The

Aligning practice with policy to improve patient care

Volume 2, Issue 3

Make
2008
Your Best Year
EVER!

CMS
NEVER
Slaying the
“SUPERBUGS” EVENTS

Back to Basics:
Perioperative
Patient Positioning
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 The

OR Connection
Aligning practice with policy to improve patient care

Editor PATIENT SAFETY

Sue MacInnes, RD, LD
8 Three Important National Initiatives for Improving Patient Care
Clinical Editor
Alecia Cooper, RN, BS, MBA, CNOR 19 Handwashing vs. Hand Antisepsis
Clinical Team 26 Back to Basics: Perioperative Patient Positioning
Jayne Barkman, RN, BSN, CNOR 35 Counting & Accountability
Rhonda J. Frick, RN, CNOR
Anita Gill, RN 56 Imagine Ensuring Patient Safety with Standardized Sterile
Kimberly Haines, RN, Certified OR Nurse Procedure Packs
Carla Nitz, RN, BSN
Connie Sackett, RN, Nurse Consultant
Page 5
Claudia Sanders, RN, CFA
OR ISSUES
Angel Trichak, RN, BSN, CNOR
Perioperative Advisory Board
18 APIC Grand Rounds
Cathy Crandall, RN 38 Hypothermia
HealthTrust Purchasing Group, Tennessee
Larry Creech, RN, MBA, CDT
41 Airborne Disease and Surgical Site Infection
Carilion Clinic, Virginia 45 Preventing Mediastinitis
Barbara Fahey, RN 50 SSIs and Prosthetics
Cleveland Clinic Foundation, Ohio
Susan Garrett, RN Page 38
Hughston Orthopedic Hospital, Georgia SPECIAL FEATURES
Zaida Jacoby, RN, MA, M.Ed
NYU Medical Center, New York
5 Rule Denying Payments for “Never Events”
Diane Thompson, RN, MS Will Force a Close Look at Current Practice
Nurse Consultant, Kansas
48 Tips for “Going Green” in the Operating Room
Margie Voyles, RN, MS, CNOR
Lakeland Regional Medical Center, Florida 59 Competency-Based Learning
Donna Watson, RN, MSN, CNOR, ARNP, FNP 65 When Healthcare Facilities Need Partners ...
St. Joseph’s Medical Pavilion, Washington
Yvette West, RN, MSN, CNOR
Look to Your Vendors
Page 45
Duke University Hospital, North Carolina 80 “Dr. Marla” Battles Breast Cancer
Margery Woll, RN, MSN, CNOR 88 Conquering Cancer with a Nurse Hero
Rush North Shore, Illinois
91 Aurora’s History Lesson

About Medline
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products to hospitals, extended care facilities,
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Page 48
and other markets. Medline has more than 700 86 Best Day/Worst Day
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94 Injury Risks and Safety Considerations when
Positioning Patients
96 How Well Do You Know Pressure Points?
98 Patient Positioning Policy & Procedure
101 Indications for Hand Hygiene © 2007 Medline Industries, Inc.
The OR Connection is published
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Aligning practice with policy to improve patient care 3

 THE OR CONNECTION I Letter from the Editor

Dear Reader,
Our world in health care as we’ve known it is chang-
ing. This past August, the final rule for the Inpatient
Prospective Payment System (IPPS) was released.
This marks the beginning of change in reimburse-
ment for hospitals. As a result of the new ruling, the
hospital-acquired conditions (HAC) provision will go
into effect October 1, 2008. Eight conditions were
selected by the Centers for Medicare and Medicaid
Services (CMS) based on three criteria: 1) the
condition was high cost, high volume, or both; 2) it
was assigned a higher paying DRG when present
as a secondary diagnosis; 3) it was reasonably
prevented through the application of evidence-based
guidelines. These newly announced conditions are
as follows:1
Recently, we invited a group of perioperative direc-
tors and infection control practitioners to discuss
innovations in health care, ways to improve perform-
ance and challenges that they faced on a day-to-day
basis. We asked the group to rank their biggest
concerns as they relate to HACs. Interestingly we
found many similarities in their answers. Here was
the result of the perioperative rankings:
1 Objects left in surgery (62 percent)
2 Surgical site infections (62 percent)
3 Pressure ulcers/vascular catheter-associated
infections (25 percent each)

1-3 Serious preventable events

This edition begins our journey in educating the
masses on the issue and offering potential solutions
that you can bring back to your facility. You will find
“ We all can agree
that we should do
things right … but
it is our goal to
– Objects left in during surgery articles on three of your top four rankings (objects left make it hard for
– Air embolism in surgery, SSI and pressure ulcers). We need to be the healthcare
– Blood incompatibility the ambassadors of change and make prevention a
4 Catheter-associated urinary tract infection part of our everyday practice.
worker to do
5 Pressure ulcers
things wrong.”
6 Vascular catheter-associated infection Sincerely,
7 Surgical site infection
8 Falls and trauma

There was strong public support for CMS to pay less Sue MacInnes, RD, LD
for conditions that are acquired during a hospital stay. Editor
And so, in less than a year from now, there will be a
financial impact if a patient acquires any one of these
eight conditions after they have been admitted.

1. Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions. Available at: http://www.cms.hhs.gov/Hospital
AcqCond/06_Hospital-Acquired%20Conditions.asp. Accessed November 26, 2007.

Content Key
We've coded the articles and information in this magazine to indicate which patient
care initiatives they pertain to. Throughout the publication, when you see these
icons you'll know immediately that the subject matter on that page relates to one
or more of the following national initiatives:
• IHI's 5 Million Lives Campaign
• Joint Commission 2007 National Patient Safety Goals
• Surgical Care Improvement Project (SCIP)

We've tried to include content that clarifies the initiatives or gives you ideas and
tools for implementing their recommendations. For a summary of each of the above
initiatives, see pages 8 and 9.

4 THE OR CONNECTION

Rule denying payments for
'never events' will force a close
look at current practice
By George E. Brandon
AORN Management Connections
Under a mandate established by Con-
gress in the Deficit Reduction Act of 2005,
hospitals that provide Medicare and Medi-
caid services were required to begin
reporting on Oct. 1 secondary diagnoses
“present on admission” of patients. The
new data-collection requirement sets
the stage for the next major step in the
federal government’s continuing push
toward Pay for Performance—beginning
Oct. 1, 2008, hospitals no longer will be
reimbursed for eight preventable “hospital-
acquired conditions,” several of which are
associated with surgical procedures.
Special Feature
The Fiscal Year 2008 Inpatient
Prospective Payment System (IPPS)
rules adopted by the federal Centers for
Medicare and Medicaid Services (CMS)
in August go beyond previous require-
ments that hospitals report on an array
of quality-of-care measures in order to
receive full annual cost updates for
Medicare and Medicaid reimbursements.
For the eight avoidable “hospital-acquired
conditions” identified by CMS, the outcome
of care— rather than the quality of care
provided during a patient’s stay—will
be the determinant, noted Paul Keckley,
Ph.D., executive director of Deloitte
Center for Health Solutions in
Washington. D.C.
Continued
 Reimbursements won’t just be reduced 2% treatment), but the balance of evidence may
annually for failing to report on quality measures; point in a different direction,” Keckley added.
they will be denied altogether when hospitals
fail to take steps needed to ward off the eight Under the new rules, CMS will not pay hospitals
conditions that are, as CMS put it in a Fact for the higher costs of treating patients for the
Sheet on its FY 2008 IPPS final payment eight “hospital-acquired conditions” assigned
rules, "reasonably preventable through as secondary diagnoses, unless the secondary
application of evidence-based guidelines." diagnoses were “present on admission.” The
eight conditions subject to the new policy
“Traditionally, we have been keen on what we Oct. 1, 2008, are:
do and our processes, but we have taken the
position that outcomes are out of our control,” 1. Catheter-associated urinary
Keckley observed. “This ruling is a step in tract infections
the direction of saying the results of what 2. Vascular catheter-associated infections
we do should be how we are judged, how 3. Mediastinitis, a surgical site infection
we are paid.” following coronary artery bypass
graft surgery
How will the policy shift affect perioperative 4. Pressure ulcers
practice? "If we are following our standards
to ensure patients are getting the best care
possible, then these new [CMS] rules for non-
payment shouldn't be an issue. Unfortunately,
these ‘never events’ do occur," acknowledged
“ This ruling
is a step in the
direction of saying
5. Falls
6. Retained objects in surgical patients
7. Blood incompatibility
8. Air embolisms

Jane Kusler-Jensen, RN, BSN, MBA, CNOR, Also included in the FY 2008 IPPS final rule
the results of what
FABC, director of perioperative services with we do should be were five new quality measures that hospitals
Columbia St. Mary's Healthcare system in will have to report in order to qualify for
Wisconsin and a member of AORN's Board the full annual payment schedule updates.
how we are judged,
of Directors. "This new ruling may force all how we are paid.” Several will directly affect perioperative
healthcare professionals to take a closer look managers, including reporting cardiac surgery
at their practice and lead to greater support from risk patients with controlled 6 a.m. postoperative serum glucose,
managers and other hospital quality departments." reporting surgery patients with appropriate hair removal and
reporting surgical patients on beta blocker therapy before
Keckley believes the new IPPS rules and a host of outcome- admission who received a beta blocker during the
based reimbursement policies to follow in future years will perioperative period.
pose a challenge for hospital administrators and department
managers to move beyond “the old model in which the doctor CMS will also be working to create codes to identify ventilator-
or surgeon says what goes, and the manager’s job is to associated pneumonia and to determine when septicemia and
accommodate them, even though we know that in some deep vein thrombosis are not present on admission and preventa-
cases it may lead to substandard outcomes.” ble in the hospital. These additional conditions may be added
to CMS' list of nonpayable conditions for the next fiscal year.
Under the old model of perioperative practice, “the surgeon is
captain of the ship,” Keckley explained. “Under the new model, Carina Stanton and Cathy Sparkman contributed to this story.
the focus is on optimal outcomes, and the surgeon becomes
Reprinted with permission from AORN (www.aorn.org) AORN Manage-
part of a team, working in a coordinated effort to establish ment Connections (October 2007) online newsletter. Copyright © AORN,
evidence-based processes of care and measure the outcome Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231.
of those processes,” he said.
The Association of periOperative Registered Nurses (AORN) is the national
association committed to improving patient safety in the surgical setting.
The focus on outcomes adds the concept of “effective care” With over 41,000 members, AORN is the premier resource for perioperative
to the ongoing healthcare industry focus on “safe care,” Keckley nurses, advancing the profession and the perioperative professional with
noted. The goal isn’t just to avoid harm to the patient or care- valuable guidance as well as networking and resource-sharing opportunities.
AORN is recognized as an authority for safe operating room practices
givers but to use evidence-based practices to develop treatment and a definitive source for information and guiding principles that support
plans that will yield optimal outcomes, he said. “The system day-to-day perioperative nursing practice. For more information, visit
now rewards doctors for making these judgments (about www.aorn.org.

6 THE OR CONNECTION
The National
Quality Forum Checking in with IHI
What’s ahead
Facts at a glance in 2008
Origin
In a report issued in 1998, a Presidential Commission
recommended the creation of a national forum in which
healthcare’s many stakeholders could, together, find Strengthening the “National • Seeking, at the hospital level,
ways to improve the quality and safety of American Learning Network”: The [5 Million to create a critical mass of
healthcare. The National Quality Forum (NQF) was Lives] Campaign currently has field successful facilities on each
incorporated as a new organization in May 1999. offices (often consisting of state intervention in each state.
hospital associations, quality • Connecting with new audiences
Purpose improvement organizations and and stakeholders (e.g., payers,
To improve the quality of American healthcare by setting other state-level stakeholders in purchasers, policymakers,
national priorities and goals for performance improvement, quality and safety) in every state, patients and families)
endorsing national consensus standards for measuring and several affinity groups for rural,
and publicly reporting on performance, and promoting
pediatric and public facilities. These Execution: We must transfer the
the attainment of national goals through education and
field offices, together with local practical approaches and methods
outreach programs.
mentor hospitals, provide energy of those hospitals that succeed
The National Quality Forum has broad participation and support to area facilities as most rapidly and completely to all
from all branches of the healthcare system, including they pursue improved quality. In the participating facilities, with a specific
national, state, regional and local groups representing next year, the Campaign will emphasis on the leadership roles,
consumers, public and private purchasers, employers, strengthen the national learning management structures and skill
healthcare professionals, provider organizations, health network that these organizations sets that enable significant change.
plans, accrediting bodies, labor unions, supporting comprise by A major activity here includes the
industries and organizations involved in health care focusing on several levels: identification of at least one mentor
research or quality improvement. • Seeking, at the national level, hospital (i.e., a high-achieving hos-
to better coordinate improvement pital willing to coach other facilities)
Strategic goals
priorities and support activities for every intervention in every state,
1. NQF-endorsed standards will become the primary
standards used to measure the quality of healthcare with partners like AHA, AMA, taking us to a critical mass of suc-
in the United States. ANA, CMS, CDC and the cessful facilities across the nation.
2. NQF will be the principal body that endorses national Joint Commission.
healthcare performance measures, quality indicators • Seeking, at the state level, to Enrolling 4,000 hospitals
and/or quality of care standards. empower local field offices to
3. NQF will increase the demand for high-quality better support local improvement Conducting measurement
healthcare. activities through an infusion of studies: In order to thoroughly
4. NQF will be recognized as a major driving force for expert support, quality improve- assess national progress, the
and facilitator of continuous quality improvement of ment training and other helpful Campaign will be conducting or
American healthcare quality.
resources. In addition, inviting helping to design several studies
the most successful state efforts to track national change in mortality,
Organizational goals
1. Promote collaborative efforts to improve the quality to document their “recipes for harm and performance on the
of the nation's healthcare through performance success” and act as laboratories Campaign interventions.
measurement and public reporting. for improvement to lead the rest
2. Develop a national strategy for measuring and of the nation. To learn more,
reporting healthcare quality. • Seeking, in large public and visit www.ihi.org
3. Standardize healthcare performance measures so private systems, to establish
that comparable data is available across the nation. and support ambitious aims
4. Promote consumer understanding and use of for improvement.
healthcare performance measures and other
quality information.
5. Promote and encourage the enhancement of system
capacity to evaluate and report on healthcare quality.

To learn more, visit www.qualityforum.org.

Aligning practice with policy to improve patient care 7

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

1 5 MILLION LIVES CAMPAIGN

Origin: Launched by the Institute for Healthcare Improvement (IHI) in December of 2006
Purpose: To prevent unintended physical injury resulting from or contributed to by medical care that requires
additional monitoring, treatment or hospitalization, or that results in death
Goal: 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 guides and
tools for data measurement and submission. IHI tracks Acute Care Inpatient Mortality rates for all participating hospitals.

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

2 JOINT COMMISSION 2008 NATIONAL PATIENT SAFETY GOALS

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

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

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

3 SURGICAL CARE IMPROVEMENT PROJECT (SCIP)

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

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

8 THE OR CONNECTION
 Patient Safety

5 MILLION LIVES CAMPAIGN: TWELVE INTERVENTIONS

1. Prevent pressure ulcers 9. Deliver evidence–based care for acute myocardial infarction
2. Reduce methicillin-resistant staphylococcus 10. Prevent surgical-site infections
aureus (MRSA) infection 11. Prevent central-line infections
3. Prevent harm from high-alert medications 12. Prevent ventilator-associated pneumonia
4. Reduce surgical complications
By the numbers:
5. Deliver evidence-based care for congestive heart failure
• >3,600 hospitals currently enrolled
6. Get boards on board
• The Top 3 Interventions:
7. Deploy rapid response teams
1. Adverse Drug Events (ADEs) – >2,834
8. Prevent adverse drug events (ADEs)
2. Acute Myocardial Infarction (AMI) – 2,749
• Comprehensive Execution Strategy 3. Surgical Site Infection (SSI) – 2,746
FOCUS FOR • Increasing enrollment to 4,000
2008! • Strengthening the “National Learning Network”
• Conducting Measurement Studies To learn more, visit www.ihi.org

JOINT COMMISSION 2008 NATIONAL PATIENT SAFETY GOALS

NEW FOR • Improve accuracy of patient identification • Reduce risk of surgical fires
2008! • Improve effectiveness of communication • Encourage patient’s active involvement in their care
among caregivers • Prevent healthcare-associated pressure ulcers
• Improve medication safety (decubitus ulcers)
• Reduce risk of healthcare-associated infections • Identify safety risks inherent in patient population
(Expanded in 2008 to include either WHO (suicide, home fires)
or CDC Hand Hygiene Guidelines) • Rapid response to changes in patient condition
• Reduce risk of patient harm from falls (new for 2008)
• Reduce risk of influenza and pneumoccocal disease • Implementation of Universal Protocol for preventing
through immunization wrong-site, wrong-person, wrong-procedure surgery

To learn more about the potential goals in their entirety, go to www.jointcommission.org.

SURGICAL CARE IMPROVEMENT PROJECT (SCIP): THREE TARGET AREAS

1. Surgical-site infections
By the numbers:
• Antibiotics, blood sugar control, hair removal, normothermia
• 3,740 hospitals are submitting
2. Perioperative cardiac events data on SCIP measures, representing
• Use of perioperative beta-blockers 75 percent of all U.S. hospitals
3. Venous thromboembolism • Currently, SCIP has more than 36
• Use of appropriate prophylaxis association and business partners
4. Ventilator-associated pneumonia has been removed
and data is being collected by the Joint Commission

NEW FOR SCIP is eagerly awaiting the official draft of CMS’s 9th Scope of Work to determine future
2008! program updates and changes.

To learn more visit www.medqic.org/scip.

Aligning practice with policy to improve patient care 9

News from AORN
Association of periOperative Registered Nurses
Register for Congress now!
Start looking forward to Congress 2008 and register online using the
new Congress Online Registration System! Visit the newly designed
Congress Web site (www.aorn.org/Education/EducationEvents/ Congress)
and explore the many education sessions, events and other activities
planned for Congress 2008 in Anaheim, California. Register now and
save big!
Revised PNDS on the way
A revised, updated second edition of the Perioperative Nursing Data
Set (PNDS) – the structured vocabulary used in uniformly documenting
the practice decisions and interventions that lead to positive outcomes
for patients undergoing surgical and/or invasive procedures – will soon
be available at AORNBookstore.org.
While the underlying standardized PNDS data set hasn't changed,
the newly Revised Second Edition of PNDS contains a set of powerful
examples illustrating how several perioperative nursing and informatics
teams have benefited from implementing PNDS. The examples cover
use of PNDS in various clinical settings, in orientation and educational
programs for perioperative RNs, as well as in electronic health record
systems and other record-keeping applications, including staff job
descriptions and documenting staff competencies.
To learn more about AORN and the Recommended Practices for
periOperative Services, go to www.aorn.org.
Aligning practice with policy to improve patient care 11
News from AST – Association
for Surgical Technologists
Surgical technology is one of the fastest-growing
professions in the country. It is projected to
grow faster than the average of all other
occupations through the year 2012. As baby
boomers approach retirement age, the volume
of surgery will increase exponentially.
To view statistical information about the profession,
including a map of the average hourly pay rate
of AST members by state, go to www.ast.org.
Council on Surgical &
Perioperative Safety
Formed by the AST, the Council is a coalition
of seven professional organizations involved
in surgical patient care has incorporated as the
Council on Surgical & Perioperative Safety.
The mission of the group is to promote a culture
of patient safety with members of the surgical
team working together to provide optimal
patient care and a caring perioperative work-
place environment.
The seven organizations include the American
Association of Nurse Anesthetists, American
Association of Surgical Physician Assistants,
American College of Surgeons, American
Society of Anesthesiologists, American Society
of PeriAnesthesia Nurses, Association of
periOperative Registered Nurses and the
Association of Surgical Technologists.
For more information related to the Council
on Surgical & Perioperative Safety, go to
www.cspsteam.org.
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 Hospitals begin to tout ability to control infection;
Mining the available data

Putting SUPERBUGS
on the DEFENSIVE
By Theo Francis
The Wall Street Journal

14 THE OR CONNECTION

Hospitals are prime breeding grounds
for antibiotic-resistant "superbugs" that
kill tens of thousands of Americans each
year. But most people have had no way
of knowing how well their hospital keeps
these bacteria – and infections in general
– under control.
That is starting to change. Nineteen states
have adopted laws in recent years
requiring hospitals to report overall
infection rates publicly, with more likely
to follow suit. And Thursday, nearly two
dozen federal lawmakers, headed by
Pennsylvania Rep. Tim Murphy,
proposed legislation requiring
nationwide public reporting.
So far, just four states have published
some infection rates for individual hospitals,
and only one state, Pennsylvania, breaks
out different types of infections. But even
where patients can't find state-mandated
infection reports, they can increasingly
get information from their local hospital
about practices to prevent super-bugs
and other infections. Some hospitals
have found a marketing opportunity in
infection prevention: They are pushing
overall infection rates toward zero – and
advertising it. They are trumpeting preven-
tion efforts, such as campaigns to improve
hand washing. And some are tracking
patients who have been infected with
superbugs such as methicillin-resistant
Staphylococcus aureus, or MRSA, and
monitoring them to prevent the spread.
"This is one of those cases where
quality is also the best business case,"
says Jonathan Perlin, chief medical
officer at hospital chain HCA Inc., which
has enlisted staffers and visitors alike in
its own campaign to keep germs away
from patients.
While antibiotic-resistant infections have
gotten the attention of late, hospitals have
long struggled with infections of all kinds.
Common bacteria including Staphylococ-
cus aureus can infect the bloodstream,
urinary tract, lungs or surgical incisions
of patients whose immune systems are
already compromised. Over time, some
strains of these bacteria have developed
powerful defenses against antibiotics,
leaving them harder to kill.
Aligning practice with policy to improve patient care 15
Special Feature
Hospitals have long attempted to keep
infection rates low, but the spread of
resistant strains has made the fight that
much more urgent in recent years. Last
week, concerns came to a head with a
new study showing that antibiotic-resistant
infections are probably far more extensive
than previously thought. The study pub-
lished in JAMA, the Journal of the Ameri-
can Medical Association, concluded that
MRSA causes 94,000 infections a year.
The study estimated that MRSA, one of
the biggest infection concerns in hospitals,
contributes to nearly 19,000 deaths. The
vast majority were linked to health care,
including hospitals, nursing homes,
dialysis and others.
At the same time, recent student
illnesses and deaths have prompted
school closings in some states. And
starting next year, Medicare will no longer
reimburse hospitals for some infections
acquired after admission, in an effort
both to encourage vigilance and to
save money.
Continued
 BUG OFF
Hospital chain HCA has taken its campaign
against antibiotic-resistant infections to
the public as well as its medical staff. Go
to www.hcahealthcare.com to find:
• Handout: Stopping Infections Is
In Your Hands2
• Poster: Stopping MRSA Is In
Your Hands3
Among the four states that have published
infection rates, Missouri and Vermont let
consumers learn the number of blood
infections related to central lines – tubes
inserted into or near the heart, often to
give medications or fluids – and how that
compares with state or national averages.
Pennsylvania provides multiple reports on
different kinds of infections, and lets con-
sumers look up infection-related mortality,
length-of-stay and cost data for several
kinds of infections. A Web site from
Consumers Union, www.stophospitalin-
fections.org, has links to reports from
each state, including Florida, according
to Lisa McGiffert, director of the Stop
Hospital Infections Campaign.
“Ahead of the Curve”
Information from Florida is nearly two years
old, and Missouri's dates to December
2006. But the information released so far
is an important start, say public-health
experts, since most of the hospital-infection
reports mandated by the new state laws
won't be available before about 2009.
"Those states that have already
released data are ahead of the curve,"
says John Jernigan, a medical epidemiol-
ogist with the Centers for Disease
Control and Prevention in Atlanta.
So far, infection reports available to the
public aren't consistent enough to allow
consumers to compare hospitals across
state lines, and even comparing facilities
within a state can be tricky. Some facilities
may treat sicker patients, for example,
who are more likely to become infected
16 THE OR CONNECTION
when exposed to MRSA or other
resistant bugs.
Indeed, the data are probably too technical
for most consumers, says Carlene Muto,
medical director of infection control at the
University of Pittsburgh Medical Center.
Still, she is a strong supporter of the
reporting requirements as a way to push
hospitals to improve. "Clearly, it's a
good idea just to measure adverse
events," she says. "You can't change
what you do not measure, because
you won't know that it's broken."
In areas where patients can't learn actual
infection rates, they can watch for key
signs that a hospital is on top of preventing
both superbugs and infections generally.
National studies suggest, for example,
that hospital personnel don't wash their
hands nearly as often as they should.
Nashville, Tenn.-based HCA has been
putting up posters exhorting doctors to
wash their hands, and is even distributing
a card to visitors that explains the impor-
tance of hand washing when coming in
contact with patients. The company says
its purchases of hand-sanitizing alcohol
gel -- available from dispensers through-
out its hospitals -- have risen 600% since
early this year. (Company officials say
they didn't measure infection rates at the
start of the campaign and so don't know
how much infections have fallen.)
Other hospitals say they have pushed
antibiotic-resistant-infection rates down
sharply through a combination of tech-
niques. The University of Pittsburgh
Medical Center, for example, has cut
MRSA infection rates in half
at its main hospital since 2001
in part by screening all intensive-care
patients to see if they are carrying the
bug; it is now expanding use of the tests.
To reduce certain kinds of bloodstream
infections, the 19-hospital system bundles
sterile material needed to insert central
lines and has stepped up training; central-
line associated blood-infection rates have
fallen by 80% since 2002, to fewer than
one per thousand such procedures.
It also has taken steps to deal with the
emergence of a different strain of bacteria
that can cause potentially fatal diarrhea.
The hospital lets nurses order tests for the
bug; requires longer isolation periods for
those infected with it; gives their rooms
an additional cleaning with bleach; and
requires physicians to get approval from
an antibiotic-management team when
using certain high-powered antimicrobials
that could affect the body's natural de-
fenses against the bacteria. UPMC's in-
fection rates for the organism, Clostridium
difficile, have fallen two-thirds since a spike
in 2000.
Intermountain Healthcare, a Salt Lake
City-based chain of 21 hospitals, keeps a
database of every patient who has been
infected with MRSA. Those who return to
the hospital for some other reason are
immediately monitored by an infection-
control nurse and tested to see if they
are carrying the bacteria.
"Those patients are at higher risk
of potentially getting it again, and at
higher risk of spreading it to other
patients," says the hospital's chief medical
officer, Brent Wallace. Together with a
concerted campaign to improve hand-
washing, the database has helped stop
an increase in the number of MRSA
infections at the hospital over the past
year, he says.
Broader Testing
Some states are also beginning to mandate
broader testing specifically for MRSA,
since patients can carry the bug and
spread it without showing signs of infection.
Pennsylvania will soon require hospitals
to test high-risk patients, including those
admitted from nursing homes. In August,
New Jersey and Illinois adopted legisla-
tion requiring hospitals to identify patients
carrying MRSA and isolate them,
among other provisions.
Don Goldmann, senior vice president of
the Institute for Health Care Improvement
and a Harvard Medical School pediatrics
professor, says that factors beyond infec-
tion rates should play into picking a hos-
pital. "There may be a lot of
information to weigh."
On their own, some hospitals have been
turning to a variety of new technologies to
try to cut down on infections, particularly
superbugs, ranging from antibiotic-coated
catheters to work surfaces made of copper,
which has antimicrobial properties, as
well as software. For several years, many
hospitals have also participated in federally
sponsored programs to reduce surgical
complications, including infections acquired
in the hospital.
Write to Theo Francis at theo.francis@wsj.com4
URL for this article:
http://online.wsj.com/article/SB119309446460567619.html
Hyperlinks in this Article:
(1) http://online.wsj.com/article/SB119309360318867665.html
(2) http://www.hcahealthcare.com/CPM/PATIENT-
VISITOR_HANDOUT.pdf
(3) http://www.hcahealthcare.com/CPM/CLINICIAN_AD_
SINGLE_PAGE_lg.pdf
(4) mailto:theo.francis@wsj.com
Reprinted with permission of The Wall Street Journal
Aligning practice with policy to improve patient care 17
 OR Issues
APIC Grand Rounds
SURGICAL
SITE
INFECTIONS
By Shawn Boynes
The Association for Professionals in Infection
Control and Epidemiology, Inc. (APIC)
launched a nationwide series of educational
programs this past spring to showcase best
practices related to preventing surgical site
infections. The APIC Grand Rounds: Protecting
Patients from the Risk of SSIs is underwritten
by an unrestricted educational grant from
ETHICON, INC. and provides a comprehensive
approach to understanding the nature and
risks associated with surgical site infections.
This programming is particularly important
given CMS’s recent decision that reimburse-
ment for SSIs will cease as of October 2008.
Preventing surgical site infections requires
engaging professionals across the continuum
of health care, including infection prevention
and control professionals, operating room
nurses, physicians and hospital administrators.
For this reason, the SSI Grand Rounds
emphasizes a team approach to the reduction
of SSIs, concentrating on the partnership
between the operating room and infection
prevention and control.
The Grand Rounds program provides a
framework for addressing clinical impact of
SSIs as well as the financial impact on
healthcare facilities. Practical presentations
provide ways to develop a program for the
elimination of SSIs using evidence-based
practices and include:
• Sustaining System-Wide SSI
Rate Reductions
• Reducing the Risks of SSI:
Medical Techniques
18 THE OR CONNECTION
• View from the OR: Partnering About APIC
for Prevention APIC’s mission is to improve health
• Working Towards A Zero and patient safety by reducing risks
Infection Rate of infection and other adverse
outcomes. The Association’s more
Featured presenters are nationally than 11,000 members have primary
recognized experts, including: responsibility for infection prevention,
• Marilyn Jones, RN, MPH, CIC, BJC control and hospital epidemiology
Healthcare (St. Louis, Mo.) in healthcare settings around
• Charles Edmiston Jr. PhD, MS, CIC, the globe, and include nurses,
Froedtert Hospital (Milwaukee, Wis.) epidemiologists, physicians, micro-
• Sina Matin, MD, Baylor Health Care biologists, clinical pathologists,
Systems (Irving, Texas) laboratory technologists and public
• Maureen Spencer, RN, M.Ed, CIC, health practitioners. APIC advances
New England Baptist Hospital its mission through education,
(Boston, Mass.) research, collaboration, public policy,
• Lillian Burns, MT, MPH, CIC, practice guidance and credentialing.
Greenwich Hospital
(Greenwich, Conn.)
• Elizabeth Duthie, RN, PhD,
NYU Hospitals Center (New York, N.Y.)
• Kristina Dreifuerst, MSN, RN,
APRN-BC, CWOCN,
University of Wisconsin School of
Nursing (Madison, Wis.)
• Michael McGuire, MD, FACS,
St. Johns Hospital (Santa Monica, Calif.)
• Ramon Berguer, MD, FACS,
Contra Costa Regional Medical Center
(Martinez, Calif.)
About the author For more information about the
Shawn Boynes is the senior director of Grand Rounds, including the
education for the Association for Professionals
2008 schedule,
in Infection Control and Epidemiology, Inc.
visit www.apic.org.
Do you know the difference?
Perioperative professionals who routinely
scrub in surgical procedures are well aware
of the protocols and procedures for surgical
hand antisepsis. Those who scrub are familiar
with the debate over whether to use water-
aided brush scrubs or alcohol-based hand
rubs. These people also know that many
facilities are choosing alcohol-based rubs
for their efficacy, tolerability, staff acceptance
and cost.1
But what about those healthcare professionals
who don’t scrub on a routine basis? Do you
know the difference between handwashing
and hand antisepsis? And, if you do, are
you following all of the current guidelines,
recommendations and standards to prevent
the spread in infection, as well as
protect yourself?
In patient care, hand hygiene is regarded as
essential. It is important to understand that
each element of hand hygiene has clear
indications in clinical practice. There are many
organizations and governing bodies that have
established guidelines and recommendations
for appropriate hand hygiene, including the
CDC (Centers for Disease Control and
By Lillian Burns, MPH, CIC
Prevention), WHO (World Health Organization)
and APIC (Association for Professionals in
Infection Control and Epidemiology), to name
a few. Overall, the guidelines are similar.
Safety of both healthcare worker and patients
is the overarching goal.
Preconditions
Before taking a closer look at the different
hand hygiene measures, it is important to
know that hand hygiene begins with the
personal hygiene of each healthcare worker.
Personnel need to meet several crucial
prerequisites in order to perform optimal
health care.
Clean, short nails
Several studies have documented that the
area beneath the fingernails can be colonized
with high concentrations of bacteria.2,3
Even after careful washing or the use of
soap-based surgical scrubs, personnel often
harbor substantial numbers of potential
pathogens under their fingernails.4-6
Intact skin
Healthcare providers should remember
that maintaining intact skin is a professional
Aligning practice with policy to improve patient care 19
 responsibility. Cracked, scaly skin provides
microorganisms with ideal niches in which to
hide – thus, antiseptics have a difficult time
reaching the hidden microorganisms and
hand antisepsis is at danger of not being
effective enough.7 Additionally, open sores
on hands could potentially be carrying
Staphylococcus aureus.8
No artificial nails
Whether artificial nails contribute to the
transmission of healthcare-associated infec-
tions has not been determined.14 However,
healthcare personnel who wear artificial
nails are more likely to harbor gram-negative
pathogens on their fingertips than those
with natural nails, both before and after
handwashing.5,6,9
Minimal jewelry
Several studies demonstrate that skin
underneath rings is more heavily colonized
than comparable areas of skin on fingers
without rings.10-13 Moreover, the wearing
of rings increases the frequency of hand
contamination with potential healthcare-
associated pathogens.13 Nevertheless,
the CDC does not make a recommendation
regarding the wearing of rings in healthcare
settings.14 APIC states that rings and nail
jewelry can make donning gloves more
difficult and might cause gloves to tear
more easily.15
Wearing of rings or other jewelry when
providing routine care might be acceptable,
but in high-risk settings, such as the operating
room, all rings and other jewelry should be
removed. A simple and practical solution is
to suggest that healthcare workers wear their
ring(s) on necklaces as pendants like many
do who scrub in surgical procedures.16
Hand antisepsis
The term “hand antisepsis” is commonly
defined as “disinfection of hands with an
antiseptic agent that prohibits growth and
development of microorganisms.” In line with
this definition, the CDC, IHI (Institute of
Healthcare Improvement) and WHO recom-
mend using an alcohol-based hand antiseptic
for disinfecting hands.14,16,17 Therefore, if
an indication requires hand antisepsis,
handwashing with antimicrobial soap and
20 THE OR CONNECTION
water should only be a last resort, e.g., if
alcohol-based hand rubs are not available.
If hands are not visibly soiled, hand antisepsis
should be performed for routinely disinfecting
hands. The clinical situations requiring hand
antisepsis are:
Before any direct contact with
patients, including:
• Before donning exam and sterile gloves
• Before donning and removing PPE such
as gown and mask
• Before inserting indwelling urinary
catheters or other invasive devices that
do not require a surgical procedure
During patient care:
• Moving to a clean body site during pa-
tient care coming from a contaminated
body site
After any contact with the patient or the
patient’s environment, including:
• After contact with a patient’s intact skin
• After contact with body fluids or excre-
tions, mucous membranes, non-intact
skin and wound dressings if hands are
not visibly soiled
• After contact with inanimate objects
(including medical equipment) in the
immediate vicinity of the patient
• After removing gloves
There are a few clinical situations that
also require an additional handwash.
The exceptions and appropriate measures
are as follows:
• Heavily soiled hands should be carefully
rinsed, then washed with soap and
water, being careful not to spread con-
taminants on clothing or surroundings.
When wearing a gown, the gown should
be changed and then the hands should
be disinfected.18
• If contamination occurs due to a puncture
or glove perforation, gloves should be
removed, hands should be disinfected
and new gloves should be applied.
• Other than with the above exceptions,
the following applies: If an additional
handwash is desired, it should be per-
formed after antisepsis.18 If hands are
washed prior to using a hand antiseptic,
 Sterillium® Comfort Gel®

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antisepsis

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And, by virtue of its ethyl alcohol concentration, it does more for your infection control efforts

that Sterillium Comfort Gel achieves reductions of ≥ 5 log10 (≥ 99.999 percent) on a broad
while using up to 50 percent less volume per application.* Independent in vitro testing demonstrated

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Sterillium® Comfort Gel® is a registered trademark of Bode Chemie GmbH.
 microorganisms are distributed wherever
the water splashes during the hand-
washing process and are transmitted to
the environment and/or the clothing of
the personnel.
• Contamination with spore-forming bacteria:
It is suggested to disinfect hands first in
order to reduce the vegetative cell of the
spore-forming bacterium. Then hands
should be washed to reduce the remain-
ing spores.18 The physical action of
washing and rinsing hands under such
circumstances is recommended because
alcohols, chlorhexidine, iodophors
and other antiseptic agents have poor
activity against bacterial spores.14
Handwashing
Guidelines state that either a non-antimicro-
bial or an antimicrobial soap can be used if a
situation requires a handwash.14-17 The WHO
also states that antimicrobial soap should not
be used when an alcohol-based hand rub
is already in use.16 Hence, why not wash
with plain (non-antimicrobial) soap when
a situation requires handwashing?
Handwashing should be performed:14
• When hands are visibly dirty or contami-
nated with infectious material or are visibly
soiled with blood or other body fluids
• Before eating
• After using the restroom
Gloves
Wearing gloves during patient care is an
additional intervention to help reduce the
transmission of infectious organisms. Gloves
protect patients by reducing contamination
of the healthcare worker’s hands and subse-
quent transmission of potentially pathogenic
microorganisms to other patients.
Having more than one type of glove (i.e.,
latex, synthetic and powder-free) is desirable
because it allows personnel to select the
best match for their personal needs.14 The
use of therapeutic gloves that have been
shown to moisturize and soothe dry, chapped
hands can also assist in hand hygiene com-
pliance by improving overall skin care.
22 THE OR CONNECTION
However, gloves must be used properly. Like
hands, gloves can become contaminated
during care, so they have to be removed
after use. Also, gloved hands can become
contaminated by tiny punctures or during
glove removal – therefore, hands must be
disinfected immediately after glove use.14,16,17
Skin care
Skin care is a preventive measure, supporting
the skin’s natural barrier and regeneration
process. Skin care has two components:
1. Prevention of skin-stressing activities
The following activities contribute to skin
irritation and should be avoided, as they
are the most common causes of skin
irritations in healthcare workers:
• Too-frequent handwashing
• Handwashing times exceeding
one minute
• Use of brushes19
• Handwashing before hand antisepsis
(unless hands are visibly soiled)
• Prolonged wearing of gloves
• Contact with irritant substances19
2. Use of skincare products
Skincare products (such as lotions and
creams) should be utilized frequently,
such as:
• Before shift
• After breaks
• When required or desired
• After shift and in leisure time as needed
Putting it all together
• Appropriate hand hygiene in healthcare
settings is key to protecting patients and
personnel against possibly pathogenic
microorganisms.
• Frequent handwashing can damage the
skin. Alcohol-based hand antisepsis is
effective and less irritating to the hands.
Handwashing should therefore be kept
to a minimum and only performed when
hands are visibly soiled.
• Alcohol-based hand antiseptics have a
rapid and broad-spectrum effect against
microorganisms.
• Each healthcare provider must fulfill
various preconditions in order to perform
and ensure optimal hand hygiene.
Sensicare Surgical Gloves ®

Let us care for your hands and change your opinion on latex-free gloves

THE CLINICAL RATIONALE

Dryness and irritation are the top barriers to hand hygiene protocol
compliance, according to published reports. Based on this data, the CDC
strongly recommends the regular use of products designed to prevent and
treat dryness and irritation.

Medline’s Sensicare surgical gloves with aloe have demonstrated the ability
to moisturize and soothe dry, chapped hands.When these conditions are
improved, hand hygiene rates increase.

Sensicare surgical gloves with aloe are specially formulated with ISOLEX®, a
proprietary synthetic polyisoprene that has the physical properties of natural
rubber latex.

“Hand hygiene is the most important step to preventing nosocomial infection.”5

-Elaine Larson, Ph.D., RN, Columbia University professor

Skin irritation is the biggest barrier

to hand hygiene compliance.1,2

Gloves containing aloe are clinically

proven to reduce skin irritation.3

Reduced skin irritation leads to

better hand hygiene compliance.4

References
1 Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control
Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. American Journal of Infection Control.
2002 Dec;30(8):S1-46.
2 Larson E, Kretzer EK. Compliance with handwashing and barrier precautions. Journal of Hospital Infection. 1995;30:88-106.
3 West D, Zhu YF. Evaluation of aloe vera gel gloves in the treatment of dry skin associated with occupational exposure. American
Journal of Infection Control. 2003;31:40-42.
4 McCormick R, Buchman T, Maki D. Double-blind randomized trial of scheduled use of a novel barrier cream and an oil-containing
lotion for protecting the hands of health care workers. American Journal of Infection Control. 2000;28:302-10.
5 Larson EL, 1992, 1993, and 1994 Association for Professionals in Infection Control and Epidemiology Guidelines Committee. APIC
guideline for hand washing and hand antisepsis in health care settings. American Journal of Infection Control. 1995;23:251-69.

Isolex is a registered trademark of Baxter International, Inc.

Sensicare®
 • Gloves provide an added level of protec-
tion and help reduce the transmission of
infectious organisms.
• Skin care plays a decisive role in ensuring
the safety of personnel. Proper skin
moisturization and care helps improve
patient safety.
To assist you in knowing when to use hand
antisepsis versus handwashing, as well as
when to wear gloves and when to use skin-
care lotions, a chart has been included in
the Forms & Tools section on Page 102.
This chart can be easily displayed in your
work areas as a reference and reminder for
all caregivers.
About the author
Lillian Burns, MPH, CIC is currently the
epidemiology/infection control coordinator
for Greenwich Hospital in Greenwich, Conn. Lillian
serves on the Centers for Disease Control and
Prevention’s Healthcare Infection Control Practices
Advisory Committee (HICPAC) and is a faculty
member for the Institute of Healthcare Improve-
ment’s Reducing Hospital-Acquired Infections
Learning and Innovation Community.
References
1 Kramer A, Schwebke I, Kampf G. How long do
nosocomial pathogens persist on inanimate sur-
faces?
A systematic review. BMC Infect. Dis. 2006;6:130.
2 McGinley KJ, Larson EL, Leyden JJ. Composition and
density of microflora in the subungual space of the
hand. J Clin Microbiol.1988;26:950-953.
3 Hedderwick SA, McNeil SA, Lyons MJ, Kauffman CA.
Pathogenic organisms associated with artificial finger-
nails worn by healthcare workers. Infect Control Hosp
Epidemiol. 2000;21:505-509.
4 Gross A, Cutright DE, D’Allessandro SM. Effect of
surgical scrub on microbial population under the
fingernails. Am J Surg. 1979;138:463-467.
5 Pottinger J, Burns S, Manske C. Bacterial carriage by
artificial versus natural nails. Am J Infect Control.
1989;17:340-344.
6 McNeil SA, Foster CL, Hedderwick SA, Kauffman CA.
Effect of hand cleansing with antimicrobial soap or
alcohol-based gel on microbial colonization of artifi-
cial fingernails worn by health care workers. Clin
Infect Dis. 2001;32:367-372.
7 Kownatzki E. Hand hygiene and skin health. J Hosp
Infect. 2003;55:239-245.
24 THE OR CONNECTION
8 Brooks T. Preventing Occupational Contact Dermati-
tis. EndoNurse 2003. Available at: http://www.en-
donurse.com/articles/341feat2.html. Accessed June
12, 2007.
9 Rubin DM. Prosthetic fingernails in the OR. AORN J.
1988;47:944-945, 948.
10 Lowbury EJL. Aseptic methods in the operating
suite. Lancet. 1968;1:705-709.
11 Hoffman PN, Cooke EM, McCarville MR, Emmerson
AM. Microorganisms isolated from skin under wedding
rings worn by hospital staff. Br Med J. 1985;290:
206-207.
12 Jacobson G, Thiele JE, McCune JH, Farrell LD.
Handwashing: ringwearing and number of microor-
ganisms. Nurs Res. 1985;34:186-188.
13 Trick WE, Vernon MO, Hayes RA et al. Impact of ring
wearing on hand contamination and comparison of
hand hygiene agents in a hospital. Clin Infect Dis.
2003;36:1383-1390.
14 Boyce JM, Pittet D. Centers for Disease Control and
Prevention, Guideline for Hand Hygiene in Health-
Care Settings. Recommendations of the Healthcare
Infection Control Practices Advisory Committee and
the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task
Force. MMWR. 2002;51:1-45.
15 Larson EL, APIC Guidelines Committee. APIC guide-
line for handwashing and hand antisepsis in health
care settings. Am J Infect Control. 1995;23;251-269.
16 World Alliance for Patient Safety. WHO Guidelines in
Hand Hygiene in Health Care (Advanced Draft),
Global Patient Safety Challenge 2005-2006: “Clean
Care is Safer Care.” April 2006.
17 Institute for Healthcare Improvement. How-to Guide:
Improving Hand Hygiene. Available at:
http://www.ihi.org/IHI/Topics/CriticalCare/
IntensiveCare/Tools/HowtoGuideImprovingHand
Hygiene.htm. Accessed June 12, 2007.
18 Commission for Hospital Hygiene and Infectious Dis-
ease Prevention of the Robert Koch Institute. Hand
hygiene. Bundesgesundheitsbl – Gesundheitforsch –
Gesundheitsschutz. 2000;43:230-233.
19 Kampf G, Loeffler H. Dermatological aspects of a
successful introduction and continuation of alcohol-
based hand rubs for hygienic hand disinfection. J
Hosp Infect. 2003;55:1-7.
 Back to
Perioperative
Patient
Positioning

BASICS
Sixth in a Series

26 THE OR CONNECTION
 Patient Safety
By Alecia Cooper, RN, BS, MBA, CNOR

“
“Vulval injury due to perineal post on fracture table.”

“Brachial plexus injury related to patient positioning.”

“Well leg compartment syndrome during prolonged

surgery in the lithotomy position.”

“Ophthalmologic complications associated with

prone positioning in spine surgery procedure.”
“Erectile dysfunction after perineal compression in a young

S
man undergoing internal fixation of a femur fracture.”
“Lower limb acute compartment syndrome after

”
colorectal surgery in prolonged lithotomy position.”

cary as they sound, all of the above are examples of real outcomes that occurred following
routine surgical procedures. We cannot say that every one of these injuries was caused due
to improper positioning, nor can we say that each injury could have been prevented. What
we can say is that improper positioning and lack of prevention and safety measures can
result in patient injury and lead to debilitating consequences, even death. Intraoperative

Intraoperative positioning injuries are devastating for both patients and surgical team members. function of unre-
skin injury is the

Potential positioning injuries include:

lieved pressure,

1 Pressure ulcers
duration of the
pressure and
2 Alopecia the location of
3 Nerve injuries
the pressure on

4 Physiologic compromises
the body surface.

Injury mechanisms that contribute to positioning include pressure (i.e., gravity), friction and
shear forces.¹
The risk of pressure
ulcers occurring as

Pressure ulcer injuries

a result of surgery
may be as high
The operating room is a high-risk environment for the development of pressure ulcers. as 66 percent.
Preoperative identification of this risk is imperative if measures can be developed that
meet evidence-based criteria and demonstrate prevention.²
Procedures lasting
Pressure sores have been thought of as slothful chronic wounds that form slowly and occur longer than two
as a result of poor nursing care. In fact, they are acute injuries that develop rapidly when and one-half to
compression of tissues causes ischemia and necrosis during serious illness and trauma, three hours signifi-
including surgery.2 cantly increase
the patient’s risk
Pressure ulcers that originate during surgical procedures may appear within a few hours for pressure
postoperatively, but the majority usually present one to three days after surgery. Tissue ulcer formation.
damage resulting from prolonged, intense pressure created during surgical procedures
often results from a “burn” or bruises in early stages and can be misdiagnosed. These
so-called “closed” pressure ulcers deteriorate fairly rapidly to Stages III or IV.

Aligning practice with policy to improve patient care 27


Endogenous factors predisposing
pressure ulcer development
Advanced age
Malnutrition
n
Alcohol abuse
n
Diabetes
n
Advanced cancer
n
Terminal illness
n
Sepsis
n
Vascular disease
n
Neurological disease
n
n hyperflexed or
As part of their 5 Million Lives campaign, IHI
states that because surgical patients who are
under anesthesia for extended periods of time
often have an increased risk of developing
pressure ulcers, all surgical patients (pre-operative,
intraoperative, post-anesthesia) should re-
ceive a skin assessment and risk assessment.
Caregivers should then implement prevention
strategies such as ensuring repositioning and
placing patients on appropriate redistribution
surfaces for all surgical patients who are iden-
tified as being at risk.3 CMS has declared that
as of October 1, 2008, hospitals will no longer
be reimbursed for eight preventable “hospital-
acquired conditions,” several of which are
associated with surgical procedures. One
of the eight is pressure ulcers.4
Alopecia
An 11-year-old boy underwent vitreoretinal
surgery for left retinal detachment. One week
postoperatively, his parents noticed a patch
of alopecia where his head may have been in
contact with the wrist-rest assembly placed
around the head during the surgical procedure.
The result was diagnosed as pressure alopecia
on the parieto-occipital region of the scalp.
Hair re-growth occurred during the
follow-up visits.5
Pressure alopecia is an under-recognized and
rare complication of lengthy surgery. Precautions
should be taken to avoid this preventable
complication. Even though in most instances
the results are minimal and cosmetic in nature,
alopecia has been documented as a precursor
for pressure ulcer development when occurring
after sustained immobility and pressure to the
occiput. Alopecia associated with pressure
ulcers usually develops within three days of a
28 THE OR CONNECTION
surgical procedure and is preceded by pain,
swelling and exudates.1
Nerve and muscle
Ulnar nerve injuries
trauma result from
A patient undergoing abdominal surgery was
stretching or
placed on the operating table with his arms
compression when
extended at 45 degrees on the arm boards.
upper extremities are
The surgeon stood at the patient’s right side
abducted at greater
throughout the hour-and-20-minute procedure.
than 90 degrees to
Postoperatively, the patient reported numbness
the body, hips are
and tingling in his right hand that persisted
placed in excessive
well after his discharge from the hospital.
rotation and/or the
Eventually, the patient was diagnosed with
head and neck is
an ulnar nerve injury, with numbness and pain
that did not respond to physical therapy. The
hyperextended.
patient alleged a lawsuit and the jury found
for the plaintiff.6
In surgery, arms on arm boards are not extended
more than 45 degrees, which increases the
likelihood that a surgeon or other caregiver
could inadvertently lean on the arm while
carrying out the surgical procedure. This can
lead to ulnar nerve injury. The standard of
care when arm boards are used is to have
the arms positioned with palms up, with plenty
of padding under them and with extensions
of 45 degrees or less. Elbow protection is
often recommended.7 Respiratory function
Physiologic compromise
can be decreased by
The most common example of physiologic
mechanical restriction
compromise is effects to the respiratory system
of the rib cage, which
due to positioning interfering with the patient’s
can occur with certain
ventilatory system. All of the most common
positions (e.g., prone,
patient positions (i.e., supine, prone, lateral,
lateral, lithotomy)...
sitting, lithotomy) have proven to cause
ventilatory impedance when patients are
not positioned appropriately. Patients are
most vulnerable in the prone position.1
Circulatory function
is influenced by
The cardiovascular system can also be at
anesthetic agents
risk. The cardiovascular system is influenced
and surgical
by anesthetic agents, inhibition of normal
procedures that
compensatory mechanisms, cardiac reserve,
may result in
venous return and vascular resistance. Blood
vasodilatation,
may pool in a patient’s extremities, causing
hypertension,
hypotension, and cerebral perfusion may be
decreased cardiac
altered by head positions.8
output and
inhabitation
The Joint Commission collects sentinel event
of normal
data for all operative injuries. Category 488,
compensatory
operative/post-op complications, excludes
mechanisms.
wrong-site surgery, medication errors, unintended
retention of foreign bodies, infection-related
events, anesthesia-related events, medical
equipment-related events and fire. As of June
30, 2007, there have been 534 op/post-op
Ask these very important questions
complications, comprising 11.9 percent of all before each patient procedure:
reported sentinel events – third only to wrong
site surgery and suicide. The op/post-op cate- 1. How many people will be needed to transfer the patient to
gory includes injuries from patient positioning, the operating table and to safely position the patient?
but only if the injury resulted in death. Also,
this category includes all unexpected patient Tip: Never transport or begin movement of the patient
deaths as a result of all surgical complications.9 until the appropriate number of personnel is available.
Therefore, there is not a reporting system that
captures the total number of patient injuries 2. What positioning devices will be needed to adequately and
due to surgical positioning. completely support the patient in the necessary position to
perform the operation?
Prevention of positioning injuries
The first step in preventing positioning errors
Tip: Have all necessary positioning devices and
is the development of a zero-tolerance atti-
padding materials in the operating room prior to
tude toward preventable patient injury among
transporting the patient.
all perioperative healthcare providers. This at- 3. Will the plan for positioning provide for airway management,
titude then lends itself very easily to imple- ventilation and monitoring access for the anesthesia
mentation of the necessary steps to prevent care provider?
and protect patients from injury. A comprehen-
sive positioning safety initiative must include
best practice, education and best products –
Tip: If the answer is no, change the positioning plan

and it all begins with the basics of care.10

of care.

4. Have plans been developed and supplies been addressed

to maintain the patients’ dignity by controlling unnecessary
exposure during the positioning procedure?
Assessment for both the patient
and intraoperative factors includes: Tip: Ensure applicable transfer devices and blankets

Age
are available to allow for minimal patient exposure

Height and weight

n during the transfer and positioning procedure.

Skin condition
n
5. Do I know the pressure points for the position that my
Nutritional status
n
patient may be prone to due to patient positioning?
Preexisting conditions (e.g., vascular,
n

respiratory, circulatory, neurologic,

n

immunocompromise)
Tip: Refer to the pressure points labeling exercise on

Physical/mobility limits (e.g., prostheses,

Page 98 to identify specific pressure points for various

implants, range of motion)

n surgical positions.

Type of anesthesia
Length of surgery
n
n
n Position required

External pressure

Before the patient ever enters the operating

Assessment exceeding normal

theater, assessment for positioning needs

capillary interface

should be made.11
pressure (i.e., 23
to 32 mm Hg) can
cause occlusion

Positioning devices should be provided for

Appropriate positioning devices that will restrict

each surgical position and its variations.

or block blood flow.

These devices include padding and pressure-

relief devices. Firm and stable devices help

Aligning practice with policy to improve patient care 29

 distribute pressure evenly and decrease the
potential for injury. Studies suggest that
positioning devices should maintain normal
capillary interface pressure of 32 mm Hg
or less.11
When selecting positioning devices, keep the
following in mind:
n Be sure to have a variety of devices in the
appropriate size and shape to cover all of
the procedures performed in your
operating room.
n Select positioning and pressure-relieving
devices that are made of durable material
and design.
n Assure that the positioning device has
been tested to maintain normal capillary
interface pressure (not applicable for
padding materials).
n Additional traits to look for:
• Resistant to moisture and
microorganisms
• Radiolucent
• Fire resistant
• Nonallergenic
• Ease of use
• Easily cleaned/disinfected if
not disposable
• Easily stored, handled and retrieved
The use of gel pads or similar devices over
the OR table decreases pressure at any given
point by redistributing overall pressures
across a larger surface area.11 Typical foam
mattress pads are not effective in reducing
capillary interface pressure because they
quickly compress under heavy body areas.
For years, pillows, blankets and molded foam
devices have been used to not only pad bony
prominences but to position patients on surgi-
cal tables. These devices typically produce
only a minimum amount of pressure reduction
and are not adequate for patient positioning.11
Foam and gel pads provide better support for
padding of bony prominences. They are also
excellent adjuncts when used to protect patients’
skin from injury. Do not forget to adequately
pad positioning devices in critical areas where
skin will be in contact with the device.
30 THE OR CONNECTION
Documentation should include but not be
Documentation
limited to the following:
n Preoperative assessment
n Type and location of positioning
and/or padding devices
n Names and titles of persons
positioning the patient
n Postoperative outcome evaluation
At the end of every surgical procedure and
before the patient is transferred from the
operating table to the post-anesthesia care
unit, a thorough visual assessment should be
performed and documented in the patient’s
record. Any areas that are reddened, show
signs of bruising or tissue damage, skin irritations
or any variation from the preoperative skin
condition should be discussed with the surgeon
and documented in the patient record as well
as provided in the patient hand-off report
given in the post-anesthesia care unit.
Policies and procedures related to positioning
Policies and procedures
should be developed and reviewed annually,
revised as necessary and readily available in
the practice setting.12 A sample policy and
procedure developed at the University of
North Carolina Hospitals has been included
on Page 98 for your consideration.
Comprehensive staff training
There are several books and educational
and education
programs available to those seeking to provide
additional training and education on patient
positioning. A few include:
Textbooks
Surgery, 13th Edition by Jane C.
n Alexander’s Care of the Patient in
Rothrock (Published by Mosby)
Technique, 11th Edition by Nancymarie
n Berry & Kohn’s Operating Room
Phillips (Published by Mosby)
Online courses
n ENST06-0905: Positioning:
Patient Safety Initiative
Available at: www.endonurseinstitute.com
Programs for purchase
n Periop 101: A Core Curriculum
Available at: www.aorn.org
n Safely Positioning the Surgical Patient
AORN Video Library
Available at: www.cine-med.com
The perioperative nurse’s role
in patient positioning
At many facilities, the anesthesia provider
assumes the responsibility for patient positioning.
In no way does this practice obliterate the
responsibility of the RN circulator to ensure
proper patient care alignment and tissue integrity
for each patient. For specific injury risks and
safety considerations to be followed when
positioning the patient, we have provided a
copy of AORN’s Injury Risks and Safety
Considerations when Positioning Patients
on Page 94. This tool is designed to assist
caregivers in making sure patient injury does
not occur.
After positioning, the perioperative nurse
should evaluate the patient’s body alignment
and tissue integrity.11 This evaluation should
include, but not be limited to, the
following systems:
Respiratory
Circulatory
n
Neurologic
n
Musculoskeletal
n
Integumentary
n
n
After repositioning or any movement of the
patient, procedure bed or devices that attach
to the procedure bed, the patient should be
re-assessed for body alignment.11
Bringing it all together
A positioning safety program begins with zero
tolerance for errors and includes best practices
for patient assessment, selection of the best
products for appropriate positioning and pressure
relieving devices, comprehensive staff training
and education and collaboration among the
perioperative team members. Best practices
include policies that identify the requirements
for each surgical position, identifying the
anatomy at the highest risk for damage,
identifying patient risk factors that predispose
patients to adverse outcomes and providing
clear instructions for protecting the patient
adequately.10 Education ensures that all prac-
titioners have the knowledge and skill to apply
the policies, education and training effectively.
Best products ensure that the items we use
to protect our patients provide the protection
we expect.10
The “Back to Basics” series was developed
due to our belief that perioperative profession-
als should adhere to basics of practice and
incorporate new technologies with evidence-
based strategies to improve patient outcomes.
Our readership is requesting “Back to Basics”
topics in order to provide in-service, education
and training in their facilities. The OR Connec-
tion is dedicated to continuing this service and
wants to hear from you regarding future “Back
to Basics” topics. Email your requests for
future “Back to Basics” topics to
acooper@medline.com.
References
1. McEwen DR. Intraoperative positioning of surgical patients. AORN Journal. 1996 Jun;63(6):
1059-63, 1066-79; quiz 1080-6.
2. Schultz A, Bien M, Drummond K, Brown K, Myers A. The etiology and incidence of pressure
ulcers in surgical patients. AORN Journal. 1999 Sep;70(3):434, 437-40, 443-9.
3. Institute for Healthcare Improvement. Getting Started Kit: Prevent Pressure Ulcers:
How-to Guide. 2006:13.
4. Brandon GE. Rule denying payments for ‘never events’ will force a close look at current
practice. Available at: www.aorn.org/Managers/October2007Issue/. Accessed November
14, 2007.
5. Bhatt HK, Charma MS, Blair NP. Pressure alopecia following vitreoretinal surgery.
American Journal of Opthalmology. 2004 Jan;137(1):191.
6. Millsaps C. Pay attention to patient positioning! Available at: www.mediwire.skyscape.com.
Accessed November 14, 2007.
7. Legal Eagle Eye Newsletter for the Nursing Profession. Operating room nurses share fault
for improper positioning of patient. Available at: www.nursinglaw.com.
Accessed November 14, 2007.
8. Sewchuk D, Padula C, Osborne E. Prevention and early detection of pressure ulcers in
patients undergoing cardiac surgery. AORN Journal. 2006 Jul;84(1):78.
9. The Joint Commission. Sentinel Event Statistics: As of June 30, 2007.
Available at: www.JointCommission.org. Accessed November 14, 2007.
10. EndoNurse Institute. Positioning: Patient Safety Initiative.
Available at: www.endonurseinstitute.com/positioning. Accessed November 14, 2007.
11. Association of periOperative Registered Nurses. Standards, Recommended Practices
and Guidelines. Denver, Colo: AORN Publications; 2007.
12. Positioning the Surgical Patient. University of North Carolina Hospitals: Nursing Procedure
Manual. January 2005.
Aligning practice with policy to improve patient care 31
 Crossword Puzzle – Back To Basics

Perioperative Patient Positioning

hour of
To receive one r your 1
te
CE credit, en ne at 2
answers onli sity.com
niver
www.medlineu

3 4

5 6

7
8

9 10 11 12 13 14

15 16 17 18

19 20

21 22 23

24

25
26

27

28

29

32 THE OR CONNECTION
Across
3 Best practices include _____ that identify
the requirements for each surgical position.
5 The most common cause of _____ nerve
injury in surgery is arms on arm boards not
being extended more than 45 degrees.
7 Intraoperative skin _____ is the function of
unrelieved pressure, duration of the
pressure and the location of the pressure
on the body surface.
9 The operating room is a high-risk
environment for the development of _____.
(2 words)
12 The most common example of physiologic
compromise is effects to the respiratory
system due to positioning interfering with
the patient’s _____ system.
18 Potential positioning injuries include
pressure ulcers, _____, nerve injuries,
and physiologic compromises.
19 The result of pressure ulcers occurring as
a result of _____ is thought to be as high
as 66 percent.
21 Before the patient is transferred from the
operating table, a thorough visual
assessment should be performed and
_____ in the patient’s record.
23 Pressure alopecia is an under-recognized
and rare complication of _____ surgery.
24 Pressure ulcers are _____ injuries that
develop rapidly.
25 The Joint Commission collects _____ event
data for all operative injuries.
26 Preoperative identification of _____ for
pressure ulcers is imperative.
27 Positioning _____ should be provided for
each surgical position and its variations.
28 Procedures lasting longer than two and
one-half to three hours significantly _____
the patient’s risk for pressure ulcer
formation.
29 After positioning, the perioperative nurse
should _____ the patient’s body alignment
and tissue integrity.
1. Register (free) or log in
www.medlineuniversity.com
2. Click Free Courses tab
3. Locate the puzzle and click Learn More,
then Begin Course
4. Certificates are available online after
puzzle completion
Aligning practice with policy to improve patient care 33
Down
1 Injury mechanisms that contribute to
positioning include pressure, _____ and
shear forces.
2 The standard of care when arm boards are
used is to have arms positioned with palms
up and to ensure adequate _____.
3 Patients are most vulnerable to respiratory
compromise in the _____ position.
4 ____ ensures that all practitioners have the
knowledge and skill to apply the policies,
education and training effectively.
6 Pressure ulcers originating during surgical
procedures may appear within a few hours,
but the majority present one to three
_____ after surgery.
8 Positions such as lithotomy and
Trendelenburg’s can cause redistribution
and congestion of the _____ supply.
10 Beginning October 1, 2008, hospitals will
no longer be _____ for eight preventable
“hospital-acquired conditions.”
11 After repositioning or any movement of the
patient, procedure bed or devices that
attach to the procedure bed, the patient
should be ______ for body alignment.
13 Category 488, operative/post-op
complications, currently ranks _____
overall in the number of sentinel events
reported.
14 Alopecia has been documented as a
precursor for pressure ulcer development
when occurring after sustained immobility
and pressure to the _____.
15 The first step in _____ positioning errors is
the development of zero tolerance toward
preventable patient injury among all
perioperative healthcare providers.
16 Best _____ ensure that the items we use to
protect our patients provide the protection
we expect.
17 Patients under anesthesia for extended
periods can have an increased risk of
developing pressure ulcers, so all surgical
patients should receive a skin _____ and
risk assessment.
20 Before the patient _____ the operating
theater, assessment for positioning needs
should be made.
22 Firm and stable positioning devices help
distribute pressure evenly and _____ the
potential for injury.
 Patient Safety

COUNTING ACCOUNTABILITY

Sandy and Joe sat on

the deck enjoying the Though they were on call, Sandy and Joe

crisp fall evening, sipping

had decided to attend Dr. Michael’s annual
employee appreciation party and cross
their soft drinks and their fingers that they wouldn’t be called in.

listening to the band.

By Jayne Barkman, RN, CNOR
The party was held at Andy and Charlie’s
Lakeside Restaurant and was looked for-
ward to by staff and physicians alike. This
year, the entertainment was provided by the
Cutups, a band composed of general
surgery residents Tom, Mike, Kurt and
Sydney. Kurt’s wife Jackie was the lead
singer, and the band was quite good. As
the set ended, Sandy’s cell phone rang.
“It’s the hospital,” she mouthed to Joe as
she flipped her phone open.

A few minutes later, Sandy and Joe were

on their way to the hospital. They were
called in for a leg exploration on a postoper-
ative coronary artery bypass patient. On the
short drive to the hospital, they wondered if
this was possibly another postop wound
infection. The surgical site infection rate
at their facility was well below the national
average; however, earlier in the year there
had been a sharp increase in surgical site
infections. To make matters worse, several

Aligning practice with policy to improve patient care 35

 of the wounds were infected with MRSA.
Strict adherence to aseptic and sterile tech-
nique was the norm in the operating room,
but additional measures were advocated
after the outbreak of infection. Alcohol-based
hand rub delivered via touchless dispensers
was implemented and all scrubbed personnel
involved in draping the patient were required
to change their outer gloves prior to the
incision being made.

At the last monthly in-service, Infection Control

had presented updates on surgical site
infection rates as well as information on the
Centers for Medicare & Medicaid Services’
new pay-for-performance guidelines regarding
“never event” reimbursement for surgical
site infections and retained objects. Accord-
ing to Infection Control’s data, the surgical
site infection rate had decreased and was
again below the national average.
When Sandy and Joe arrived at the hospital,
Jane, the weekend in-house RN, was open-
ing their case. The patient arrived from the
ER and was in the OR shortly thereafter.
The surgeon arrived in the OR and initiated
the time out as he exposed the operative left
leg. Sandy placed the safety strap across
the non-operative leg and could feel heat
resonating from the left leg. While she ap-
plied the one-step prep, Sandy noted the left
leg looked as though it had been burned and
was nearly twice the size of the right leg.
There was exudate seeping from one of the
endoscopic saphenous vein-harvesting stab
wounds. The patient was draped, the skin
incision made and a Weitlaner retractor
placed to gain exposure. Joe grabbed an
emesis basin off the back table as the surgeon
pulled a handful of hemorrhagic tissue out of
the patient’s leg. Sandy watched Joe probe
the emesis basin with a tissue forceps. He
reached into the basin and unrolled a four-inch
square X-ray detectable swab. The surgeon
looked up at the swab and muttered some-
thing unintelligible. Joe tossed the black-
ened swab into the kick bucket while the
surgeon continued to explore the wound.
The leg wound was debrided, irrigated and
closed. After the patient was extubated,
Sandy and the CRNA transported the patient
to PACU, where Sandy finished her charting
and filled out an incident report. Joe arrived
in PACU as Sandy was pulling up the
patient’s old chart on the computer. Together,
they scanned the previous perioperative
record and were surprised to see the
sponge count documented as correct.
Joe and Sandy decided to go home rather
than back to the party. On the drive to
Sandy’s house, they discussed the need to
review and possibly revise the hospital’s
policy and procedure on sponge counts.
With coronary artery bypass, the PA harvested
vein as the surgeon worked simultaneously
on the chest. Typically a sponge count was
not performed when the PA closed the
minute incisions made for the endoscopic
harvests. This was despite the fact that X-ray
detectable swabs were occasionally tucked
into the endoscopic tunnels or cavities in
the leg to apply pressure.
Working with a SafetyNet
In 2004, AORN began a voluntary reporting
system as part of the Patient Safety First
initiative. The system, known as SafetyNet,
encourages perioperative nurses to report
near misses or close calls in the perioperative
setting. The anonymous information provided

36 THE OR CONNECTION
to SafetyNet is analyzed to look for patient
safety trends and assists AORN in developing
educational programs, recommended practices
Retained sponge costs $2.4 million
A first-grade teacher in Pembroke Pines, Fla. was
and position statements to assist perioperative
nurses in providing safe patient care.
awarded $2.4 million in damages after a foot-long
According to SafetyNet data, several factors sponge was left inside her abdomen during a
contribute to variable sponge counts. These routine cesarean section.1
factors include distraction, such as the
circulating nurse leaving the room to obtain Karlene Chambers gave birth to her first child on
additional supplies during the counting September 11, 2001. She began to experience
process; excessive talking when counts are
excruciating pains in her abdomen shortly after
performed; sponges packed into cavities and
counts not being performed but documented the birth and returned to the hospital to find out
as having been done.1 what was wrong.

To reduce the likelihood of a retained foreign She was initially prescribed antibiotics for what she
object, AORN and the American College of was told was an infection. When the antibiotics did
Surgeons recommend that sponge counts
not alleviate her pain, the same physician who had
be performed in a systematic order, such as
smallest to largest, and according to national
performed her C-section, ordered an X-ray of her
standards and facility policy. Other recom- abdomen. The X-ray revealed that a one-foot surgical
mendations by the agencies include providing sponge had been left in her uterus after she gave birth.
adequate personnel to support safe practices;
using only X-ray detectable sponges, towels An X-ray alone would not have revealed the sponge
and instruments in surgical sites; developing if the manufacturer had not attached a blue thread to
and reviewing policy and procedures related
it to make it X-ray detectable.
to counting to promote consistent practices
and utilizing technology such as radio
frequency detection to ensure that all Reference
sponges, towels and instruments are MSNBC.com. Woman awarded $2.4 million after surgical sponge
removed from the patient.1 left in abdomen. Available at:
http://www.msnbc.msn.com/id/21128136/.
To learn more about SafetyNet and Accessed October 15, 2007.
the Patient Safety First initiative, visit
ww.patientsafetyfirst.org.
Reference
Best practices for preventing a retained foreign body.
AORN Journal. 2006;84(1) Supplement 1:S30-S36.

Jayne Barkman, RN, BSN, CNOR, has 29

About the author

years of perioperative experience in various

roles, including surgical technologist, staff
nurse and clinical educator. She currently
works as a nurse consultant.

Aligning practice with policy to improve patient care 37

 HYPOTHERMIA
We hear it every day from patients presenting
By Gary Nitz, CRNA

for surgery: “Why do you keep it so cold in

here?” No matter what part of the country
you are practicing in or what kind of surgical
procedures are being performed, the patient
will complain about being cold. Not only that,
but there is a large population of operating
room personnel who also complain about the
“frigid” conditions. This is a real situation in
that we request patients to strip their clothes
off and place a paper or flimsy cloth gown on,
get onto an uncomfortable stretcher and then
be placed in a rather sterile holding area. This
by itself is a chilling experience, let alone being
concerned about their upcoming surgery!
This sets the stage for hypothermia. Hypothermia, by definition, is “a reduction of
core body temperature to 35 degrees C or lower, usually due either to coldness of the
environment or artificial inducement.”1 Hypothermia develops when thermoregulation
fails to control the balance of metabolic heat production and heat loss. There are certain
factors of the environment that we cannot control, such as the temperature in the
preoperative holding area and the continuous exchange of air in the operating rooms.
To maintain a clean operating room environment, the total volume of air is exchanged
15 times per hour.2 Many times we explain to the patient that being cool in the OR is
good for them because the cool environment deters the growth of bacteria.

38 THE OR CONNECTION
 OR Issues
Heat loss in a patient in the operating room can be from conduction, convection,
radiation and/or evaporation.3 Conduction heat loss begins in the preoperative holding
area lying a on cool stretcher and continues in the OR while lying on the table. Military
personnel doing nighttime tactical operations where concealment is essential can
lose a significant amount of heat by being in close contact with rocks or outside walls
over a prolonged period. Heat loss by convection involves the ambient air moving How hypothermia develops
over the body, decreasing the body’s core temperature. Because air is technically a Hypothermia develops
fluid, the analysis of heat transport from the patient involves convection. When a body during general anesthesia
in three phases:
is submerged in water, heat loss from convection is 32 times greater than when it is
exposed to air. Heat loss from radiation is the process where a person’s body radiates 1. Initial rapid reduction in core
heat away from the body and into the room. Evaporation is the loss of heat via temp after anesthesia induction
perspiration, open wounds and natural secretions. resulting from internal redistribu-
tion of body heat

General anesthesia takes away the body’s natural responses to increase heat pro- 2. Core temp decreases at a rate
determined by the difference
duction. Heat loss is common because anesthetics alter thermoregulation, prevent between heat loss and production
shivering and produce peripheral vasodilatation. All perioperative and anesthesia
3. When sufficiently hypothermic,
personnel should always keep in mind that once the core temperature of a patient thermoregulatory vasoconstriction
begins dropping, it will continue to drift unless actions are taken to help prevent is triggered and core-to-peripheral
worsening hypothermia. Postoperative warming should not be a routine substitute flow of heat is restricted
for maintaining intraoperative normothermia.

Through simple actions, we can disrupt the cascade effect of hypothermia. Active
“prewarming” for 30 to 60 minutes usually minimizes hypothermia. Having the patient References
undress in a warm environment and covering them with warm blankets preoperatively 1 Dorland. Dorland’s Illustrated
aids in the prewarming. Commercial gown heaters are on the market and act as a nice
Philadelphia, Pa.: Saunders; 2007.
Medical Dictionary, 31st Edition.
adjunct to the warm blankets. Warming of the OR table with forced warm air and/or
2 Spry C. Essentials of Periopera-
warm blankets reduces the convection heat loss aspect. Intraoperative use of forced-air tive Nursing, Third Edition. Boston,
blankets, with the recommended associated blankets, and warmed intravenous solutions Mass.: Jones and Bartlett Publish-
all aid in the heat retention of the patient. Airway heating and humidification are ers; 1997.
3 Barash PG, Cullen BF, Stoelting
ineffective4; however, I have found that certain airway filters and single-limb anesthesia
RK, eds. Clinical Anesthesia, 2nd
circuits help preserve normothermia. Edition. Philadelphia, Pa: JB Lippin-
cott; 1992.
Measuring of the patient’s temperature is vital and continuous intraoperative core 4. Roizen MF, Fleisher, LA.
temperature can be obtained from the pulmonary artery, distal esophagus, tympanic
Second Edition. Philadelphia, Pa.:
Essence of Anesthesia Practice,

membrane and nasopharynx. The rectum, mouth, axilla and bladder can be used except Saunders; 2002.
in cardiopulmonary bypass. If there is any vital discrepancy between intraoperative and
immediate postoperative temperatures, a core temperature should be sought to verify
the patient’s temperature status.

With the number of warming adjuncts at our disposal, all perioperative and anesthesia
personnel should be cognizant of our patients’ physiological need to stay warm, and
help deter the “worst part of surgery.”

Consequences of hypothermia in surgical patients

• Adverse myocardial outcomes
— 1.5° C core temperature decrease triples the risk of
morbid myocardial events About the author
• Coagulopathy Gary Nitz, CRNA, is a staff
— Impairs platelet function and coagulation cascade anesthetist for Washington
University School of Medicine in
• Reduces drug metabolism St. Louis, Mo. and is a Captain
• Thermal discomfort (patient satisfaction) in the U.S Navy Reserves, serving
• Surgical wound infection with the 4th Medical Battalion
— Thermoregulatory vasoconstriction as the Senior Nurse Executive.

Aligning practice with policy to improve patient care 39

 OR Issues

Airborne Disease and Surgical Site Infection

The floating danger
By Russell N. Olmsted

The extent to which airborne contaminants contribute to surgical site infec-

tion (SSI) is unknown but has long been a shared concern of perioperative
and infection control professionals. There is mounting evidence that they are
underrecognized and might play a larger role than previously believed.

Adding to the complexity of this risk for the patient are the emerging airborne
infectious diseases, which can make their way into the operating room (OR).
A case in point involves the emergence of drug-resistant strains of tuberculosis
(TB), particularly XDR-TB (strains which are extensively drug resistant). In
addition to XDR-TB, the potential for emergence of pandemic influenza, possibly
from strains causing avian influenza, and recent experience with worldwide
SARS pandemic are other unwelcome visitors to the OR.

The alarming number of airborne pathogens that pose a serious threat to

public health has prompted new awareness of pandemic preparedness within
the healthcare community. Our response to appropriately understand how
these diseases impact healthcare delivery, however, has been unsatisfactory
to date and few studies on this matter have been conducted.

Aligning practice with policy to improve patient care 41


Surgical site infection background
Over the last decade, surgical site infection has had the dubious The CDC represents the risk of SSI with the
distinction of moving from the third to the second most common
healthcare-associated infection (HAI). In America alone, SSI
represents 22 percent
of an estimated 1.7
million HAIs and Dose of bacterial contamination × virulence
contributes to the Resistance of the host patient
more than 99,000
deaths associated
with this complication of hospitalization.1,2 The preventable
pain, suffering and loss this represents is not only staggering
in terms of patient well-being but also generates a huge
financial burden. A recent study placed the average additional
incremental direct cost of patients with an HAI at $8,8324,
which puts the total burden of managing this situation at
more than a staggering $15 billion without consideration of
indirect costs.
This financial burden has and will have a dire negative impact
on the financial health of both healthcare and the insurance
institutions. The Centers for Medicare & Medicaid Services
(CMS) recent decision not to cover “conditions that could rea-
sonably have been prevented” beginning in 2008 is intended
to put financial pressure behind the movement to reduce
HAI.6 The potential impact of these “no-pay” procedures on
hospitals has already generated much debate. Regardless of
the outcome, CMS is representative of a growing industry
and social unwillingness to tolerate current HAI levels.
42 THE OR CONNECTION
Contact vs. airborne transmission
Because most endemic infections are transmitted by direct
or indirect contact, hand hygiene has been identified as the
number one way to reduce HAIs.3 This underlines a wide
body of research that has been able to directly and clearly
test the dangers and potential solutions associated with direct
contact or breaks in aseptic technique that can in turn lead to
contamination of the surgical site. The role of airborne trans-
mission in SSI is much less well understood and only now
gaining wider attention.
There is mounting evidence that airborne transmission of mi-
crobial populations may play a greater role in postoperative
infections than previously thought. Edmiston and others,
using sophisticated genetic fingerprinting, demonstrated that
many microorganisms recovered from air samples taken near
the surgical site matched the strains colonizing members of
the surgical team.9 Testing is difficult, however, because par-
ticulates of different sizes may or may not follow the rules of
Brownian motion and are difficult to conclusively track.10 It is
also very challenging to demonstrate that microbes present
during a procedure are genetically identical to pathogens that
may subsequently cause a SSI. Advances in equipment and
computer modeling have given us a better understanding of
airborne particulate circulation.
Understanding airborne transmission
following relationship:12
= Risk of surgical site infection
In terms of airborne transmission, it follows that reducing
overall levels of airborne contaminants and establishing
airflow patterns that move potentially contaminated air away
from the surgical site will minimize the potential for surgical
site contamination and subsequent SSI.
Patients with airborne or droplet nuclei transmitted infectious
diseases pose a special category of risk. All patients are a
potential source of OR air contamination,7 but in the case of
patients with these classes of infectious diseases the danger
of self-contamination is that much more salient. The illness
itself may also reduce host resistance. Thus, the risk of SSI
is increased on two fronts. These patients pose an additional
risk for caregiver occupational exposure10 that must also be
considered when establishing OR airflows.
Keeping OR air clean
Using Mycobacterium tuberculosis as the prototype of an
airborne infectious pathogen, the CDC recommends that the
ventilation of the OR remain in positive pressure if needed for a
patient with active TB disease but also include an anteroom just
outside the main OR door.11 The anteroom safeguards against
the release of airborne contaminants into other occupied areas.
It also helps maintain proper airflow within the OR, which is
important to protect the patient’s surgical site. The Association
of periOperative Registered Nurses (AORN) has also recently
released new recommended practices with consideration for
preventing both airborne and contact infectious disease
transmission which reinforce prior CDC Guidelines.15
General OR recommendations for reducing contaminants
include supply air being delivered from the ceiling, with top-down
direction to perimeter exhaust outlets on walls nearer to the
floor.12 The theory is that clean air should be pulled down and
away from the patient as it is potentially contaminated. By actively
pulling air away from the OR table and toward the door, the
anteroom helps establish this airflow pattern.
The availability of ORs with permanent anterooms is likely rare
in most surgery suites in the U.S. Therefore, one alternative is
to use temporary anterooms that are equipped with portable
HEPA filters. This offers an effective, flexible solution for use
over the entrance to any standard operating room and can not
only capture airborne microbes but also facilitate removal of
particulates from the OR. An alternative option is to place
free-standing portable HEPA devices in the OR; however,
these must be turned off during the surgery as they may
disrupt patterns of ventilation in the OR. In addition to surgery,
temporary anterooms can be used whenever there is
concern over aerosol generation, such as during special
pulmonary procedures.
As highlighted, there might be additional benefit from use of
temporary anterooms for removal of contaminants in the critical
environment of the OR for cases where air quality is of particular
concern, e.g., orthopedic implants. Of note, a recent investiga-
tion highlighted that opening of doors during procedures without
an anteroom is positively correlated with increased microbial
counts at the surgical site.13 While further study is needed, a
temporary anteroom may provide assistance with mitigating
airflow disruption caused by entry and exit from the OR and
enhance removal of contaminants.
References:
1 Klevens RM, Edwards JR, Richards CL Jr., et al. Estimating health care-associated
infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007 Mar-
Apr;122(2):160-6.
2 Centers for Disease Control & Prevention (CDC). Data & Statistics for Surgical Site
Infections. Available at: www.cdc.gov/ncidod/dhqp/
dpac_ssi_data.html. Accessed November 14, 2007.
3 Murphy DM, et. al. Dispelling the Myths: The True Cost of Healthcare-
Associated Infections. Available at: www.apic.org/Content/
NavigationMenu/PracticeGuidance/Reports/hai_whitepaper.pdf. Accessed November
14, 2007.
4 Centers for Medicare & Medicaid Services (CMS). Medicare Program; Changes to the
Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates. 42
CFR Parts 411, 412, 413, and 489. Available at: www.cms.hhs.gov/AcuteInpa-
tientPPS/downloads/CMS-1533-FC.pdf.
Accessed November 14, 2007.
5 Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-
Care Settings: Recommendations of the Healthcare Infection Control Practices Advi-
sory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR. 2002;51(No. RR-16):1-56.
Aligning practice with policy to improve patient care 43
Summary
Airborne contaminants are a known cause of infection. Studies
establishing specific SSI rates have not yet been conducted,
in part because of the difficulty of conclusively identifying the
movement of airborne particulates and causality. The ability of
various products and procedures to reduce airborne particulates,
however, is demonstrable. The implied connection is clear:
fewer contaminants near the surgical site can be expected to
result in fewer SSI. It is also worth noting that while infectious
disease patients have more specific containment requirements,
the benefits of contaminant reduction apply to the broader base
of surgery patients as well.
About the author
Russell N. Olmsted, MPH, CIC has more than
24 years of experience in the field of infection
control/applied epidemiology. He is an epidemi-
ologist with Infection Control Services at Saint
Joseph Mercy Health System, headquartered
in Ann Arbor, Mich., and President of Applied
Epidemiology Solutions, Inc., a private consulting
business that covers the field of infection prevention/control and
healthcare epidemiology.
6 Edmiston CE et al. Molecular epidemiology of microbial contamination in the opera-
tion room environment: Is there a risk for infection? Surgery. 2005;138:573-82.
7 Memarzadeh F, Manning A. Reducing risks of surgery. ASHRAE Journal. Feb.
2003:28-33.
8 Mangram AJ et. al. Guideline for Prevention of Surgical Site Infection, 1999. Centers
for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advi-
sory Committee. Am J Infect Control. 1999 Apr;27(2):97-132.
9 Hutton MD, et al. Nosocomial transmission of tuberculosis associated with a draining
abscess. J Infect Dis. 1990 Feb;161(2):286-95.
10 Centers for Disease Control and Prevention. Guidelines for Preventing the Trans-
mission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR.
2005;54(No. RR-17):1-147.
11 Edmiston C et al. Molecular epidemiology of microbial contamination in the operation
room environment: Is there a risk for infection? Department of Surgery, Medical Col-
lege of Wisconsin. 2005.
12 ASHRAE. 1999 ASHRAE Handbook: HVAC Applications. Atlanta: ASHRAE; 1999.
13 Scaltriti S et al. Risk factors for particulate and microbial contamination of air in oper-
ating theaters. J Hosp Infect. 2007;66:320-6.
 Circuits

Masks

Filtration products

Breathing bags

Anesthesia accessories

Laryngeal masks

Endotracheal tubes

Oral airways

Laryngoscopes

Oxygen therapy

For more information, contact us at 1-800-MEDLINE | www.medline.com

 OR Issues

PREVEN TIN G

M EDIA
STIN Mediastinitis,
inflammation

ITIS of the area

between
the lungs (the
mediastinum),
can be one
of the most
devastating
complications of
cardiac surgery.1

By Denice Summerlin, RN

Aligning practice with policy to improve patient care 45

 It occurs, on average, in 1 to 2 percent of surgical
patients, but certain subsets of patients such as
heart transplants, obesity and diabetes are at a
much higher risk.2 COPD, smoking, renal failure
and advanced age can also be contributors.
Certain procedures and conditions increase the
risk of postoperative mediastinitis. Other risk
factors include: 1,2,3,4
• Use of bilateral internal mammary grafts
• Emergency surgery
• Cardiopulmonary resuscitation
• Prolonged bypass and operating time
• Postoperative shock
• Obesity greater than 20 percent of ideal
body weight
• Re-exploration following initial surgery
• Sternal wound dehiscence
• Surgical technique, including excessive use
of electrocautery and bone wax, paramedian
sternotomy and pacing wires
Staphylococcus aureus and Staphylococcus
epidermis are the causative organisms in 70 to 80
percent of infected patients. The rise in methicillin-
resistant Staphylococcus aureus (MRSA) infections
is impacting prevalence of this condition and
accounts for 25 to 30 percent of all cases of
mediastinitis following coronary bypass surgery.1
When mediastinitis occurs, re-operation, prolonged
ventilation, additional time in critical care units and
increased therapy and treatment compound the
cost of recovery and increase the risk of death.2
We have never wanted mediastinal infections to
occur, but now we have even stronger incentives
for prevention. In the current system for reim-
bursement for healthcare-associated complications,
including infections, a trigger occurs that results
in higher payments. The more severe the compli-
cating condition, the higher the payment assigned.
CMS (Centers for Medicare & Medicaid Services)
believes there is a significant public health interest
in focusing on serious preventable events. In August
2007, CMS announced eight healthcare-associated
conditions that they believe could be prevented.
One of the eight conditions is Surgical Site Infection
– Mediastinitis after Coronary Artery Bypass Graft
(CABG) Surgery and includes codes 519.2 MCC
and 36.10-.19. Beginning October 1, 2008, CMS
cannot assign a case to a higher DRG based on
the occurrence of one of the selected conditions
if that condition was acquired during hospitalization.5
46 THE OR CONNECTION
Although there have been mixed opinions on this
decision among providers and caregivers, there
has been strong public support for CMS to pay
less for conditions that are acquired during a hospital
stay. Considerable national press coverage has
prompted dialogue of how to further eliminate
healthcare-associated infections and conditions.
Prevention strategies now take on even more
meaning because preventable complications will
not be paid for and hospitals will be left holding
the bill.
Perioperative professionals are on the front line
when it comes to making a difference in patient
outcomes. By knowing the risk factors and the
signs and symptoms of mediastinitis, we can
implement prevention measures that not only
reduce the risk but also promote prevention.
This is the future of holistic nursing healthcare.
About the author
Denice Summerlin, RN, BSN, is the Cardiac Product
Line Nurse Manager at Centennial Medical Center in
Nashville, Tenn. She has worked as a CVOR Nurse
for the past 22 years. Denice is currently working on
her MSN.
References:
1 Lavoie-Vaughn N. Recognizing Mediastinitis. Available at:
www2.nurseweek.com/articles/print.html?AID=14478.
Accessed November 9, 2007.
2 Mueller D. Mediastinitis. Available at: www.emedicine.com/
med/topic2798.htm. Accessed November 9, 2007.
3 King R, Barnes A. Mediastinitis. Curr Treatment
Options Infect Dis. 2003:5:377-386.
4 El Oakley RM, Wright JE. Postoperative mediastinitis:
classification and management. Ann Thoracic Surgery.
1996:61(3):1030-1036
5 Valuck TB. CMS Progress Toward Implementing Value-Based
Purchasing. Presentation at 10/18/07 meeting.
6 Huber S, Bergmann P, Schweiger S, Machler H,
Oberwalder P, Rigler B. Endoscopic vein harvesting in
coronary artery bypass surgery. European Surgery. 2007;
39(2), 96-104.
Infection prevention measures
for cardiac patients:
Step 1: Assess all cardiac patients prior to
surgery for common clinical risk factors, i.e.,
diabetes, immune deficiency, malnutrition, hepatic
dysfunction, alcohol or drug abuse, COPD,
smoking and obesity.
Step 2: For scheduled procedures, assess pa-
tients prior to admission for signs and symptoms
of secondary infection. One example would be
Nare cultures preoperatively for MRSA as part
of the pre-admission protocol.
Step 3: Instruct use of chlorhexidine showers
the night before surgery and the morning of surgery.
Step 4: Warm patients for a minimum of 30
minutes prior to the surgical procedure.
Step 5: Implement preoperative, individualized
insulin protocol for diabetic patients before and
after surgery.
Step 6: Utilize alcohol-based hand antiseptic
products prior to patient contact and for the
surgical scrub prior to donning surgical gloves.
Step 7: Assure that all supplies, personnel and
equipment are ready and available prior to bring-
ing the patient into the OR and beginning the
surgical procedure to prevent any unnecessary
intraoperative delays.
Step 8: Do not shave the surgical site. Clip
only the hair necessary for operative preparation
immediately before the surgical procedure.
Aligning practice with policy to improve patient care 47
Step 9: Use a surgical prep solution containing
CHG (chlorhexidine) to provide maximum
residual kill.
Step 10: Administer prophylactic antibiotics
within one hour of the surgical incision and
postoperatively for a minimum of 48 hours.
Step 11: Utilize maximal barrier precautions
(AAMI Level 4) for surgical gowns and surgical
drapes around all fenestrations.
Step 12: Segregate surgical instruments
between the graft harvest site (leg) and the chest
cavity instruments.
Step 13: Closely monitor and document blood
loss intraoperatively.
Step 14: Consider using endoscopic vein har-
vesting (EVH) technology for vein graft harvest.
The advantages of EVH are the reduced trauma
to the leg and the painless and faster mobilization
of the patients.6
Step 15: Consider silver antimicrobial
dressings postoperatively.
Step 16: Assure that all pertinent information
regarding the surgical procedure and patient
tolerance is documented and communicated
at the time of hand-off in the critical care unit.
 Special Feature

Tips for
“Going Green”
in the
Operating
Room

By Ann Shimek

Healthcare facilities are faced with limited abilities to channel the stream of
waste due to government regulations, restrictions on incinerators and the decreasing number
of landfills that will accept medical waste.1 Couple this with escalating environmental concerns
for our planet and layer on top of that the call for “zero tolerance” in strategies to stop the
spread healthcare-associated infections.

All of this is leading to more product introductions, more chemicals and more single-use products.
What’s an operating room to do? After giving this some thought, I started making a list of how
we could possibly initiate a “Go Green” strategy in the OR and remarkably came up with an
entire list of ways to begin!

We’ve also provided a list of 20 tips for effective recycling and waste segregation in your facility.
Read through the list and see how many of these practices you’re already using – and how
many you can add to your routine!

See if you can add to the list and take this as a challenge to “Go Green” in your practice setting!

48 THE OR CONNECTION
 “Go Green”
Tips for the OR1

1. Implement paperless systems

2. Use office paper with at least 30 percent recycled contents
3. Receive supplies in reusable shipping containers
4. Reprocess disposable products according to FDA and manufacturer guidelines
5. Turn off the water at scrub sinks when not in use
6. Turn off lights in rooms that are not is use
7. Look for alternatives to polyvinyl chloride (PVC) and di(2-ethylhexyl)phthalate (DEHP)
8. Turn off radios and stereos when rooms are down
9. Turn off all equipment when not in use
10. Purchase sterile supplies in procedure packs to limit packaging waste
11. Purchase nontoxic/less toxic alternatives for janitorial chemicals
12. Provide alcohol-based hand gels and rubs to control water consumption
13. Replace ethylene oxide sterilization
14. Only open products that are not used in surgical procedures an average of
90 percent of the time at the point of use in non-emergency procedures
15. Provide recycling bins in frequent, convenient locations
16. Go latex-free throughout the department
17. Do not purchase equipment containing mercury About the author
Ann Shimek, RN, BSN, CASC
18. Ensure that disposable products are biodegradable is the director of materials manage-
19. Limit the use of formaldehyde ment at United Surgical Partners
International. She has 15 years of
20. Limit the use of glutaraldehyde perioperative experience in various
21. Limit the use of products that contains DEHP roles, including clinical director,
private scrub nurse and staff nurse
22. Choose products with minimal packaging at a number of acute care facilities
23. Choose products that are fragrance free and ambulatory surgery centers.
24. Recycle toner cartridges
25. Recycle lead aprons
26. Recycle computers Reference:
1. Illinois Environmental Protection
27. Recycle batteries Agency. Thinking “Green” Saving Illinois
Hospitals Dollars. Available
28. Do not dispose of caustic materials through drains at: www.epa.state.il.us/environmental-
progress/v24/n1/green-hospitals.html
29. Integrate sharp-free systems where applicable Accessed November 8, 2007.
30. Standardize as many product categories as feasible

Aligning practice with policy to improve patient care 49

50 THE OR CONNECTION
SSIs
and Prosthetics
“joint”
A Surgical site infections (SSIs) are the
concern
Table 1: Participation in
mandatory surveillance of
SSI in orthopedics2
Total no.
Trusts
Total Procedures 146
Total hip prosthesis 109
Hip hemiarthroplasty
Knee prosthesis
Open reduction long
bone fracture
most common healthcare-associated
infection in surgical patients. Current data
tell us that SSIs occur in 2.6 percent of all
operations and lead to increased cost
and increased length of stay (LOS).1
The Centers for Disease Control and
Prevention (CDC) define SSIs as those
infections occurring within 30 days of an
operation, and within one year if an
implant was placed surgically.
Developing an infection in any orthopedic
procedure with or without implants can
be devastating, but when an implant is
infected you have major trouble. Studies
show that the incidence of SSIs is greater
in total joint arthroplasties than other
orthopedic procedures (see Table 1).
Total no.
Procedures no. SSI % infected
4242 593 1.44
16809 208 1.24
71 5364 217 4.05
96 15792 102 0.65
26 3277 66 2.01
As long as the world’s population lives
to be older, the incidence of degenerative
joint disease and consequently the
need for prosthetic joint replacement
will continue to grow. Inevitably, some of
these patients will acquire an infection of
their prosthesis. Although the rates are
down, postoperative infections in total
joint arthroplasties are still a serious
concern.3
Aligning practice with policy to improve patient care 51
OR Issues
Who is at risk?
Even though the infection rate has
decreased considerably over the years
there are still factors that will put some
patients at a higher risk than others.4
Health concerns such as
diabetes, obesity, history of
smoking, rheumatoid arthritis,
periodontal disease, HIV,
hemophilia, malnourishment,
advanced age and immune
suppressive therapy increase
a patient’s chances of acquiring
an infection and should be taken
into consideration.5
Other risks that might put the total joint
replacement candidate at a greater
risk include psoriasis (especially at the
incision site), previous prosthetic joint
infections and a lengthy operative time,
especially if that time is longer than 2.5
hours.3
What to look for
There are two major categories of post-
operative join infections: early and late.
Early (or Type I) infections occur at the
time of surgery and symptoms are noted
within one month.4 Early infections
present as painful red, swollen wounds.
Purulent drainage is common and there
are usually complaints of continuous pain.
Systemic symptoms, such as an elevated
temperature, occur as well.3 These infec-
tions are usually caused by hematomas
that act as bacterial culture mediums.
 “ Two major carriers of bacteria in
an operating room are the staff
and the patient.”
They can also be triggered by super-
ficial wound infections spreading to
the periprosthetic space.4
Late (or Type II) infections are also
thought to originate at the time of
surgery, but the onset of symptoms
is delayed. These patients present
between six months to two years
after an operation. Delay in onset
occurs because the bacteria are able
to adhere to the prosthesis and survive
undetected beneath a coating of
“slime” that the organism formed.3
The patient will begin to note pain
and inflammation at the operative
site. These symptoms, as well as
findings on examination, are often
non-specific and akin to those
seen with aseptic loosening of
the prosthesis.3
Diagnosis
The diagnosis of a prosthesis infection
is not easy because the results are
so similar to those of aseptic joint
loosening. Additionally, in the postop-
erative period, signs and symptoms
often noted with infection (swelling,
redness and drainage) are seen as
normal postoperative changes.4
Images produced by CT scans and
MRIs are often distorted by artifact
caused when metallic images are
filmed in this way.4 Bone scans can-
not differentiate between infection
52 THE OR CONNECTION
and prosthetic loosening.5 An X-ray of scrubs can greatly reduce the
the area will show destruction of bone chances of these bacteria infecting
around the prosthesis. Most surgeons the surgical site.3
will suspect infection when this is
seen, but there is no way to definitively Clothing that can act as a barrier
diagnose it. Direct microscopic exami- between these bacteria scales and
nation and bacteriological cultures of the patient is also necessary. Over
tissue samples obtained during the the years, different kinds of occlusive
revision procedure are the most surgical gowns have been produced
common ways to obtain a definitive that are as effective, less costly to
diagnosis.3 make and more comfortable to wear.
These materials are impermeable
Prevention is the best treatment to bacteria, yet permeable to air.3
1. Preoperative IV antibiotic
administration is considered Operating rooms must be ventilated in
to be the most successful way such a way to keep bacteria removed.
to reduce infection rates. One such system is called laminar
2. The number of personnel in the air flow. These systems produce large
surgical room should be kept to a amounts of clean air that is continu-
minimum and traffic in and out ously pumped into the room, changing
of the room should be limited to the entire room air volume up to
essential tasks. five hundred times an hour.3
3. Copious amounts of irrigation, both
plain saline and antibiotic-infused,
are often utilized before insertion
of prosthetic components.6
Two major carriers of bacteria in an
operating room are the staff and the
patient. Thousands of bacteria are
found on our body surfaces and travel
through the air on tiny scales of skin.
Even healthy people produce about
one thousand of these bacteria-
carrying scales each minute. Proper
handwashing techniques and appro-
priate preoperative patient skin
 SILVASORB®
PERFORATED SHEET

Treatment
When faced with an infection, the
surgeon considers individual patient
characteristics, timing of the diagnosis
Spotlight on silver dressings
and the organism causing the infection.
An additional prevention strategy with increasing interest is the use
Although there are a few treatment
of silver dressings, which can provide localized broad-spectrum options, surgical removal of the
antimicrobial properties and an additional line of defense.8 prosthesis is almost always necessary.7

Silver does not promote bacterial resistance and is effective in Antibiotic therapy is used in con-
treating resistant bacterial species. The antimicrobial efficacy of silver junction with other treatments. Alone,
antibiotics are ineffective because
dressings depends on the silver content, the dressing formulation
bacteria attach themselves to the
and the way the dressing is made. A 1 percent silver sulphadi-
prosthesis and form a protective
azine cream has historically been used for burn wounds, and there barrier of slime that antibiotics are
are now silver dressings emerging on the market that are less toxic unable to penetrate. Once the revision
than silver sulphadiazine.9 Several dressings on the market are has been performed, patients are
impregnated with sustained-release ionic silver. Most of these usually on antibiotics for six weeks.
dressings absorb fluid from the wound bed and have The dose and type of antibiotic
used depends on the specific
antimicrobial protection.9
bacteria found.4

Studies are currently being proposed to measure the impact of Some patients might not be able to
applying silver directly into the surgical wound prior to closure. tolerate or refuse to have revision
surgery. These patients are often put
on suppressive antibiotic therapy for
the rest of their lives. It has been
demonstrated that in these patients,
infection was suppressed for four
years in about 60 percent of
all cases.4

Arthroscopies are often performed on

infected total knees in order to irrigate
and debride the area as well as take
tissue samples for culturing.

Aligning practice with policy to improve patient care 53

 “ Proper handwashing techniques
and appropriate preoperative
patient skin scrubs can greatly
reduce the chances of bacteria
infecting the surgical site.”
Revision surgery
In most cases, it is necessary to
remove the infected prosthesis and
insert a new one. There are two types
of revisions: first stage and second
stage reimplantation.6
In a first stage reimplantation,
everything is done at the same time.
In order for reimplantation to be
successful, all foreign material must
be removed and the area fully
debrided. Bone cement mixed with
antibiotics is used to affix the new
prosthesis. This procedure is frequently
not an option because of proximal
bone loss due to the infection.5
Second stage revisions are consid-
ered to be the gold standard in the
treatment of joint prosthesis
infections.7 After the infected prosthesis
is removed, cultures are obtained and
the operative area has been fully
irrigated and debrided, an antibiotic
spacer is made and inserted into
the wound. Antibiotic spacers are
made from bone cement, usually two
to three packs, with 1000 mg van-
comycin and 2.4 g tobramycin mixed
into each pack. This spacer will then
maintain soft tissue length and integrity
across the joint until it is time to
implant the new prosthesis. The new
prosthesis is usually inserted soon
54 THE OR CONNECTION
after this, as waiting more than six to
twelve weeks can lead to excessive
joint stiffness. Unlike a first-stage revi-
sion, this procedure has the benefit of
antibiotic therapy from the spacer
as well as allowing the surgeon to
press-fit the prosthesis without ce-
ment.6 The success rate of second
stage revisions is between 80 and
95 percent.6
About the Author
Megan Giovinco, RN, CNOR, RNFA,
currently a clinical nurse consultant, has
been an RN for more than 10 years.
Previously, she worked as a nurse at
a number of acute care facilities and
trauma centers.
References:
1 Feature: surgical site infections: epidemiology,
prevention, and emerging treatment guidelines.
Podiatry Today. 2006;A(12A):8-10.
2 Health Protection Agency. Mandatory surveil-
lance of surgical site infection in orthopaedic
surgery: April 2004 to March 2005. London:
Health Protection Agency, October 2005.
3 Larikka M. Diagnosis of orthopedic prosthe-
sis infections with radionucleotide techniques;
clinical application of various imaging methods
[thesis]. Oulu, Finland: University of Oulu; 2003.
4 Valdemar HB. Total Hip Infections. Available
at: www.totaljoints.info/totalhip_infection.htm.
Accessed October 15, 2007.
5 Peersman G, Laskin R, Davis J, Peterson M.
Infection in total knee replacement: a retrospec-
tive review of 6489 total knee replacements.
Clin Orthop Relat Res. 2001 Nov;(392):15-23.
6 Orozco F, Haas S. Diagnosis and Treatment
of an Infected Total Knee. Available at
www.medscape.com/viewarticle/412898.
Accessed October 15, 2007.
7 Medhaven et al. Deterioration of theater
discipline during total joint replacement. Ann R
Coll Surg Engl. 1999;81:262-65
8 Streeter NB, McCain J. Surgical site infections
in patients with diabetes. In: US Nursing Lead-
9 Tomaselli N. Prevention and treatment of
ership 2006.
surgical-site infections. Infection Control
Resource. 2(2):5.
 Imagine ensuring patient safety with standardized

Sterile Procedure Packs

By Claudia Sanders, RN, CFA

Improving patient safety and lowering the risk of potential

surgical complications are very real concerns in our world
today. Imagine if there was a way we could simplify our
When supplies are not readily available
complex world. One way to move toward simplification is during surgical procedures, delays
to develop a standardized approach to sterile procedure increase patient risks for complications,
packs. Through standardization, risks are reduced and
processes are improved.
including infection, hypothermia and
bleeding, to name a few.
Now don't get scared! This does not mean you cannot
have custom packs or that you must always work with a
A consolidated system for procedure packs not only saves
standard stock pack. It is possible to standardize using
you time and improves efficiency, it also improves accu-
custom packs
racy, eliminates waste and helps the entire surgical team
and complete
become adept at procedures more quickly.
delivery systems.
Standardization can work in all surgical specialities
Current reality
The standardization concept not only holds true for the
Pulling supplies
more complex procedures, it can also be beneficial for
and equipment
those quick procedures that require clinicians to be efficient
for a total joint
and proficient. Room turnover becomes smoother in between
replacement, lum-
quick procedures. With increased speed, you can ensure
bar laminectomy
greater accuracy in necessary supplies.
or an open-heart
procedure is both
National support for standardization in health care
complex and time
According to the World Health Organization (WHO),
consuming. Time
adverse events may result from problems in practice, products,
spent can be any-
procedures or systems.1 The Institute of Medicine’s report
where from 30 to
on medical errors and patient safety, To Err is Human,
45 minutes pulling
called for a comprehensive and strong response to this
supplies, not to
most urgent issue facing the American people.2 This was
mention the
followed by a report to President Clinton, Doing What
number of trips
Counts for Patient Safety: Federal Action to Reduce Medical
in and out of the room. What if you forget something or drop
Errors and Their Impact, which outlined a road map for ac-
a necessary supply item while setting up? Yet another trip
tion including more than 100 activities. This plan addressed
in and out of the room.
issues such as national focus and leadership, identifying
and learning from errors, setting performance standards
Most ORs allow for a wide variation of customization, in part
and expectations for safety, building public and purchaser
due to physician preference. But consider if something as
awareness, working with providers, using decision-support
simple as standardization of sterile procedure packs and
systems and information technologies, using standardized
their many components could help to eliminate just one or
procedures and addressing and strengthening standards
two medical errors while reducing overall costs, saving time
and integrating data for reporting and analysis.3
and improving efficiency.

56 THE OR CONNECTION
What is meant by a standardized
sterile procedure pack program?
Take a quick survey of the following items
included in your current procedure packs
and also stocked on your shelves:
Q
Needle counters: How many variations
do you currently have in your packs?
Surgical gowns: Are they the
appropriate level of protection for the
procedure to be performed? Are they the
correct size?
Which components contain latex and
which ones are latex-free?
Are safety blades, needles and
syringes immediately available?
Are sterile skin markers at
your fingertips?
How many specialty drapes are
stocked in your facility and included
in your packs?
Where are the medication labels?
Are they the appropriate size and do
they stick well?
The standardization process is simple
and only requires a few strategies:
• A team approach (attitude) to work
on standardization
• Ability to communicate
• A willingness to work with your
pack manufacturer
In most cases, your pack manufacturer will
come in and do most of the work for you!
The work is in analyzing the components
used in each procedure, determining like
items and agreeing to standardize on the
one best component that will meet the
needs of 90 percent of the end users. It
really is that simple and can be performed
on-site by qualified clinicians.
Imagine having your sterile pack contain
everything you need, from basins to
gowns, from blades and labels to drapes.
Top 10 benefits of a standardized
procedure pack system
1. Less OR traffic
2. Standardization of commonly used items, i.e.,
needle counters, medication labels, skin markers,
electrocautery pencils, etc.
3. Appropriate levels of protection for surgical gowns
according to the procedure being performed
4. Increased space in supply areas
5. Improved staff productivity
6. Streamlined orientation process
7. Less risk for error
8. Fewer SKUs to order and inventory
9. Reduction in waste
10. Overall cost savings to the system
You could have most everything that you
need in one sterile pack or kit and have
it immediately available, ready to open
and be used.
Circulator supplies can also be included,
such as grounding pads, bag-a-jets,
Foley kits and syringes. You could even
About the author
include turnover kit supplies, i.e. bed
Claudia Sanders, RN, CFA, is
sheet and draw sheet, trash bags and
currently a clinical nurse specialist.
linen bags as well as cleaning cloths.
She has practiced in the medical
Anesthesia items can be added as well.
field for more than 30 years as
And best of all – the products look, feel a surgery technologist and
and work the same from procedure to perioperative nurse.
procedure. Only the procedure specialty
items would deviate from case to case.
It is not just a dream. Standardization can
become a reality. We invite you to join us
References
and try it. Then we can live in a world 1 World Health Organization,
where OR supplies can be as one.... Fifty-Fifth Word Health Assem-
bly, Provisional agenda item
13.9, A55/13, March 23, 2002.
2 Kohn LT, Corrigan JM, Donald-
Please refer to the Form & Tool on son MS, eds. To Err Is Human:
Page 103 for Tips for Building a
System. Washington, DC:
Safe Pack.
Building a Safer Health
National Academies Press; 1999.
3 Quality Interagency Coordina-
tion Task Force. Doing What
Counts for Patient Safety: Fed-
eral Actions to Reduce Medical
Errors and Their Impact. Avail-
able at: www.quic.gov/report/
mederr2.htm. Accessed
November 14, 2007.
Aligning practice with policy to improve patient care 57

CBL addresses Competency-based learning is a very powerful
the requirements foundation for the construction of any e-based
or closed loop systems training modules. CBL
necessary to targets the crucial skills and practices that directly
perform a skill, contribute to the overall organizational goals.
but it also com- The reason that it works so well with e-learning,
i.e., learning through electronic media, is because
municates clear
it enables organizations to deliver content or
expectations and learning objects to individuals. Proponents of CBL
enhances critical typically choose this learning method because
thinking skills. it leads most directly to learning opportunities
that are intensely focused and are populated by
learners and employers who are chiefly inter-
ested in the shortest route to results.1
HOW DOES CBL FIT INTO
PERIOPERATIVE NURSING?
According to Sharron Abramson, RN, clinical
nurse practice leader of operating rooms at
Humber River Regional Hospital (HRRH) in
Weston, Ontario, CBL is a method of learning
that addresses the requirements necessary to
perform a skill, but it also communicates clear
expectations and enhances critical thinking skills.
It utilizes electronic media as well as preceptors
and many forms and tools to assess and
measure skills and competency. Abramson
says it not only works in perioperative services,
but CBL has improved the orientation process
and resulted in greater longevity and satisfaction
among employees at her facility.
Aligning practice with policy to improve patient care 59
OR Issues
To fully understand the impact of CBL at Humber,
you need to know a little about the facility.
HRRH has 600 beds on three campuses. They
employ more than 3,000 staff and have more
than 700 credentialed physicians and two oper-
ating room sites with 15 operating rooms and
three cysto rooms. Personnel at the facility
perform more than 23,000 day surgeries and
8,000 inpatient surgeries per year.
HRRH is a regional pediatric center and a
member of the Child Health Network in Canada,
as well as a regional dialysis center. They are
located in an ethnically diverse community in the
North-West region of Metropolitan Toronto. Patients
come from more than 140 countries and together
speak more than 80 different languages.
CBL AT HRRH
Humber’s perioperative staff is as diverse as its
patients. This became apparent to Abramson
four years ago when she took the position of
clinical practice leader, responsible for clinical
education, orientation and advancing clinical
practice throughout the organization.The current
program was not meeting their departmental
needs. The orientation program then consisted
of a six-inch binder and a one-week class.
Following the class, the trainee was assigned to
work with a staff member to apply the knowledge
learned in the class and from reading the manual.
Not only was the manual overwhelming, but the
 Through
performance
gap analysis,
individual
results are
addressed one
by one until the
competency skill
is mastered.
interpretation of data varied to a great extent
among new employees based upon their diverse
cultural backgrounds.
A COMMON LANGUAGE
When dealing with learning outcomes, a common
language set is critical.2 The need for a common
language was well established at HRRH. For
example, aseptic technique as well as handling
of sharps had differing interpretations among
diverse cultures and countries where many of the
caregivers had previously trained and practiced.
This diverse perioperative staff needed a stan-
dard set of definitions to be established. Ac-
cording to Abramson, not everyone had the
same frame of reference. Therefore, concepts
and practices varied greatly. Learning through
reading a manual and attending one week of
class was not providing the necessary results.
ASSESSMENT
The next step following the establishment of a
common language is to determine the caregivers’
current skills and competencies. This is accom-
plished through multiple assessment strategies.
Abramson believes in both a self-assessment
and an assessment by preceptors who are
assigned to help train the caregivers in the
clinical area. A generic tool for tasks is provided
and each individual is expected to perform each
task according to the established competency.
Each procedure has been broken down step by
60 THE OR CONNECTION
step according to the task and protocol and each
step is assessed for accuracy and completeness.
The caregiver also performs the self-assessment
on the same set of competencies and in the
same manner.
Results provide a measurement of individualized
performance gaps that can be addressed one on
one by either the clinical educator or the preceptor
assigned to the orientee. Performance gap
analysis is a simple method to gather information
about the competency skills and knowledge
that exists in an organization.2 Through per-
formance gap analysis, individual results are
addressed one by one until the competency
skill is mastered.
TRAINING METHODOLOGY
Once performance gaps are identified, CBL
goes to work to train the individual according to
Humber’s standards of care in perioperative
services. The cornerstone of this program is the
CD that houses all of the information contained
in the six-inch binder (which still exists and is
still provided) as well as the many forms and
training tools and support materials. The CD
materials are offered online at Humber and are
a convenient way to access information that
might have become foggy over time. Abramson
makes it her responsibility to keep the learning
CD and online data up to date and current.
 The typical training course takes approximately
12 weeks, start to finish, but the CD remains
available to all as a resource. The original
program also included videos, which have all
been updated and incorporated into the CD
and online program.
When asked where she came up with the pro-
gram’s contents, Abramson responded that she
pulled data from three primary sources: Associa-
tion of periOperative Registered Nurses (AORN),
Operating Room Nurses Association of Canada
(ORNAC) and the Australian College of Operat-
ing Room Nurses (ACORN).
“I used the best from all three organizations to
Feedback is
develop this program that has significantly
continuous evolved over the last five years,” Abramson
through a team said. She added that AORN does an excellent
approach, job with identifying the theory and rationale
behind its recommended practices and standards,
consisting of
while ORNAC is, in her opinion, more proce-
the educator, dure-driven. ACORN has included evidenced-
resource nurse, based underpinning to their standards.
Abramson maintains that blending materials
a buddy
from the three sources provides a standard
system and method of training and sets both clear and
self-assessment. common expectations for each caregiver.
Aligning practice with policy to improve patient care 61
Nurses at Humber learn to both circulate and
scrub surgical procedures. Typically, the training
begins in the general surgical specialty. Then
the caregiver progresses to plastics and basic
orthopedics. At this point in the program, it is
established whether the individual is going to
be able to master perioperative nursing. While
most are successful, there have been those
who have not found that the operating room
is the best fit for them.
FEEDBACK LOOPS
As a new employee goes through the program,
the ongoing assessment pinpoints any specific
problem areas and one-on-one guidance is pro-
vided. Feedback is continuous through a team
approach, consisting of the educator, resource
nurse, a buddy system and self-assessment.
Individual learning plans are communicated
to the caregiver as needed via Humber’s
email system.
Expectations are clearly defined, instructions
are provided and the caregiver is provided
resources that they can refer to as needed.
The clinical educator spends time observing
and assures that basic skills are solid before
caregivers move on to more advanced skills.
When questions arise, evidence-based criteria
are relied upon to support standards and proto-
cols. Abramson provided an example of when
this strategy came in handy. Some employees
had become accustomed to wearing surgical
masks inappropriately – or not wearing them at
all – at their former places of employment. By
providing evidenced-based criteria, a standard
for Humber was established.
OBSTACLES TO CBL
When about the biggest challenges she has
experienced during the development and imple-
mentation of CBL, Abramson said the number
one challenge was gaining the support of senior
nurses. She said she heard comments such as
“Why are you babying them?” and “We had to
learn by trial and error!” Next, when new care-
givers were placed with senior nurses as resource
nurses or preceptors, the senior nurses had dif-
ficulty in “letting go” and letting the new caregivers
perform tasks on their own.
 A side-by-side comparison of U.S. and Canadian healthcare1
WHAT’S THE DIFFERENCE?

They’re often compared, but just how do Canada and the United States measure up against each
other in terms of health systems and other health-related issues? We’ve assembled this chart for
your reference. Take a look – do any of the figures surprise you?

Canada United States

DEMOGRAPHIC STATISTICS
Population 32,268 298,213
Life expectancy at birth (male) 78 75
Life expectancy at birth (female) 83 80
HEALTH SYSTEMS
Number of physicians 66,583 730,801
Physicians per 1K population 2.14 3.65
Number of nurses 309,576 2,669,603
Nurses per 1K population 9.95 9.37
Total % of GDP spent on health 9.8% 15.4%
Total % of GDP spent on health by gov’t 69.8% 44.7%
Private expenditure on health as % of total expenditure on health 30.2% 55.3%
Total % of gov’t expenditure spent on health 17.1% 18.9%
Social security expenditure on health as % of general gov’t 2.1% 28%
expenditure on health
Out-of-pocket expenditure as % of private expenditure on health 49.4% 23.8%
Private prepaid plans as % of private expenditure on health 42.3% 66.4%
RISK FACTORS
Obese adults* as % (male) 15.9% 31.1%
Obese adults* as % (female) 13.9% 33.2%
Prevalence of adult* tobacco use (%) (male) 22% 24.1%
Prevalence of adult* tobacco use (%) (female) 18% 19.2%

* Adult = ≥15 yrs

Reference:
1 World Health Organization. World Health Statistics 2007. Available at: http://www.who.int/whosis/whostat2007/en/index.html.
Accessed November 13, 2007.

To address these challenges, Abramson decided Abramson’s experience is similar to that of

that the entire department needed to take
ownership in this program and responsibility for
the new employees’ success. That’s when she
decided to put the CD and training tools online
and provide access to all caregivers. She encour-
aged them to make suggestions and updates to
the entire CBL training program.
others. According to experts, innovations foster
resistance.2 Competency-based learning models
are certainly no exception. Some have said they
are too restrictive. Most complaints stem from
requiring others to perform and document ongoing
assessments that are viewed as time-consuming.
Despite these criticisms, results show universal
benefits through growth and maturity.

62 THE OR CONNECTION
References THE BIGGEST BENEFITS To learn more about the CBL program at Humber
1 Squires P. Concept
Competency-based models ultimately rely on and how it could benefit your own facility, or to
Paper on Supporting
Competency-Based measurable assessment. If a proposed compe- request a copy of the CBL CD, you are invited
Learning, Applied Skills tency cannot be described and measured in to contact Abramson via the information below.
& Knowledge, LLC.
ways that are comprehended by all, learners
2 Voorhees RA. can go back and repeat only the areas of The OR Connection thanks Sharron Abramson
Competency-based
learning models: deficiency versus repeating an entire program. and Humber River Regional Hospital for
A necessary future. sharing this information and their success
In: Voorhees RA, ed.
Abramson listed the following as the top with our readers!
benefits of a CBL program:
Measuring What Matters:
Competency-Based
• It allows everyone to understand To contact Sharron Abramson:
Learning Models in

expectations. Sharron Abramson, RN

Higher Education: New

Humber River Regional Hospital

Directions for Institu-

110. New York, N.Y.: • It can make a big difference in the

tional Research, No.

John Wiley & Sons, Inc.;

interpretation of feedback.
2001.
• It can be adapted to any operating room in
any location and in any setting.
Clinical Practice Leader, Operating Rooms
Office: 416-744-2500 ext. 2640
Pager: 416-680-1556
SAbramson@HRRH.ON.CA

Continue your CE coursework at

Medline University
Courses you can attend at any time, from anywhere
you have Internet access.
Medline University offers more than 50 self-study
nursing CE-credit courses.
An affordable online resource.
Visit www.medlineuniversity.com

Aligning practice with policy to improve patient care 63

 Special Feature

“ How
I got
into this
mess
in the
first
place.
”
When healthcare facilities need
partners…look to your vendors.
By Wayne Malone

Aligning practice with policy to improve patient care 65

 A n old friend recently lured me out
of a life of relative comfort back to my
roots in the OR. I had spent the previ-
ous three years away from the OR as
“We also need to order supplies,” added
Marko. Let me guess…yep, all of them.
a manager and interim director of the “We need more staff to help us get ready
to open,” added Claudia, my OR manager.
performance improvement department We were on a roll now….

of a large hospital. In this department, The conversation went on, but you get the

I handled risk management and per- idea: no instruments, no sutures, no supplies,

no staff and precious little time. We were
formance improvement duties. I really scheduled to open in six weeks. I paid a visit

liked the nine-to-five, hour for lunch,

to my mentor and friend (you remember, the
one who said I’d have nothing to do) to give

no holidays/nights/weekends lifestyle.
her a status report. I assured her that even
though we were six months behind schedule,
we would open on time. Her obvious question
– “How?” – was met with a simple “I don’t
Really, I did.
know, but we will.” What I lack in judgment,
But Deby started calling “just to ask a couple
I more than make up for in confidence.
of questions” and then to invite me to “come
take a look at the new hospital.” After a while,
After several very long days on the phone
like a trout that keeps seeing a fly in front of
spent trying to track down vendors, sales reps
his nose, I bit. I became the first (and so far,
and distributors, I caught a break. Our admin-
only) Director, Perioperative Services in the
istrative team had contracted with a medical
history of Patients Medical Center, a brand-
supply company to handle the bulk of our supply
new hospital in Pasadena, Texas. It took Deby
needs, and they wanted to bring the sales
so long to convince me to take the job that we
representative in to meet me. Our “new” rep
had a running joke: “By the time you actually
was an old acquaintance. I breathed an
get down here and start, you won’t have
immediate sigh of relief that at least our
anything to do.”
supplies would get here on time. Assuming
Right.
we could figure out which ones to order….

Needs assessments and status reports

I know what you’re thinking – he’s worked in
My first day at Patients Medical Center started
the OR most of his adult life, and now he
with a meeting of my entire staff. The four of
doesn’t know what supplies he needs? Try
us sat at the front desk and got to know each
this: While sitting at home some evening, take
other. My first assignment was a status report.
out a notepad and pen and write down every
“Bring me up to speed on what’s been done,
supply on your shelves at work. All of them.
and what remains,” I instructed. The responses
Every single one. Take that list to work the
caused me to go in search of a white flag and
next day and see how well you did. I’m betting
the job listings section of the classified ads.
that the very best of you probably did a little
better than me. But more on that later.
“Well, we need to order instruments,” said
Bryan.
The three Cs
“Which ones?” I inquired.
Finding this company, this sales representa-
“All of them.”
tive and his colleagues, was a serendipitous
Gulp.
accident, but it was also vital to our initial and

66 THE OR CONNECTION
The pre-op holding room/PACU,
stocked and ready for opening day.

“ I coined a phrase that

is still joked about here:
‘You don’t know what
you don’t have until
you don’t have it.’
”
Aligning practice with policy to improve patient care 67
 ongoing success. This representative lived
and breathed customer service and came in
every day for several weeks, from our initial
conversation through opening day and continuing
until we were confident that we had everything
we needed to operate effectively. This guy
earned our business. And he didn’t come
alone. He brought in a variety of specialists,
experts on a variety of topics, ranging from
gloves to sterile custom packs to (Eureka!)
instruments. And this is really where this story
begins. I had allowed my enthusiasm and my
confidence to write checks that my team and
I now had to cash. Fortunately, I was able to
draw upon the bank of knowledge and expertise
of our supplier.
Learning about all the services, programs,
support, and expertise that our vendor had to
offer gave me an idea for accomplishing the
seemingly impossible task at hand. I developed
a strategy that I have continued to live by
since the beginning of this process, and it
is what I refer to as the “Three Cs”:
1. Communicate
2. Consolidate
3. Concentrate.
It is, like me, painfully simple, and is intended
to get as much accomplished as possible in
as little time as possible.
First, communicate with your vendors. Find
out everything you can about their product
lines, the services they provide and their will-
ingness to go above and beyond to help you
meet your goals. My litmus test for a vendor
is, “Are you willing to hand deliver a single
item at 3 a.m.? At no additional charge?”
Second, consolidate as many eggs as possi-
ble into as few baskets as possible. If you can
get supplies, instruments, cleaning solutions
and scrubs all from the same vendor, why
waste your time talking to four (or maybe
40) vendors?
I know, you think it’s more expensive if you
don’t shop around, buying everything piece-
meal from the lowest bidder, right? Wrong.
Discuss the idea of product line consolidation
with your vendors and you’ll find that most all
of them are happy to negotiate better prices
on their products if they can provide you with
a larger array of products.
68 THE OR CONNECTION
The final C is concentrate. Concentrate your
time, energy and effort on getting as much as
possible accomplished with this cadre of first-
line vendors. Get as much as you can from
them in terms of both products and services.
Then spend your remaining time gathering up
the stragglers and tying up the loose ends.
Apply the time-tested 80/20 Rule: 80 percent
of your work can be accomplished with 20
percent of your vendors. Now that I’ve laid a
little groundwork, I’ll continue my explanation
as to why this methodology is so important,
particularly in busy surgery departments.
Give me a case of everything
My first real, sit-down meeting with our vendor
was very short. He asked me what I needed in
the way of supplies, and I answered him with
one word – everything. He asked me to elabo-
rate, but I was really at a loss as to how to
even begin to list “everything.” This is when I
began to realize that this guy was more than a
salesman. He acted like he wanted to become
my partner and ease the pain by offering solu-
tions. His response was typical for this guy,
and for most of his company: He pulled inven-
tory lists from other comparable clients and
used them as jumping-off points. We went
through the lists, adding and deleting as we
felt necessary and appropriate for our facility.
One thing we noticed immediately was that we
had overlooked a surprising number of “obvi-
ous” supplies. We’d also missed a few not-so-
obvious ones.
I began to get worried. I coined a phrase that
is still joked about here: “You don’t know what
you don’t have until you don’t have it.” Yes, I
studied at the Yogi Berra School of Philoso-
phy, but there is a nugget here for anyone at-
tempting to build a hospital from scratch. You
must plan ahead for everything, conduct Fail-
ure Mode Effects Analyses (FMEAs) on your
intended processes and always keep one eye
on the weeks ahead of your current schedule.
We developed a process where members of
our blossoming OR staff pulled schedules
more than a week in advance, went through
them case by case, and called physicians
directly to discuss their preferences. We found
that “It’s all on my preference card” isn’t very
helpful if the preference card is from another
facility and hasn’t been updated in several
years. And this is where having a vendor that
acts like a partner paid dividends. We’d find
out a week or less before a case that we

“
needed something but didn’t have it. Our part-
ner worked miracles, and, lo and behold, the
needed item would show up at our doorstep I had allowed my
the day before we needed it. Sometimes two
days before. enthusiasm and
One day, our vendor overheard a conversa- my confidence to
tion about instruments that I was having at the
front desk. He casually said, “You know, if
you need help with instruments, we have an
write checks that
inventory of the most common ones. I can
have our instrument expert give you a call.” my team and I
He did better than that. The product manager
for their instrument line actually flew down
here, made copies of our hand-written count
sheets, and talked at length with our new
sterile processing department and OR staff
regarding physician preferences, wants,
now had to cash.
”
needs and obstacles. A few days later, I had a
quote covering all our outstanding instrument
needs as well as a list of alternate sources for
those instruments not already in their rather
large inventory. We not only solved our instru-
ment problem, we also got a jump-start on our
computerized instrument inventory and count
sheets. The vendor actually sent us all of our
count sheets, in spreadsheet format, with
all the instrument names, model numbers
and quantities, ready to print.

After taking a look at our list of physicians

and specialties, we noted that we had two
neurosurgeons who would have privileges
here on opening day. Our rep inquired as to
their preferences and made a suggestion.
We could build a custom pack for our neuro-
surgery cases and save substantial money
over individually packaged items. We could
OR #1 on opening day

also decrease our turnover time by decreas-

ing the time it takes to open a room. He intro-
duced us to a specialist in the sterile tray
division. She met with my new neuro team,
reviewed the preference lists and built a
mock-up of the neuro pack for my team to
review. The pack was subsequently put into
production and now resides in our supply
room, where it occupies far less shelf space
than all the individual items it contains. We
have also established an average turnover
time for neurosurgery of less than ten min-

Aligning practice with policy to improve patient care 69

 utes. This specialist is
now working on custom
packs for cardiovascular
and orthopedic services.
She keeps asking me
about our basin packs,
and that’s on my hit list
as well.
I’ve also developed collegial and mutually
beneficial relationships with my vendors and
reps, rather than adversarial ones. It means
better and more successful negotiations,
lower operating costs, and more time for what
I love – being in the OR, working side by side
with possibly the best OR staff on the planet.

I have also spent time
with a specialist from the
orthopedics line (casting
materials, postop shoes,
slings, et cetera), one
from wound care (ostomy
supplies, wound care
products, specialty dress-
ings) and…well, you get
the idea. The benefit here
is that I didn’t have to make all those initial
Dr. Glen Garner,
Epilogue: So, how did it turn out?
We opened our doors in late April 2007
with an intentionally small surgery sched-
ule. We had three surgical techs and two
nurses. We did 32 cases, using one OR
suite at a time. By October 2007, we were
doing more than 400 cases per month.
I now have a perioperative services staff
of 40, and we’re continuing to grow. Our
average room turnover time is an eye-

contacts, nor do I have to dive into my office popping 7.8 minutes, and we intend to
general surgeon, gives

improve on that. My vendor partners are

Patients Medical Center
to hide from a horde of reps out to steal my
still on board and although we’re down
a thumbs-up during his
first procedure at the time. All of these folks have provided
new facility valuable service and loads of information, to a modest two to three visits per week,
but they’ve done so on my schedule, and my needs are being addressed.
all of the meetings have been coordinated
by my primary sales rep, whom I now refer The moral of the story is that relationships
to as our partner. I only have to remember
are all the same. Whether you are in a
one number.
personal or business relationship, you
must share in the problems and be part
I have also cultivated this type of relationship
with a handful of other vendors. These com- of the solutions. When you find a true
panies have virtually no overlap in product vendor partner, you have earned the
lines. And that’s the beauty of the Three Cs. business for life.
What they do have in common is a broad
range of service or product lines, outstanding
customer service and a willingness to bundle
product lines at a reduced cost per item. I
save a substantial amount of money, but the
real savings is in time, effort and aggravation.
By putting my eggs in fewer baskets, I have
reduced the effort required to keep our
facility running.

Wayne Malone, RN, has held various positions

in Perioperative Services during his 15 years of
nursing experience. He also has experience in
Performance Improvement, Infection Control and
Risk Management, and has been a healthcare
consultant. He is currently Director of Periopera-
tive Services at Patients Medical Center, a new
acute care hospital in Pasadena, Texas.

Aligning practice with policy to improve patient care 71

 How to make

2008
BEST your
year ever!

7
Seven strategies
to help you thrive
By Wolf J. Rinke, PhD, RD, CSP

72 THE OR CONNECTION
 Caring for Yourself

Health care is getting more competitive every day.

The following seven strategies will help you
thrive in tough times.

1 Get paid less

Yes, you read right! I said less! Why? Because if you get paid
more than you are worth, you will be out of a job soon! It's
elementary, Watson! In our capitalistic society, you must gener-
ate more worth or value than you receive, otherwise the system
will go kaput. Besides, “golden handcuffs” make you a slave.
What you want to do is give your employer more than he or she
expects. Start right now. In the long run, you will be compensated
according to the value you deliver. I have designed an elegant
lapel pin to remind myself of this concept at all times. The 111%
pin comes with a card that reads:

Give 100% and you'll survive.

Give 110% and you'll thrive.
Give 111% and you'll MAKE it a Winning Life!
Here is a little exercise that will keep you on track. Compute
your weekly pay, add about a third for benefits, and divide by
five. Put the value you just computed on a 3 x 5 card or a sticky
note and place it where it is clearly visible to you several times a
day. At the end of each day, ask yourself, “Did I generate $x of
value today?” If your typical answer is “yes,” keep on keeping
e on. If the answer is “no” more than 50 percent of the time, it’s
time for you to look around and figure out how you can add
more value.

2 Value yourself
Who is your most important patient, client or customer? If you answered “me!”
you have the right answer. This is super important because I’ve found that
most healthcare professionals are really great at taking care of others –
however, they often forget themselves! Want proof? Ask anyone in sales what
it takes to be a sales superstar, and they will tell you that you've
got to love what you sell. Notice I said love, not like! Even
though you are probably not in sales, even in health
care you sell yourself all the time! You sell your-
self, your ideas, your proposals, your be-
liefs etc. to your patients, boss, spouse,
children and even your pet. And for you
to be able to do that successfully,

Continued

Aligning practice with policy to improve patient care 73

 you've got to value, like and even love
yourself, because if you don't have it you
can't give it away! So start right now to
love yourself the way you are, not the
way you ought to be. (Read that again –
it’s a biggie. It took me about 35 years to
master!) That means that you have been
able to turn off that internal negative voice
that keeps focusing on all your weak-
nesses. Begin to recognize that of the
more than 6 billion people on this earth,
there is not one perfect person! All of us
are a composite of strengths and weak-
nesses. The trick is to value yourself for
your strengths and forget your weak-
nesses. If you can’t forget them, then
team up with someone who compen-
sates for your weaknesses.
3 Chase your passion
When your opportunity clock rings in the
morning, are you anxious to get up and
go to work? (I believe that starting your
day alarmed is counterproductive.) Are
you excited to be in your profession? Do
you love what you do? Does work seem
like play to you? Do you actually look for-
ward to work at least four out of five days
each week? If the answer is yes to all of
these, count yourself lucky because you
are part of a very small minority. If your
answer is no, it's time to make a change.
Don't have the skills or the education to
do what you love to do? Keep your cur-
rent job, and make time to get what you
need to be successful in your dream job.
Watch less TV, go to fewer ballgames,
pay any price, make any sacrifice, just do
it! Then start working part time in your
dream job. Can't find someone to pay
you for it? Volunteer. Once you are cer-
tain that you have found your passion,
give up your day job. Not getting paid as
much as in your former job? Not to worry.
Just stay with it. I've learned after more
than 40 years of employment that
overnight success takes a long time. But
74 THE OR CONNECTION
I've also learned that once you chase
your passion, not your pay, you will have
more fun and make more money, much
more money than you have ever thought
possible. Why? Because if it is fun, it gets
done! Want proof? Look around you at
the people who have made it to the top
in their professions. I bet you that virtu-
ally all of them love what they do, have
lots of fun and are compensated hand-
somely.
4 Have goals
It's been said that if you don't know
where you’re going, the last thing you
want to do is get there any faster. And
yet most people have absolutely no idea
what they want to get out of life. Write
down three “fire-in-the-belly” lifetime
goals for yourself. Prioritize these, and
then put them on two 3 x 5 cards or
sticky notes. Put one on your desk or
planner, and the other on your bathroom
mirror. Then get busy visualizing and
internalizing these goals. (If they are run-
ning inside your head like a perpetual
movie loop, you've got it.) Follow that up
with a detailed step-by-step action plan
that will get you to where you want to go.
Now work that plan!
5 Do what you don't
feel like doing
One of the comics I like to show in my
Make It a Winning Life seminars is from
Mother Goose & Grimm. Grimmy – that's
the dog – is standing in front of a full-
length mirror. He says, “Sit!” In the next
frame, he sits down, wags his tail and
says to the mirror, “Good dog, good dog.”
The next frame has Grimmy smiling at
the mirror saying, “I'm a self-motivator.”
That's what this is all about – having the
discipline to do what you don't feel like
doing. Chances are, those are the things
that others don't feel like doing either!
When you do those things, you will suc-
ceed faster. To help me with this, I've
developed this axiom: If I don't feel like
doing something, I go do it. If I really feel
like doing something, I think about it
twice. For example, I'm sitting in front of
my computer and writing this article on
an incredibly beautiful fall day. The awe-
some colors of the leaves and the
sparkling sunshine are beckoning me
to go out and go hiking with my Super-
woman — that's my sweetheart of almost
40 years. Yet, after thinking about it, I
discipline myself to sit here and do what I
really don't want to do. Here is a bonus
strategy that will enable you to make it to
the top even faster, especially if you are
employed: Figure out what your boss
does not like to do, and do more of it!
6 Invest in yourself
It's been said that if you want to earn
more, you've got to learn more. And it's
true. Statistics tell us that if you have a
high school diploma, you'll earn an aver-
age of $750,000 in your lifetime. With a
bachelor’s degree, that figure jumps to
approximately $1.5 million. With a pro-
fessional degree, such as an MD, JD or
PhD, you'll earn about $3 million. But
don't stop there! Take a look at how
much of your disposable income you
spent on your own development during
the past 12 months. If it is less than 3
percent, it is likely that you are becoming
If you don't know where you’re
going, the last thing you want
to do is get there any faster.
And yet most people have
absolutely no idea what they
want to get out of life.
obsolete. In this era of rapid change, the
only way you can maintain a competitive
advantage is to invest in the most impor-
tant resource you own – you! Read at
least half an hour every day. Reading at
least one nonfiction book every year puts
you ahead of about 45 percent of the
U.S. population. If, however, you want to
make it into the top 3 percent of the pop-
ulation, you'll have to devour 16 books a
year. Listen to motivational and educa-
tional audio programs in your car. By lis-
tening only half the time while in your
car, you'll earn the equivalent of two
three-credit college courses every year.
Attend seminars and courses. After all,
learning from other peoples' experiences
(OPE) is a shortcut to success. If you still
make the same mistake I made for many
years by saying, “Yeah, but my employer
won’t pay for continuing education!” then
it’s time to read this paragraph again to
figure out who the ultimate beneficiary is.
7 Maintain balance
All my life I was materialistically motivated
– until that fateful day in December 1997.
Superwoman and I were on our way to
Paris, France. Both of us were very ex-
cited. Marcela was going to one of her
favorite cities, and I was on my way to
speak to more than 300 managers from
19 different countries. We had an un-
eventful trip until we got to France, when
Aligning practice with policy to improve patient care 75
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we noticed that we were in a holding pat-
tern. After about 20 minutes, the pilot
calmly advised us that the indicator light
for the landing gear was not working, and
that the cockpit crew was trying to diag-
nose the problem. About 30 minutes
later, the pilot told us that there was
nothing wrong with the indicator light,
which meant that either the landing gears
were not extended or they were not
locked in. “We will now,” he continued,
“fly over the tower so that they can make
a visual inspection.” After doing that
twice, the pilot advised us that “the land-
ing gears appear to be extended, so we
must assume that the gears are not
locked in.” After what seemed like an
eternity, the captain got on the intercom
again and said, “Ladies and gentlemen,
the flight attendants will provide you with
emergency landing instructions. Now I
know that you've heard these many
times before, but this time I need you to
pay very close attention because we are
going to be making an emergency landing
at Charles de Gaulle International Airport.”
He also told us that the airport had been
closed and that emergency equipment
was standing by. The flight attendants
very calmly and professionally instructed
us to get rid of all sharp objects, clear all
aisles and put everything in the overhead
bins. They also had us practice the
emergency landing position – putting our
heads between our arms, leaning for-
ward and bracing ourselves against the
seat in front of us. After more than two
hours, the captain finally began his de-
scent and everyone quietly assumed the
Who is your most important
patient, client or customer?
If you answered “me!” you
have the right answer.
emergency landing position upon his com-
mand. What occurred to me during those
eternal two hours is that at no time did I
say to myself, “Wish I had worked
harder, wish I had made more money,
wish I had bought a bigger house, wish I
had bought more stuff.” Instead I thought
about relationships – my relationship with
my wife and if I had told her how much I
love her often enough; my relationship
with my daughters, and how they would
About the author
cope without us; my relationship with Dr. Wolf J. Rinke, RD, CSP is a
my parents and whether I had given keynote speaker, seminar leader,
ample credit where credit is due; my rela- management consultant, executive
coach and editor of the free
tionship with my friends and if I had told
electronic newsletters Make It a
them how much I value them and my rela- Winning Life and The Winning
tionship with my team members and if I Manager. To subscribe, go to
had expressed my deep appreciation for www.WolfRinke.com. He is the
author of numerous books, CDs
all they had done for me. and DVDs, including Make It a
for Life, Love and Business, avail-
Winning Life: Success Strategies
What I learned from all this is what
is really important in our lives. able at www.WolfRinke.com. His
company also produces a wide
variety of quality pre-approved
Not money, not things, not stuff,
continuing professional education
but relationships.
Of course, being a professional speaker,
(CPE) self-study courses, available
at www.easyCPEcredits.com.
I also thought, “If you make it out of this Reach him at wolfrinke@aol.com.
alive, you'll have one heck of a story to
tell.” After the captain gave the command
to assume the emergency position, he
landed the plane so softly that we did not
even know we had landed, right between
rows of fire engines. By the way, that trip
concluded with the loudest round of ap-
plause, cheers and joy I have ever heard
on any flight. So whatever you do, keep
your life in balance and don't forget to
spend quality time on the really important
stuff, your relationships.
© 2008 Wolf J. Rinke
Aligning practice with policy to improve patient care 77
 How By Miriam Nelson, Ph.D.

does Determine your risk

One way to determine whether you have an increased

your chance of developing heart disease, certain cancers

and diabetes is to compare your body's shape to a
fruit. Apple-shaped people are at greater danger
than pear-shaped people.
• An apple-shaped body is wider around the

body's middle than on the hips.

• A pear-shaped body is wider on the bottom
than in the waist.

shape To further determine your risk, measure the size of

your waist.
• Wrap a tape measure snugly around the narrowest
part of your waist, usually near your belly button.

influence For women, if your waist measures more than 35

inches, you're at greater risk; for men, it's 40 inches.
However, even people who are moderately overweight
may have an increased chance for certain health

your conditions, even if their waist size doesn't exceed

these measurements.

Get the facts

Carrying excess fat around your middle — specifically

health? the abdomen — increases your risk of developing

certain health problems. These can include:
• High blood pressure
• Type 2 diabetes
• High levels of LDL, or "bad" cholesterol
• Heart disease
• Colon and breast cancer

About the author

Dr. Miriam Nelson is the director of the John
Hancock Center for Physical Activity and Nutrition
at Tufts University. She's also the author of the
international best-selling Strong Women book
series. A fellow of the American College of
Sports Medicine, Dr. Nelson's research has
revolutionized how people understand nutrition,
strength training, aging and health.

78 THE OR CONNECTION
Eat smart, move often
The good news is you can lose excess body fat no
matter where it's located. Combining a sensible eating
plan with a realistic exercise program is your best bet
for success. Remember — you always should talk
with your doctor before beginning any diet or exer-
cise program. Use these tips to get started:

Snack sensibly
• Always keep sliced fruits and vegetables on hand.
Low-fat, low-calorie snacking between meals will
help you avoid overeating.
• Focus on eliminating processed foods from
your diet.

Add aerobics
Activities such as walking, biking, dancing or swimming About the Book:
keep your heart healthy and burn calories. Gradually In this accessible guide, trusted women's
work your way from 30 to 60 minutes of aerobic exer- health author and exercise physiologist
cise at least three times a week, if possible. Talk with Miriam E. Nelson presents the information
your doctor before beginning a new exercise routine every woman needs to know to maintain a
healthy back. Complete with clear explanations,
or significantly increasing your activity level.
practical advice, and lively anecdotes from
women who have benefited from this simple
Start strength training and effective program, the book reveals:
Resistance training helps build muscle and works off • the major causes of back pain in
additional calories. Slowly develop a routine of 10 to women;
12 exercises that target your major muscle groups, • how stress and other emotional
factors play a key role;
and do them two times a week.
• a straightforward exercise program
to improve flexibility, strength, and
aerobic fitness-designed specifically
for women;
• what you need to know to create a
back-friendly home and office; and
• explanations of what medical options
are available-and how to know when
they might be necessary

Whether you've struggled with back problems

for years or are hoping to prevent them in the
first place, this is an essential guide to have
a strong back for life.

To purchase this book for $25.95, go to

www.strongwomen.com

Aligning practice with policy to improve patient care 79

“ Dr. Marla”
battles breast
cancer

By Marla Shapiro, MD

80 THE OR CONNECTION
 Caring for Yourself

“
I felt like my identity was
being stripped away.”
It was a routine mammogram, but when the X-ray was done, the
radiologist asked for a magnified view of my right breast. She needed to get
a better look at something.

I wasn't anxious. I knew that this was fairly routine. If the breast tissue is
dense, the X-ray film can be difficult to interpret.

But when she came back, the news wasn't good. She tried to be reassuring,
but her eyes were fixed on the floor as she suggested that I undergo
a biopsy.

I could feel the fear rising. I knew I was in trouble. After all, I was a doctor too.

But on that day, Friday, Aug. 13, 2004, without warning, I switched roles and
became a patient. It was foreign territory for me, and now, having spent 14
months there, I have to admit the journey has not been easy. The biopsy
led to surgery that ultimately confirmed I was suffering from invasive
breast cancer.

In many ways, where Dr. Marla ended and just Marla began was poorly
defined. My profession was inextricably woven into the very fabric of who
I was – someone taught to be a clear thinker and problem solver whose
decisions are based on evidence, even if it's just the best that science can
offer at the moment.

And when it comes to cancer, the evidence is staggering. According to the

National Breast Cancer Foundation, women in the United States develop
breast cancer more than any other type of cancer, except skin cancer. It
also has the second highest rate of cancer death in females. An estimated
200,000 women will be diagnosed with breast cancer this year and it will
lead to the deaths of more than 40,000 of them.

However, this disease does not only affect women. The NBCF also notes
that approximately 1,700 men are diagnosed with breast cancer each year.
It will kill roughly 450 of them.

As a doctor, you learn to respect those numbers and screen as effectively

as you can, be it clinical examination, diagnostic tests or lifestyle counseling.
As a patient, your life is changed forever. And mine has.

As well as the feelings everyone has when faced with a life-threatening

diagnosis, I had to deal with the fact that, thanks to my appearances both
on [Canadian morning news show] “Canada AM” and on [health and lifestyle
program] “Balance,” my own show, I am a public figure.

Aligning practice with policy to improve patient care 81

 Just what this meant was driven home
the day I went for my first oncology
appointment. As my husband, Bobby,
and I stood at the reception desk in
Toronto's Sunnybrook Hospital, we
could see that “Balance” was playing
on the television set in the waiting
room. People behind us began to
wonder out loud if "that woman stand-
ing there" was Doctor Marla and if
"she" had cancer.
I wanted to turn around and scream,
"I may have cancer, but I'm not deaf."
And yet I realized at the same time
that I'd have to say something about
what I was going through. Keeping it
a secret was the last thing I wanted.
My goal was to deliver a message:
Fight and hope. I wanted to support
my family and friends with encour-
aging words.
So, when I wrote the first of my weekly
columns for The Globe and Mail's
health page almost exactly a year
ago, I introduced myself to readers
with the news of my recent diagnosis.
I also explained that I did not want the
disease to define me, but clearly it
has in many ways, some perceptible
and some not. I am not the same
woman who walked through the doors
of mammography that fateful day.
For one thing, the treatment meant
that I couldn't practice medicine. I
did not want to abandon this role I
felt so comfortable with – I felt like
my identity was being stripped away.
But chemotherapy wipes out your
white-blood-cell count and makes
you a sitting duck for any infection;
to keep working in such a situation
would have been like doing the tango
in a minefield.
I forced myself to keep up with
“Canada AM” and my other media
commitments. I needed to hold on to
a piece of me that was old and familiar.
But most of my energy went into
fighting the disease.
82 THE OR CONNECTION
Marla – with her hair starting to grow back – and her family.
People ask if this fight has gone better
for me because I'm an informed patient.
I really don't know. In so many ways,
it has been easier because I under-
stand the language and the uncertainty.
But in other ways, I know too much
and yet not enough. It is very hard
ever to feel reassured.
The treatment of breast cancer is
tailored to the individual and based
on where you are when you're diag-
nosed. But even then, there are many
options and no black and white, no
right answer. As I navigated through
the maze of diagnosis and treatment
options, I realized that, despite my
knowledge, I was totally unprepared.
It felt like I was running a race. There
are so many decisions that have to
be made – and made quickly. The
various treatment options were out-
lined, along with the potential benefits
and side effects, but ultimately I had
to make the choices that I hoped
were right for me.
And these choices hinged on the
fact that my tests could not confirm
whether the areas where the cancer
had invaded my body were related to
or independent of each other. As a
result, I was offered chemotherapy –
although I could have refused
that option.
After that, I had to decide between
radiation and mastectomy, therapies
that were considered equally effective
even if they are clearly so different.
So no one could tell me how to run
the race. It's something you have to
figure out yourself: what treatments
are right for you, what your comfort
level is, what risks you're willing to
take. It's a race I had to run alone.
Or so I thought.
When my husband and I told our two
older children, daughters Jenna and
Amanda, I minimized my concern.
But when I was to start chemotherapy,
I could not shield them from the
obvious side effects I would have
to endure.
We waited a while to tell nine-year-old
Matt, and thought we had done a good
job of protecting him. But children are
perceptive, and he soon sensed that
something was wrong. Which fright-
ened him because our silence
suggested there was something
that he could not talk about.
Once told, he was obviously relieved,
and being so young, he soon came
up with every conceivable question.
He found it curious that I would lose
my hair. (Actually, I did too.) He
wanted to know if cancer would just
go away, like a cold does. When we
told him it was something that had to
be beaten, he walked around for
days, boxing imaginary demons in
the air.
Also, suddenly I was home a lot. My
“ I realized that, despite
children have grown up in a busy
household with a mother who leaves
early and often comes home late. And
while they knew that I was always
"there for them," it wasn't always a
physical presence. Being there for car
pools, events and homework often re-
quired a juggling act.
My newfound free time allowed me to
rediscover my kitchen. I started baking
and cooking so much that, after a
while, the kids complained they were
gaining weight even as I was gradually
disappearing into the side effects of
my treatment.
Thanksgiving last year came right after
my first round of chemotherapy, and I
was unbelievably sick. Nothing had
prepared me for how ill I would be. I
felt like a toxic waste dump. I couldn't
move, I couldn't eat.
my knowledge, I was
totally unprepared.”
Home from school for the weekend,
the girls were confronted with just how
ill I had become. The fear in their eyes
hit me like a ton of bricks. Clearly this
wasn't just about me. This was their
fight too.
As I tried to suppress my dark
thoughts about not being around to
see them marry, have children and
move through life, I suddenly realized
that they had the exact same fears.
And while I felt I could force myself to
deal with anything, I could barely cope
with their pain and fear. Try as I might,
I could not make it go away.
But as time went by, I found there were
things I could do.
The email and letters of support and
concern I received were overwhelming.
I am eternally grateful to the women
Marla with Amanda, one
of her two daughters...
and with her son, Matt.
who came forward to share their stories.
I did not have to be alone.
Then one day my husband asked me
why, if one in nine of us has breast
cancer, does Canada not have more
bald women running around?
The answer is that we are here but
often silent. We carry on. We wear
our wigs. We move forward as best
we can, considering so little is said
about how nothing in life prepares
you to deal with a curve ball like this.
But when I was invited to go to Van-
couver to appear on “Vicki Gabereau,”
I wondered about leaving the wig at
home. The truth was that I was wear-
ing it only on “Canada AM.” In real life,
I walked around bald. I gave speeches
bald, went to dinner bald. But I knew
that this was different: national televi-
sion without a wig.
I decided that this was who I was in
real life, and so I headed off to the
West Coast wearing just my little
black hat to keep me warm.
As I sat in makeup and Vicki came in
to say hello, she stopped and, in her
typical way, said: "You look different,
Mama." She smiled, I smiled and off
we went to do the interview.
She was frank and curious and asked
tough questions. I was totally comfort-
able in my own skin – and totally
unprepared for what happened next:
Letters came from women saying they
had taken off their wigs after seeing
the show.

I realized then that many people had
thought I was sailing through my fight
with cancer, that somehow I had the
inside track. In reality, on many levels,
it was exactly the opposite: I am no
different from anyone else in the
same situation.
It soon became apparent to me that I
had a story to share – and it wasn't
as much about the medicine and
scientific advances as it was about
the impact on my family, my life and
all the things we don't talk about.
When I spoke to CTV about making a
documentary, the network was protec-
tive of me and said it was my decision,
but I felt strongly that I wanted to do
this. A crew more or less moved in
and followed me around. My family
and friends and physicians were open
and honest, and the result is called
Run Your Own Race.
Today, my chemotherapy is behind
me. The surgeries I elected to have
rather than radiation are over, and I
have gone back to my office and a
career I love.
So how have I changed? In many
ways, I am the same – juggling a zillion
work balls and loving the return. But
in so many other ways, I am different.
The only word I can think of to de-
scribe it is mindful. I am so much
84 THE OR CONNECTION
Physicians and Surgeons of Canada.
She is an Associate Professor in the
Department of Family and Community
Medicine at the University of Toronto
and is in private practice.
Laughing with chocolate
breasts before her In 1993 she joined City TV in Toronto,
Ontario as the medical expert on the
bilateral mastectomy.
nationally syndicated show “Cityline.”
Shortly thereafter she became the medical
expert for “City Pulse” and CP24 News.
In 2000, she left City to become the
health and medical contributor for CTV's
“Canada AM.” In addition to her weekly
appearances on “Canada AM,” she is
seen on “Newsnet” and as the medical
more mindful of the decisions I make,
consultant on CTV’s “News with Lloyd
my family, my children and how I
Robertson.”
choose to live my life.
2003 saw the exciting addition of
My children would say that my values
“Balance: Television for Living Well.” Dr.
have changed, and perhaps they are
Shapiro hosted this exciting daily health
wiser than their mother, who has
and lifestyle show. It is seen across North
finally learned to match her emotional
America and has sold internationally.
and her time commitments.
Dr. Shapiro is the recipient of the 2005
There are those who insist that I
Media Award from the North American
have inspired them with my so-called
Menopause Society for her work in ex-
courage, when, in fact, they have in-
panding the understanding of menopause,
spired me with their stories. It doesn't
and won the Society of Obstetricians and
take courage to fight when there is no
Gynaecologists of Canada/Canadian
other option. I am not alone. You are
Foundation for Women's Health Award for
not alone. Together, we all make
Excellence in Women's Health Journalism
a difference.
in 2006 for her documentary Run Your
Based on an article originally
Own Race.
appearing in The Globe and Mail,
October 2005.
Mark you calendar!
Medline Industries will be hosting
About the author
their annual AORN Breast Cancer
For years, well-known medical contributor
Awareness Breakfast, by invitation only,
Dr. Marla Shapiro has waded through the
at the 2008 AORN Congress. The event
constant barrage of medical research and
will take place at the Marriott Anaheim
has disseminated the most sensible med-
on Monday, March 31, 2008 from 6:30 to
ical information you need to make smart
7:30 a.m. We are honored to announce
healthcare decisions. She completed
that this year’s speaker will be Dr. Marla
medical school at McGill University and
Shapiro and you will receive one CE
trained at the University of Toronto for her
credit with your attendance. Contact your
Master’s of Health Science in Community
Medline sales representative if you would
Health and Epidemiology. She concluded
like more information about this event.
her specialty training in Community Medi-
cine receiving her Fellowship in Commu-
nity Medicine from the Royal College of
 Tips for Early Detection
The most important thing any woman can do to fight breast
cancer is to practice tips for early detection. Many women
are not familiar with the territory, so here are some early
detection tips, signs and symptoms from the National
Breast Cancer Foundation, included as reminders.

Three recommended screening methods

A Must-Read
Life in the Balance is Dr. Marla
Shapiro’s inspirational account of her
battle with breast cancer from diagnosis
to surgeries to chemotherapy and her
agonizing decision to have both breasts
removed. It is also the personal story of
how her family handled the news and
came together to achieve newfound
balance in their lives. This is a book for
anyone whose life has been touched
by cancer or who knows someone
who has.
• Breast Self-Exam
– Studies show that regular (monthly) breast
self-exams, combined with an annual exam by
a doctor, improve the chances of detecting
cancer early.
• Breast Physical Exam (By a doctor)
– This should be done on an annual basis and
in conjunction with breast self-exams.
• Mammograms
– The National Cancer Institute, the American
Cancer Society and the American College of
Radiology now recommend annual mammograms
for women over 40.
Symptoms and signs
• A new or persistent lump or a thickening in or
near the breast or possibly in the underarm area
• A change in the size or shape of your breast
• Discharge from either of the nipples that has not
occurred before
• Changes in the color or feel of your breast,
areola or nipples, which might consist of
dimpling, puckering or a scaliness of the skin.
It’s critical to carry out regular breast self-examinations –
this way, you will be able to detect any of these signs or
symptoms. If you find something that you feel is abnormal,
arrange an appointment to see your doctor.

Order your copy at one of these Reference

online retailers: breastcancer.org. Symptoms and diagnosis.
Available at: http://www.breastcancer.org/symptoms/.
Amazon.ca
Accessed August 21, 2007.
Chapters.Indigo.ca
McNallyRobinson.com

Together w e can save lives through early detection

In 2005, Medline launched a year-round breast cancer awareness
campaign with two critical goals: education and early detection. We
partnered with the National Breast Cancer Foundation (NBCF) to
provide breast cancer education and help fund mammograms for
underserved women. Since the launch, Medline has donated more
than $250,000 to the NBCF and has distributed thousands of copies
of “Beyond the Shock,” a patient education DVD developed by more
than 70 leading oncologists in the United States. Medline is proud to
donate to this cause. The statistics tell us that ten percent of the
women who receive free mammograms will be diagnosed with
breast cancer -- this makes it clear that we can help save lives.

Aligning practice with policy to improve patient care 85

 “
BEST day
Everyone has them, but often we do not take time to reflect and learn from whatever made the day
either the best or the worst we’ve encountered. Many lessons could be learned from taking a few
minutes to sift through details and analyze data so that we can choose to either replicate or
eliminate the factors that contributed to the success or demise of a given workday.

Below are some situational examples to stimulate your mind and help you start thinking about
your own best and worst days!

After opening my room, I went to the

pre-op area to interview the patient
and review her chart. The patient was
undergoing a left thoracotomy and
lower lobectomy. She was four years
post-left mastectomy for breast can-
cer. After interviewing the patient
and answering her questions, I was
about to excuse myself and return to
the room to finish some last-minute
preparations. The patient grabbed my
hand and said, ‘Thank you. When I
look into your eyes I see hope, and it
is something I haven’t had since the
mass in my lung was discovered.’ At
that moment, I realized the profound
effect we as perioperative nurses have
on our patients in our brief interactions
before the patient is anesthetized.”

We want to hear
from YOU!
Please email stories about your
best and worst days at work
to smacinnes@medline.com.
We will share many of the
responses in future issues
of The OR Connection!

86 THE OR CONNECTION
 Caring for Yourself

WORST day
“Ironically, the best day I ever spent in my eight years in hospital PR was also the worst. Our local
high school had a shooting this past spring and the victim was brought to the hospital. The entire
Communications Department, save me, was out of the office at a seminar three hours away. Being a
part-time writer, I had to step up and do interviews with national news agencies, over the phone with
NPR, etc., which was a huge learning experience. And we were the heroes, because our staff saved
this kid’s life (he was shot four times, three in the torso). But not soon after, his mom is in the paper
trashing the hospital for not covering his bills, etc.
The good and the bad. That’s working in a
hospital for me.”

“The phone rang at 2 a.m. It was the

hospital calling to see if I would come
in even though I wasn’t on call. Both
call teams were on their way in and
there was a third emergency that

”
needed immediate surgery as well.
Since I lived close to the hospital, it
wasn’t uncommon for them to call me
when they needed additional help. I
agreed to cover the third emergency
with the stipulation that I was relieved
if either of the other two teams finished
before I did. The three emergencies
were young men in their early twenties
who were drag racing on their motor-
cycles and collided. My patient was
nearly severed in half and arrived
in the OR with CSF running out of his
nose. None of these young men were
surgical candidates, but because of
their young ages the surgeons decided
to try and save their lives. Needless to
say, all three died on their respective
OR tables. One poor decision changed
the lives of three families forever.

Aligning practice with policy to improve patient care 87

 Clockwise from above:
Diana crosses the finish
line in Washington state;
Diana with her good friend
Jamie Morrow in San
Diego; Diana on her bike in
Chicago. All photos were
taken at races that were
part of the Women’s
Triathlon Series Benefiting
the Ovarian Cancer
Research Fund, Inc.

S
Conquering Cancer with a Nurse Hero
o many nurses say they got into nursing
because they wanted to help people.
Diana is no exception. Even at an early age,
she knew she would go into health care. She
has worn many hats. She began her career
as a candy striper and nursing home volunteer.
She entered the world of perioperative services
as a surgical scrub technician and then went on
to become a registered nurse.

Diana is a natural leader and gets along with

everyone. She’s not only there for her patients,
but her fellow staff as well. These characteristics
made her the perfect person to run the board for
a busy 13-room OR in Tampa, Fla. Like every-
thing in her life, she met this challenge head on
and was great at it – but she found she missed
direct patient care. While working full time, she
went back to school and became a family nurse
practitioner. She then worked for a spinal/ortho-
pedic surgeon and an orthopedic group. Both
were invaluable learning experiences for Diana.

88 THE OR CONNECTION

“All of my
life I was
taught that
the gift of life
was just that
A cancer diagnosis,
– a gift – so an outpouring of support
Shortly thereafter, Diana was diag-
enjoy every nosed with stage IIIC ovarian cancer.
She underwent two major surgeries
possible and a total of eight rounds of
chemotherapy, both IV and intraperi-
minute!” toneal. Diana admits that this was a
very frightening time for her. “I cried,
but I just couldn’t let this get the best
of me,” she said. She attributes being
a nurse, athlete and generally positive
person as the reasons she was able
to do this.
From the beginning, everyone around
Diana pitched in with cards, phone
calls, parties, fundraisers and “just
believing.” “I cannot begin to tell you
about the cards and money people
gave us. The pictures sent and par-
ties that were thrown were just what
I needed. All of these things helped
me get through the tough times,”
Diana said.
Her friend Jamie kept everyone up
to date on Diana’s progress. Friends
came out of the woodwork to cook,
clean house and even mow the lawn!
Her dad was with her for her chemo
appointments and follow up. Family
flew in to visit and help. One of her
brothers is even a nurse with chemo
experience! He was able to help
her understand the side effects of
Aligning practice with policy to improve patient care 89
Diana with her friend
Colleen Cannon at a
triathlon in Fort
Desoto, Fla.
chemotherapy and the importance
of taking her meds.
Embracing the future
We are happy to report that Diana’s
cancer is in remission and that she is
back to work as the charge nurse for
pediatric surgical services in the OR
where she used to run the board.
She is an excellent perioperative
nurse and everyone is happy to have
her back on the team.
Diana has always loved the outdoors
and being active. While in school,
she ran on the track team and now
finds running is a great stress re-
liever. She runs marathons and en-
durance races. A physician friend got
her started on triathlons and she en-
joys the challenge. She and Jamie
recently finished the last of a series
of triathlons to raise money for
ovarian cancer.
Diana is a truly amazing nurse,
athlete and person. She is a source
of inspiration to many of her friends
and colleagues – not only because of
the illness she beat, but the passion
she puts into everything she does.
In Diana’s own words: “You know, all
of my life I was taught that the gift of
life was just that – a gift – so enjoy
every possible minute!”
 By Laura Kuhn
The OR Connection staff writer
I
t didn’t seem possible to Aurora, Angel, Ami and Anastasia
that the holidays were upon them once again – hadn’t they
just finished the last of the turkey soup and turkey sand-
wiches? And yet here they were, all four sisters at home
again, just like it used to be when they were children.
Synchronizing days off from their busy nursing schedules
had been a challenge!
Aurora had settled in for a nice, quiet evening in the family living
room. She was sprawled on the floor in front of the fireplace,
basking in the warmth and flipping through an old family photo
album that she had found in the attic while helping her mother
locate holiday decorations.
She knew that her mother was not the first family member to
enter the nursing profession, but Aurora was still surprised to
see woman after woman in the photo album dressed in variations
on nursing attire.
Her mother walked into the room, arms filled with garland, and
stopped to look over Aurora’s shoulder.
“Oh, that brings back memories,” she said. “My mother put that
album together for me when I couldn’t decide whether or not I
wanted to go into nursing. Those are the women in our family
who have been nurses. Funny to see how uniforms have
changed, isn’t it?
“You should have heard the stories my grandmother told me
about assisting with surgery in the early 1900s,” her mother
continued as she wrestled with the garland. “Oftentimes, surgeries
were performed in private residences. When it came to sterili-
zation, they just dusted down the walls and wiped the floor with
a damp cloth!”
Aligning practice with policy to improve patient care 91
Aurora laughed, thinking of how much the profession had
evolved. One of the next pictures she saw was a woman who
was almost unrecognizable underneath her stark white gown
and surgical mask.
“They thought white emphasized cleanliness,” Aurora remarked
to her mother. “I can’t imagine wearing a white gown in a bright
operating room – it would be blinding!”
“Not to mention how unpleasant it is to see red blood splashed
on a white gown!” laughed her mother. “Thank goodness they
started switching to green and other colors.”
Aurora flipped another page in the album and came face-to-face
with a black-and-white photo of a fair-haired nurse in a trim
white uniform, a graduate nurse’s cap and a dark cape.
“Who’s this?” she asked her mother.
Her mother grinned. “That’s your great-aunt Alice,” she said.
“Oh, the stories I could tell you about her!”
Just then, Angel, Ami and Anastasia burst into the room. “Mom,
you promised us that this would be the year you would share
your secret pecan pie recipe,” Ami said. “Let’s go!”
Their mother glanced back at the photo of Alice once more.
“I guess we’ll have to talk about Alice another day,” she told
Aurora. “But I promise her story is worth the wait.”
Stay tuned to future editions of The OR Connection to
learn more about the sisters and meet the next addition
to their family!
 Champagne and Chocolate Covered Strawberries

Ingredients:
Your favorite champagne or sparkling cider
Fresh strawberries with the stems intact
Recipes for Strong, Chocolate hazelnut spread (such as Nutella®)
Several tbsp of heavy cream
Healthy Living. Wash the strawberries and chill them. Place a cup of the
chocolate hazelnut spread in a double boiler or fondue pot
and heat slowly. Add 1 to 2 tbsp of heavy cream and heat
From strongwomen.com
over low temperature until it is the consistency of heavy
cream.

To serve cold: Dip the strawberries in the warm chocolate,

place on waxed paper and chill.

To serve warm: Sit around the table and dip the strawberries
in warm chocolate using a fondue pot. Eat immediately.

Either way, enjoy with your favorite champagne or

sparkling cider!

Nutritional information: Strawberries are an excellent

source of vitamin C!

Mim’s Meltaways
Makes 45 to 60 cookies

Ingredients:
¾ c ground unblanched hazelnuts or blanched almonds
¼ c whole-wheat flour
½ c all-purpose flour
4 oz (1 stick) unsalted butter, at room temperature
½ c confectioner’s sugar, plus more for sifting
Grated zest of one orange
1 tsp vanilla

Combine the hazelnuts and whole wheat and white

flours and set aside. In a mixing bowl with an electric
mixer, beat the butter until it is light. Add the confectioner’s
sugar and orange zest and beat until fluffy. Beat in the
vanilla. Add the dry ingredients and mix very well, scrap-
ing down the sides of the bowl as necessary. Cover with
wax paper and refrigerate for about 30 minutes or until
firm enough to handle.

Preheat the oven to 350˚ F. Grease cookie sheets or line

with parchment paper (the paper is easier to handle and
makes for much easier cleanup). Shape the dough into
balls ¾-inch to one inch in diameter and place 1½ inches
apart on the cookie sheets. Bake in the middle of the oven
for about 15 minutes, or until golden around the edges,
rotating the pans halfway through baking. Cool the cook-
ies for 2 to 3 minutes on the pans, then carefully slide
them off onto a sheet of waxed paper. Sift confectioner’s
sugar over the cookies while they are still warm. The cook-
ies are fragile while hot, so don’t handle until they are cool.

Nutritional information (per 2 to 3 cookies): 51 calories,

3.9g fat (1.5g saturated), 3.8g carbohydrate, 0.6g protein,
0.3g fiber

92 THE OR CONNECTION
Forms & Tools
The following pages contain practical
tools for implementing patient-focused
care practices at your facility.

Perioperative Patient Positioning

Injury Risk and Safety Assessment ............94
How Well Do You Know
Pressure Points? ..........................................96
Policy & Procedure ....................................98

Hand Hygiene
Indications for Hand Hygiene ................101

Surgical Packs
Safety Checklist ........................................103

Aligning practice with policy to improve patient care 93

 Risk Assessment
INJURY RISKS AND SAFETY CONSIDERATIONS WHEN POSITIONING PATIENTS

Position Risk Safety Consideration

Supine Pressure points, including occiput, scapulae, • Padding to heels, elbows, knees, spinal
thoracic vertebrae, olecranon process, column, and occiput alignment with hips,
sacrum/coccyx, calcaneae, and knees. legs parallel and uncrossed ankles.

Neural injuries of extremities, including brachial • Arm boards at less than 90-degree angle
plexus and ulna, and pudendal nerves. and level with floor.
• Head in neutral position.
• Arm board pads level with table pads.

Prone Head • Maintain cervical neck alignment.

Eyes • Protection for forehead, eyes, and chin.

Nose • Padded headrest to provide airway access.

Chest compression, iliac crests • Chest rolls (ie, clavicle to iliac crest) to
allow chest movement and decrease
abdominal pressure.
Breasts, male genitalia • Breasts and male genitalia free from torsion.

Knees • Knees padded with pillow to feet.

Feet • Padded footboard.

Lateral Bony prominence and pressure points on de- • Axillary role for dependent axilla.
pendent side • Lower leg flexed at hip.
• Upper leg straight with pillow between legs.

• Maintain spinal alignment during turning.

Spinal alignment
• Padded support to prevent lateral neck
flexion.

• Place stirrups at even height.

Lithotomy Hip and knee joint injury
Lumbar and sacral pressure • Elevate and lower legs slowly and simultane-
Vascular congestion ously from stirrups.

• Maintain minimal external rotation of hips.

Neuropathy of obturator nerves, saphenous
nerves, femoral nerves, common peroneal
nerves, and ulnar nerves.
• Pad lateral or posterior knees and ankles to
prevent pressure and contact with metal
surface.

• Keep arms away from chest to facilitate respiration.

Restricted diaphragmatic movement • Arms on arm boards at less than 90-degree
Pulmonary region angle or over abdomen.

94 THE OR CONNECTION
 Forms & Tools
PATIENT POSITIONING

How well do you know pressure points?

Choose from (some may be used more than once)
Ankle
Dorsal thoracic area 2.
Elbow
Face
Foot
3. 1.

Greater trocanter
Heel
Hip
4. 5. 6. 7.
Supine
Ischial tuberosity
Knee
Lateral foot
Lateral leg
Neck
14.

Occiput
Posterior knee
Sacrum
Shoulder
8. 9. 10. 11. 12. 13. 15. 16. 17.

Thoracic area
Prone

Toes
Under strap

18.

19. 20. 21. 22. 23. 24. 25.

Lateral

Answer key on Page 100

96 THE OR CONNECTION
 Forms & Tools
PATIENT POSITIONING

1.
2.
3.
4.
29. 5.
6.

7.
8.

9.
10.
11.
26. 27. 28. 30. 31. 12.
Trandelenburg 13.

14.

15.
16.

17.

18.

19.

20.
33. 21.

22.

23.

24.
25.
32. 26.

27.

28.
29.
30.

34. 31.
32.
35. 36. 37. 38.
33.

Lithotomy 34.
35.

36.
37.

38.

Aligning practice with policy to improve patient care 97

 Policy & Procedure
PATIENT POSITIONING

Positioning the Surgical Patient

Excerpted from University of North Carolina Hospitals policy.

PURPOSE:
To outline the nursing management of the surgical patient during the process of
operative positioning.

LEVEL:
Shall be performed by surgeon and RN with assistance from support staff (*required MD order).

SUPPORTIVE DATA:
The patient’s position: (1) should provide optimum exposure and access to the operative site, while
sustaining body alignments, circulation and respiratory functions, and skin integrity; (2) must
provide access to the patient for adminstration of intravenous fluids, drugs, and anesthetic agents,
and (3) should afford as much comfort to the patient as possible.

Nurse needs to make the following assessments prior to starting the procedure.
• Assess patient’s size and identify any existing respiratory, skeletal,
or neuromuscular limitations.
• Determine position of choice by consulting surgeon’s preference card for the scheduled
procedure and/ or posting slip.

EQUIPMENT:
• Foam rings
• Eggcrate padding
• Wilson Frame
• Gel pads
• Bean bags (Vac-Pack)
• Laminectomy frame
• Bolster
• Horse shoe head rest

98 THE OR CONNECTION

Steps:
1. Do not allow instrument table, mayo stand,
or other equipment to rest on or put pressure
on patient.
2. Do not allow surgical team members to lean
on patient.
3. Avoid unnecessary exposure of patient before,
during, and after positioning.
4. Assure that all equipment/ supplies used are
clean and in working order.
5. Assure that proper side is exposed if
procedure is unilateral.
6. Move the patient only after the anesthesia care
team gives approval; move gently and slowly.
7. Provide adequate numbers of personnel for the
safe movement of the patient.
8. Do not abduct arms to greater that 90ˆ.
9. Place safety belt 2” above the knees and not
so tight as to impeded circulation. This will
provide optimum control of patient during
induction and emergence from anesthesia.
10. Assure that legs and / or ankles are not crossed.
11. Avoid having body surfaces in contact with
one another.
12. Assure that patient is not touching any exposed
table parts or hanging over sides.
13. Check catheters, tubes, and drains for patency
once patients is positioned.
14. Assure that kidney rest on OR bed is at
lowest position.
15. Place padding under heels and head. If foam ring
is used, do not remove foam from hole. Removing
the center could diminish circulation.
16. Position arms on arm board or secure under draw
sheet at patient’s side. Palms should either turned
toward the patient or turned down. Pad elbows with
towel or foam.
Aligning practice with policy to improve patient care 99
Policy & Procedure
PATIENT POSITIONING
17. Place a small pillow under calves supporting the
full length of the lower legs.
a. Care must be taken not to put pressure on
popliteal space.
b. This helps to minimize pain in patients with
low back pain.
18. Apply Anti-embolism stockings.
19. Place small sandbag or blanket roll under right
hip to relieve pressure on inferior vena cava in
patients who are obese, have large abdominal
masses or are pregnant.
Semi - Fowler’s Position:
20. Assure that hand(s) and arm(s) that have been
secured under draw sheet are free of excess
pressure created by flexing OR table.
Trendelenburg Position:
21. Move patients into and out of Trendelenburg’s
position slowly to avoid sudden changes in
blood pressure. Do not use Trendelenburg in
patients with increased intracranial pressure
or poorly controlled glaucoma.
Reverse Trendelenburg:
22. Use a padded foot board to support patient.
Lithotomy Position:
23. Assure that patient’s buttocks do not extend
over the break in the bed. Pad sacrum with
foam or other padding if necessary.
24. Raise and lower legs with knees together
simultaneously, very slowly, and never abduct
legs without first externallu rotating the hip.
25. Position thighs so they do not exert pressure
on the abdomen or groin.
26. Secure arms on arm-board or across abdomen.
27. Adjust and secure safety belt as in #9 above
before and after lithotomy position. The safety
belt should be secured over the thighs during
anesthesia induction and emergence. The
safety belt may be used over the abdomen
during the surgery if it does not get in the way
of the procedure (e.g. gynecological laparoscopy).
 Policy & Procedure
PATIENT POSITIONING

28. Pad legs at any points where they come in
contact with stirrup. Use safety straps if applicable.
Prone Position:
29. Provide chest rolls (bath blanket wrapped in
eggcrate foam) or laminectomy frame, a pillow
for under the feet and padding for ear, eyelids,
and cheeks.
30. Assure that there is no compression of female
breast (place laterally if necessary) or
male genitalia.
42. Stabilize patient using safety belt and/or 3”
adhesive tape across hips and secured to OR
Table. Assure that female breast and male
genitalia are free from compression.
43. Elevate head on folded towels and/ or foam
padding.
44. Do not allow kidney braces (if used) to come in
direct contact with patients.
45. Refer to owner’s manual if Vac-Pak is used.

31. Position arms either at patient’s side with palms
turned inward or upward or over the head on arm
boards. If positioned over the patient’s head, they
should be slowly lowered toward the floor and
brought up in an arc while the elbow is flexed.
Securely support the elbow and shoulder during
this movement.
32. Secure safety belt 2” above knees.
Frog-Leg Position:
46. Provide four to six folded blankets to elevate
and support knees and legs.
47. Secure feet to OR bed with 3” adhesive tape.
Protect feet from adhesive using folded towel.
Specialty Tables:
48. Refer to reference materials supplied
by manufacturers.

Lateral Position: Documentation:

33. Turn shoulders and hips simultaneously. There should
be a minimum of four persons helping with
this position.
34. Assure that the iliac crest is level with the break
of the bed if the patient will be flexed.
35. Flex lower leg at hip and knee. Allow upper leg to
remain straight.
Document implementation of procedure. Document on
Perioperative Standard Care Statement:
• Position of patient
• Type and location of padding
• Support used
• Radial pulse assessment (from item #41 above)
• Use of anti-embolitic devices and the
times(s) activated

36. Place pillow between knees and feet.

PRESSURE POINT ANSWER KEY
from pages 96-97.
37. Place padding or foam under bony prominences: 1. Heel 20. Shoulder
ankle, knee, hip. 2. Under strap 21. Hip
3. Occiput 22. Greater Trocanter
38. Secure upper arm with Kerlix roll on overbed 4. Dorsal thoracic area 23. Knee
arm-board (“airplane”) with elbow slightly flexed 5. Elbow 24. Lateral foot
and palm up. 6. Posterior knee 25. Ankle
7. Ankle 26. Occiput
8. Occiput 27. Dorsal thoracic area
39. Secure lower arm on arm-board with elbow slightly
9. Face 28. Elbow
flexed and palm up. 10. Shoulder 29. Under strap
11. Thoracic area 30. Posterior knee
40. Position lower shoulder slightly forward with 12. Elbow 31. Heel
axillary roll under axilla. 13. Hip 32. Ankle
14. Under strap 33. Lateral leg
41. Check radial pulses after positioning is completed. 15. Knee 34. Ischial tuberosity
16. Foot 35. Sacrum
17. Toes 36. Elbow
18. Occiput 37. Shoulder
19. Neck 38. Occiput

100 THE OR CONNECTION

 Recommended Practices
INDICATIONS FOR HAND HYGIENE

Hand Hand Use of a Handwash

Indication antisepsis antisepsis Use of gloves skincare with soap
before after lotion

When hands are visibly dirty or

contaminated with infectious material or
are visibly soiled with blood/ other body
fluids (incl. diarrhea)

Before eating

After using the restroom

Having direct contact with patients

Donning exam and sterile gloves

Inserting indwelling urinary catheters,

peripheral vascular catheters or other
invasive devices that do not require a
surgical procedure

Moving to a clean body site during

patient care when coming from a
contaminated body site

Contact with body fluids or excretions,

mucous membranes, non-intact skin
and wound dressings if hands are not
visibly soiled

Contact with patient’s intact skin

Removing gloves

Contact with inanimate objects (including

medical equipment in the immediate
vicinity of the patient

Before shift

After breaks

When required or desired

After shift and in leisure time as needed

*Gloves should be worn for all types of contact if the patients is on isolation precautions.

Aligning practice with policy to improve patient care 101

 Recommended Practices
INDICATIONS FOR HAND HYGIENE

Answer Key
Hand Hand Use of a Handwash
Indication antisepsis antisepsis Use of gloves skincare with soap
before after lotion

When hands are visibly dirty or

contaminated with infectious material or
are visibly soiled with blood/ other body
fluids (incl. diarrhea)

Before eating

After using the restroom

Having direct contact with patients *

Donning exam and sterile gloves

Inserting indwelling urinary catheters,

peripheral vascular catheters or other
invasive devices that do not require a
surgical procedure

Moving to a clean body site during patient

care when coming from a contaminated Change gloves
body site

Contact with body fluids or excretions,

mucous membranes, non-intact skin
and wound dressings if hands are not
visibly soiled

Contact with patient’s intact skin

*
Removing gloves

Contact with inanimate objects

(including medical equipment in *
the immediate vicinity of the patient

Before shift

After breaks

When required or desired

After shift and in leisure time as needed

*Gloves should be worn for all types of contact if the patients is on isolation precautions.

102 THE OR CONNECTION

 Safety Checklist
FORMS & TOOLS

Aligning practice with policy to improve patient care 103

MKT207354/LIT581/20M/WMP5