medline.com

STOP!!!

Perform “TIME OUT” Verify correct:

Person

Procedure

Site & Side

Date: ______ Time: ______

Surgeon’s Initials: _____

S

mrofrrfePreV

osreP

ecorP

&etiS

____:etaD _

’noegruS

!!!POTS

”TUOEMIT“m:tcerrocyffyir

no

erude

ediS&

______:emiT__

_____:slaitinIs’

S.T.O.P. strip and sticker

S.T.O.P. for safety.

References1 The Joint Commission. The Statistics page. Available at: http://www.jointcommis-sion.org/NR/rdonlyres/D7836542-A372-4F93-8BD7-DDD11D43E484/0/SE_Stats_12_07.pdf.Accessed March 13, 2008.

* Patent pending


They have worked with insurance companies, thesenate in New Jersey, local citizen groups and other sup-porters throughout the state to spread the word.

In July of 2008, Bill S755/A2083, known as the New Jer-sey Hero Act, was signed by Acting Governor RichardCodey. New Jersey is the first state to require organ do-nation decisions before applying for a driverʼs license andmandatory high school education regarding organ donation.1

It is hoped that other states will follow the example of thisfirst-in-the-nation initiative. You can learn about yourstateʼs policies on organ donation by visitinghttp://www.donatelife.net/CommitToDonation/.

Who is on the transplant waiting list?According to information from the Department of Healthand Human Services (DHHS), there were 100,238 waitinglist candidates as of October 20, 2008.2 Kidneys are theorgans needed by the largest number of waiting list can-didates, accounting for 76 percent of all organ needs.3

Other commonly needed organs include lungs, hearts,intestines, livers and the pancreas.3

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

How to encourage donation at your own facilityIn 2003, the DHHS created the Organ Donation Break-through Collaborative with the goal of “saving or enhancingthousands of lives a year by spreading known best practicesto the nationʼs largest hospitals, to achieve donation ratesof 75 percent or higher in these hospitals.”7

The Collaborativeʼs members represent all members ofthe organ donation and transplant community – criticalcare nurses, organ procurement and transplant coordina-tors, hospital administrators, physicians, clergy, socialworkers, family members of organ donors and transplantrecipients.7

Organ donation myths“I canʼt donate because Iʼm too old/young/sick.”According to the DHHS, there are no strict upperor lower age limits when it comes to organ dona-tion.5 There are very few illnesses that completelyexclude people from donating. The exceptions areHIV, active cancer and systemic infections.5

“My religion prohibits it.”Most religions encourage organ donation or leavethe decision to be made by the individual. To viewa listing of the official stances taken by churches,please visit http://organdonor.gov/donation/religious_views.htm.

“I have to donate my whole body.”The DHHS details four different types of donation.They are6:• Organ and tissue donation from living donors• Donation after brain death• Donation after cardiac death (DCD)• Whole body donation


Critical care nurses are an integral part of the donationprocess. In this spirit, the Collaborative made the follow-ing recommendations to critical care nurses to aid themin turning best practices into common practice in theirintensive care units7:• Refer all potential donors: Identify potential donors in

your unit, familiarize yourself with your facilityʼs criteriafor clinical triggers and promptly get in touch with yourorgan procurement organization (OPO).

• Partner with your OPO: Introduce yourself to OPOcoordinators and help them become part of your team.

• Become a donor “champion”: Talk to your fellownurses and colleagues about the importance of organand tissue donation.

• Advocate for your patients and their families: Honoryour patientsʼ last wishes, including those related toorgan donation. Be sure that families are aware of thedonation option.

• Educate yourself and your colleagues: One optionfor education is to invite your OPO to conduct in-servicetraining sessions in your unit.

• Be a change agent: Focus on system issues, examinewhat your facility is doing right and determine whatneeds to change to better your organ donor policies.

• Understand the data: Compare your hospitalʼs dataon organ donation to national benchmarks.

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

References1 The State of New Jersey Office of the Governor. Acting Governor Codey SignsNew Jersey Hero Act. Available at: http://www.nj.gov/governor/news/news/2008/approved/20080722a.html. Accessed October 20, 2008.2 OrganDonor.Gov. Waiting list candidates. Available at: www.organdonor.gov.

Accessed October 20, 2008.3 Transplant Living: Organ Donation and Transplantation Information for Pa-tients. Organ Facts. Available at:http://transplantliving.org/beforethetransplant/organfacts/default.aspx. AccessedOctober 20, 2008.4 OrganDonor.Gov. What Can Be Donated. Available at:http://organdonor.gov/donation/what_donate.htm. Accessed October 20, 2008.5 OrganDonor.Gov. Who Can Donate. Available at: http://organdonor.gov/dona-tion/who_donate.htm. Accessed October 20, 2008.6 OrganDonor.Gov. Types of Donation. Available at: http://organdonor.gov/dona-tion/typesofdonation.htm. Accessed October 20, 2008.7 Tamburri LM. The role of critical care nurses in the Organ Donation Break-through Collaborative. Critical Care Nurse. 2006;26(2).

Victims of traumawere not planningon dying – and theymight have very strongfeelings on whetherthey want to participatein this final act.


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Supply Management forPerioperative Services

How to get your inventoryunder control

OR Issues


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

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

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

Getting your inventory under controlWhen hospital CFOs mentions the word “inventory” to key hospital directors, theyʼre oftentalking about inventory reduction. While many ORs doubtless have the capability to reduceinventory, itʼs still crucial that the right products are in the right place, at the right time. Simplycutting back on inventory might not make your OR more cost effective and might evencreate a situation that could affect patient care, patient and staff safety and surgeon andstaff satisfaction.

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

1. OrganizationOrderly and organized supplies are often more effectively managed.

2. SystemsAn effective OR materials management system and accurate reporting tools are criticalfor effective inventory management.

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

4. ConsignmentConsignment can be a great tool for high-cost supplies such as implants, grafts andcustom packs.

5. Annual inventory countsAlthough annual inventory counts can be time-consuming and a task that volunteers rarelyline up to help with, these counts are vital to managing inventory and identifying obsoletesupplies.

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

References1 Davis E. Educating perioperative managers about materials and financial management.AORN Journal. 2005;81(4):798-812.

About the authorNed Turner has spent the past 29 years working in surgical supplymanufacturing and supply management consulting. Ned joined Medline in2003 after a lengthy career at Cardinal Health that included serving as AreaManager of the Western U.S. He is currently the vice president ofMedlineʼs Sterile Procedure Tray Division – Sales and Supply Manage-ment Consulting Services.

By Ned Turner



A New Way to “Pack” It All In

Think about the last time you put a surgical packtogether. You probably had a lot to think about. Could youlower costs? Increase productivity? Are all of the productsyouʼre ordering latex-free? Is there any way to standard-ize it all?

On average, operating room supplies account for morethan 50 percent of a hospitalʼs budget.1 It makessense that youʼd want to get as much bang for yourbuck as possible!

In the spring of 2008, Medline launched a program toreduce the headaches typically associated with packmanagement. Med-Pack is a Web-based, real-time packmanagement tool that was created following intense inputfrom focus groups and advisory boards.

Med-Pack, which is available to anyMedline pack customer, operatesthrough a series of iViews, which areessentially microsites supplying specificinformation to users. Examples of iViewtopics include Safety, Analysis Tools,Alerts, Savings, Standardization andSupply Management, plus many more.

The goal of each of these iViews is toquickly provide critical information in ahassle-free format. Users simply click onan iView icon to get the material theyneed, eliminating the need to jump fromWeb site to Web site to track downinformation on latex-free options,industry initiatives, etc.

Each Med-Pack user also has an online “eBook” createdfor them. This eBook contains:• Component lists• Pack history• Documents• Pack images• Pack changes• Eco-friendly components

As you can see, the eBook is a great way to keep criticaldocuments together – without creating a mountain of paper.

Since its launch, hospitals throughout the country haveadopted Med-Pack at their facilities. We wanted to shareone facilityʼs success story with you.

St. Vincentʼs storySt. Vincent Health is the largest health-care employer in the state of Indiana,with 17 health ministries serving 45counties in the central portion of thestate. It is also a member of theCatholic Healthcare System and As-cension Health, the nationʼs largestnot-for-profit.

St. Vincent Indianapolis Hospital isranked nationally for cardiac, stroke,orthopedic and gastrointestinal care. Itis also Indianaʼs only hospital to berecognized for excellence in four spe-cialty areas by HealthGrades, theleading provider of independent hos-pital ratings in the U.S.2

An interview with members of St. Vincentʼs perioperative team

St. Vincent Carmel Hospital

OR Issues

Becky Hodson is the OR Materials Team Leader at St.Vincent and estimates that the facilityʼs 10 operatingrooms perform around 150 bariatric surgeries a month inaddition to other types of procedures. With the hospitalʼshigh volume of surgeries, Becky has found Med-Packʼstime-saving features especially beneficial.

Simplifying pack changesBefore using Med-Pack, Becky recalls that surgicalpacks would have to be built by arranging to have asales rep visit the facility and complete paperwork. Mak-ing pack changes required more back-and-forth with pa-perwork. Now, Becky can view her packs online andrequest changes with a few clicks of her computermouse. This comes in handy because team leaders atSt. Vincent meet once a month to discuss any changes

they would like to makewith packs, which couldcreate more time-drain-ing paperwork with an-other system. All packchanges are approved bythe management team.

Vicky Smith, CST, SpineTeam Lead at St. VincentIndianapolis, appreciateshow Med-Pack enablesher to see when a packchange is about to occur.


This gives her time to alert staff that a change is comingand prevent potential frustration. Itʼs also easy to identifythe most recent pack versions on St. Vincentʼsshelves because Med-Pack automatically changes thelast letter in the packʼs product number each time a packis altered.

StandardizationBecky has also used Med-Pack to help make stridestoward St. Vincentʼs goal of pack standardizationacross its multiple facilities.

“When you can have one pack, why have three outthere?” she said.

In one instance, Becky was able to use Med-Packto view the pack used at a sister facility by one of St.Vincentʼs top-volume orthopedic doctors. Since thatsurgeon was also practicing at the Carmel location,Becky was able to standardize using his pack at bothlocations.

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

eBook OR Corner Safety

SpendandTrend

Standardization SupplyManagement

Analysis Tools Alerts Savings

Vicky Smith

Left to right; Vicky Smith, Gussie B. Johnson, BarbWeimer, Karen Fox, Sondra Jones and Francie Dolder


Talk to your sales representative to obtaina Med-Pack login and experience Med-Packfor yourself.

www.medline.com

Everything you need toknow about your packs

at your fingertips.

Introducing Med-Pack, an interactive,real-time data management tool for sur-gical procedure pack management.

Whether you’re an OR director, materials manager or

GPO administrator, Med-Pack has many different

“iViews” that provide specific information to help you

manage your surgical packs and your OR.

• View photographs of your packs and components

• View inventory in real time

• Get alerts for pack changes

• Run safety and latex analyses on your packs

• Run reports by component, pack or discipline


Featuring OR Corner, whereyou can find the latest indus-try news, hot topics andindustry calendar of events.


eBook

Pack Detail

Pack Image

Safety Center

Safety Analysis

Latex Analysis

Safety Articles

Supply Management

Alerts

Inventory

Savings

Analysis Tools

Standardization

Component Utilization

OR Corner

Hot Topics

Link to Industry Experts

Clinical Logistical Financial

Cost savingsBoth Vicky and Becky praised Med-Pack for its ability to callattention to cost savings options.

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

To learn more about how Med-Pack could benefit your ownfacility, please contact your Medline sales representative.

References1 Davis E. Educating perioperative managers about materials and financial manage-ment. AORN Journal. 2005;81(4):798-812.2 St. Vincent Health. St. Vincent Indianapolis Hospital. Available at: http://www.stvin-cent.org/ourlocations/hospitals/indianapolis/default.htm.Accessed November 13, 2008.

Note: iViews can host clinical, operational or financial information.Which iViews would be most helpful to you?

Lu McKee and Becky Hodson


Medline is proud to introduce our Gold Standard Safety

Program, designed to break down barriers in surgical

safety compliance by offering products, analysis tools

and checklists to help you reach your safety goals.

The program offers four levels of safety options:

1. The Gold Standard Safety Bundle: Includes six

products to serve as visual safety reminders to reduce

needle sticks and wrong site surgery.

2:Innovative safety products: Surgical Time Out

Procedure (S.T.O.P.™) Drapes (patent pending),

RF Surgical® Detection System and Universal

Electrosurgical Pads.

3.AORN Checklist: Wrong site, wrong procedure,

wrong patient surgery prevention.

4. Med-Pack™: Electronic pack audit and a

review of safety components.

To learn more about the Gold Standard SafetyProgram, contact your Medline sales represen-tative, call us at 1-800-MEDLINE or visitwww.medline.com.

www.medline.com

We’resettinga new

standardin patient

safety.

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


Why isPressure UlcerRisk AssessmentSo Important?

Letʼs examine what a patient and nursing student have to say!By Alecia Cooper, RN, BS, MBA, CNOR

My name is Euretha and I have a story to tell you. I think itcould help folks like you who work in hospitals and nursinghomes alike. My granddaughter is studying to become a nurseand she thinks what she and I have learned about my experi-ence can help everyone. So I agreed to help.

I am 79 years old and have been in pretty good health all of mylife until I started getting feeble these last few months. Sincethe passing of Theodore, my beloved husband, three years

ago this past September, I have livedalone and got along pretty well caringfor myself. But as of late, I have beengetting “blue” more often than not. Idonʼt have much of an appetite and I canʼt get around as wellas before. I become dizzy in the early mornings and I havetaken a fall several times. Most of my friends are either too sickto get out much or they have passed on.

About 70 percent ofall pressure ulcersoccur in people 70years and older.1


On November 1, I went to stay at Happy Valley Nursing Homefor what I thought was only temporary, no more than a couple ofmonths. Today is Christmas Day and I hope the kids get heresoon as I just cannot bear the thought of being away fromhome on my favorite holiday. As hard as I tried to persuadehim otherwise, Dr. Hill said I am not ready to leave yet. You see,what I have not told you yet is that I had one of those dizzy spells14 days after I came to Happy Valley.

It was early that morning when I got out of bed to go to the bath-room. I lost my footing, slipped and fell hard on my right hip andit broke. We were not sure it was broken at first, but once I gotto the hospital, they were sure. I had surgery and a stay in thehospital and then came backto Happy Valley with thisdoggone bedsore on myother hip. It is not healing toowell. In fact, it just keeps get-ting worse. Those “blue”days have just been gettingworse. I thought I would cryall day when Dr. Hill let meknow that he now thinks thatthis bedsore could beinfected.

This whole situation worried my poor granddaughter, so shetalked to one of her nursing instructors who gave her an ideafor a school research proj-ect. She said she needed myhelp. Imagine that. I get tohelp her figure out what couldhave prevented my bedsorefrom developing after I brokemy hip.

I asked her how could I possibly help, and she told me that weneeded to go through every event from the time my injuryoccurred until the bedsore developed. She explained that shewould take every part of the story and research the preventionmeasures that, if they had been done, might have prevented thatbedsore from developing. To prove her point, she brought me anarticle to read that she found in one of her nursing journals. Thatarticle said that the experts say bedsores can be prevented inmost cases. If all this is true, then I think we need to all worktogether to prevent them from happening. Oh, I know that mis-takes can happen unintentionally. People can forget when theyare working so hard, under stressful situations, Lord knows Ihave nothing better to do to occupy my time these days. Hereʼsa look back at what was going on when that bedsore developed.

November 15, 20075:47 a.m.I remember that I had tossed and turned all night, and eventhough I was still so tired, I just could not fall back to sleep no

Patient Safety

Confinement to a bed or chairfor a week has been found toincrease the prevalence of pres-sure ulceration by 28 percent.4

Why is pressure ulcer riskassessment so important?Because it helps identify whichpatients or residents may benefitmost from preventable measures.2

The best way to prevent pressureulcers may be through the use ofevidence based of pressure ulcerrisk assessment tools.3

Then things got worse. I tripped walking back from the mailboxa few months back and skinned my arm, my nose and bruisedmy left hip. My whole body was bruised up pretty bad. Mydaughter June insisted that I go see my doctor, Dr. Hill. I havebeen cared for by Dr. Hill for more than 30 years and pretty muchthink he is one of the smartest doctors I know of, so when he toldme that he thought it was time for me to go live in a nursinghome, only for a while, so I could get stronger, eat better andfind out what was causing all these dizzy spells, I didnʼt muchargue with him.



Recent studies have shown that pressure ulcers can start to

form in as little as 20 minutes in the operating room.1 When

every second counts, the surfaces used for positioning and

transporting patients need to be chosen carefully.

Medline’s gel positioners are designed to help reduce pressure

while providing exceptional support during surgical procedures.

They’re latex- and silicone-free, antimicrobial, antibacterial and

radiolucent. They’re also reusable and can easily be cleaned

and disinfected with standard hospital disinfectants.

Our gel positioners are available in a wide variety ofshapes and sizes to meet your needs.To learn moreabout Medline’s comprehensive Pressure UlcerPrevention Program, contact your sales representativeor visit www.medline.com/pressureulcerprevention.

www.medline.com

No pressure, just support.

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.


matter how hard I tried. So Igot up to use the bathroomand fix my dentures so Icould go to breakfast. MaybeI got up too fast, or I wasdizzy for some reason, but assoon as my feet hit the floor,I slipped and fell hard on myright hip. I think I rememberhearing something snap, but Iʼm not certain. I yelled for helpand that nice girl Sheila ran in and found me lying on the floor.She told me not to move if possible and she quickly ran to getsome help. The head nurse came in and they got me stretchedout as best they could and said they called my doctor and anambulance was on the way to come get me and take me toMercy Medical Center so I could be checked out.

7:46 a.m.The ambulance came to take me to the hospital (1 hr and 59minutes after the incident occurred). I looked at the verysmall stretcher with that tiny mattress – I donʼt think it could havebeen more than one or two inches thick – and worried how theywere ever going to get me on and off that safely, but they did.And trust me, it was one of the most uncomfortable beds that Ihave ever laid on. Theystrapped me in and got meinto the ambulance. I was inso much pain, but the emer-gency medical personnel toldme they could not give meanything to dull it until I was checked out at the hospital. I couldnot even have anything to drink. I think that was the worst part,but they said if I needed to have surgery it could hurt me.

8:37 a.m.I am rolled off the ambulance and rolled into the hospitalʼs emer-gency room. Finally, after some confusion, I am moved from thattiny stretcher to a bigger bed that was a little wider, but that mat-tress was not much better than the one before. They nurses anddoctors told me that I had to lie still while they checked me out,otherwise I might further injure my hip. For what seemed like for-ever, they checked me out.Then they told me they hadcalled Dr. Hill and that he wason his way, but had giventhem orders over the phonefor me to have an EKG, achest X-ray and an X-ray ofmy hip. Also, June and the kids had arrived by now and theylet June come back to sit with me for a while until it wastime for me to go to the X-ray department.

For consideration:1. Was a pressure ulcer risk and skin assessment

performed and documented on admissionto the nursing home?

2. Was an admission pressure ulcer risk and skinassessment performed, documented and comparedto the assessment performed at the nursing home?

9:57 a.m.I am rolled down the hallway to the X-ray department for the X-rays that Dr. Hill ordered. The boys moved me from mystretcher to a very hard and very cold table in a darkened room.A very nice lady came in andexplained what was going tohappen. Pictures were takenof my chest and hip and thenthose sweet boys came backand moved me off that hard table and back to that uncomfort-able stretcher and I was rolled back to the emergency room.When I got back, Dr. Hill was waiting on me and the first thing Iasked for was a drink of water as I was so parched. I remem-bered that I had not had anything to drink since before 8 p.m. thenight before and nothing at all to eat since dinner. He said heknew that I was dry, but it was unsafe to give me anything to drinkuntil we knew whether I needed surgery. I asked if they couldplease hurry and find out.

Nurses need more education in: 8

• Risk assessment (interpretation of Braden Scale)• Pressure ulcer staging• Proper positioning• Effects of moisture on the skin (including incontinence,

humidity and maceration)• Pressure relieving products• Proper application and usage of prevention products

11:02 a.m.The nurse comes in to tell me that the X-rays show that my righthip was indeed broken and that the surgeon, a Dr. Cloud, or oneof his assistants would be heresoon to discuss the plan for sur-gery with me. I was getting sotired of just laying in one spot forso many hours, but she explainedto me that they had to keep mybody straight so I did not injuremy hip more. I asked her what time it was, and when she said11:02, I realized that it had been over six hours since I fell andthat I had been in one position for as many hours. No wonder Iwas getting so stiff. If I could have only turned over and had aglass of water.

For consideration:1. Did the stretcher pads used in the ambulance

and in the emergency room have pressureredistribution capability?

2. Were pressure-relieving devices used to frequentlyreposition the patient?

One pressure ulcer can costan average of $43,180. CMSand other providerswill not reimburse for theadditional costs associatedwith hospital-acquiredpressure ulcers.5

Pressure ulcer incidence isover 60 percent for high-riskpatients with femoral fracturesand/or hip fractures.1

The incidence of pressureulcers occurring as a resultof surgery may be as highas 66 percent.8

70 percent of nurses considertheir basic wound educationto be insufficient.7

Pressure ulcers are definedas areas of localized damageto the skin and underlyingtissue caused by pressure,shear, or friction.6


11:35 a.m.Dr. Cloud comes in, intro-duces himself and explainsthat I need to have surgery.He was dressed in whatlooked like pajamas with awhite coat and a blue cap.He told me that he had beenin surgery all morning andthat he had one more proce-dure to finish and then hewould be able to get me allfixed up. I told him how sore Iwas and how much pain thathip was giving me, so he toldthe nurse to give me a shotfor pain and that he would goahead and have me movedto the surgery holding area,where they could get meready for surgery. About 20minutes later, a boy who wasdressed like Dr. Cloud camein and told me he was there to roll me up stairs to where the Sur-gery Department was located. I said my goodbyes to June andthe kids and they told me not to worry, that I was going to befine. I told them I knew that, I just wanted to get this over with.

1:08 p.m.I am finally being rolledback to the operating roomto get this old hip fixed.They started an IV in theholding area and gave mesome medicine that wasmaking me very drowsy. Inow had on one of thoseblue hats, too. They movedme over to a table that looked just as uncomfortable as thatgurney I had been lying on for the past five or six hours. Afterthat, I donʼt remember much, so I have to turn the story overto my granddaughter to explain what happened in surgery.

For consideration:1. Each time the patient was moved from stretcher

to stretcher and table to table, were the staff welltrained in transfer and positioning techniquesthat reduce friction and shear?

Granny was positioned on her left hip, prepped and draped witha full-body drape and only her right hip exposed to the op-erative field. The procedure started at 1:45 p.m. and was com-pleted at 3:30 pm., lasting one hour and forty-five minutes.During the surgery, Granny has some reasonable blood lossand the hip was irrigated with antibiotic fluid. At 3:45 p.m., after

an immobilizer was positionedbetween her legs to keep herin proper body alignment, shewas rolled onto her bed andtaken to the recovery room,where she remained for twohours until she was stableenough to be taken back toher own room. Iʼll let Grannytell you how she was feelingwhen she got out of surgery.

For consideration:1. Was the OR table pad a pressure redistribution pad?2. Were all bony prominences and pressure points

padded appropriately to minimize pressure that mightoccur during a surgical procedure?

6:00 p.m.June and the kids were all waiting for me when I got to my room.There was a pitcher of water waiting and that was the first thingI wanted – a cold drink. My nurse for the evening came in and in-troduced herself and checked me out. They gave me some brothto eat a little later. My hip was beginning to hurt again, so theygave me some more pain medicine and I drifted back to sleep.I guess I was really tired because I slept more that evening thanI had in weeks. I woke up a few times during the night andneeded some more pain medicine, but then I went right backto sleep.

For consideration:1. Was the patientʼs skin thoroughly cleansed and

inspected after surgery before leaving the operatingroom to ensure that there was no pooled blood or prepsolutions under bony prominences?

November 16, 20077:00 a.m.Breakfast arrives and I amawake and ready to eat.Soon afterward, the day shiftnurse comes in and says shehas to check me out head totoe. In doing so, she finds abig red mark on my left hipand asked me if it had beenthere before I arrived at the hospital. I told her it hadnʼt been asfar as I knew, but that I had been falling easily and bumping intothings so it was possible that I was there and I didnʼt know it.There was still some paint from surgery and a few blood spots onmy skin, so she got some soap and water and cleaned me upreal good. My granddaughter can tell you what came out of allof this.

Key causes of OR-relatedpressure ulcers8:• Immobility during the

procedure• Pressure on bones close

to the skin• Diminished tissue tolerance• Excessive moisture

The most frequent predictorsof perioperative pressureulcers have been found to be8:• Increasing age of the

patient• A patient diagnosed with

diabetes or vasculardisease

• Vascular procedures

The greatest incidence ofnew-onset postoperativepressure ulcers for elderlypatients with hip fracturesoccur within the first twopostoperative days.4

Pressure ulcers can developwithin two to six hours of theonset of pressure.1

While AORN guidelinesrecommend pressure reliefsurfaces for surgeries lastinglonger than 2 hours, pressureulcers can start to form in asfew as 20 minutes.9

According to AORN, surfacesin the OR for both positioningand transporting patientsshould be smooth and intactbecause surfaces that holdmoisture or wrinkle contributeto skin breakdown.8



www.medline.com

right when you need it most.

The programyou need ...

“In many of the recent legal cases I have reviewed following

facility acquired pressure ulcers, I have seen that an increasing

number are occurring in post surgical patients. A pressure

ulcer prevention program for perioperative services that

addresses risk assessment as well as comprehensive

prevention measures is more critical than ever.”

– Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN,Wound and Skin Care Consultant

Studies suggest that the incidence of pressure ulcers occurring

as a result of surgery may be as high as 66 percent.1 With

that in mind, Medline has developed a companion program

to its highly successful Pressure Ulcer Prevention Program

especially for perioperative services.

Reference1 Recommended practices for positioning the patient in the perioperativepractice setting. In: Perioperative Standards and Recommended Practices.Denver, CO: AORN, Inc; 2008.

Topics addressed in

the program include:

I. Implications of the New CMS

Payment Provision

II. Incidence of Perioperative Pressure Ulcers

III. Perioperative Risk Factors

IV. Perioperative Assessment

V. Perioperative Prevention Measures

To learn more about Medline’s Perioperative Pressure

Ulcer Prevention Program, contact your Medline

representative, call 1-800-MEDLINE or visit us at

www.medline.com.

Pressure Ulcer Prevention Program For the OR


For consideration:1. Should soap and water be used to cleanse patients

at high risk for development of pressure ulcers?

By now, you must know the rest of the story. Granny was in thehospital for five days after surgery and then returned to HappyValley Nursing Home. The reddened area eventually devel-oped into a Stage III pressureulcer that is now infected.From my research, we havedeveloped a protocol forthe prevention of pressureulcers that includes a com-munity effort between thenursing home and acute-care facility to prevent facility-acquiredpressure ulcers. In Grannyʼs case, the ulcer could have devel-oped due to pressure, moisture, friction, shear, poor nutri-tion, tissue injury or tearing, but most likely from a combinationof all of these factors. Not all pressure ulcers are avoidable, butmany are. I encourage you to work closely within your medicalcommunity to make sure your pressure ulcer prevention meas-ures and protocols are up to date and that everyone is fullytrained to execute them appropriately.

Critical stepsCritical steps in pressure ulcer prevention and healing include8:

• Identifying the individual resident at risk fordeveloping pressure ulcers

• Identifying and evaluating the risk factors andchanges in the patientʼs condition

• Identifying and evaluating factors that can beremoved or modified

• Implementing individualized interventions to attemptto stabilize, reduce or remove underlying risk factors

• Monitoring the impact of the interventions• Modifying the interventions as appropriate

Risk factorsRisk factors for pressure ulcer development include8:

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

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

higher acuity, requiring moreresources and services to beprovided and at a higher costburden for both the payerand the provider. Added ontop of this is the at-risk con-dition for the development ofadditional complications, such as additional pressure ulcers,deep vein thrombosis, pulmonary embolism and additionalinfections.

Prevention is paramount. It begins with proper risk and skinassessment, combined with proper prevention measures(including the appropriate prevention products). The cement thatholds it all together is proper education and training of personnelacross the complete continuum of health care, including thecommunity of hospitals, nursing homes and emergencymedical professionals.

Refer to the Forms & Tools section to learn more about howyou can prevent pressure ulcers at your facility.

This story is a fictional account based on the real-life experiencesof the author.

References1 Medical News Today. Clinical Trial Shows 96% Improvement In Pressure UlcerHealing Among Nursing Home Residents. Available at: http://www.medicalnewsto-day.com/articles/39327.php. Accessed September 3, 2008.2 Ayello E, Braden B. Why is pressure ulcer risk assessment so important? Nursing.2001;31(11):74-80.3 Walsh K, Bennett G. Pressure ulcers as indicators of neglect. Nursing & ResidentialCare. 2000;2(11):536-539.4 Maklebust J. Pressure ulcers: The great insult. Nursing Clinics of North America.2005;40(2):365-389.5 CMS, Proposed Changes to the Hospital IPPS and FY2009 rates;http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf accessed October 24, 2008.6 Lepisto M, Eriksson E, Hietanen H, Lepisto J, Lauri, S. Developing a pressure ulcerrisk assessment scale for patients in long-term care. Ostomy/Wound Management.2007;53(10):34-38.7 Zulkowski K, Ayello E, Wexler S. Certification and education: Do they affect pres-sure ulcer knowledge in nursing? Advances in Skin & Wound Care. 2007;20(1):34-38.8 AORN 2008 Perioperative Standards and Recommended Practices, “Recom-mended Practices for Positioning the Patient in the Perioperative Practice Setting.”9 Akridge J. Pressure ulcers hit a sore spot in the OR. Healthcare PurchasingNews. August, 2007.

When a Stage I pressureulcer develops, the risk foradditional ulcers on thesame individual is reportedto increase tenfold.4

All members of the healthcareteam need to know theirresponsibilities and how theirtasks relate to each other inthe prevention and manage-ment of pressure ulcers.

Pressure Free, Medline’s new OR table pad features 3 layers of

foam covered in our exclusive Nirvana “Memory” Foam which not

only completely conforms to the patient’s body contours and

gently cradles delicate bony prominences but keeps its shape

throughout even the longest procedure. All of this is encased in

our state-of-the-art Proknit ticking to eliminate the “hamocking

effect” seen in other vinyl pads.

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

throughout. It is also antifungal, fluid proof, stain, fungal and fire

resistant—making it reusable and easy to clean.

To learn more about ourpressure reducing tablepads, contact your Medlinerepresentative, call1-800-MEDLINE or visitwww.medline.com.

www.medline.com

It all adds up. The Pressure Reducing OR Table Pad


Pressure FreeOR table pad


Keep your surgical patient desert dry

FluidFlow

Disruption?

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

They assisted the paramedics and anesthesiologist in liftingthe patient from the stretcher onto the operating room bed.Joe then grabbed a gown and a pair of gloves from theroom stock supply to scrub in and help Tom, the scrubnurse, finish setting up. Sandy secured the patient to thebed with the safety strap and began cutting off the young

manʼs clothing. The attending poked his head into theroom. “Letʼs go!” he barked. Sandy inserted a temperature-sensing Foley and Laura, the room circulator, poured be-tadine over the patientʼs chest and abdomen. Sandy tiedup the attending and two surgical residents as Joe and

By Jayne Barkman RN, BSN, CNOR

According to a report from the ECRIInstitute, an evidence-based practicecenter, injuries related to the use ofa warming/cooling blanket tend tooccur in lengthy procedures in whichthe aorta is cross clamped.


Tom draped the patient. Within in a minute, the youngmanʼs abdomen was opened. Blood immediately beganpouring out.

“Get me another cell saver. Come on, I need moresuction!” the surgeon yelled. Sandy delivered another cellsaver tubing to the field and Joe handed it off to the perfu-sionist as the whirl of the second cell saver machine filledthe room. Sandy and the anesthesiologist checked fiveunits of emergency release blood as a CRNA squeezedthe packed cells into the patient. Sandy and Joe thencounted the additional packs of lap sponges that Sandyhad tossed onto the field and began placing the soiledsponges from the kick bucket into the sponge counterbags. Next, Sandy carefully wiped up the blood that hadpooled around the surgeonʼs feet and showed the anes-thesiologist the blood-soaked bath towels so that he couldincorporate the blood on the towels into the blood loss es-timate. Soon, the attending had the bleeding under con-trol.

“Clamps on,” the surgeon said as the anesthesiologistnoted the time. The attending asked for an 18 woven graft.Before opening the graft to the field, Sandy and Joe verifiedthe graft size. Jim, the senior resident, and the attendingsurgeon changed sides of the table. Jim asked for some3-0 prolene suture and began sewing the graft into thepatientʼs ruptured aorta. The anesthesiologist motioned forSandy to come to the head of the bed. He asked her tocheck the warming blanket, as both the bladder andesophageal temperatures registered at 35 degrees.

Sandy checked the hypo/hyperthermia machine. The low

fluid light was blinking on the machine. Sandy grabbed abottle of sterile water and added the fluid to the machine.The low fluid light continued to blink an amber warning.Sandy called the control desk and requested an additionalhypo/hyperthermia machine. When the machine arrived,she disconnected the faulty machine, inserted the warm-ing blanket tubing into the new machine, plugged it into thewall and turned the machine on. The low fluid light beganblinking on the new machine. Sandy went to the anesthe-siologist and explained what was happening. Mike, theanesthesiologist, asked for some warm blankets that hethen wrapped around the patientʼs head.

When things slowed down, Sandy read the accidentdetails provided by the paramedics. The patient had suf-fered an aortic injury due to deceleration when heslammed into another vehicle while running a red light.When Joe asked to do the initial counts, Sandy was sur-prised at how quickly the past three hours had gone. At theend of the case, Laura brought the ICU bed into the oper-ating room. Sandy stood by the OR bed with warm blan-kets to cover the patient as Joe removed the drapes andLisa secured the dressing. As she was placing the blan-kets on the patient, Sandy realized the draw sheet and thelinen on the OR bed were saturated with fluid. She askedLaura to get a couple of bath towels to dry off the patient.A dry draw sheet was placed under the patient, who was

OR Issues


MMeeddlliinnee’’ss SSaahhaarraa®® SSuuppeerr AAbbssoorrbbeenntt OORR ttaabbllee sshheeeettss aarree

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Braden Scale tells us that moisture is one of the major

risk factors for developing a pressure ulcer.1 We also

know that as many as 66 percent of all hospital-acquired

pressure come out of the operating room.2

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References1 Braden Scale for Predicting Pressure Sore Risk. Available at:www.bradenscale.com/braden.PDF. Accessed November 6, 2008. 2 Recommended practices for positioning the patient in the perioperative practicesetting. In: Perioperative Standards and Recommended Practices. Denver, CO:AORN, Inc; 2008.

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then lifted onto the ICU bed. The patient was gently turnedso Sandy and Laura could assess the patientʼs skin, whichwas intact with no redness noted. As the patient was beingtransported out of the OR, Sandy pulled the fluid-saturatedsheets off the OR bed and placed them in the laundryhamper. She examined the reusable warming/coolingblanket and realized there was no fluid left in the blanket.She could not see a hole in the blanket, but nonethelessdisconnected the blanket from the machine and placed itin the trash.

A couple of days later, after she had transported a patientto the CVICU, Sandy decided to check on the young manwith the ruptured aorta. She poked her head into theCVICU room. The patient was lying on his side, asleep.His nurse, Jennifer, was in the room doing her charting.Sandy asked how the patient was doing. Jennifer repliedthat he was progressing remarkably well, and his maincomplaint was pain on his back where it appeared pres-sure ulcers were developing. Jennifer and Sandy gentlylifted the blankets off the patientʼs back. There were red-dened areas on both scapulae as well as a four-inch longred area on his thoracic spine. They covered the patient.

Back in the OR, Sandy found Joe. She gave him an updateon the patientʼs condition and the pressure ulcers devel-oping on the patientʼs back 48 hours postoperatively, quitepossibly related to lying on the fluid-saturated operatingroom bed linens.

Preventing pooling fluids and pressure ulcers Great care is taken by preoperative nurses to avoid theformation of pressure ulcers in surgical patients. Bonyprominences are padded and towels are placed to avoidpooling of solutions under the patient. The use of water-based hypo/hyperthermia systems in the operating roomshould not be overlooked as a potential cause of pressureulcer formation in operative patients.

Minute holes in water-based hypo/hyperthermia blanketsmight not be evident until the pressure from the weight ofa patient is placed onto the blanket, causing the fluid in thecoils to leak out. According to a report from the ECRIInstitute, an evidence-based practice center, injuries

related to the use of a warming/cooling blanket tend tooccur in lengthy procedures in which the aorta is crossclamped. ECRI recommends the following when using ahypo/hyperthermia blanket in the operating room1:• The blanket should be covered with a sheet.• The circulating water temperature as well as the patient

temperature should be monitored.• The thermostat on the unit should be set at a maximum

temperature of 42 degrees Celsius.• The machine should be used and maintained according

to the manufacturerʼs recommendations.

Additional recommendations from the ECRI Institute toavoid skin injuries in the operating room include1: • Check the OR bed mattress for sufficient padding

and thickness.• Verify that the patient safety strap is not placed too tightly,

restricting circulation or placed over a grounding pad orECG electrode.

• Lift anesthetized patients rather then rolling or tugging them.

• Avoid pooling of solutions under the patient.

Todayʼs technology offers impervious disposable fabrics tocover the operating room bed. Some of these fabrics trapfluid, wicking moisture away from the patient. This helpsto reduce the possibility of the patient lying on wet bedlinens during the operative procedure, potentially resultingin the formation of a pressure ulcer.

Keep your patient desert dry. As with any surgical compli-cation, prevention is the key.

Reference1 ECRI Institute. Skin Injury in the OR and Elsewhere. Available at:http://www.mdsr.ecri.org/summary/detail. aspx? doc_id=8185. Accessed Novem-ber 4, 2008.


As with any surgical complication, prevention is the key.


Two out of three employees feel that the flow of communication between the departments of their

facility is poor.

All information is important, but different

disciplines value and prioritize it in different ways.


Does your facility have a failure to communicate?If it does, youʼre not alone. Surveys show that two out of three employeesfeel that the flow of communication between the departments of their facilityis poor.2

First and foremost, healthcare providers, no matter what their discipline,want to give their patients the best possible care. If this is true, why arethere so many problems? It all comes down to communication.

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

Although important, communication takes time – time that many peoplesimply do not feel they have.

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

How can you help your own facility?So what can you do? There is no one simple solution for breaking down thebarriers of communication between healthcare providers of differentorganizations. Improvements need to be tailored to the needs of eachfacility. However, there are some basic guidelines that we can all follow.

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

Why Can’t We All Just Get Along?

By Dayna Lowe, Clinical Instructor

Improving relationships within healthcare facilities

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cation checklists for different departments could be devel-oped so that only necessary information is shared andnothing is missed. They would ensure the sharing of “need toknow” rather then “nice to know” information.2

Properly conducted team-buildingexercises can dramatically improve howwell department heads and staff mem-bers work with each other. Typically, thisrequires the use of an outside profes-sional with experience getting fellowemployees to unite as a team. Part ofthese exercises could also include staffrotating to other facilities to see “how theother half lives.” Not only does this giveeveryone a better understanding of whatother facilities do, it also gives employ-ees a more rounded perspective of howthe work of the organization is con-ducted and the importance of sharinginformation between departments. Itis also a great way for different or-ganizations to get to know one another.2

Facilities need to look into available com-munication technology and train theirstaff how to use communication toolsproperly. Without adequate education,these tools can be used incorrectly,causing more problems then they solve.

As we plunge headlong into the 21stcentury, health care will only continue toget bigger and more complex. Staff willbe expected to provide skilled services faster then everbefore. Administrators and managers of these organizationsmust set good examples for their staff. They must be ableto put aside any personal differences and work with one

another. They must communicate in an efficient and propermanner. Last but not least, they need to ensure that the bestpossible communication tools are available and that their staffhas adequate training on their use. Staff must learn to workwith new technology and with each other. They must

remember that this is all done for thegood of the patient.

References1 Plsek P. Interdepartmental communication in alarge hospital. Available at: http://www.plexusinsti-tute.org/ edgeware/archive/think/main_tales9.html.Accessed September 2, 2008.2 Katcher BL. How to improve interdepartmental communication. Available at: www.discovery-surveys.com/articles/itw-017.html. Accessed September 2, 2008.3 Spring Valley Hospital Medical Center. High marksfor prompt ER care. Available at: http://valleyhealth.uhspublications. com/winter2007/story2.html. Accessed September 2, 2008.

About the authorDayna Lowe has been a surgical tech-nologist for six years. She currentlyworks at a hospital in Florida and as anInstructor of Surgical Technology atCentral Florida Institute.

Communication checklistsfor different departmentscould be developed so that only necessary information is shared and nothing is missed.


When you donʼt set priorities, you tend to follow the pathof least resistance. Youʼll pick and sort through the thingsyou need to do and work on the easiest ones, leaving themore difficult and less fun tasks for a “later” that, in manycases, never comes. Or, worse, the “later” may come just be-fore the action needs to be finished, throwing you into a whirl-wind of activity, stress and regret. There are three basicapproaches to setting priorities, each of which probably suitsdifferent kinds of personalities.

The first is for procrastinators, people who put off unpleas-ant tasks.

If you are a procrastinator – eat a frog!Thereʼs an old saying that if you wake up in the morning andeat a live frog, you can go through the day knowing that theworst thing that can possibly happen to you that day hasalready passed. The day can only get better!

Popularized in Brian Tracyʼs book Eat That Frog!, the ideahere is that you tackle the biggest, hardest and leastappealing task first thing every day. Just knuckle down anddo it, and the rest of the day will be a breeze.

The second approach is for people who thrive on accom-plishment, who need a stream of small victories to get throughthe day.

If you thrive on accomplishments – move big rocksMaybe youʼre someone who fills your time fussing over littletasks. Youʼre busy all the time, but somehow, nothing impor-tant ever seems to get done. You need the wisdom of thepickle jar. Take a pickle jar and fill it up with sand. Now try toput a handful of rocks in there. You canʼt, because thereʼsno room.

If itʼs important to put the rocks in the jar, youʼve got to putthe rocks in first. The pickle jar is all the time you have in a

How to Set Priorities and Get the Job Done


day. You can fill it up with meaningless little busy-work tasks,leaving no room for the big stuff, or you can do the big stuff

To put it into practice, sit down tonight before you go to bedand write down the three most important tasks you have toget done tomorrow. In the morning, take out your list andattack the first “big rock.” Work on it until itʼs done or you canʼtmake any further progress. Then move on to the second, andthen the third. Once youʼve finished them all, you can start inwith the little stuff.

The third approach is for the more analytic types, who needto know that theyʼre working on the objectively most importantthing possible at this moment.

If you are analytical – use the Covey quadrantsIf you just canʼt relax unless you absolutely know youʼre workingon the most important thing you could be working on at everyinstant, Stephen Coveyʼs quadrant system might be for you.

Covey suggests you divide a piece of paper into foursections, drawing a line across and a line from top to bottom.Into each of those quadrants, you put your tasks according towhether they are:

I. Important and Urgent II. Important and Not Urgent III. Not Important but Urgent IV. Not Important and Not Urgent

If youʼre really on top of your time management, you canminimize Q1 tasks, but you can never eliminate them – a caraccident, someone getting ill, a natural disaster. These thingsall demand immediate action and are rarely planned for.

After youʼve plotted out your tasks on the Covey quadrantgrid, according to your own sense of whatʼs important andwhat isnʼt, work as much as possible on items in quadrant II(and quadrant I tasks when they arise).

Spend some time trying each of these approaches on for size.Itʼs hard to say what might work best for any given person.In the end, setting priorities is an exercise in self-knowledge.

Reprinted with permission from www.mercola.com.

If you thrive on accomplishments –move big rocks

Special Feature

Conquer Stress DuringTough Economic

TimesBy Wolf J. Rinke, PhD, RD, CSP



Housing market imploding? Your 401(k) downthe tubes? Uncle Sam bailing out everyone ex-cept you? No wonder stress is at an all-time high,to the point that many stress-related diseases areincreasing logarithmically. (Things are so bad thatthe Occupational Safety and Health Administrationhas classified stress as a workplace hazard.) Eventhough some stress is good for us – for example,the excitement (stress) you experience when youare getting ready to go on vacation or start a newproject – most other forms of stress, especially thetype that you experience when you feel out of con-trol, are bad for us (dysfunctional stress). It turns onyour fight or flight response and causes your body toproduce more adrenaline and hormones such ascortisol, norepinephrine, epinephrine and DHEA-S,which increase your blood pressure and pulse,tense your muscles and diminish the effectivenessof your immune system. Dysfunctional stress willlead to fatigue, frequent headaches and upset

stomach. Long-term dysfunctional stress con-tributes to chronic health problems such ashigh blood pressure, heart disease, depres-sion and memory loss. It may also lead to

family breakdowns and injuries, especially onthe job. To manage stress during tough eco-

nomic times, I recommend you master the mostpowerful stress reduction technique of all time. Itconsists of just three steps:

Three steps to stress reduction1. Change the changeableDonʼt like something? Change it! Your stocks driv-ing you nuts? Sell them! Is the media giving you acidindigestion with their incessant stream of bad news?Turn off the TV! Donʼt fret, complain or whine … justdo it! Remember, you donʼt have to do anything youdonʼt want to do. All right, you caught me. There isone thing you have to do – die. Everything else is achoice. So what can you do? Get rid of the words “Ihave to.” Using these three little words generates“victim” behavior patterns. And victims experiencedysfunctional stress, which will make you sick.

2. Remove yourself from the unacceptableFind something unacceptable? Get out of the way!Your credit card debt interfering with your sleep?

Caring for Yourself


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

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

3. Get your life in balance If youʼre experiencing problems at home and at work, youʼllaccelerate the burnout process. So think creatively, anddevelop a strategy for balancing personal and professionaldemands. For example, if you know youʼll be working lateall week, arrange to meet your family for dinner one ofthose evenings at a nearby restaurant or plan a weekendouting. Recognize that the most important things in life arerelationships – not stuff! So make time for the real importantthings in your life: your spouse, your children, your parentsand your friends.

4. Cut the electronic umbilical cordToo many of us simply no longer know how to relax. Whenwe leave work to go home or on a vacation, we not onlytake work with us, we are still tied into the office via pager,email, cell phone or our “crackberries.” Discipline yourselfto turn those things off. (Heads up: you are not nearly asimportant as you think you are.) Better yet, donʼt even giveout your cell phone number. I use mine only for bona-fideemergencies. Also, leave work at work so that you can setaside time to relax and recharge – recreate yourself.

5. Reduce your commuting timeIf you are commuting more than one hour a day, itʼs time tomove. One hour a day means that you are wasting about30 working days per year. Plus, you are already stressed bythe time you get to work. If you must commute, get in thehabit of listening to motivational and educational CDs – itwill reduce your perceived commuting time dramatically. (Ifyou donʼt know where to start, go to www.WolfRinke.com.We have several powerful CDs to choose from.)

Start paying them off now and cut up all your credit cardsexcept one for true emergencies. Being followed by some-one who is overdosing on road rage? Move out of her wayand let her have a “coronary” without your help. Workingfor a toxic boss? Start shopping for a new one. Whateveryou do, just do it without fretting, whining … I know youʼrecatching on!

3. Accept the unchangeableThere are lots of things beyond your control – for example,the crashing global economy. Regardless of how much youstress yourself, you will likely not be able to change it. Solet it go. And then there are your parents. No matter howmuch you would like them to be different, they wonʼt be. Solove them the way they are, not the way they ought to be.(By the way, that is a great prescription for getting alongwith all people!) Getting older – accept it. You are beautifuljust the way you are! Donʼt sweat your chronological age –something that you canʼt change. Instead, take care of yourbody. Thatʼs something you can have a positive impact onright now.

15 stress-reduction strategiesOnce you have mastered the basic three, here are 15additional stress-reduction strategies to help you kiss stressgood-bye once and for all.


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10. Get eight hours of sleep a dayIf you find you donʼt have eight hours, reduce TV viewing byone hour per day. (Good advice even if you do get enoughsleep.) That will give you – are you ready for this? – 15extra days per year. Just think how much fun stuff you coulddo if you had 15 extra days!

11. Manage prioritiesYou canʼt manage time. We all get the same 24 hours everyday. But you can manage your energy and your priorities.(Have you ever noticed that all of us make time for all theimportant things in our lives?) Each day, figure out whatyour high pay-off items are and do them when you are atyour best. For most of us, thatʼs in the morning. And donʼtforget to make vacation and play time a priority.

12. Get rid of conflictIf youʼre having problems with a family member or someoneat work, arrange to meet and discuss the situation. Byopening the lines of communication, youʼll set the stage fora fair resolution. You might even find out that what seemedlike a major and stressful conflict was actually a minormisunderstanding. And donʼt forget to master the mostpowerful conflict and stress reduction phrase in the world:“You are right about that.” Try it any time conflict rears itsugly head and conflict will vaporize.

13. Celebrate more often than you think is wiseSet attainable and measurable goals for each of yourprojects, whether they are at home or at work. Then cele-brate each baby-step accomplishment with small rewards,such as taking time to go out to lunch with your spouseor colleagues. It will keep you motivated and increaseyour productivity.

14. Reduce informationMost of us suffer from TMI – too much information. So whenyou need to make a decision, avoid whatʼs referred to as“decision optimization” in systems language. (A friend ofmine refers to it as contemplating your navel.) Instead, gofor decisions that are minimally acceptable. Itʼs faster andleads to better decision outcomes in the long term. I trulybelieve that most of us need lots more reminding and lessinformation. In other words, I believe most of us know howto do the right thing – we just forget what we already know.If youʼd like help with this, I have just the right tool for you.It is my Make It a Winning Life: Success Strategies for Life,Love and Business perpetual calendar, available at

6. Find a boss who knows how to MBA – manage by associationIf you report to a toxic boss, someone who constantly“builds you down,” or who practices seagull management,itʼs time to look for a new boss, or at least stay away fromyour current boss as much as you can. (Seagull manage-ment is when the boss flies in, makes a lot of noise, eatsyour lunch, craps on you and flies back out.) If you are amanager and the shoe fits, you owe it to yourself to read –no, wait, devour – my book Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations.

7. Move your bodyWeʼve made our lives too simple. Make yours more difficultby conducting your next meeting while walking (walk andtalk), use a stand-up desk, park in the farthest spot fromthe door, take the stairs, walk into the bank instead of usinga drive up window, mow your lawn with a push mower, andso on.

8. ExerciseDo approximately 30 minutes of aerobic exercise everyother day, such as jogging, biking or fast walking. Alternatethat with resistance exercise like lifting weights or using a“gym” machine. And be sure to start every exercise sessionwith light warm-up exercises and end with a comprehen-sive stretch routine.

9. Take breaksYouʼll be surprised how refreshed you feel just by takingbrief stretch breaks throughout the day. Simple actions suchas taking three very deep breath and exhaling slowly, goingfor a short walk or just standing up and stretching atyour desk are a powerful way to alleviate stress andboost productivity.


www.WolfRinke.com. Every day, it provides you with aninspirational message – a reminder of what you probablyalready know. However, then it takes you to the next levelby providing you a specific action step that helps youimplement what you already know in a dramatically newand different way. When you get to the end of the year, youcan start the calendar all over again.

15. Ask for helpIf you still have dysfunctional stress after all this, itʼs time toask for help. (Remember that asking for help is a sign ofstrength, not weakness.) While sometimes it might seemlike itʼs you against the world, keep in mind that this is rarelythe case. Often the help you need is available simply byasking for it. Reach out to family members, colleagues oryour boss by letting them know of your challenges. You canavoid being perceived as a complainer by objectively out-lining how others can help. If that still does not do the trick,talk with your mentor or coach (you do have one, donʼtyou?) or a professional counselor. Because they areremoved from a situation, they are more likely to provideyou with a fresh perspective that will enable you to developnew strategies for conquering stress once and for all.

About the authorDr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminarleader, management consultant, executive coach and editor ofthe free electronic newsletters Make It a Winning Life and TheWinning Manager. To subscribe, go to www.WolfRinke.com. Heis the author of numerous books, CDs and DVDs, includingMake it a Winning Life: Success Strategies for Life, Love andBusiness; Winning Management: 6 Fail-Safe Strategies forBuilding High-Performance Organizations and Donʼt Oil theSqueaky Wheel and 19 Other Contrarian Ways to Improve YourLeadership Effectiveness, available at www.WolfRinke.com. Hiscompany also produces a wide variety of quality pre-approvedcontinuing professional education (CPE) self-study coursesavailable at www.easyCPEcredits.com. Reach him [email protected].

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Medline Industries, Inc. will be hostingits annual AORN Breast Cancer Aware-ness Breakfast, by invitation only, at the2009 AORN Congress. The event will takeplace at the Hyatt Regency McCormickPlace in Chicago on Monday, March 16,2009. We are honored to announce thatthis yearʼs speaker will be Linda Ellerbee,an outspoken journalist, award-winning tel-evision producer, bestselling author, breastcancer survivor, mother and grandmother.

About Linda EllerbeeEllerbee began her career at CBS, andthen moved to NBC News where, afteryears covering national politics, shepioneered the late-night news programNBC News Overnight, which she wrote andanchored. Overnight was cited by theduPont Columbia Awards as "the best writ-ten and most intelligent news programever." In 1986, Ellerbee moved to ABCNews to anchor and write Our World, aweekly primetime historical series. Herwork on Our World won her an Emmy.

In 1987, Ellerbee and Rolfe Tessem, herpartner, quit network news to start LuckyDuck Productions, first producing docu-mentaries for PBS. In 1991, Lucky Duckbegan producing Nick News for Nick-elodeon with Ellerbee writing and hosting.Seventeen years later, Nick News iswatched by more children than watch allother television news shows put together—and has earned honors traditionally associ-ated with adult programming. Known for therespectful and direct way it speaks to chil-dren about the important issues of our time,Nick News has collected three PeabodyAwards (including one personal Peabodygiven to Ellerbee for her coverage of theClinton investigation), a duPont ColumbiaAward and six Emmys.

These days, Ellerbee and her work can beseen all over the television universe. LuckyDuck has and continues to produce prime-time specials for ABC, CBS, HBO, PBS,Lifetime, MTV, Logo, A&E, MSNBC, SOAP-net, Trio, Animal Planet and TV Land,among others. Ellerbee was honored withan Emmy for her series, When I Was a Girl,which aired on WE: Womenʼs Entertain-ment network.

Ellerbeeʼs first foray into books for kids, aneight-part fiction series titled Get Real, pub-lished in 2000, won her raves among mid-dle school readers. Both of Ellerbeeʼsprevious adult books—And So It Goes, ahumorous look at television news, andMove On, stories about being a workingsingle mother, a child of the ʻ60s and awoman trying to find some balance in herlife—have been national best sellers. Eller-beeʼs recent book, also a best seller, TakeBig Bites: Adventures Around the Worldand Across the Table, a tribute to her love oftravel, talking to (and eating with) strangers,and, according to Ellerbee, “oh, just makingtrouble in general.”

As a breast cancer survivor, Ellerbeetravels thousands of miles each yeargiving inspirational speeches to others.She is as direct with women as she is withkids; they understand that she understandstheir lives.

Although Ellerbee has won all of televi-sion's highest honors, she says itʼs her twochildren whoʼve brought her the richestrewards. Ellerbee spends her personal timein New York City and Massachusetts withRolfe, her partner in work and life and theirdogs, Daisy and Dolly.

Mark Your CalendarSpecial Feature


Bruschetta DeliziosoA delicious and easy appetizer!

Ingredients5 tomatoes (chopped)1/2 cup extra-virgin olive oil2 tablespoons balsamic vinegar5 fresh basil leaves (julienne cut)1 bulb of garlic1 loaf of French breadSalt and pepper to taste

DirectionsPreheat oven to broil. Combine the tomatoes, extra-virginolive oil, balsamic vinegar, basil, salt and pepper in amedium bowl. Set the bowl aside. Slice the loaf of Frenchbread so that each slice is about one-half inch thick. Placethe bread on a cookie sheet and toast on the top rack of theoven. Once the bread has turned a golden-brown color, flipeach piece in order to toast the other side. Remove thebread from the oven once both sides have been toasted.Peel the garlic cloves and rub directly on each side of thetoast. Spoon the tomato mixture on top of the breadand serve.

Note: This recipe, created by Emily MacInnes, won an award atMedlineʼs Employee Appreciation Week International Cook-Off!

Healthy Eating


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

Forms & Tools

SCIPFact Sheet ..................................................80

Hand-Off Communication Policy and Procedure ..................................82Perioperative SBAR ....................................85Endoscopy SBAR........................................86

Pressure Ulcer PreventionChecklist ................................................89


FACT SHEET

Summary of SCIP Measure Changes for 10/1/08+ Discharges All Measures:

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

VTE-1 and VTE-2:

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

Data Element and Table Changes

Data Element or Table

New Clarification Change

Beta-Blocker Perioperative

Documentation of a time associated with the last dose of the beta-blocker is necessary to verify that it was taken within the perioperative time frame. If the patient arrives on the day of surgery and there is documentation that the beta-blocker was taken on that same day prior to admission, the abstractor can select “Yes.”

Beta-Blocker During Pregnancy

The data element Sex will be used in the algorithm to exclude male patients.

Contraindication to VTE Prophylaxis

Physician documentation of a bleeding risk associated with surgery, such as the normal risk described in the operative permit, will not be considered a contraindication to pharmacological prophylaxis.

Discharge Time

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

Other Surgeries

Implanted or pocketed cardiac devices that are performed without general anesthesia will be abstracted as “Yes” for Other Surgeries because the antibiotic prophylaxis given for these procedures could interfere with the prophylaxis for the principal procedure.

Summary of 10/1/08 SCIP Manual Revisions Page 1 of 2 Hospital Interventions QIOSC/Hospital Quality Measures Special Study September 2008

Summary of 10/1/08 SCIP Manual Revisions Page 2 of 2 Hospital Interventions QIOSC/Hospital Quality Measures Special Study September 2008

Data Element or Table

New Clarification Change

Preoperative Hair Removal

Documentation that does not reflect actual hair removal, such as surgeon documentation in the operative report that the patient was “shaved and prepped,” should not be considered when answering this data element.

Hair removal that is documented as performed with scissors will be collected with Value 3 – Clippers.

Exclusions were added for non-surgical site hair removal and hair removal performed during the patient’s daily hygiene routine.

Surgery End Time

The inclusion terms are now prioritized as 1st, 2nd and 3rd. The data sources are no longer prioritized.

Priority order applies to items in the inclusion table, not to source document. Also, the synonyms in the lists are alphabetized, not prioritized.

The Notes for Abstraction were modified to be consistent with the instructions for Surgical Incision Time.

Surgical Incision Time

The priority lists were changed to more accurately reflect the wording commonly found in operating room documentation.

Priority order applies to items in the inclusion table, not to source document. Also, the synonyms in the lists are alphabetized, not prioritized.

The Notes for Abstraction were modified to be consistent with the instructions for Surgery End Time.

Vancomycin Allowable Value 2 was revised to include MRSA colonization or infection.

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

Table 1.3 Beta-Blockers

5 medications were added to the table of beta-blockers.

Table 2.1 Antimicrobial Medications

Doripenem was added to the antibiotic table.

For a complete list of changes please see the “Release Notes,” located in the Specifications Manual for National Hospital Quality Measures for discharges 10/1/2008. The manual can be found at http://www.qualitynet.org/dcs/ContentServer?cid=1192804535739&pagename=QnetPublic%2FPage%2FQnetTier3&c=Page This material was prepared by Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for Oklahoma, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 4-728-OK-0908



Forms & Tools Hand-Off Communication

Policy• “Hand-offs” are interactive communications that allow

the opportunity for questioning between the giver and receiver of patient information.

• Hand-off communication includes:• Accurate patient information regarding care,

treatment and services• Patientʼs current condition and diagnosis• Recent or anticipated changes in the patientʼs

condition• What to watch for in the next interval of care

• Specific examples of times when the transfer of responsibility for the surgical patient, i.e., hand-offs, occur include, but are not limited to, the following:

• Shift change or break relief• Physician to surgeon/nurse to nurse/surgical

technician to surgical technician transfer of patient responsibility

• When surgeons and nurses are transferring the patient to another level of care within or outside of the organization

• Patient care unit RN/ambulatory care RN report to the holding area RN

• Holding area RN reports to anesthesia, the surgeon and the circulating RN

• Circulating RNs report to the PACU RN and/or the patient care unit RN

• Anesthesiologists report to the PACU RN and/or to the patient care unit RN

• Surgical team (surgeon, nurse, surgical technologist) transfer of on-call responsibility

• Surgeon hand-off from the perioperative area to inpatient units

• Critical laboratory and radiology results disseminated to the surgical team

Procedure:• Healthcare professionals shall be allotted the time

for hand-off patient communication and to ask and answer questions with minimal interruption. It is hoped that this will lessen the amount of information that might be forgotten or simply not conveyed.

• Healthcare professionals shall find a quiet area to givea verbal report (hand-off communication) to ensure accurate, clear and concise information is given with a minimum of interruptions.

Hand-Off Communication in the Perioperative Setting

Introduction

State nameand unit

State patientname, age,gender

Situation

Pre-op diagnosis

NPO status (# of hours)

Procedure

Mental status

Patient stable/ unstable

Allergies

Advance Directive

Code status

Family (location,contact person/number)

Background

History/past hospitalization

Infection control/ isolation

Primary language

Sensory impairment

Special needs: spiritual,cultural, learning, communication

Religious needs: refuses blood transfusion

Disposition of patientbelongings

Assessment

Vital signs

Isolation required

Pain assessment

Medications

Activity/mobility/falls risk

Risk factors

Other issues

Recommendations

Pain control

IV pump

Family communication

EKG

Treatments

Radiology

I-SBAR: An example of hand-off communication


• Hand-off communication shall be conducted face-to-face.

• Healthcare professionals shall give each other the opportunity to ask questions, answer questions and read-back or repeat-back information, as needed.

• The following is an example of a generic hand-off communication that may be used.

Perioperative hand-off communication:

• At specific points within the perioperative continuum, specific communications shall occur and shall include, but are not limited to:

Patient care unit/holding area to operating room:• Patient identification• Planned surgical procedure • Site marking• Planned anesthesia type• Allergies• Antibiotics to be given• Significant medical history• Family contact information• Other issues (i.e., NPO, blood products available)• Last voided• Equipment needs• Pre-operative medications

Change of shift/breaks/lunch relief:• Procedure• Surgeon plan and preferences (where we are in

the case)• Anesthesia • Allergies• Significant medical history• Counts• Irrigation• Medications• Instrumentation on and off field• Specimens on and off field• Tubes, lines, equipment

Operating room team to post anesthesia care unit:• Surgical procedure (completed vs. planned)• Anesthesia • Estimated blood loss• Input and output (i.e., straight catheter, Foley)• Allergies• Medications (received intra-op)• Significant medical history (i.e., contact precautions)• Family contact information• Equipment needs (i.e., sequential

compression devices)• Other issues (i.e., blood products, anesthesia

concerns)

ReferencesJoint Commission. Improving Hand-off Communications: Meeting NationalPatient Safety Goal 2E. Joint Perspectives on Patient Safety. 2006;6(8):9-15.http://www.jcipatientsafety.org/15427/. Accessed May 8, 2007.AORN. “Perioperative Patient 'Hand-Off' Tool Kit, http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/. Last Accessed September 28, 2007.

Reprinted with permission from Medical Consultants Network, Inc.

Hand-Off Communication Forms & Tools


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SBAR Hand-Off Communication Forms & ToolsLabel

This document is not a part of the permanent medical record

TMC Perioperative Hand-Off Communication Date:

S

Family MD:

Surgeon:

Anesthesia:

Admitting Diagnosis:

NKA

Allergies:

Core Measures

SCIP/SIP CHF

DNR: Yes No Modified

Isolation/Infection:

MRSA ! VRE !

C Diff ! Other !

NPO: Yes No

O2 Needs:

Vision Impairment: Contacts Glasses

Method of transfer: Wheelchair Cart

Ambulatory

Mobility: Bedrest Assist

Ambulatory

Fall Risk:

Low ! High !

Communication: HOH R L

Speech Clear: Yes No

Non-English speaking !

IV Fluids:

IV Access: PICC

Saline Lock

Central Line

Peripheral

Mental Status: Alert

Restless

Confused

Combative

Unresponsive

B

Past Medical History: Diabetes HTN CAD PVD

CVA Arthritis Renal disease

COPD Asthma Seizure

Pacer/AICD

Other: ETOH Smoker

Dentures/Partials/Loose teeth

*No B/P ______ arm*

Initial vitals: TPR _____________

B/P_________02 Sat_____________

Height________Weight__________

Admission Blood Glucose___________

ASA Score __________

H&P Yes No

Pre-procedure verification: Yes No

Site Marking: Yes No N/A

Pre-op Antibiotic:

Time:

Med Given:____________Time______

Med Given:____________Time______

Med Given:____________Time______

Last pain med:

A

Anesthesia: MAC Local

General Spinal Block Epidural

Procedure/Operation:

__________________________

Dressings:

Penrose: Yes No Packing: Yes No

Drains: JP Hemovac

NG gravity suction G-tube

Stryker Reinfusion start time:

Chest Tube: Suction Water Seal Heimlich

Foley: Yes No

Straight Cath: Yes No

OR Intake:

Blood/Blood Products:

OR Output:

EBL:

Pertinent Assessment Findings:

PACU Vitals: PACU Intake:

IV #____IV credit on Transfer_________

ASA________ PACU Output:

Pain Control: (circle one)

PCA Epidural Intermittent IV

PO N/A

Medication:

Duramorph: Yes No

PACU discharge pain score_______

Med Reconciliation completed !

Operation End Time:____________

Cardiac Rhythm________________

Treatments: TEDS SCD’s CPM

Foot Pumps Polar Care Binder

R

Misc. Information:

Family Notified: Yes No

Pre-op RN Sig: __________________

Intraop RN Sig:___________________________

Postop RN Sig:___________________________

Call______________for any

questions @ ext.___________.

Label

This document is not a part of the permanent medical record

TMC Endoscopy Hand-Off Communication Date: Room/location:

S

Admitting MD:

Surgeon:

Admitting Diagnosis:

NKA

Allergies:

DNR: Yes No

Modified

Isolation/Infection:

MRSA ! VRE !

C Diff ! Other !

NPO since: _________

O2 Needs:

Vision Impairment: Contacts Glasses

Method of transfer: Wheelchair Cart Ambulatory

Mobility: Bedrest Assist Ambulatory

Fall Risk:

Low ! High !

Communication: HOH R L

Speech Clear: Yes No

Non-English speaking !

IV Fluids:

IV Access: PICC

Saline Lock

Central Line

Peripheral

Mental Status:

Alert

Restless

Confused

Combative

Unresponsive

B

Past Medical History:

Diabetes HTN CAD PVD

CVA Arthritis Renal disease

COPD Asthma Seizure

Pacer/AICD

Other: ETOH Smoker

*no B/P ______ arm*

Initial vitals: TPR _____________

B/P_________02 Sat_____________

Height________Weight__________

ASA Score __________

H&P Yes No

Pre-procedure verification: Yes No

Site Marking: Yes No N/A

Do home meds include:

B/P ____

Cardiac_____

Diabetes: oral____ insulin_____

MAO inhibitor_____

Pain Status:____________________

A

Anesthesia: MAC

Procedural Sedation

Procedure/Operation:

EGD

ERCP

Peg Tube

Bronchoscopy

Colonoscopy

Polypectomy: Yes No

__________________________

Medications given:

Demerol __________

Fentanyl __________

Versed ____________

Cetacaine Spray: Time____________

Other Med:______________________

Reversal agent: Yes No

________________________________

Aldrete Score:__________________

Cardiac

Rhythm:________________________

Endo discharge pain score_________

Med Reconciliation Completed !

R

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

Procedural RN :___________________________

Postop RN: ______________________________

Call______________for any

Questions @ ext.___________.


Forms & Tools SBAR Hand-Off Communication

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Pressure Ulcer Prevention Checklist: Perioperative Services

Yes No Position Comments/NotesResponsible

Do you have a policy and procedure for skin and risk assessment that addresses:a. How and when a patient is considered at risk for

development of a pressure ulcer and in need of prevention intervention(s)?

b. Who is responsible for developing, implementing and monitoring the prevention care plan?

Do you have prevention protocols for staff to implement when specific pressure ulcer risk factors are identified?Do you have a policy and procedure for positioning patients at risk for pressure ulcer that addresses:

a. Pressure redistribution OR table pads for procedures lasting longer than two hours?

b. The use of gel table pads when indicated?Do you warm your patients 30 minutes prior to the surgical procedure to maintain core body temperature intraoperatively?Does the individualized care plan for each patient at risk for pressure ulcers address the following prevention interventions:a. Pressure, friction and shear reduction

1. Pressure redistribution OR table pads or overlays (foam, gel)?

2. Positioning/repositioning techniques?3. Positioning devices (foam, gel, wedges, etc.)

to prevent pressure on bony prominences? 4. Mechanical aids (lifts, slide boards, sliding

sheets) for lifting, moving and positioning/repositioning?

5. Protection for head, elbows and heels?6. OR tables of sufficient sizes to fit your

patient population?b. Skin care

1. Does skin inspection occur prior to and immediately following the surgical procedure?

2. Is skin is kept dry during the surgical procedure with minimal exposure to moisture, perspiration and drainage?

3. Is it ensured that warming blankets are not placed between the pressure redistribution table pad and the patient in high-risk patients?

Pressure Ulcer Prevention Policy and Procedure Forms & Tools


Forms & Tools Pressure Ulcer Prevention Policy and Procedure

Yes No Position Comments/NotesResponsible

4. Is skin cleansed with a skin-cleansing agent and thoroughly dried as soon as the surgical procedure is complete (before moving to the holding room)?

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

When Ami arrived at work and obtained herassignments for the day, she learned thatthe patient in Room 210 had contractedClostridium difficile. She proceeded tothe isolation cart to obtain her personalprotective equipment before enteringthe room.

The patientʼs name was Jeffrey, andhe was three days post inguinalhernia repair.

“How are you feeling today, Jeffrey?”Ami asked him. “Iʼm so sorry to hearabout the infection. Weʼre going to doeverything we can to make sure thatyou donʼt pick up any other infections.Iʼm sure Dr. Payton will be by soon tocheck in on you.”

Ami had no more than said his name when Dr.Payton walked into the room. He had been a surgeon atthe hospital for as long as anybody could remember andwas beloved by his patients for his gentle bedside manner.

“Hello there, Jeffrey,” Dr. Payton said. “You should be ableto get back to skiing in six to eight weeks, if you take care ofyourself. Now, letʼs get a look at my handiwork.” He peeledJeffreyʼs bandage back to inspect his wound. Then, satis-fied, he placed the bandage back over the wound.

“Everything looks good,” Dr. Payton told Jeffrey. “We needto get this nasty infection cleared up so that we can get youhome. Iʼll stop by later and check in on you again.” He stoodto leave, and Ami followed him from Jeffreyʼs room.

“Dr. Payton, I noticed you didnʼt sanitize your hands beforetouching Jeffrey,” she said to him quietly once they were inthe hallway.

Dr. Payton sighed. “I know, Ami, but this cold weather isreally wreaking havoc on my skin. If I sanitized my handsall the times weʼre supposed to, they would be unbearablysore. And letʼs face it, this is a job where I need my handsto be in good condition!”

“I agree,” Ami said. “But maybe using lotionwould help moisturize your hands so sani-

tizing them wouldnʼt hurt. You know, itʼs amyth that the alcohol in those sanitizers

makes them sting. It only stings ifyour skin is already compromised.And you could always find a littlebottle of it to carry around with youso itʼs always available.”

Dr. Payton sighed. “Look, Ami, Iknow. Iʼll talk to you later, okay?”With that, he was off to his next patient.

Ami stood in the hallway for amoment, deciding what to do. Then

she smiled to herself and walked to thenursesʼ lounge. She picked up the phone

and dialed the facilityʼs hand hygieneproduct vendor.

A few days later, Dr. Payton entered his office to findsample-sized bottles of hand lotion and the same handsanitizer that the hospital used. He laughed to himself andtucked the bottles inside his coat pocket.

The next day, Ami saw Dr. Payton in the hallway. Hecaught her attention, took the bottle of hand sanitizer out ofhis pocket, applied it to his hands and waved at her beforeentering a patientʼs room.

Ami smiled and gave him a thumbs-up.


By Laura KuhnThe OR Connection staff writer

Ami Lends a Hand

Stay tuned for the continued adventures of Medline’s familyof nurse dolls, Ami, Angel, Alice Aurora and Anastasia!

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