OR Connection Magazine - Volume 5 Issue 1

VOLUME 5, ISSUE 2
The
Aligning practice with policy to improve patient care
Volume 5, Issue 2
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THE OR CONNECTION
SSI Reduction
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The
OR Connection
Aligning practice with policy to improve patient care
Never miss an issue of The OR Connection!

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continue to receive this info-packed magazine and won’t miss You will need to provide:
out on our industry updates and articles addressing on-the- Your name
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We also welcome any suggestions you might have on how we can continue to improve
The OR Connection! Love the content? Want to see something new? Just let us know!
Content Key
We've coded the articles and information in this magazine to indicate which patient
care initiatives they pertain to. Throughout the publication, when you see these icons
you'll know immediately that the subject matter on that page relates to one or more of
the following national initiatives:
• IHI's Improvement Map
• Joint Commission 2009 National Patient Safety Goals
• Surgical Care Improvement Project (SCIP)
We've tried to include content that clarifies the initiatives or gives you ideas and tools
for implementing their recommendations. For a summary of each of the initiatives,
see pages 8 and 9.
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Editor
Sue MacInnes, RD, LD
PATIENT SAFETY
Clinical Editor
8 Three Important National Initiatives for Improving Patient Care
Alecia Cooper, BS, MBA, RN, CNOR
Senior Writer 12 New Joint Commission Report Shows Continued Improvement
Carla Esser Lake in Quality of Patient Care
Creative Director
13 The Joint Commission Tracer Methodology: Surgical
Mike Gotti
Site Infections
Clinical Team
Jayne Barkman, RN, BSN, CNOR 22 #2 on the Joint Commission List: Retained Foreign Objects Page 10
Margaret Falconio-West, BSN, RN, APN/CNS,
48 CAUTI Alert: Proceed with Caution
CWOCN, DAPWCA
Rhonda J. Frick, RN, CNOR
54 Reducing CAUTI with Bladder Ultrasound
Anita Gill, RN
Kimberly Haines, RN, Certified OR Nurse OR ISSUES
Jeanne Jones, RNFA, LNC
10 Ambulatory Surgery Center Quality Collaboration
Carla Nitz, RN, BSN
Connie Sackett, RN, Nurse Consultant Expands Mission
Claudia Sanders, RN, CFA 18 Indiana Surgeon Lowers Surgical Site Infection Rates Page 22
Megan Shramm, RN, CNOR, RNFA
Angel Trichak, RN, BSN, CNOR
30 Harm is Not an Option: Lessons from HROs
Perioperative Advisory Board 58 New Regulations for Infection Prevention in Ambulatory
Larry Creech, RN, MBA, CDT Surgery Centers
Carilion Clinic, Virginia
Sharon Danielewicz, MSN, BSN, RN, RNFA
SPECIAL FEATURES
St. Luke’s The Woodlands, Texas
Tracy Diffenderfer, RN, MSN
5 Let’s Talk About You! Survey
Vanderbilt University Medical Center, Tennessee 20 The Future is Now for New Learning Technologies Page 30
Barb Fahey RN, CNOR
42 Preparing Your Organization for Color-by-Discipline Uniforms
Cleveland Clinic, Ohio
Susan Garrett, RN
62 A State-of-the-Art Hybrid Program for the OR
Hughston Hospital Inc., Georgia 65 Never Lose Sight of Why We Are Nurses
Zaida I. Jacoby, RN, MA, M.Ed 68 Medline Hosts 5th Annual Breast Cancer Awareness Breakfast
NYU Medical Center, New York
Jackie Kraft, RN, CNOR
Huntsville Hospital, Alabama CARING FOR YOURSELF
Tom McLaren 74 Win-Win Negotiation: How to Get More of What You Want
Page 42
Florida Hospital, Florida
82 Healthy Eating: Syrian Salad
Donna A. Pritchard, RN, BSN, MA, CNOR, NE-BC
Kingsbrook Jewish Medical Center, New York
FORMS & TOOLS
Debbie Reeves, RN, CNOR, MS
Hutcheson Medical Center, Georgia 85 2009 AAAHC/CMS Crosswalk for Infection Control
Diane M. Strout, RN, BSN, CNOR 89 Pressure Ulcer Prevention Checklist: Perioperative Services
Chesapeake Regional Medical Center, Virginia
93 WHO Surgical Safety Checklist
Margery Woll, RN, MSN, CNOR
North Shore Shore University Health System, Illinois
Page 58
About Medline
Medline, headquartered in Mundelein, IL, manufactures and distributes more than Meeting the highest level of national and international quality standards, Medline is FDA
100,000 products to hospitals, extended care facilities, surgery centers, home care QSR compliant and ISO 13485 registered. Medline serves on major industry quality
dealers and agencies and other markets. Medline has more than 800 dedicated committees to develop guidelines and standards for medical product use including
sales representatives nationwide to support its broad product line and cost manage- the FDA Midwest Steering Committee, AAMI Sterilization and Packaging Committee
ment services. and various ASTM committees. For more information on Medline, visit our Web site,
www.medline.com.
©2010 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
Aligning practice with policy to improve patient care 3

THE OR CONNECTION I Letter from the Editor

Dear Reader,
Wow! This edition of The OR Connection is just full of You will also find updates on the activities of the
informative material! Ambulatory Surgery Center Quality Collaboration,
tracking surgical site infections using The Joint Com-
Beginning with the cover, let me introduce to you Dr. mission Tracer Methodology, and on pages 38 and 39,
Michael Turner, a neurosurgeon with Goodman Camp- some highly recommended books to read!
bell Brain and Spine in Indianapolis, Ind. We were
delighted to meet with Dr. Turner, who invited us to join As you know, for the past five years Medline has been
him in surgery to observe what he is doing to reduce an active supporter of breast cancer awareness.
surgical site infections. See page 18 for more information This year, once again, we hosted a Breast Cancer
or go to http://www.medline.com/turner-video to Awareness breakfast attended by the biggest crowd
“
view a short video clip of Dr. Turner describing his ever, over 1,200 people! Our guest speaker was Peggy
Medline is committed
techniques. Fleming, Olympic Gold Medalist from 1968 and a
to providing quality
breast cancer survivor. I can remember when she won;
Next, you’ll notice on the opposite page a fun survey the young girl in the chartreuse dress, winning the only products, educational
you can take online. We have survey information from gold medal from the United States at the Grenoble offerings and innova-
AORN attendees, but now we want to open it up to Olympics. Prior to the breakfast, I had the pleasure of tions to make your
”
everyone who reads The OR Connection. We will be interviewing Peggy Fleming. I was in third grade when job easier.
posting the survey results in our next edition and sharing she won, and now so many years later I was inter-
success stories from our readers on innovative viewing her for The OR Connection. Today, she is every
programs, initiatives and solutions in the OR! Can’t wait bit the person I remembered… graceful, calm and
to show you what we have so far. oh, so strong. Take a look at page 68 for highlights
from Congress.
Another part of the survey asks questions about tech-
nologies you use, such as cell phones and Blackberries Finally, I am so excited to show you our newest nurse
and iPhones. We have been taking a close look at how doll. She is the “Pink Glove Doll,” and her name is Deb.
our lives have changed and continue to change based Deb is a true inspiration of the caring spirit we have
upon new and exciting technology releases. We know inside and the support we bring to such a great cause.
that as more and more new nurses and physicians Take a closer look at Deb on page 73.
enter the work force, the way they communicate may
be much different from someone who has been in Medline is committed to providing quality products,
health care for 25 or 30 years. educational offerings and innovations to make your job
easier. We want to continually lead the way in developing
It is important that the industry keeps in step with the cost-effective, safe and practical solutions. There are a
rest of our culture, so we are excited to announce that host of things on the horizon, and we are excited to
Medline has just released its first-ever iPhone app. It’s hear your reaction.
on Medline University now, and it’s FREE! You can
download the app on your iPhone or iPod Touch. Some Please call or e-mail me any time! I’d love to hear
of the app features include real-time industry news, from you.
video courses, audio download courses, competencies
and the list goes on. Now learning can be fun and
interactive! Medline University “students” also have the
ability to report completed courses to their employer. Sue MacInnes, RD, LD
Learn anywhere, anytime! How’s that for keeping up Editor
with the times?
On the cover:
Indianapolis neurosurgeon Michael Turner, MD,
applies Arglaes after closing a surgical incision.
4 The OR Connection
Let’s Talk About Special Feature
You!
All winne
will be featu rs
upcoming is red in
sues of
The OR
Connection
!
Step 1: Complete the Survey!

The first 1000 survey submissions will receive the latest
and greatest addition to our Medline Doll collection.
Results of the survey will be published in the next

issue of The OR Connection!
Step 2: Answer the Bonus Question!

In 50 words or less, describe an innovative program, initiative and/or
solution implemented at your facility that made a significant impact
on quality and patient/resident care.
First Prize
The entire Medline Doll collection
A plaque awarding the 2010 Contribution to The OR Connection!
Second Prize
There will be several second place award winners, who will all
receive the entire Medline Doll collection.
Everyone
can be a winner!
You can submit the survey three ways:
1. Complete the survey online at
www.medline.com/orconnection
2. Manually complete the survey, tear it out
and fax it to 847-949-3073.
3. Mail it back to us at Medline Industries, Inc.,
One Medline Place, Mundelein, IL 60060
Attn: Marketing Department – The OR Connection
MEDLINE HEALTHCARE SURVEY Let’s talk about you!
1. Tell us about yourself 5. What are your top three priorities? 10. Are the number of Foley catheters
Name ________________________________ placed for surgical procedures increasing
1. __________________________________
or decreasing at your facility?
Credentials (i.e., RN, LPN, etc.)______________ 2. __________________________________
3. __________________________________ ❏ Increasing ❏ Decreasing
Facility ______________________________
❏ Staying the same
Street Address ________________________ 6. Which of the following is most helpful
in improving patient care? 11. Circle your top three worst custom
City/Town ____________________________
procedure tray experiences below:
State/Providence ______________________ ❏ Continuing Education
❏ Competency 1. Unauthorized changes/situations
Zip/Postal Code ________________________
2. Delays in requested change
Phone ( ) ________________________ 7. How often do you believe education 3. Running without - supply(ies) missing from
is transferred by the clinician to kit/tray
E-mail ______________________________
bedside practice? 4. Foreign body found in tray (e.g., insect,
2. Where do you work? hair, etc.)

❏ 0% – 20% ❏ 61% – 80% 5. Inventory supply out
❏ Hospital ❏ 21% – 40% ❏ 81% – 100% 6. Waste (unused items)
❏ Surgery Center ❏ 41% – 60% 7. Wrong items/missing items (e.g.,
❏ Other (please specify) non-radiopaque sponges/miscounted
8. Which staff member are you most sponges)
concerned about when it comes to
implementing the necessary changes
3. Number of beds at your facility? 12. Do you see perioperative pressure
at your facility to be successful?
ulcers as a problem in your facility?
❏ < 100 ❏ 350-499
❏ Nursing
❏ 101-199 ❏ 500+ ❏ Yes ❏ No
❏ Aides/Technicians
❏ 200-349
❏ Managers
13. Do you have a facility protocol
❏ Physicians
4. What is your job title? for prevention of perioperative
❏ Other (please specify)
pressure ulcers?
❏ Chief Nursing Officer (CNO)
❏ Director of Nursing (DON) ❏ Yes ❏ No
❏ Staff Nurse - OR 9. What medium would you like to
❏ Staff Nurse see education materials offered in? 14. How much time do you spend on
❏ Staff LPN - OR (Choose all that apply) perioperative pressure ulcers during new
❏ Staff LPN employee orientation?
❏ OR Nurse Manager ❏ Online (e-Learning)
❏ OR Aide/Technician ❏ Written
❏ VP/Director of Perioperative Services ❏ Audio
❏ Wound Care Nurse ❏ Video/CD/DVD 15. What percentage of time do you feel
❏ Clinical Educator - OR ❏ Live Presentation the facility protocol is followed?
❏ Risk/Quality Manager ❏ Webinar
❏ Other (please specify) ❏ 25% ❏ 75%
❏ Aide/Technician
❏ 50% ❏ 100%
❏ Other (please specify)
6 The OR Connection
16. Do you currently have protocols in

place for handoff communication?
Bonus Question:
❏ Yes ❏ No (For a chance to win the entire Medline Doll Collection)
Everyone whose answer is chosen for publication in The OR Connection
will receive the collection.
17. What is your facility’s pressure ulcer
incidence? In 50 words or less, describe an innovative program, initiative and/or
solution implemented at your facility that made a significant impact
on quality and patient care.
18. What are your biggest barriers to

pressure ulcer prevention in the OR?
19. Has your organization ever been

involved in a legal suit involving
pressure ulcers?
❏ Yes ❏ No
20. Have you personally ever been

involved in a legal suit involving
pressure ulcers?
❏ Yes ❏ No
21. Which of the following technologies

do you have? (Check all that apply)
❏ PDA (Blackberry®, Palm®, iPhone®)

❏ Cell phone
❏ iPod®/mp3
❏ DVD player
❏ CD player
❏ Electronic reading device (Kindle®,
Sony®, iPad®)
❏ Computer
Submit your survey online at:
www.medline.com/orconnection
22. If you checked PDA, what type do
Blackberry is a registered trademark of Research
In Motion Limited
you have?
Palm is a registered trademark of Research In
Motion Limited
❏ iPhone® ❏ Droid™ iPhone is a registered trademark of Apple Inc.
iPod is a registered trademark of Apple Inc.
❏ Palm ®
❏ Other Kindle is a registered trademark of Amazon
Technologies, Inc.
❏ Blackberry® Sony is a registered trademark of Sony Corporation
Droid is a trademark of Lucasfilm Ltd.

Three Important National Initiatives

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

Origin: Launched by the Institute for Healthcare Improvement (IHI) in January 2009
Purpose: To help hospitals improve patient care by focusing on an essential set of processes needed to
achieve the highest levels of performance in areas that matter most to patients.
Hospitals sign up through IHI and can choose to implement some or all of the recommended interventions.
IHI provides how-to guides and tools for all participating hospitals.
The IHI Improvement Map covers the entire landscape of outstanding hospital care to help hospitals make sense of countless requirements
and focus on high-leverage changes to transform care. There are 70 processes grouped into three domains: leadership and management,
patient care and processes to support care.
2 Joint Commission 2010 National Patient Safety Goals

Origin: Developed by Joint Commission staff and the Patient Safety Advisory Group
(formerly the Sentinel Event Advisory Group)
Purpose: To promote specific improvements in patient safety, particularly in problematic areas
Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission offers
guidance to help organizations meet goal requirements.
Over the next year, the current National Patient Safety Goals (NPSGs) will undergo an extensive review process. As a result,
no new NPSGs will be developed for 2010; however, revisions to the NPSGs will be effective in 2010.
3 Surgical Care Improvement Project (SCIP)

Origin: Initiated in 2003 as a national partnership. Steering committee includes the following
organizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the
Joint Commission
Purpose: To improve patient safety by reducing postoperative complications
Goal: To reduce nationally by 25 percent the incidence of surgical complications by 2010
SCIP aims to reduce surgical complications in three target areas. Participating hospitals collect data on specific process and
outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgical
complications annually (just in Medicare patients) by getting performance up to benchmark levels.
8 The OR Connection
Patient Safety
IHI Improvement Map: 70 Processes to Transform Hospital Care

The IHI Improvement Map is an online tool that distills the best knowledge available on the key process
improvements that lead to exceptional patient care.
Top 5 Key Processes Viewed by Improvement Map Users Top 5 Key Processes Shared by Improvement Map Users
1. Acute Myocardial Infarction (AMI) Core Processes 1. Central Line Bundle
2. Set Direction: Aims 2. CA-UTI
3. CA-UTI 3. Anti-Biotic Stewardship
4. Communication and Teamwork 4. Falls Prevention
5. Central Line Bundle 5. Heart Failure Core Processes
To learn more about the IHI Improvement Map and the 70 processes to transform hospital care, go to www.ihi.org/imap/tool
Joint Commission 2010 National Patient Safety Goals

• Improve the accuracy of patient identification. • The organization identifies safety risks inherent in
• Improve the effectiveness of communication its patient population.
among caregivers. • Universal Protocol for Preventing Wrong Site,
• Improve the safety of using medications. Wrong Procedure, and Wrong Person Surgery.™
• Reduce the risk of healthcare-associated
infections.
• Accurately and completely reconcile medications No new NPSGs have been developed for 2010.
across the continuum of care. Effective January 1, 2010, organizations are expected
• Reduce the risk of patient harm resulting from falls. to have fully implemented the requirements related to
• Prevent healthcare-associated pressure ulcers healthcare-associated infections established in 2009.
(decubitus ulcers).
To learn more about National Patient Safety Goals, go to www.jointcommission.org.
Surgical Care Improvement Project (SCIP): Target Areas

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

(Left to right) David Shapiro, MD,

Donna Slosburg, BSN, LHRM, CASC
and Kimberly Wood, MD of the ASC
Quality Collaboration.
“ Our goal is to help ASCs learn about the new regulations and
supplement their existing infection control programs with
helpful tools and resources for key infection control processes.
”
10 The OR Connection
OR Issues
Ambulatory Surgery Center

Quality Collaboration
Expands Mission
Back in 2006, when the Ambulatory Surgery Center (ASC) Qual- Starting in 2008, the data became publicly available. The
ity Collaboration was created, its mission was – as it is now – to National Quality Forum has endorsed these measures, and the
improve the quality of care and safety in ambulatory surgery cen- data – updated quarterly – can be found on the ASC
ters. In the four years of its existence, it has quite an impressive Quality Collaboration website at www.ascquality.org.
list of accomplishments.
The data is currently being collected on these measures from
According to co-chairs David Shapiro, MD, and Kimberly Wood, approximately 1,000 ASCs nationwide through the following
MD, when the collaboration began, one of its main initiatives was organizations: Ambulatory Surgery Center Association,
to identify a standardized set of quality measures appropriate to Ambulatory Surgical Centers of America (ASCOA), AmSurg,
ASCs. Like other segments of health care, such as hospitals, the HCA Ambulatory Surgery Division, National Surgical Care (NSC),
goal was to develop specific quality measures by which individual Nueterra, Surgical Care Affiliates (SCA), Symbion and United
ASCs could measure or benchmark themselves in order to Surgical Partners International (USPI).
improve quality of patient care. At the time, there were no
nationally endorsed ASC benchmarking measures, though the “We hope ASCs look at the data,” said ASC Quality Collabora-
Ambulatory Surgery Foundation had a successful comprehensive tion Executive Director Donna Slosburg, BSN, LHRM, CASC,
data collection instrument available for some time. “and see where they stand with these industry benchmarks
to ensure they are achieving a high level of quality.”
The leadership also had the vision to be the first healthcare
entity to voluntarily report data on its own industry to publicly The Collaboration’s most recent project stems from revised ASC
show its commitment to quality. The data also could be used in Conditions for Coverage, which CMS implemented on May 18,
“discussions on pay-for-performance, responding to state data 2009, and which represent the first significant changes to the
collection initiatives, collaborating with payors and others in Conditions since 1982.
providing consumer information, and benchmarking information
primarily for quality improvement goals in individual ASCs.” Dr. Wood explained these new changes would expand the
scope of the CMS surveys. Among the changes in the Condi-
But what they found, according to Dr. Shapiro, was that none of tions for Coverage were new requirements for infection control.
the existing quality measures in healthcare fit exactly with ASCs. Surveyors would now have a specific tool to gather information
“Now we had to become developers of quality measures,” on infection control practices in ASCs.
said Dr. Shapiro. Consensus of the leadership group was to
initially focus on patient safety-related measures. “The surveyors are now looking at the infection control practices
of ASCs more intensely and with much more scrutiny than ever
The ASC Quality Collaboration worked with several before,” Dr. Wood said. “Our goal is to help ASCs learn about the
industry groups to study and then develop the following new regulations and supplement their existing infection control
initial ASC facility-level performance measures: programs with helpful tools and resources for key infection
• Patient Falls in the ASC control processes.”
• Patient Burns
• Hospital Transfer/Admission
• Wrong Site, Side, Patient, Procedure, Implant
• Prophylactic IV Antibiotic Timing
• Appropriate Surgical Site Hair Removal

Patient Safety
New Joint Commission Report

Shows Continued Improvement
in Quality of Patient Care
Hospitals accredited by The Joint Commission continue to improve quality of patient care, according to the
recently released Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety
2009. The fourth annual report shows continual improvement over a seven-year period (2002-2008) on 12
quality measures reflecting the best evidence-based treatments – practices demonstrated by scientific
evidence to lead to the best outcomes. The magnitude of national improvement on these measures ranged
from 4.9 percent to 58.8 percent. Surgical measures in all three areas of antibiotics administration have shown
a steady improvement from 2005 to 2008. (See chart below.)
Improved quality saves lives, improves health and reduces costs

“In addition to saving lives and improving health, improved quality reduces health care costs by eliminating
preventable complications,” said Mark R. Chassin, MD, MPP, MPH, president, The Joint Commission.
“Quality improvement is an important aspect of the ongoing reform effort to make health care accessible to
more Americans and ‘bend the curve’ on increasing costs. By eliminating the preventable complications that
today drive up the cost of care, we would easily save the many billions of dollars lawmakers are struggling so
hard to locate.”
Surgical Care Measures

National Performance Summary, 2005-2008
2005 2006 2007 2008
Antibiotics within one hour before the first surgical cut 81.8% 86.6% 89.5% 93.5%
Appropriate prophylactic antibiotics N/A N/A 94.9% 96.8%
Stopping antibiotics within 24 hours 73.5% 79.1% 85.6% 90.5%
Source:
Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2009. Available at:
http://www.jointcommission.org/NR/rdonlyres/22D58F1F-14FF-4B72-A870-378DAF26189E/0/2009_Annual_Report.pdf
Patient Safety
The Joint Commission

Tracer Methodology:
Surgical Site Infections
Connie Yuska, RN MS CORLN
The Joint Commission introduced the tracer methodology into the

survey process in 2004. The purpose behind the tracer methodology is to
help the surveyor assess the facility’s compliance with selected standards and
evaluate systems for providing care and services. When using the tracer method-
ology, the surveyor selects a patient, resident or client, and then, using the
medical record as a road map, follows that individual through the facility.
As surveyors trace a patient’s path of care, they may identify compliance issues
in one or more elements of performance. The process allows the surveyor to
identify trends in compliance that may point to potential system-level issues.

Emergency
Tracer Methodology in Action

Radiology
OR
Patient Room
Recovery
One example of a tracer that touches several hospital depart-

ments is surgical site infection (SSI). Having effective infection
control and prevention policies in place is critical to providing
safe, quality patient care. Following patients through their
hospitalization can help the organization assess the overall
quality of care provided and make improvements if gaps
are uncovered.
ICU
Infection control system tracers are applicable in any health-
care setting and are linked with National Patient Safety Goal
07.05.01. This patient safety goal asks that hospitals and
The tracer process requires a healthcare organization to work ambulatory healthcare organizations “implement evidence-
as a team rather than prepare one particular area for a Joint based practices for preventing surgical site infections” and
Commission survey. In addition, it enables the organization to require compliance with the following elements of performance:1
quickly identify issues related to communication between • Educate surgical staff, licensed independent practitioners,
departments. Organizations have found that this process patients and families about SSIs and SSI prevention.
results in less time spent on document review and more time • Implement policies and procedures to reduce the risk
spent on actual observation of what happens to a patient as of SSIs.
they move through the organization. The information collected • Measure SSI rates and provide process and outcome
from the tracer process is invaluable, as it gives the organi- measure results.
zation a roadmap for identification of potential breakdowns in • Conduct periodic risk assessment, check SSI measures,
care. This provides the opportunity to focus on improving monitor compliance, and evaluate effectiveness.
processes to help ensure patient safety and provide high • Administer prophylactic antimicrobial agents.
quality care. • Use only clippers or depilatories for hair removal.
Now available from Joint

Commission Resources!
Mock Tracer Workbook
Tracer methodology is the most

prevalent part of The Joint Com-
mission and Joint Commission
International on-site accreditation survey process. So what’s
the best way for health care professionals to learn about
tracers? Practice.
Let’s take a look at a typical tracer that involves a patient who The Mock Tracer Workbook provides practical exercises to
was admitted to a community hospital through the same-day help healthcare professionals practice skills needed to conduct
surgery area, entered the operating room for a left hip an effective tracer in any healthcare setting. During an on-site
replacement and two days after surgery was discovered to survey, surveyors use tracers to evaluate the care of an indi-
vidual or to evaluate a specific care process as part of a system.
have an SSI.
By doing so, the tracer provides an accurate assessment of
the daily functions at a healthcare organization.
The surveyor typically begins the tracer in the area where the
patient is currently located and receiving post operative care,
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in this case, on the orthopedic unit. Questions that the Mock Tracer Workbook
surveyor may ask the staff nurse include the following: Price: $89
• How did you assess the patient for SSI risk factors Item number: MTW09
associated with orthopedic surgery? ISBN: 978-1-59940-306-9
• What did you do when you suspected the patient had 148 pages
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• What is the process to receive orders for and To order, call 877-223-6866 (M-F, 8 am to 8 pm Eastern time),
administer prophylactic antibiotics? or online at www.jcrinc.com/Books-and-E-books/Mock-Tracer-
• What education was provided to the patient about his Workbook/1637.
surgery and SSI prevention?
• What is your hospital’s SSI prevention plan?
• How do you monitor for SSIs after surgery?
Questions for the staff in the operative area may possibly
• How do you conduct and document assessments after
include the following:
a patient has surgery?
• Describe how you prepare the patient’s surgical site.
• How are the patient and their loved ones told about an SSI?
• What is your organization’s policy on hair removal?
• What type of ongoing training do you receive about
On prophylactic antibiotic use?
preventing SSIs?
• How would you care for a patient with a
preoperative infection?
The next step would be to follow the path that the patient took
• Describe your staffing levels.
two days earlier into the operating room suite. The entire
• What and how do you communicate when the patient
operative process as it relates to SSI prevention should be
transitions out of the operating room to the post
traced. Specific measures in the pre-, peri- and postoperative
anesthesia recovery room?
areas can be examined to determine their effectiveness in
• What is the organization’s SSI reduction program?
preventing SSIs.

Using a focused approach like the tracer

methodology allows you to examine your
organization from the patient’s perspective.
The surveyor may then ask the patient if she could ask him a The surveyor may ask the infection preventionist the following
few questions about his hospital experience. The patient may questions:2
express concern about the infection, but hopefully the surveyor • What policies and procedures are implemented regarding
will hear that the physician has explained how the infection SSI prevention?
occurred and what is being done to treat it. • What data do you collect regarding SSIs?
• How do you evaluate the data and communicate to
The next step for the surveyor would be to conduct a broader key stakeholders in the organization?
system-based infection control tracer. At this point, the infec- • How often are the data communicated?
tion preventionist would share their surveillance data related to • What kinds of improvements have you implemented as
SSIs. The surveyor would ask how this data is communicated a result of your data collection and analysis?
to key stakeholders and what kinds of risk assessments are • What kind of initial and ongoing training about SSIs is
performed. The surveyor will be looking for an ongoing process provided to surgical staff?
that is effective in reducing surgical site infections.
Using a focused approach like the tracer methodology allows
you to examine your organization from the patient’s perspec-
tive. This can provide valuable information about your systems
and processes and can help you make improvements that will
improve the quality and safety of the care that you provide.
References
1. 2009 Hospital Accreditation Standards. Oakbrook Terrace, IL : Joint Commission
Resources, Inc.; 2009.
2. Tracer methodology 101: infection control tracer—surgical site infection focus.
The Joint Commission: The Source. 2010; 8(3):6-10.
ARGLAES IN THE OR
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• Non-attaining assay • Arglaes Island features a calcium alginate pad for fluid
• Transparency for wound monitoring management in addition to controlled-release silver.
To schedule a FREE demonstration of Arglaes

in your OR, contact your Medline representative,
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OR Issues
Indiana Surgeon Reduces

Surgical Site Infections with
Optifoam and Arglaes
Neurosurgeon Michael Turner, MD, was looking for a way
to reduce surgical site infections in his patients at Park Nicol-
let Methodist Hospital’s Surgery Center in Indianapolis, Ind.
Most of his surgeries involve implanting morphine pumps,
spinal cord stimulators and shunts. He found the solution in
Medline’s Optifoam and Arglaes wound dressings.
Dr. Turner explained that if an infection develops in an implant

patient, it often means having to perform a second surgery,
discarding a $20,000 to $30,000 device, plus the expense to
replace the implant. Not to mention the patient having to
endure not only an infection and related physical deficits, but
also the trauma of another surgery.
“So infection avoidance is really very important to us,” Dr.

Turner said.
Dr. Turner and his team had always applied surgical prep to
the patient’s skin to lower colony-forming units, followed by an
iodine-impregnated drape. But the challenge was finding a
way to destroy and avoid spreading the infection-causing Dr. Turner also uses Arglaes surgical wound dressings to lower
organisms that emerge when the hair follicles and sweat the rate of abscess infections at suture sites. He said the
glands are exposed after making the surgical incision. antimicrobial silver and creation of an anaerobic environment
combine for good wound healing.
Surgical staff next have to touch the organism-laden incision to
make room for the implant. In the process, they pick up Before using Optifoam and Arglaes, study data from Methodist
organisms on their gloved hands, which then transfer onto the Hospital Surgery Center showed high infection rates among
implant, further spreading the organisms in the process. patients with pump implants. Dr. Turner said these rates
declined significantly after using Optifoam and Arglaes. He also
“So we needed to put a barrier there,” Dr. Turner said. “A num- found greatly reduced infection rates in one of the most high-
ber of studies have shown it only takes 100 organisms to risk groups of stimulator implant patients: obese smokers.
develop a clinical infection. Trying to get rid of the 100 organ-
isms is really where we’re aiming – and Optifoam does that.” “We’ve continued to use Optifoam long after our study, and
really find that our infection rate continues to drop as we
Dr. Turner applies Optifoam to the edges of the incision sec- become better at putting it on earlier and maintaining that
onds after making the cut. “We found that Optifoam has a environment of not touching the skin with our gloves at any
great consistency, and it contains silver to kill organisms.” time,” Dr. Turner concluded.
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1. Data on file.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. www.medline.com
The Future
is NOW
for New Learning
Technologies
Don’t get left behind!
Advances in technology have resulted in numerous online Other colleges and universities are catching on to the
educational opportunities that are both free and easy to iPhone as an educational tool as well. Students enrolled in
access. In fact, electronic learning tools have nearly elimi- the undergraduate journalism program at the University of
nated the need to actually attend a class for continuing Missouri are required to have an iPod Touch® or an iPhone
education. Online webinars, e-textbooks and podcasts are to download course material.2 And the Blackboard app is
just a few of the options. And how about iPhone® apps? gaining popularity at many high schools and colleges as a
way to post assignments, grades, documents, discussion
Beginning with the 2008-2009 school year, all incoming boards and anything else associated with a course.3
freshmen at Abilene Christian University in Texas are
required to have an iPhone. Apps are used to turn in home- Posted on wired.com by: Panacea | 12/8/09 | 6:04 pm1
work, look up campus maps and check class schedules The community college where I teach nursing piloted giving
and grades. For classroom participation, there’s even iPods to students a few years ago, with the idea of using
polling software so students can digitally raise their hand to iTunes U. They like being able to replay lectures. I don’t do
answer questions.1 a traditional lecture in class anymore. The students down-
load their lectures. Class time is for interactive assignments
William Rankin, a professor at Abilene Christian, comments, such as care mapping, case studies, and discussion. Stu-
“This is a question of how do we live and learn in the 21st dents still get to ask questions about the iTunes content.
century now that we have these sorts of connections? Grades have been steadily improving over the last 3 years
I think this (the iPhone) is the next platform for education.”1 since I’ve moved to iTunes U. Retention has improved 15%.
Special Feature
Teaching & Learning: THE PRINT AGE Teaching & Learning: THE DIGITAL AGE
Course activity typically focuses on presentation of infor- Course activity typically focuses on students contextualizing,
mation with students contextualizing, practicing or using practicing, or using information with presentation of infor-
information at home. mation occurring at home through media or online access.
The classroom is the primary site of access to course con- Access to course content is augmented by electronic
tent, and access is often “linear” – students cannot typically sources and media, and access is often recursive or
return to previous class presentations. “on-demand,” allowing students to return to content when
and as often as they’d like.
Students and teachers have access to one another prima- In addition to classroom access, students and teachers
rily in the classroom. have access to one another via “virtual” means – online
discussions, e-mail, chat, social networking, etc.
Source: Dr. William Rankin, “Abilene Christian University 2008-09 Mobile-Learning Report.” Available at: http://www.acu.edu/technology/mobilelearning.
References:
1. Chen BX. How the iPhone could reboot education. Wired – Gadget Lab. Available at: http://www.wired.com/gadgetlab/2009/iphone-university-abilene. Accessed March 29, 2010.
2. Dignan L. Apple’s iPod Touch, iPhone as education tool: should universities dictate whether you’re a Mac or PC? Available at: http://blogs.zdnet.com/BTL/?p=17775. Accessed March 29, 2010.
3. The Next Generation of Educational Leadership: A blog for educational leaders who want to learn, share and discuss 21st-century education leadership strategies. March 29, 2009. Available at:
http://nextgeneduleaders.blogspot.com/2009/blackboard-app-for-iphone-great-tool.html. Accessed March 31, 2010.

Patient Safety
Back to Basics Twelfth in a Series
#2 on the Joint Commission List:

Retained Foreign Objects 4
By Alecia Cooper, RN, BS, MBA, CNOR
“Foreign objects like sponges, scalpels and surgical instru- Whether or not you have been part of a retained objects
ments should never be left in the body cavity after an oper- lawsuit, it’s important to know that the issue of retained
ation. Surgeons who commit this serious and completely foreign objects (RFOs) is a serious, preventable complication
avoidable medical error must be held accountable. At Fried- that is increasing in incidence and complexity.
man, Domiano & Smith, our lawyers file medical malprac-
tice lawsuits in Ohio courts, calling attention to this serious The California Department of Public Health reported 141
problem and working to achieve the best possible results retained foreign objects in patients during fiscal year 2007-
for our clients. To talk confidentially about how a retained 2008, and the count increased to 196 for 2008-2009. In
object has affected you, contact the law offices of Friedman, addition to sponges, found objects included catheters,
Domiano & Smith.”1 dentures, drill bits, electrodes and screws.5
The Joint Commission considers retention of a foreign body

“Admitted to a Macon, GA, hospital in 2004 for surgery for a sentinel event. They recommend taking the following steps
diverticulitis of the colon, Lucille Davis, then 67, left with an if a foreign object is retained in the patient:6
undetected and dangerous souvenir: a surgical sponge. • Report the incident according to state regulations
The error resulted in a $10 million settlement.”2 • Report the incident to the Joint Commission. Although
this step is not mandatory, unreported sentinel events
can adversely affect accreditation.
“These cases require a thorough understanding of appro-
• Conduct a root cause analysis to thoroughly investigate
priate operating room procedures and the various roles of
how and why the situation occurred.
the surgeons and surgical nursing staff. At Williamson &
• Develop a detailed action plan to prevent similar
Lavecchia, L.C., our attorneys have successfully handled
occurrences in the future
many cases involving retained objects during surgery.
Examples include sponges left during surgery to remove a
For FY 2007, CMS recorded 750 incidents of foreign
gallbladder, a hysterectomy, and a Cesarean section. In
objects retained after surgery, which incurred an average
each case, the patient required further surgery, lengthy
cost of an additional $63,631 per case. As of October 1,
recuperation and the patient incurred significant medical
2008, CMS introduced new regulations that deny reim-
expenses.”3
bursement for healthcare expenses related to retained for-

eign objects and other hospital-acquired conditions.7 It’s still Another study found that 88 percent of retained foreign
too soon to tell whether this measure will help reduce the objects were associated with a count that was thought to
incidence of these conditions.7 be correct. Similarly, a study by Cima et al. showed that 62
percent of retained foreign object cases involved a correct
Reasons for RFOs sponge, sharp and instrument count.9
With sponge counting as a routine procedure in most ORs,
and heightened awareness of patient safety, why are for- In a study looking at the reasons for count discrepancies,
eign objects continuing to be retained after surgery? Several 41 percent of the discrepancies were attributed to human
studies suggest possible explanations. errors involving addition mistakes, incorrect documentation
or miscounting. For these reasons, the American College
A 2003 study by Gawande et al. reviewed medical records of Surgeons (ACS) and the Association of periOperative
associated with a retained surgical sponge or instrument Registered Nurses (AORN) recommend methodical wound
between 1985 and 2001. The study included 54 patients exploration in addition to a surgical count.9
and a total of 61 retained foreign bodies.8 Findings showed
that patients with retained foreign bodies were more likely to
have had emergency surgery or an unexpected change in
surgical procedure. These patients also had a higher mean
body mass index (BMI) and were less likely to have had
counts of sponges and instruments performed during their
surgery.
In another study that reviewed 191,168 operations per-

formed at the Mayo Clinic from 2003 to 2006, there were 34
cases of retained foreign objects discovered after the pa- Factors that affect surgical count accuracy6
tient left the OR. Root cause analysis of the events showed • Failure to develop and implement an effective policy
the most common contributing factor was breakdown in and procedure for surgical counts
communication, particularly failure of team members to • Failure to follow the policy and procedure
communicate when an item was placed in the body.9 • Disruptions during the performance of surgical counts
• Change in personnel during a procedure and the lack
Ways to avoid RFOs of proper handoff
The two most frequently used methods to try to prevent • Staff fatigue, especially during lengthy and emergency
retained foreign objects are counting sponges, instruments cases
and sharps before and after surgery and X-raying the body • A knowledge deficit about performance of surgical
cavity before a procedure closes. (OR sponges and towels counts by any team member
often contain X-ray detectable material inside for this purpose.) • Failure to use X-ray detectable items (such as sponges)
• Failure to count all components of an instrument (all
Despite these measures, many studies have shown foreign removable parts) and failure to inspect all items for
objects being found inside the body after surgery in a sig- completeness (a broken needle, for example)
nificant number of cases in which counts were performed
and reconciled or radiographs came up negative for foreign
bodies before closing. A few of these studies are summa- Innovative products to minimize the risk of RFOs
rized below. In addition to the use of X-rays to detect surgical objects
inside the body, medical device companies have developed
In 2008, 1,564 reports received by the Pennsylvania Patient several options to minimize the retention of foreign objects
Safety Authority involving incorrect sponge, sharps or and assist with surgical counts. New systems such as these
instrument counts indicated that a radiograph was are recommended by the Pennsylvania Patient Safety
performed. In 1,123 (71 percent) of those reports, the radi- Authority as additional safety measures and technological
ograph was negative for a retained foreign object.9 support to further reduce the risk of retained foreign objects.9
Integrated laparotomy pad/retractor.10 This device is

composed of an outer lap pad consisting of 12 layers of
absorbent cotton wrapped around a malleable inner stain-
less steel mesh. The device reduces the use of individual
pads while also providing needed retraction. It may be
shaped to the individual needs of the operating field, pro-
viding excellent exposure while also reducing the risk of re-
tained foreign bodies. In addition, the radiologic image of
the laparotomy pad/retractor is significantly more radio-
opaque that a traditional lap pad, providing a greater sense
of security that the device will be detectable by X-ray.
RFID.11 The RFID (radiofrequency identification) system

consists of a mobile console with an electronic monitor
screen, a scanning surface for counting sponges “in” and
a waste bucket for counting sponges “out.” Each RFID
sponge has its own unique identification tag sewn into it,
which the system reads. Sponge counts are then displayed
on the monitor in real time. Also included is a wand that
may be passed over the patient’s body to detect sponges
before the case is closed.
Developers of the RFID system note that the idea for the
device was conceived by an operating room nurse. After
conducting observations in operating rooms across the
country, the nurse concluded that sponge counts were
problematic in every surgery. Therefore, the RFID system
was created with an internal counting mechanism to safe-
guard against miscounts.
RF.12 The RF system is similar to the RFID system, but it

consists of a wand device only, which is passed back and
forth and side to side over the patient’s body to detect
sponges before the case is closed. It can also be used to
scan the floor and other surfaces for missing sponges. The
system consists of three components: a handheld scan-
ning wand connected to a compact, self-calibrating con-
sole and micro RF tags that are embedded in surgical
gauze, sponges and towels.
Bar codes. Similar to the electronic RF and RFID tags, bar

codes are placed inside sponges as a tracking mechanism.
An individual data matrix code is embedded onto each
sponge. Each sponge is scanned by a handheld computer
before being placed into the patient and after surgery is
completed.13

In a study to determine the effectiveness of bar codes,14 References

1. When retained objects injure Ohio patients. Friedman, Domiano, Smith Co., L.P.A.
a total of 33 incidents of misplaced sponges were website. Available at: http://www.fdsmedicalmalpractice.com/Surgical_Errors/
Retained-Objects.shtml. Accessed March 26, 2010.
detected. Of those misplaced, 30 sponges were found in 2. Japsen B. Technology cuts risks of surgical sponges: objects left in patients
the trash, under drapes, on the floor or elsewhere on the expensive to remove. January 1, 2008. BlueCross BlueShield website. Available at:
http://www.bcbs.com/news/national/technology-cuts-risk-of-surgical-sponges-
sterile field outside the patient. The remaining three objects-left-in-patients-expensive-to-remove.html. Accessed March 5, 2010.
3. Williamson & LaVecchia, LC website. Available at:
sponges were found inside the patient. The bar code sys- http://www.wllc.com/practice_areas/retained-objects-from-surgery.cfm.
tem was found to be more effective than manual counting Accessed March 5, 2010.
4. Updated sentinel event statistics. Joint Commission Online. April 7, 2010. Available
for the detection of sponges; however, it also takes longer at: http://www.jointcommission.org/NR/rdonlyres/9621C0D4-0222-465A-B4A5-
069FBB2169ED/0/jconlineApril710.pdf. Accessed April 12, 2010.
than manual sponge counting, according to the study. 5. Clark C. Surgeons still forgetting to remove objects from patients. Health Leaders
Media. February 1, 2010. Available at: http://www.healthleadersmedia.com/
QUA-245777/Surgeons-Still-Forgetting-To-Remove-Objects-from-Patients.
What does the future hold? Accessed March 5, 2010.
6. Campione BA. Know the risk factors for retained foreign bodies. OR Nurse. July
Although technology has focused mainly on the detection 2009:56.
of sponges, methods for detecting surgical instruments are 7. Centers for Medicare & Medicaid Services. Proposed Changes to the Hospital
IPPS and FY2009 rates. Available at: http://edocket.access.gpo.gov/2008/pdf/E8-
also under development.10 Clearly, more research and 17914.pdf. Accessed April 7, 2010.
8. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for
technological advances are needed to further pinpoint the retained instruments and sponges after surgery. New England Journal of Medicine.
reasons for retained foreign objects and reduce their 2003;348(3):229-235.
9. Beyond the count: preventing retention of foreign objects. Pennsylvania Patient
occurrence. Safety Advisory. 2009;6(2):39-45.
10. Enker WE, Martz JE, Picon A, Wexner SD, Fleshman JW, Koulos J, et al.
An incremental step in patient safety: reducing the risks of retained foreign bodies
by the use of an integrated laparotomy pad/retractor. Surgical Innovation.
2008;35(3):203-207.
11. McGowan A. “Smart” sponge detection. Surgical Products. Available at:
http://www.surgicalproductsmag.com/scripts/ShowPR~PUBCODE~0S0~
ACCT~0006505~ISSUE~0904~RELTYPE~PR~PRODCODE~2805~
PRODLETT~A.asp. Accessed March 29, 2010.
12. RF Surgical Systems, Inc. Features. Available at:
http://www.rfsurg.com/features.htm. Accessed April 1, 2010.
13. Bar codes help improve safety in operating room; system helps identify additional
miscounts. HealthCare Benchmarks and Quality Improvement. August 2008.
Available at: http://findarticles.com/p/articles/mi_m0NUZ/is_8_15/ai_n32370597.
Accessed April 1, 2010.
14. Greenberg CC, Diaz-Flores R, Lipsitz SR, Regenbogen SE, Mulholland L, Mearn F,
et al. Bar-coding surgical sponges to improve safety. Annals of Surgery. 2008;
247(4):612-616.
15. Recommended practices for sponge, sharp, and instrument counts. In: Retzlaff K,
ed. Perioperative Standards and Recommended Practices. Denver, Colo.:
AORN Recommended Practices for Sponge, Association of PeriOperative Registered Nurses; 2010:207-216.
Sharp and Instrument Counts15
I. Sponges should be counted on all procedures in
which the possibility exists that a sponge could
be retained.
II. Sharps and other miscellaneous items should be
counted on all procedures.
III. Instruments should be counted for all procedures
in which the likelihood exists that an instrument
could be retained.
IV. Additional measures for investigation, reconciliation,
documentation, and prevention of retained surgical
items should be taken.
V. Sponge, sharp and instrument counts should be
documented on the patient’s intraoperative record
by the registered nurse circulator.
VI. Policies and procedures for sponge, sharp, and
instrument counts should be developed, reviewed
periodically, revised as necessary, and readily
available in the practice setting.
The benefits of counting

and detection in one
advanced system.
The SmartSponge® System takes the worry

out of finding and counting surgical sponges
For stressed nurses facing time pressures and distractions,
there’s nothing more relieving than getting an accurate
surgical sponge count. So it’s worth noting that the
SmartSponge® System counts, locates and recounts each
sponge up to 80,000 times during a single surgery. And
because it is the only FDA-approved system that uses
radio-frequency identification, it uniquely identifies each
sponge, so you can use the SmartWand-DTXTM to find
missing sponges below, beside or inside a patient.
A quick demonstration will give you the practical proof
of how the ClearCount SmartSponge System can make
your time in the O.R. a little less stressful. Call your
Medline representative or 1-800-MEDLINE today and
find out how you can get 10% off your first order.
Visit Booth 3601 at AORN Congress
SmartSponge® is a registered trademark of ClearCount Medical Solutions.
Back to Basics CE Test Questions
#2 On the Joint Commission List:

Retained Foreign Objects
True/False 8. According to AORN Recommended Practices, policies
1. The incidence of retained foreign bodies has been and procedures for sponge, sharp and instrument
declining in recent years. T F counts should be developed, reviewed periodically,
revised as necessary and ______________.
2. Staff fatigue during lengthy and emergency a. Kept in a locked file cabinet
procedures is one factor that affects surgical count b. Shared only with surgeons
accuracy. T F c. Made readily available in the practice setting
d. Forwarded to the Joint Commission
3. The Joint Commission does NOT consider retention
of a foreign body a sentinel event. T F 9. The two most frequently used methods to try to
prevent retained foreign objects are counting sponges,
4. New technologies for counting surgical instruments instruments and sharps before and after surgery and
are currently under development. T F __________________.
a. Using a bar code system
5. The California Department of Public Health reported b. X-raying the body cavity before a procedure closes
141 retained foreign objects in patients during fiscal c. Minimizing traffic flow in the OR during surgery
year 2007-2008. T F d. None of the above
Multiple Choice 10. For FY 2007, the Centers for Medicare & Medicaid
6. Which of the following sponge detection technologies Services (CMS) recorded 750 incidents of foreign
does NOT include a wand? objects retained after surgery, which incurred an
a Bar coding average cost of an additional $__________
b. RF per case.
c. RFID a. 1,153
d. None of the above b. 63,631
c. 138,954
7. Which of the following is NOT recommended by the d. 14,849
Joint Commission if a foreign object is retained in
the patient?
a. Conduct a root cause analysis to thoroughly
investigate how and why the situation occurred. This course is approved for
b. Develop a detailed action plan to prevent similar one continuing education hour
occurrences in the future. by the Florida Board of Nursing
c. Find out who is to blame for the incident. and the California Board of
d. Report the incident according to state regulations. Registered Nursing
Submit your answers at

www.medlineuniversity.com
and receive 1 FREE CE credit
KEEP YOUR SURGICAL

PATIENTS DESERT DRY.
Medline’s Sahara® Super Absorbent OR table sheets QuickSuite®
OR Clean Up Kit
are designed with your patients’ skin integrity in mind.
The Braden Scale tells us that moisture is one of the

major risk factors for developing a pressure ulcer.1 We also
know that as many as 66 percent of all hospital-acquired
pressure ulcers come out of the operating room.2
That’s why we developed the Sahara Super Absorbent

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

as a component in our QuickSuite® OR Clean Up Kits,
which were designed to help you dramatically improve To sign up for a FREE webinar on perioperative
your OR turnover time and help reduce cross contamina- pressure ulcer prevention, go to
www.medline.com/pupp-webinar.
tion risk through a combination of disposable products.
References
1
Braden Scale for Predicting Pressure Sore Risk. Available at:
www.bradenscale.com/braden.PDF. Accessed November 6, 2008.
2
Recommended practices for positioning the patient in the perioperative practice setting. In:
Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008.
Harm is Not an Option:

Lessons from HROs
(High Reliability Organizations)
By Spencer L. Byrum and

Kathleen Bartholomew, RN, RC, MN
W hen you board an airplane, do you stop

and ask which pilot is in command for
that particular flight? Do you query his
team and ask others what they think of
his/her flying? Of course not!
OR Issues

When you or a close relative

is scheduled for surgery, do you
request a particular surgeon?
Because you know that all pilots follow very specific proven tol for justice. Except for a few famous people, such as the Den-
procedures that all but guarantee they won’t forget anything. nis Quaid twins, these accidents and deaths have gone unnoticed.
That’s why even though 3,400 commercial airlines controlled by The sad truth is that because these deaths occur one-by-one in a
6,800 pilots fly across the United States every day, not a single litigious culture that swears to secrecy and vows to “cover each
passenger died in a five year span from 2001 to 2006. Airlines, other’s backs,” the dramatic impact of the 21 people per hour who
like nuclear power plants, infectious disease researchers, atomic die from preventable healthcare errors is virtually ignored.
submarines and high-rise construction companies are all high re-
liability organizations (HROs) that have one thing in common. They The same is not true for other industries. For example, when Gen-
have learned how to make their organizations exceptionally safe eral Motors experiences a fatality or serious accident in their facil-
despite operating in an extremely challenging environment. These ity, the plant immediately shuts down until the system issue is
organizations simply can’t afford not to get it right the first time. addressed so the error will never happen again. When a worker is
harmed or killed at a petroleum refinery, everything comes to a halt
When you or a close relative is scheduled for surgery, do you immediately, and everyone is briefed about the event.
request a particular surgeon? If you work in a hospital, then you
most likely do. Why? Because you have witnessed firsthand that But when two patients died within one month on the same teleme-
outcomes vary. You know which surgeons or teams you like to try unit as the result of communication errors at a Florida hospital,
scrub in with, as well as the ones you would rather avoid at all 99 percent of all hospital staff never knew the events occurred –
“
costs. Most of all, you know exactly who you will recommend to
your loved ones for their surgical procedure.
THE VOLUME AND COMPLEXITY
Do you know the healthcare safety record during the same five
OF KNOWLEDGE TODAY
years there were no accidents in aviation? If you translated it into has exceeded our ability as individuals
aviation terms, the equivalent of 1,427 Boeing 747s filled with pas- to properly deliver it to people – consistently,
sengers crashed, and 500,000 people died. These healthcare- correctly, safely. We train longer, specialize
related deaths still have not made the headlines; and there are no more, use ever-advancing technologies,
major TV documentaries or advocacy groups storming the Capi- and still, we fail.” A. Gawande
Continued on page 34
PROTECTION, PERFORMANCE & COMFORT
WITHOUT COMPROMISE
SensiCare® surgical gloves address a rising concern in the OR — latex allergies.
The American Latex Allergy Association estimates that • SensiCare® with Aloe – standard thickness,
8 to 17 percent of healthcare workers are sensitized to smooth grip
natural rubber latex.1 • SensiCare® LT with Aloe – standard thickness,
textured grip
Medline’s Sensicare® latex-free polyisoprene surgical • SensiCare® Green with Aloe – 10% thinner for
gloves are made from Isolex™ (synthetic polyisoprene) enhanced tactile sensitivity
that has a molecular structure that is virtually identical • SensiCare® Ortho – 40% thicker for extra protection
to natural rubber latex. for enhanced tactile sensitivity
• SensiCare® SLT – A non-aloe version of SensiCare
In fact, it is softer, more elastic and more comfortable. LT that’s slightly thinner for improved sensitivity
So never compromise again. Choose the SensiCare®
glove that best fits your needs.
Get a FREE one-day supply of SensiCare surgical
gloves to try for yourself. To learn more, contact
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or e-mail glovedivision@medline.com.
References:
1
American Latex Allergy Association. Latex Allergy Statistics. Available at: www.latexallergyresources.org/topics/LatexAllergyStatistics.cfm. Accessed March 2, 2010.
The same lack of coordination and communi-

cation that bedevils health care’s adoption of
HRO principles was the primary cause of the
Three-Mile Island meltdown, which changed
the nuclear power industry forever.
even weeks later. A hospital is supposed to be a high reliability did things a certain way simply because no one was willing to risk
organization, but the vast majority of hospitals still have not the lives of any or all of the team members.
adopted the practices that have demonstrated time and again
how to prevent human error in a dangerous and complex system. So what exactly is it that HROs do to perform so well in a time-
compressed, high-risk and stressful environment? They realized
What is an HRO? that reducing the number of variables was critical, so these
By definition, a high reliability organization (HRO) is an organization organizations standardized processes and procedures whenever
that manages an inherent risk with great precision and few, if any, possible. They defined roles, practiced rigorously and conducted
serious accidents or incidents ever occur. The term HRO was both a pre-procedure and post-procedure briefing for every com-
coined by Karl Weick, a professor of organizational behavior and plex procedure, and by doing so, they became predictably safe.
psychology at the University of Michigan. Dr. Weick identified a
group of organizations that stood out because of consistently High stress…High tech….High chance something could go
superior performance despite the fact that all of their environments wrong. By nature, most people want to do their best. But stress
were exceptionally demanding and contained significant elements can be exceedingly high, processes can be flawed and preventa-
of time compression and stress. ble errors are still a common occurrence in hospitals. All HROs
conduct a pre-procedure briefing and a post-procedure debriefing
Common Characteristics of HROs every single time for every error-intolerant process. They report all
1. High individual and organizational accountability incidents, regardless of whether there was any actual or perceived
2. Preoccupation with avoiding failure harm, in order to learn and apply this knowledge to avoid future
3. Broad knowledge base and high situational awareness accidents. HROs recognize that in time- and task-intensive envi-
4. Rebound quickly after an undesired event ronments, good people still have the potential to make serious
5. Consistently link cause and effect – continuous learning errors, but the impact of those errors can be significantly reduced
or even eliminated if they are identified early. Standard operating
He found that these organizations were “highly reliable” because procedures are followed without exception, as well as checklists
the errors they experienced were caught and corrected before for best practice, because they’re not willing to bet their life (or
they progressed to a catastrophic event. Because failure of one another team member’s life) on the chance that someone could
member of the team could mean death to the whole team, they inadvertently make a mistake. Today’s healthcare culture, how-
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ever, tolerates quite the opposite. A recent data review revealed Case Study – Individual
that physician compliance with protocols is far from ideal.1 There Dr. Z., a high energy, demanding emergency physician, was the
are many exceptions to the rule; and even best practices are not biggest skeptic. He was known for his volatile temper, which was
always implemented. Here are some examples: evident every time things weren’t going smoothly, and he put staff
on edge. He even went to administration complaining about the
Last week the surgeon walked into the OR with his cof- “toxic culture” of the unit. One day he attended a workshop on
fee cup, unmasked. We wrote it up in an incident report, HRO team processes – not because he wanted to further his
and the next day, he did the exact same thing – with an knowledge, but rather to show what a waste of time it was. He
attitude. So we stopped writing it up. came away with a profound sense of amazement and actually
went back to administration to say he thought his own behavior
“I don’t want to hurt my team’s feelings because I
and attitudes had been contributing to the chaos in the ED. He
depend on them, so let’s pretend this whole thing
finally recognized that the more effectively the team functions, the
(sentinel event) never happened.
better it communicates, and the better the collective decision-
making for the patient. Even the EMTs noticed the ED was less
A review of 189 closed malpractice claims demonstrated
chaotic and functioned more smoothly. And both patient and staff
that 40 percent of adverse outcomes related to intra-
satisfaction increased significantly.
partum fetal hypoxia may have been avoided if 24-hour
in-house coverage had been available. Despite this
information, this coverage does not represent the cur-
Case Study – Organizational Use of HRO Techniques1
The rate of cesarean deliveries in the United States has continu-
rent standard of care.2
ally increased (except for a plateau trend in the 1990s because of
VBACs). Malpractice claims have increased with the rise of
An HRO culture would simply not allow maverick behavior, non-
cesarean delivery rates. The use of three specific drugs was noted
compliance or failure to report an error or do the right thing. A pilot
as a common denominator, and protocols for administration and
who “didn’t feel like using the takeoff checklist” because he was
checklists were put in place, combined with effective peer review.
in a hurry; or an infectious disease specialist who didn’t use best
Incorporating HRO features at 120 facilities improved outcomes,
practice for isolating a Level 3 virus because it was too costly,
reduced the cesarean delivery rate, lowered maternal and fetal
would be quickly unemployed. Yet, the current healthcare culture
injury and reduced litigation five-fold.1
still tolerates non-HRO practices? Why?
Barriers to HRO technique application. The greatest barrier to

adopting HRO principles and practices is a culture of hierarchy
where autonomy is the core value. Physicians, the very people
who we need desperately to champion a cultural change, fre-
quently complain that the applicability of HRO principles to their
practice is “cookbook medicine.” Many physicians claim tools
such as checklists detract from their autonomy and lack a per-
sonal touch. Knowing what we know today about human error,
these objections are not only dangerous, but absurd. Very simply
put, if you had the opportunity to choose between an OR that
could statistically ensure greater safety by using HRO principles
and one that did not, which one would you choose? From an eth-
ical perspective, healthcare demands that we “get it right” the first
time. It is our moral obligation to significantly decrease the chance
for human error.
HRO 101. The element that is undoubtedly the most crucial part
of becoming an HRO is effective communication. Members of the Six-Step Communication Procedure in the OR3
team are encouraged to speak up any time to anyone. High func- 1. Make sure team members know each other.
tioning HRO teams realize silence is never an option. They 2. Verify patient’s identity and procedure.
embrace their responsibility as a member of the team to share 3. Specify what the procedure involves, and review
their observations and knowledge using precise, standardized ter- necessary supplies:
minology. HRO teams focus on making every critical communica- a. Ask the surgeon to articulate the procedure and
tion clear, timely and solutions-driven, despite the inevitable chaos specific steps.
of daily events. HRO leaders understand that it is their ethical and b. Complete process for identifying and marking the
moral responsibility to remove the hierarchy and create an envi- proper site.
ronment where everyone feels safe. In the operating room, the sur- 4. Ask questions: Nurse circulator should ask if there are
geon is in the best position to encourage questions and create an any questions.
atmosphere conducive to a two-way flow of information. Follow- 5. Discuss past procedures: Was anything done in a past
ing this six-step communication procedure is a great start for any procedure that could influence today’s operation?
ambulatory surgery center or OR. 6. Debrief after every procedure: This is the best opportunity
to improve communication, safety and quality.
“
(Editor’s note: This procedure is similar to the Surgical Safety Check-
Healthcare is a decade or more behind list developed by the World Health Organization (WHO). A copy of the
WHO checklist is available at www.who.int/patientsafety/safesurgery/en
other high risk industries in its attention
”
and in the “Forms & Tools” section of this issue.)
to ensuring basic safety.

Institute of Medicine Continued on page 40

Must Reads
To help you enhance your high reliability organization
The Checklist Manifesto:

How to Get Things Right
Atul Gawande, MD
Henry Holt and Company, 2009
We live in a world of great and increas-

ing complexity, where even the most
expert professionals struggle to master
the tasks they face. Longer training,
ever more advanced technologies—
neither seems to prevent grievous errors. But in a hopeful turn,
acclaimed surgeon and writer Atul Gawande finds a remedy in the
humblest and simplest of techniques: the checklist. First intro-
duced decades ago by the U.S. Air Force, checklists have
enabled pilots to fly aircraft of mind-boggling sophistication. Now
innovative checklists are being adopted in hospitals around the
world, helping doctors and nurses respond to everything
from flu epidemics to avalanches. Even in the immensely com-
plex world of surgery, a simple 90-second variant has cut the rate
of fatalities by more than a third.
revolution into fields well beyond medicine, from disaster response
In riveting stories, Gawande takes us from Austria, where an emer- to investment banking, skyscraper construction and businesses
gency checklist saved a drowning victim who had spent half an of all kinds.
hour underwater, to Michigan, where a cleanliness checklist in
intensive care units virtually eliminated a type of deadly hospital An intellectual adventure in which lives are lost and saved and one
infection. He explains how checklists actually work to prompt strik- simple idea makes a tremendous difference, The Checklist Mani-
ing and immediate improvements. And he follows the checklist festo is essential reading for anyone working to get things right.
To Err is Human: updated, the second edition of Managing the Unexpected uses
Building a Safer HROs is a template for any institution that wants to better organize
Health System for high reliability.
Linda T. Kohn, Janet M. Corrigan,
and Molla S. Donaldson, eds. The authors reveal how HROs create a collective state of mindful-
National Academy Press, 2000 ness that produces an enhanced ability to discover and correct
errors before they escalate into a crisis. A mindful infrastructure
This now classic Institute of Medicine
continually:
report, according to many experts,
• Tracks small failures
marks the beginning of the patient
• Resists oversimplification
safety movement in U.S. health care.
• Is sensitive to operations
• Maintains capabilities for resilience
As many as 98,000 people die each year from medical errors that
• Takes advantage of shifting locations of expertise
occur in hospitals. That's more than die from motor vehicle acci-
dents, breast cancer, and AIDS – making medical errors the fifth
Why Hospitals
leading cause of death in this country. The Institute of Medicine
Should Fly
seeks to improve the quality of care in America by focusing on the
John Nance, JD
facts and making wide-ranging recommendations. Skilled and Second River Healthcare
caring professionals can – and do – make mistakes because, after Press, 2008
all, to err is human. It's time to build a better system.
Did you know that a checked bag on
This report called for a comprehensive effort by healthcare an airline flight is still exponentially safer
providers, government, consumers and others. Claiming that than a patient in an American hospital?
knowledge of how to prevent these errors already existed, it set a It is not very comforting to consider that
minimum goal of 50 percent reduction in errors over the next five a toothbrush has a better chance of
years. Though not currently quantified, as of 2007 this ambitious reaching its destination than a patient has of leaving a hospital
goal had yet to be met. unscathed. This begs the question…why? John J. Nance, JD
frames the issue this way:
Managing the Unexpected:
Resilient Performance in “Nine long years after the Institute of Medicine told us nearly
an Age of Uncertainty 100,000 patients die each year from avoidable errors in our hos-
Karl E. Weick and pitals (To Err Is Human, 2000), the struggle to significantly reduce
Kathleen M. Sutcliffe major patient injuries has barely begun. The primary reason it’s so
Wiley and Sons, 2007 tough to change the system is that no less than the culture of
medical practice has been challenged and is, in effect, resist-
Why are some organizations better able ing change.
than others to maintain function and
structure in the face of unanticipated Hospitals will only fly when doctors, nurses, CEOs, trustees and
change? The authors answer this question by pointing to high every healthcare stakeholder overcomes the inertia that is
reliability organizations (HROs), such as emergency rooms in anchoring hospitals to the failed cultural foundations of the past
hospitals, flight operations of aircraft carriers, and firefighting units, and embraces a new paradigm of patient-centered care.
as models to follow. These organizations have developed ways of
acting and styles of learning that enable them to manage the unex- The time to take this flight is now and this is your boarding call.
pected better than other organizations. Thoroughly revised and

Summary
There is no doubt that HRO best practices reduce risk, gain
efficiencies, enhance our ability to function as a productive team
and communicate more effectively.
“The application of improvement tools is not only

essential to modernizing care delivery but also the
key to preserving the values to which our current
system aspires.”4
The only real question is why do we hesitate? What prevents us

from adopting proven tools that have been demonstrated time
and again to improve patient outcomes? The Hippocratic Oath
stands in stark contrast to the current reality where thousands
of patients die yearly from preventable mistakes mainly because
About the authors
our culture impedes adoption of HRO practices. “First do no
Spencer L. Byrum is managing partner of
harm” isn’t a suggestion. It is the most basic of all promises that
Convergent HRS LLC, a premier human
we make to patients who entrust us with their care.
performance improvement company that
was specifically created and designed to
enhance individual and team decision-mak-
Interested in Learning More About HROs? ing in high-risk industries. His specialty is
Recommended reading taking lessons learned in aviation and
developing innovative process improvements and training for
Articles professions in which people need to make critical decisions in
• Swensen SJ, Meyer GS, Nelson EC, Hunt GC, Pryor DB, a stressful, demanding environment. He spent his first career as
Weissberg JI, et al. Cottage industry to post-industrial a Coast Guard pilot in charge of safety at two major air stations. He
care – the revolution in health care delivery. The New oversaw everything from hazardous materials compliance to
England Journal of Medicine. 2010;362(5):e12(10)-e12(4). complex ground and flight mishap inquiries. He has been a
Available at: http://content.nejm.org/cgi/reprint/NEJMp09\- member on military, Federal Aviation Administration (FAA)
111 99.pdf?ssource=hcrc. and National Transportation Safety Board (NTSB) accident
investigations.
• Weick KE. Organizational culture as a source of high
reliability. California Management Review. 1987;29:112-127.
Kathleen Bartholomew, RN, RC, MN,
has been a national speaker for the nursing
profession for the past seven years. Her
References background in sociology laid the foundation
1. Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Improved outcomes,
for correctly identifying the norms particular
fewer cesarean deliveries, and reduced litigation: results of a new paradigm
in patient safety. American Journal of Obstetrics and Gynecology. to health care – specifically physician and
2008;199(2):105.e1-105.e7. nurse relationships. For her master’s thesis,
2. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation
she authored Speak Your Truth: Proven
through alterations in practice patterns. American Journal of Obstetrics
and Gynecology. 2006; 112(6):1279-1283. Stategies for Effective Nurse-Physician Communication, which
3. Follow six-step communications procedure in OR to improve outcomes. is the only book to date that addresses physician-nurse commu-
Ambulatory Surgery Compliance and Reimbursement Insider. August 2004. nication. She also wrote Stressed Out About Communication, a
Brownstone Publishing: New York.
4. Swensen SJ, Meyer GS, Nelson EC, Hunt GC, Pryor DB, Weissberg JI, et al.
book designed for new nurses. Save 20 percent by using source
Cottage industry to post-industrial care – the revolution in health care delivery. code MB84712A at www.HCMarketplace.com or call customer
The New England Journal of Medicine. 2010;362(5):e12(10)-e12(4). Available service at (800) 650-6787. To increase performance with High
at: http://content.nejm.org/cgi/reprint/NEJMp0911199.pdf?ssource=hcrc.
Reliability Organization methods, Kathleen has now partnered with
Accessed March 9, 2010.
ConvergentHRS.
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COLOR BY
Special Feature
Carla Nitz, RN, BSN
Healthcare uniforms have come a long way since the days Building support
when registered nurses wore only white. Today’s nurses – The prospect of changing uniforms has the potential to be un-
and nearly all other hospital staff members – wear scrubs. And popular at first. We’re all creatures of habit, and change can be
because scrubs come in all different colors, patterns and uncomfortable. Another argument staff often raise is that uni-
styles, it can be difficult to differentiate a registered nurse from forms strip them of their individuality. Employees at the Med-
a respiratory therapist or a housekeeper. ical Center of the Rockies found a new way to express their
personality – with accessories! Kay Miller, the medical center’s
Staff members representing as many as 13 different disciplines vice president and chief nursing officer, said some nurses dec-
may enter a patient’s room each day, leaving the patient won- orate their name badges with cute pins, and others wear fun,
dering, just “who is my nurse?” It’s not uncommon for patients brightly colored shoes. In addition, the dress code allows staff
to report that “the nurse” gave them instructions, only to find to wear theme print tops underneath their scrubs for special
out later that it was a physical therapist or a dietitian. occasions such as Halloween and Christmas.
In an effort to improve patient care and satisfaction by making Similarly, at the Medical University of South Carolina (MUSC)
it easier for patients to identify their caregivers, many hospitals hospital in Charleston, S.C., staff can choose to wear either
across the country have converted to color-by-discipline uni- solid-color scrub tops and bottoms designated for their disci-
form programs. The color of the scrub uniform denotes the pline or solid-color bottoms with a print top. Registered nurses
discipline the healthcare professional represents. Patients and are also allowed to combine white with their color or print top.
staff are provided with a color key, allowing them to immedi- This decision was well-received and allowed staff members to
ately recognize each healthcare discipline according to the express their individuality.1
color they wear. At the Medical Center of the Rockies, in Love-
land, Colo., for example, nurses wear blue, lab employees When building support for your proposed color-by-discipline
wear black and radiology employees wear burgundy. program, introduce the idea gradually by generating discus-
Preparing your
Organization for
Color-by-Discipline
Uniforms
DISCIPLINE Aligning practice with policy to improve patient care 43

sions at department meetings and through hospital memos Choosing colors

and newsletters. Many hospitals also appoint a task force con- It is important to choose colors that are flattering to most skin
sisting of representatives from all disciplines (e.g., nursing, tones and suitable for both men and women. Connie Yuska,
pharmacy, radiology, laboratory) to develop their color-by- vice president of clinical services at Medline, who implemented
discipline program. Goals for the task force might include: a color-by-discipline program while serving as chief nursing of-
ficer at a community teaching hospital in the Chicago area, rec-
• Communicating with other hospitals that have ommends allowing staff to vote for their uniform color. The task
implemented a color-by-discipline program force at her hospital narrowed the color choices to three per
• Reviewing relevant data from your hospital’s discipline and organized a voting process.
patient satisfaction surveys
• Researching colors and styles of uniforms Staff members at MUSC also voted on their uniform colors.
• Finding a vendor With guidance from the task force, each discipline selected a
• Revising the hospital dress code few color choices for voting. The different color scrubs were
• Choosing a target date for implementation displayed in the hospital lobby for two days. A Web-based vot-
of the new uniform program ing tool was developed giving all staff members the opportu-
Points to consider when choosing nity to vote on their color choice. Employees of each MUSC
a uniform vendor: discipline voted on their first, second and third choices.1
• Wide selection of uniform styles and colors
• Ability to have on-site sales several times a year At the Medical Center of the Rockies, Miller cut to the chase,
• Ease of ordering and distribution (online, and instead of voting, she had a representative from each dis-
in person, by mail) cipline draw a color from a hat on a first-come, first served
• Ability to customize scrubs with your facility logo basis. “We decided on that approach because choosing col-
ors was where we encountered the greatest bumps in the
process,” Miller said.
Support Staff
Housekeeping
Patient Transfer
Nursing (RNs)
Advanced Care Partners
Respiratory Therapy
Physical Therapy
Volunteers
Nursing Assistants
LOOK GREAT AND IMPROVE PATIENT SAFETY AND SATISFACTION
WITH COLOR-BY-DISCIPLINE
SuiteStyles by Medline is a color-by-discipline uniform With SuiteStyles you will also receive:
program that helps patients quickly identify an em- • Scrubs sizing events to try on garments
ployee by the color they are wearing. The apparel line before ordering
features breathtaking colors and fabulous styles. • Bag-by-name delivery - orders are individually
bagged, boxed by department and delivered to
What people are saying about SuiteStyles… each department
“
• Custom online store for employee reorders that
…I have personally been able to compare the
complements your unique uniform program
before and after! I had surgery in December when
everyone was wearing whatever they wanted. Then,
in July, I had an emergency operation and was
thrilled to know who (nurse, tech, other) was walking
into my room before he/she got close enough for me
to see their tag. Wow, what a difference!”
- Mary McMahon, Director Perinatal Services,

Memorial Health System
Visit www.SuiteStyles.com to learn more about

color-by-dicipline and browse a sample store.
At MUSC patients and family members learn about the

Tips for Success! role-specific scrub schema via the GetWell Network, which
1. Views on uniform requirements are many and provides patients and families access to the Internet, enter-
packed with emotion. Be patient and listen to tainment, education and communications via their hospital-
staff comments. room television. A website was also developed to display the
2. Give all staff members a voice in selection of the scrub colors, frequently asked questions and the dress
uniform. Web-based voting is an effective and code policy.1
efficient method.
3. Set a short time frame for implementation and The Medical Center of the Rockies also includes the color
do not let the process take months to accomplish. coding information in all new employee orientation packets.
Deadlines longer than four months can add to
the opposition and a belief that the change will Positive outcomes
not occur. Change can be difficult for everyone, but if a uniform policy
4. Answer staff questions in a timely manner and allows for choice within parameters it can be very successful.
develop a communication tool such as an intranet Building consensus and including the staff in the decision-
site accessible to all staff members, keeping the making process will pay off in the end with a successful color-
process transparent. by-discipline program. It will also improve the professional
5. Provide each staff member with a one-time stipend appearance of your staff, improve your patient satisfaction
to aid in the purchase of their initial two sets of scores and contribute to an environment in which every
scrubs. Offer payroll deduction as an option to patient, physician and employee can identify the various
pay for additional scrubs. members of the healthcare team.
A lab employee at the Medical Center of the Rockies said the

color coding has helped her quickly identify other staff. On one
occasion, a patient asked her about a radiology procedure.
She did not know the answer, but then she spotted a person
in burgundy scrubs (radiology) walking down the hall. Even
though she did not know the person, she immediately identi-
fied their role, allowing the patient’s question to be answered
quickly and correctly.
Similarly, a cardiac nurse from the Medical Center of the Rock-

ies said color-coded uniforms allow her to quickly identify
which staff members are visiting her patients – even from down
the hall. If she sees a person in green, for example, she knows
Communication plan her patient is having his respiratory treatment. “The color cod-
Once your plan is finalized, you will need to communicate the ing really is a time saver,” she said. It also saves staff members
color-coding to staff, patients and visitors. Begin by sharing time getting ready for work not having to choose what to wear.
the revised dress code with staff about three months prior to
the conversion, recommends Yuska. Effective communication Although many staff members at MUSC were opposed at first
tools after implementation of the program are tent cards and/or to changing to the new dress code, a number of them later
posters in each patient room and throughout the hospital, voiced a change of heart. A psychiatric liaison nurse stated
showing which discipline each color represents and an that she was initially opposed to the plan and felt it would have
explanatory section in the patient admission packet. a negative impact on nurse retention.1
She now appreciates the ability to identify at a glance all of the

different healthcare professionals by the color of their scrubs.
As a consultant with responsibilities on units throughout the
hospital, she is now able to immediately identify the patient’s
nurse and other caregivers.1
At Yuska’s hospital, the implementation date went very

smoothly, and in fact, several nurses commented on the
improved professional appearance of the staff. In addition, on
the first day, a patient said he was so relieved to know that he
could instantly identify who the nurse on the floor was…he didn’t
have to guess. He told the manager that the color-coding gave
him a sense of comfort and security in an environment in which
he felt totally out of control.
“Patients want to know who’s in charge of their care. And

research shows that patients who are actively involved in their
own care and communicate with their healthcare team have a
safer, more satisfactory experience,” Yuska said. “The goal is
to help patients with identification and instill confidence that
they are being treated by an organized, professional team.”
For more information on Medline’s color-coded uniform Your Medline Doll Can Look
programs, visit www. SuiteStyles.com.
as Great as You Do!
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Brought to you by Medline’s SuiteStyles color-by-

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The doll scrubs and accessories set includes:

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Reference
1. Darby J. Thinking about changing your dress code. Gastroenterology Nursing.
2008; 31(4):295-296. Available at: http://www.nursingcenter.com/library/
journalissue.asp?Journal_ID=54035&Issue_ID=810887. Accessed April 1, 2010.
©2010 Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc.
Patient Safety
CAUTI ALERT:
PROCEED WITH CAUTION
Jayne Barkman BSN, RN, CNOR past six months that the evidence-based CAUTI strategies
were in place, the rate of catheter-associated urinary tract
Joe and Sandy exchanged a knowing glance as they took infections had dropped from 16 percent to zero hospital
their seats at the monthly patient safety council meeting. wide. After congratulating the nursing units on this accom-
They were pleasantly surprised to see both the CEO and plishment, Brianna asked the representative from each unit
CNO. The agenda included discussion of the efficacy of the to explain the initiatives they took to reduce and prevent
strategies recently implemented throughout the hospital to CAUTI. She signaled to Joe and Sandy, the OR representa-
prevent catheter-associated urinary tract infections (CAUTI). tives, to speak first.
Brianna, the infection control practitioner, arrived, and the
meeting was underway. Joe said initially he and Sandy collaborated with the sur-
geons in each specialty to review and revise the standing
Brianna was pleased to announce that the prevent CAUTI orders for Foley catheter insertion. As a result of this initiative,
interventions had been an enormous success. During the Foley catheter use in the OR had dropped by 50 percent.

Open heart was the only specialty had an indwelling urinary

where a catheter was still routinely catheter. Sandy explained that
inserted. For all other surgical spe- the OR also instituted urinary
cialties, the use of an indwelling catheter insertion as part of
catheter was evaluated on a patient- the annual staff competencies.
by-patient basis.
Catheter-
associated Monica, the medical/surgical
Sandy continued, explaining that unit representative, said the
urinary tract nursing staff in the med/surg
prior to implementing the CAUTI
protocol, the standard of care in infections account areas also found the design
the OR was to insert a 14 FR Foley for 40 percent of the single layer tray to be
in male patients and a 16 FR Foley in user friendly. Since not all staff
females. Because the size of the of nosocomial routinely inserted urinary
catheter differed for males and infections.1 catheters, the instructions
females, prior practice was to insert included in the tray were very
the catheters using an open system. helpful and the closed system
A Foley insertion kit containing PVP enabled the nurses to insert
prep, cotton balls, gloves and lubri- the catheter aseptically. The
cating jelly was opened and the packets of hand sanitizing gel
appropriate size gender-specific catheter, as well as either included in the Foley kit increased hand hygiene compli-
a drainage bag or urinemeter, were added to the insertion ance before and after placement of the indwelling
kit. This practice resulted in several single sterile items being catheter. In addition, computerized prompts reminding
opened on the small sterile surface of the insertion kit, the physicians and staff to remove the Foley catheters
potentially increasing the risk for contamination as the sup- within 24-48 hours were now part of the chart for patients
plies were opened on the sterile field. with a urinary catheter. Like the OR, urinary catheter inser-
tion was also added to the med/surg annual competencies.
The new standard of care was to insert a 14 FR catheter
in both male and female patients using a closed system Jess from the ICU said the majority of the patients admitted
in accordance with the Centers for Disease Control and to the ICU arrived with indwelling catheters. The prevent
Prevention (CDC) recommendations for indwelling CAUTI strategies implemented in the ICU were incorporat-
catheter insertion. Joe said the staff found the new kit with ing the use of antibacterial wipes for morning and evening
the troughed single layer tray design much easier to use. peri/meatal care on patients with a catheter while the
After insertion, each catheter was properly secured and catheter remained in place. The nurses also were trained to
labeled with the insertion date. In addition, the handoff report use a bladder scanner to assess urinary retention. And
for the PACU or ICU included notification that the patient nurses now had the authority to assess whether a urinary
A critical step in preventing

CAUTI is to maintain a closed
drainage system.2
catheter was still needed, and they could remove it,

ARE YOUR PHYSICIANS
if appropriate, without a physician order. MAKING THE GRADE?
Tom, the CEO, closed the meeting by saying he was truly A recent survey graded
impressed by the staff’s dedication to excellence in patient physicians’ abilities to
care and proud of their accomplishments during the prevent
recognize, assess and
/erase CAUTI mandate.
document Stage III
and IV pressure ulcers
In the course of your perioperative practice have you ever
witnessed a colleague using poor sterile technique when at a “D” level. Medline’s
inserting a urinary catheter? Have you seen a colleague new Pressure Ulcer
missing the urethra in a female patient and using the same Prevention Program MD
catheter for insertion rather than obtaining a new sterile Education CD contains every-
catheter? Catheter-associated urinary tract infections can thing physicians need to brush up on their skills
and should be prevented. CAUTI complications increase and comply with the new CMS Inpatient Prospective
patients’ length of stay and the use of antibiotics, not to Payment System (IPPS).
mention incurring needless costs. So, proceed with caution
“
when inserting urinary catheters. Your patients’ safety is in The new MD Education component of Medline’s
your hands. Pressure Ulcer Prevention Program is critical for
References acute-care facilities to ensure that physicians
1. Smith JM. Indwelling catheter management: from habit-based to evidence-based understand their role in recognizing and accurately
practice. Ostomy Wound Management. 2003;49(12).
Available at: http://www.o-wm.com/issues/994. Accessed March 16, 2010. documenting POA pressure ulcers.”
2 Smith JM. Indwelling catheter management: from habit-based to evidence-based Michael Raymond, MD,
practice. Ostomy Wound Management. 2003;49(12). Available at:
Associate Chief Medical Quality Officer,
http://www.o-wm.com/issues/994. Accessed February 24, 2010.
NorthShore University HealthSystem,
Skokie Hospital, Skokie, IL
About the author

Jayne Barkman, BSN, RN, CNOR, has over 30 years of
perioperative experience in various roles, including surgical To learn more about Medline’s Pres-
technologist, staff nurse and clinical educator. She currently sure Ulcer Prevention Programs and
works as a clinical nurse consultant. FREE webinars for acute care and
perioperative services, call your
Medline representative, or visit

What did we do after

designing a revolutionary
new catheter tray system?
We found THREE more ways

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

so you know exactly what’s inside
A photo on the package helps identify the
contents of the kit, serves as an educational
tool for the clinician and can be used to
discuss the procedure with the patient.
Also, the label opens up to a booklet with
step-by-step instructions and helpful tips
for the clinician.
2 A checklist that fits better

in the medical record
The reformatted checklist is smaller, making
it easier to fit in the patient chart or medical
record. It is also available as an attachment
for electronic documentation.
3 Education you’ll want to present

to your patient
There’s nothing like the new Patient
Education Care Card. Designed to look
and feel like a “Get Well Soon” card, it
tells patients about catheterization so
they know you are providing them the
best care possible.
E D U C IN G
R
C A U T I
W I T H
BLAD ND D ER
LT R A S O U
U
Patient Safety
An alternative to urinary catheterization

Kimberly Haines, RN, CNOR
Urinary catheters are commonly used throughout the acute care setting, from
the emergency department to surgery, yet up to 50 percent are placed
unnecessarily.1 The problem is that urinary catheterization can lead to urinary
tract infections. In fact, catheter-associated urinary tract infections (CAUTIs)
account for more than 40 percent of all nosocomial infections.2 The best way
to avoid the risk of CAUTI is by using alternatives to catheterization. One alter-
native, bladder ultrasound, will be explored here.
Urinary catheters in the OR

Let’s take a look at perioperative services, where catheters are used to monitor
bladder volume to help avoid urinary retention. Urinary retention is reported
to occur in four to 38 percent of patients.3 The incidence is independent of type
of anesthesia, but administration of excessive perioperative intravenous
fluids, as well as anticholinergic and adrenergic medications, increases the
incidence and severity of urinary retention.3 Postoperative monitoring of the
patient’s bladder volume serves to prevent overdistension, which can lead to
irreversible muscle damage and a permanent inability to empty the
bladder.3 Intermittent catheterization is the traditional way of monitoring
bladder volume, however, this can be labor intensive for nurses, a
nuisance for patients and a recipe for infection. So what’s the alternative?
Bladder ultrasound.
Using a portable bladder ultrasound scanner is an easy, accurate,

reliable and non-invasive way to measure bladder volume without having
to catheterize the patient. The device, usually no larger than a notebook com-
puter, is wheeled to the bedside. The nurse simply applies gel to the device’s
probe and places it on the patient’s lower abdomen. An image of the bladder
and a bladder volume measurement appear on the device’s screen in just
minutes. Depending on the results, the nurse then determines whether
catheterization is needed to empty excess urine from the bladder.

Using the bladder scanner

to decrease urinary catheterization
A study by Dromerick and Edwards associated residual urine
volumes of greater than 150 ml with development of urinary
tract infections, so if the bladder scanner shows a volume
measurement of less 150 ml, (or whatever amount deter-
mined by your facility), then the bladder need not be emptied,
and catheterization would not be indicated. An ultrasound
scanner is a simple and reliable non-invasive monitor
of urinary bladder filling, and should be a part of routine
monitoring equipment in the PACU.4
Similarly, Phillips described one facility’s attempt to decrease

hospital-acquired urinary tract infections and the associated
cost analysis. A portion of this program encouraged the use
of a bladder ultrasound protocol after indwelling catheter
removal. It included bladder scanning four hours after the
catheter was removed. If the bladder volume was greater than
300 ml, a straight catheterization was performed. The blad-
der scanner was used again four hours later and the patient
was catheterized for urine volumes over 300 ml. An estimated
27 UTIs and 1,392 catheterizations were avoided related to References
1. Stokowski LA. Preventing catheter-associated urinary tract infections.
use of the bladder ultrasound device.4
Medscape Nursing Perspectives. February 3, 2009. Available at:
http://www.medscape.com/viewarticle/587464_4. Accessed March 25, 2010.
Moore and Edwards reviewed one hospital’s attempt to 2. Smith JM. Indwelling catheter management: from habit-based to evidence-based
practice. Ostomy Wound Management. 2003;49(12).
decrease healthcare-acquired UTIs. They reported that of 57
Available at: http://www.o-wm.com/issues/994. Accessed March 16, 2010.
catheterized patients, 19 percent developed urinary tract 3. Rosseland LA, Stubhaug A, Breivik H. Detecting postoperative urinary retention
infections when all patients were catheterized. After intro- with an ultrasound scanner. Acta Anaestesiologica Scandinavica.
2002;46:279-282.
ducing a bladder ultrasound, there was a 50 percent 4. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations.
reduction in urinary tract infections.4 MedSurg Nursing. 2005; 14(4):249-253. Available at:
http://findarticles.com/p/articles/mi_m0FSS/is_4_14/ai_n17210413.
Accessed March 24, 2010.
Summary
Research has shown that healthcare-acquired infections are
costly for the patient and the hospital. Regarding urinary About the author
retention, noninvasive bladder ultrasound devices can assess Kimberly Haines, RN, CNOR, currently a clinical nurse con-
bladder volumes accurately and reliably. When bladder ultra- sultant, has been a registered nurse for 16 years. Previously,
sound is used, many unnecessary catheterizations can she was a staff nurse at a number of acute care facilities and
be avoided. ambulatory surgery centers.
BioCon™- 500
Bladder Scanner
Safely Measures
Bladder Volume
Minimize unnecessary catheterization
Research has shown that 80 percent of urinary tract
infections acquired at healthcare facilities are associated
with an indwelling urethral catheter.1 This type of infection
is known as CAUTI, or catheter-associated urinary tract
infection. What’s more, Medicare no longer reimburses
for treatment of CAUTI if it happens while a patient is
hospitalized, giving hospitals a major incentive to prevent
it. But how?
Avoiding unnecessary catheter use is a primary strategy

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

CAUTI prevention, visit
www.medline.com/erase
or contact your Medline
sales representative.
1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K,

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

NEW REGULATIONS FOR

INFECTION PREVENTION
IN AMBULATORY
SURGERY CENTERS:
ARE YOU READY?
By Lorri Downs, RN, BSN, MS, CIC
In May 2009, the Centers for Medicare & Medicaid Serv- Disease Control and Prevention (CDC) has noted
ices (CMS) updated the conditions of participation (CfCs) an increasing trend in healthcare-associated infections
for ambulatory surgery centers (ASCs). Included in this related to poor infection prevention techniques within ASCs.
update are new requirements for infection prevention
requiring ASCs to administer an infection prevention program One example is a 2008 outbreak of hepatitis and HIV at an
overseen by an infection prevention professional. The main ASC in Nevada. This very large outbreak was linked to
goal is to provide a “safe and sanitary environment for poor injection practices. An article in the January 6, 2009
surgical services, to avoid sources and transmission of edition of the Annals of Internal Medicine revealed
infections and communicable diseases.”1 the occurrence of 33 outbreaks of viral hepatitis in
non-hospital healthcare settings over the last decade.
Why focus on infection prevention? All of these outbreaks involved failure on the part of health-
You may be asking what prompted CMS to take a care providers to adhere to fundamental infection control
closer look at infection prevention techniques in ambu- practices, most notably by reusing syringes.2
latory surgery centers. One reason is the Centers for
OR Issues
2.
3.
6
Elements of a Complete
Infection Prevention Program
1. Infection prevention and surveillance plan
Surveillance data and reporting
Infection prevention employee education
4. Reporting and preventing transmission
of communicable diseases
5. Environment of care monitoring
6. Employee health program

8
Eight Tips for Safe Injection Practices
The following recommendations apply to the use of needles,
cannulae that replace needles, and, where applicable,
intravenous delivery systems:2
1. Use aseptic technique to avoid contamination of
sterile injection equipment.
2. Do not administer medications from a syringe to
multiple patients, even if the needle or cannula on the
syringe is changed. Needles, cannulae, and syringes What to expect during a regulatory survey
are sterile, single-use items; they should not be reused A spontaneous regulatory survey can be stressful. Organi-
for another patient or to access a medication or zation is the key to reducing staff anxiety and demonstrating
solution that might be used for a subsequent patient. confidence and knowledge to the survey team. Keep your
3. Use fluid infusion and administration sets documents current. Record and report any clusters or out-
(i.e., intravenous bags, tubing and connectors) for breaks of disease to the appropriate regulatory agencies.
one patient only and discard appropriately after use. Regulatory survey teams look for documentation showing
Consider a syringe or needle/cannula contaminated how you prevented the spread of contagion, so document
once it has been used to enter or connect to a patient’s what you did, when you did it and who you notified.
intravenous infusion bag or administration set.
4. Use single-dose vials for parenteral medications Regulatory survey teams will observe and interview staff
whenever possible. to ensure infection prevention policies have transferred into
5. Do not administer medications from single-dose vials clinical practice. Conduct mock surveys to help prepare for
or ampules to multiple patients or combine leftover a surprise survey. Coaching your staff to answer questions
contents for later use. will enable them to respond easily and briefly to the survey-
6. If multidose vials must be used, both the needle or ors’ questions. The infection preventionist will be interviewed
cannula and syringe used to access the multidose and expected to answer questions about the organization’s
vial must be sterile. infection prevention program, policies and data collection
7. Do not keep multidose vials in the immediate patient methods. Share your employee education program and
treatment area and store in accordance with the required staff infection prevention competencies with the
manufacturer’s recommendations; discard if sterility surveyors.
is compromised or questionable.
8. Do not use bags or bottles of intravenous solution as Finally, after reviewing your written infection control program,
a common source of supply for multiple patients. touring the facility, observing and interviewing staff and
physicians; the facility administration plus the survey team
These guidelines are from the Safe Injection Practices section of will participate in an exit conference to share the findings.
Standard Precautions, from the 2007 CDC/HICPAC Guideline for
Isolation Precautions
Documents CMS Surveyors Will Request References:

1. CMS Manual for Interpretive Guidelines for Ambulatory Surgery Centers.
❏ The facility’s infection prevention plan and Available at: http://www.cms.hhs.gov/transmittals/downloads/R56SOMA.pdf.
documentation that the plan is reviewed annually. Accessed March 15, 2010.
❏ A copy of nationally recognized infection prevention 2. One and Only Campaign Safe Injection Practices. The Safe Injection
Practices Coalition. Available at: www.oneandonlycampaign.org.
definitions (CDC definitions) Accessed March 10, 2010.
❏ The ASC infection risk assessment
❏ Infection prevention policies and procedures
Lorri Downs, RN, BSN, MS, CIC is a board
(e.g. hand hygiene, transmission- based precautions,
certified infection preventionist and vice
standard precautions, sterilization and disinfection)
president of infection prevention for Med-
❏ Exposure control plan and tuberculosis control plan line Industries, Inc. She has a diverse port-
❏ Outbreak investigation plan and emergency folio of more than 25 years in the nursing
preparedness plan profession. Her expertise focuses on infec-
❏ Log documenting communicable disease cases tion prevention surveillance at large acute
reported to department of public health. care organizations, plus ambulatory and
❏ Surgical site infection surveillance data public health settings. Lorri has devel-
oped hospital infection control programs and local emergency
❏ Hand hygiene program and surveillance data
preparedness plans, and she has lectured on various infection
❏ Management of employee sharps injuries, employee
prevention topics. She is a member of the Alpha Delta
health records/vaccination rates and documentation Omega Delta Chapter National Honor Society for Human
of reporting to OSHA Service Education, a member of The National Association of
Infection Prevention and Control Professionals (APIC) and a
Note: Additional documents may be requested as well. member of the local APIC Chicago area chapter.
For a complete copy of the actual CMS Infection Control

Surveyor Worksheet, visit http://www.cms.hhs.gov/transmit-
tals/downloads/R56SOMA.pdf and see Attachment 2.
Get Ready!
For further help preparing for the infection
control portion of the CMS survey, contact
your Medline representative about Medline’s
new CMS Survey Readiness Program for
Ambulatory Surgery Centers.

Booth Centennial Healthcare Linen Services
A State-of-the-Art Hybrid
Program for the OR
by Maria Ash and Mario Muff
Booth Centennial Healthcare Linen Services (BCHLS) has

launched its newest program for the OR – the Complete
Delivery Hybrid System™ (CDHS), a reusable/disposable
hybrid solution for the OR that simplifies every step of the sup-
ply chain. A complete delivery system can only truly be
“completed” by returning it to its origin, making it a full cycle.
Or recycled! BCHLS expertly packages the correct mix of
reusables and disposables, and then delivers the OR materials
to the hospital in a container of choice.
There is heightened concern to reduce biohazardous waste

within the hospital setting, not only helping green the environ-
ment, but reducing expensive disposal costs. OR budgets can Booth Centennial was the proud recipient of
an OHA Green Award for Energy Efficiency.
be helped immensely as, in many cases, a reusable item
simply has a lower unit cost than a disposable item.
Each CDHS program is designed based on the facility's

particular supply chain needs. A no-risk analysis is used to
determine savings and efficiency opportunities. The analysis
reveals the potential to significantly simplify and streamline the
clinical supply chain and identifies the right mix of reusable and
single-use surgical drapes, packs and gowns.
“It’s what we call ‘the next step’ in healthcare efficiency,”

General Manager Joe Grummel said. “By replacing certain
disposable items with reusable ones, our custom packs are The BCHLS Surgical Services division
inspects each piece of laundry. Our surgical
turned into a hybrid CDS pack, also known as CDHS.”
services area has stainless steel tables to
reduce the spread of infectious material.
Each towel pack is labeled and scanned
to a cart for tracking purposes prior
to sterilization.
Once the packs have Through OR analysis, BCHLS finds that many accessory
been sterilized, they
must stay in the cool pieces of disposable apparel are added to the case carts
down room until the to complete the pick list. These are often disposable
batch has been
examined. Once gowns, drapes and towels that can be replaced with high
cleared, the packs quality reusable linens made from advanced barrier fabrics
are scanned to
tickets for shipment
that make them stronger, lighter and easier to drape. These
to hospitals. fabrics also handle wash and dry cycles and sterilization
better than ever before. Many other items within the custom
pack can be reusable as well, such as Mayo stand covers,
back table covers, ¾ sheets, half sheets and full custom
drapes.
Soiled linen is stored
in large bags on an “Adding a reusable component to the CDS is truly an
automated future rail outstanding way to make a huge positive impact on the
system and sorted
by type. The bags environment and help cost-conscious hospitals save large
are then transferred sums of money by reducing unnecessary touch points,”
to a specified station
for processing. This Grummel said.
design reduces the
need for manual
movement of linen All pick list items, custom packs, accessories and reusable
in carts on the plant components are delivered daily in a whole case cart. Then
floor and reduces
congestion. BCHLS picks everything up at the end of day and does it all
over again the next day. Daily delivery and return by BCHLS
makes this a true Complete Delivery Hybrid Solution!
About Booth Centennial

Healthcare Linen Services
Each piece of
surgical linen is Booth Centennial Healthcare Linen Services (BCHLS) in
examined and Ontario, Canada, was founded in 1968 and is now one of
hand folded to
the largest and most state-of-the-art healthcare laundry
ensure no
defects prior facilities in North America. The business focuses solely on
to sterilization. health care, and their mission is to provide ever-expanding
value in superior linen, sterilization and logistics services to
hospitals and healthcare facilities.
BCHLS’ rapidly growing Surgical Solutions division spe-

cializes in reusable, high-barrier surgical gowns, covers,
drapes and towels and currently processes more than
1,250,000 reusable sterile packs annually for operating
rooms across Ontario. BCHLS surgical packs utilize cutting
edge, innovative fabrics and products that are superior
to their disposable counterparts in protection, comfort and
long-term costs. Complete draping systems and custom
General Manager packs are suited to customer requirements.
Joe Grummel at
the Booth plant.

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Special Feature
Never of Why
Lose We Are
Sight Nurses
Sharon Danielewicz, RN, MSN, MHA, HSA, RNFA
I began my career as an administrator of an to the demands of this role, it is not uncommon to get
ambulatory surgery center directly upon comple- caught up in day-to-day tasks and find the days flying by
tion of my associate degree. The first day I ever before your eyes. Being a type A personality, I generally
stepped foot into an operating room was one of the most attempt to maintain a very strict schedule that allows me
memorable moments in my career. I have been a nurse to complete administrative responsibilities early in the
for 19 years, and I have gone from earning an associate morning so I can focus on and actively participate in
degree to obtaining two master’s degrees in nursing and patient care throughout the day. I encourage others in
health care administration. Throughout the last 19 years, I leadership roles to do this as much as possible so that you
(like most other nurses) have experienced and witnessed never lose sight of our number one priority – the patients.
everything imaginable to the human mind that pertains to
nursing. Being in a leadership role for my entire career, it One recent evening at approximately 7:00, I was leaving
has always been part of my responsibility to attempt to work after a long and very intense day. The exit from the
motivate the nurses I oversee on a daily basis. department to the parking lot requires a walk through the
family waiting room, where I was greeted by a screaming
Leadership comes with a price tag. You are continually infant. I saw a couple, maybe in their 70s, pacing as the
attending meetings, addressing administrative responsi- woman attempted to calm the child. I placed my bags on
bilities, putting out fires and attempting to make sure that a nearby chair and asked if I could be of assistance. The
patients, surgeons and staff are as happy as possible. Due couple explained that the mother of the infant (their grand-

It is not about the thanks you

will receive; it is about the care
you will give that comes from
your heart. Never lose sight
of the patient.
daughter) was in the recovery area. The baby was hungry, but here. My advice to others is never be too busy to stop and take
his mother had his bottle. The woman explained that she was a moment to assist patients, who are much more than just
not comfortable with the baby and had attempted everything to another person coming through your department. It only takes
stop him from crying without any success. I asked her if she one experience such as this one to create many moments of
would mind if I held the child while I let her go to the recovery memories you will carry for a lifetime. It is not about the thanks
area to get the bottle from her granddaughter. The woman you will receive; it is about the care you will give that comes
handed me the baby and left to get the bottle. While holding the from your heart. Never lose sight of the patient.
child, I noticed he needed to be changed, so I asked the
grandfather for a diaper and proceeded to change the
About the author
infant. Shortly thereafter, the woman returned with the bottle.
Sharon Danielewicz, RN, MSN, MHA, BSN, HSA, RNFA is a
She was again apprehensive about feeding the child, so I director of perioperative services with 19 years of experience. She
offered to feed him. I sat with the child, fed him his bottle and began her career in 1991 after completing an associate degree in nurs-
rocked him off to sleep. ing from a then small community college in Nanticoke, Penn. She later
relocated to Lansdale, Penn., where she worked in the surgery serv-
Before I knew it, 45 minutes had passed, and the child’s mother ices department of a small community hospital for five years. In 2004,
Sharon, her husband and two children relocated to San Antonio, Tex.,
exited from the recovery area. She was very grateful that I had
and Sharon began working for a large medical center. After a few
assisted her grandparents with the baby. She also explained years, she accepted a position for Job Corps as a health services
that the baby was born just three weeks before, and he had administrator while pursuing two master’s degrees. In 2008 she
colic. She felt badly about leaving him with her grandparents in received both a Master of Nursing and Master of Health Care Admin-
the waiting room, but she had no one else to watch him. She istration. Shortly thereafter, she accepted a position as director of
could not thank me enough for helping them. I explained that it perioperative services for a facility in Houston, Tex.
was a pleasure to help and that it brought back memories of

caring for my own children so many years before.
Right there, in our family waiting room, on a day when I was

physically and emotionally exhausted, I was once again
reminded of the true meaning of nursing. We all get caught up
in the day-to-day functions of our jobs; however, it is extremely
important never to forget that patients are the reason we are
JOIN THE PROGRAM TO

REDUCE PRESSURE ULCERS
We’ve made pressure ulcer prevention easy.
“
Systematic efforts at education, heightened awareness This has been a great learning experience for
and specific interventions by interdisciplinary healthcare our staff and for our facility as a whole. I am
teams have demonstrated that a high incidence of thankful Medline had this program and that we
pressure ulcers can be reduced.1 The main challenges were able to access it. I can’t imagine recreating
to having an effective pressure ulcer prevention program this wheel!”
are: lack of resources; lack of staff education; behavioral Katrina “Kitty” Strowbridge, RN
challenges; and lack of patient and family education.2 Quality Improvement Coordinator
St. Luke Community Healthcare Network
Medline’s comprehensive Pressure Ulcer Prevention
Ronan, Montana
Program offers solutions to these challenges.
The Pressure Ulcer Prevention Program from Medline

For more information on the Pressure Ulcer
will help you in your efforts to reduce pressure ulcers in
Prevention Program, contact your Medline
your facility. The program includes:
representative, call 1-800-MEDLINE or visit
• Education for RNs, LPNs, CNAs and MDs www.medline.com/pupp-webinar to register
• Teaching materials for you to help train your staff for a free informational webinar.
• Practical tools to help reduce the incidence of
pressure ulcers
• Innovative products supported by evidence-based
information that results in better patient care
References
1
Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.
2
CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.
Medline Hosts
5th Annual Breast Cancer
Awareness Breakfast
at the AORN 57th Congress
More than 1,200 operating room nurses

attended this year’s Breast Cancer
Awareness Breakfast, “Together We Can
Save Lives Through Early Detection” to
hear Olympic gold medalist Peggy
Fleming talk about her skating career
and battle with breast cancer. The forum
was held March 15, 2010, in conjunction
with the start of the Association of
periOperative Registered Nurses’ 57th
Congress held in Denver, Colo.

Breast cancer survivor and

Olympic gold medalist Peggy
Fleming presents the keynote
speech, “The Fight of a True
Champion.”
The crowd was also treated to surprise appearances by Raising breast cancer awareness among nurses is a key
the staff members from Providence St. Vincent Medical goal of Medline’s campaign, as it is the leading cause of
Center in Portland, Ore., who starred in the “Pink Glove death for women age 40-55. The average age of a
Dance,” a YouTube video sensation that has more than 8.7 nurse is 46.
million views to date.
At the event, Medline President Andy Mills presented
“My mother was diagnosed with breast cancer at the age National Breast Cancer Foundation (NBCF) President
of 80,” said Kate Moser, a nurse at William S. Middleton Janelle Hail with a check for $117,000 to help fund
Memorial Veterans Hospital in Madison, Wisc. “Now she is mammograms for underserved women. Of that total,
85 and going strong. Hearing Peggy Fleming’s story and $17,000 came directly from the sale of Medline’s Gen-
seeing the people from the Pink Glove Dance today is eration Pink exam gloves.
exciting and inspiring.”
Over the past four years, Medline has donated more
Fleming, who won a gold medal at the 1968 Olympics at than $500,000 to the NBCF as part of its campaign to
the age of 19, was diagnosed with breast cancer in 1998. promote early detection and awareness of breast can-
She is now cancer free. cer. Early detection (mammography is among the best
forms of screening for breast cancer) can increase
the five-year survival rate by more than 95 percent.
“ When the true heroes, the BREAST CANCER

SURVIVORS stood up, the room broke into
thunderous applause.
”
Medline President Andy Mills presents a check for $117,000 to Martie Moore, assistant administrator, nursing and patient care,
National Breast Cancer Foundation President Janelle Hail. Of the Providence St. Vincent Medical Center, Portland, Ore., site of the
total, $17,000 came from the sale of Medline’s Generation Pink Pink Glove Dance video, which has received more than 8.7 million
exam gloves. hits on YouTube – and counting.
Participants enjoy a buffet breakfast before the Exhibit showcases previous Medline Breast Cancer
presentations begin. Awareness Breakfasts at AORN Congress.

Body_65488_MedCal.qxp:Layout 1 4/14/10 1:58 AM Page 72
A world without breast cancer is in our hands.

Medline’s Generation Pink latex-free, patented third-generation vinyl
exam gloves have the comfort, barrier protection and price you love.
Even better, when you choose Generation Pink gloves, you’re helping
Medline support the National Breast Cancer Foundation.
Item # Size Unit of Measure

PINK6073 XS 100/bx, 10bx/cs
PINK6074 S 100/bx, 10bx/cs
PINK6075 M 100/bx, 10bx/cs
PINK6076 L 100/bx, 10bx/cs
PINK6077 XL 90/bx, 10bx/cs
To watch the “Pink Glove Dance” video and order Medline’s

Generation Pink Gloves, go to www.pinkglovedance.com
©2010 Medline Industries, Inc. The cross-fingered pink glove hand image is a trademark
of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Introducing Deb!
Starring in “The Pink Glove Dance”
Deb is the coolest person to dance the Pink Glove

Dance while at the same time skillfully caring for
patients, especially those battling breast cancer.
In her Generation Pink Gloves, pink bouffant cap

and scrubs, she energetically raises awareness
for the “Together We Can Save Lives Through Early
Detection” campaign. To order the Deb doll visit
www.medline.com/dolls
Take an online tour of

the booklet and view the
entire doll collection, visit
www.medline.com/dolls
Introduced in 2005, the Medline Doll Collection was created to recognize the caring and dedicated
healthcare professionals in our industry. Since then, Medline has introduced seven dolls, including Deb,
who made her debut in March 2010.
Win-Win
Negotiation
Wolf J. Rinke, PhD, RD, CSP
Times are tough, and virtually all of us have a need to get more “bang for our
How to buck,” whether it’s when we want to make a purchase, attempt to get a promo-
tion or talk our children out of getting that expensive “must-have” new toy. And
get more yet most of us consider negotiating or “haggling” a distasteful activity that should
be avoided at all costs. That is especially true if you are a woman. Research
shows that women are far less likely to negotiate than men, and when they do,
of what they do it in a way that is less assertive. One study found that 20 percent of
women do not negotiate at all. To help you overcome the distaste for negotiation,
you want master the following strategies, and you will get more of what you want.
Manage Your Perceptions

Lots of people lose in negotiations because they don’t manage their perceptions.
For example, have you noticed that when you’ve tried to sell your house, there
seemed to be houses for sale everywhere? Conversely, when you were looking
to buy a house there were virtually none to be found? That happens because of
selective perception—whatever we focus on, we tend to find.
Similarly, how many times have you interviewed for a job and felt the prospective
employer had all the power because you really needed the job while the employer
appeared to have all the applicants in the world? Having been in both roles—
interviewer and applicant—let me assure you nothing could be further from the
truth. The employer almost always needs you just as much as you need him (as-
suming of course you have the right skill set), even during these tough times.
These biases come about because you are committing an “attribution error.” For
example, because the employer has certain visible attributes of power you
assume she has more power than you do which, right or wrong, becomes
your “reality.”

In other words, your perception controls your reality, which in

turn impacts how you negotiate. For example, back to buying
that house. If you perceive that there are very few houses on
the market you will feel compelled to make a quicker and
potentially higher offer than if your perception is that there are
lots of houses on the market. The same is true when you are
interviewing for a job. If you assume that the employer has all
the power, then you are going to be negotiating from a
position of weakness and you probably will compromise
your expectations.
So the first step in every negotiation is to manipulate your per-

ceptions and “do a positive number on yourself” by convinc-
ing yourself that you deserve to have your needs met. In other
words, you define an empowering positive self-fulfilling Know Your BATNA, WAP and ROSA
prophecy that at a minimum equalizes the perceived power BATNA – Best Alternative to a Negotiated Agreement – is a
between you and the other party. Of course, it is even better concept developed by Roger Fisher and William Ury, authors
if you can convince yourself you have more power than the of Getting to Yes. Negotiating Agreement Without Giving In,
other party, which is quite feasible since you are always in one of the most popular negotiation books ever written. Ac-
control of your own perceptions. (If you would like help with cording to them, BATNA “is the standard against which any
this, devour my Make It a Winning Life book available at proposed agreement should be measured.” For example, if
www.WolfRinke.com.) I’m negotiating with a client for a consulting contract I have
priced at $95,000/year, my BATNA may be $95,000 if I value
Be Willing to Walk Away my free time more than the $95,000. Or it may be $45,000 if
Being able to walk away is the single most important concept I need the money to pay my mortgage, have very little work in
to internalize if you want to get more of the things you want! the pipeline, and could hope to generate about $45,000 from
Anytime you want something so bad you are not willing to writing another book in case I do not get the contract. Ac-
walk away, it is extremely likely you will become a deal taker cording to Fisher and Ury high quality negotiation is only pos-
not a deal maker. sible if you know your BATNA, since it is the only way you can
protect yourself from accepting unfavorable terms or from re-
For example, Superwoman—that’s my wife of over 40 years— jecting a minimally acceptable deal.
and I are avid cross-country skiers, hikers, bikers and mush-
room hunters. So approximately four years ago we found this A WAP or Walk-Away Price, also known as the reservation
super idyllic resort in Canaan Valley, West Virginia. We fell in price, “is the least favorable point at which one will accept a
love with a unit that was perfectly decorated and had an awe- deal.” A CEO I coach wanted to sell his business. A protracted
some view. We just had to have it. As a result, when it came long negotiation ended up with what I thought was a very
time to negotiate price, we were not willing to walk away, and sweet deal--$23.5 million for the business and the opportunity
we ended up paying full price. to start a new online business with financial support from the
new owners. The CEO had established a WAP of $26 million

and his BATNA was that he was going to continue to run his
business as he had in the past, and be open to other offers as
they were coming along. Although I thought it was a very fair
offer, he walked away from it, which he would probably would
not have done if he was not very clear about his WAP and
BATNA. He sold that business several years later and got a
much better deal.
ROSA is your Range Of Satisfactory Agreement. “It is the area

or range in which a deal that satisfies both parties can take
place.” For example, let’s say that you want to buy a used car, Negotiate Over Interests, Not Positions
which has a sticker price of $2,900. The seller says to himself, Let’s look at a father-daughter encounter.
I will not take less than $2,400. That’s the seller’s WAP, which Father: “Drink your milk.” (That’s his position).
usually is not known to the buyer. On the other hand, you say Daughter: “I don’t like milk.” (That’s her position).
to yourself, I will not pay more than $2,700. That’s the buyer’s
WAP, which is usually not known to the seller. The ROSA in Of course, from here on, it all goes downhill. So if the father is
this case is the area from $2,400 to $2,700. All other things a “Tough Battler,” he might say: “I’m your father and you will
being equal, an agreement should be feasible between listen to me,” or “I’m smarter than you,” or “I’m wiser than
$2,400 and $2,700. you” etc; “Now, damn it, drink your milk, or you will be
grounded!” (Win-Lose.)
If you handle this purchase like a distributive negotiation, (i.e.,
Win-Lose or Lose-Lose, your conversation might go some- If the daughter is a “Tough Battler” as well, it might go something
thing like this: like this: “I hate milk. If you make me drink it I will throw up.”
You: This car has quite a few dents and a lot of mileage.
I’ll give you $2,200. Even though on the surface it might appear that the father has
Seller: Thanks, but since that is way below the all the power, it’s likely that in this case the daughter will win;
“Blue Book” value I’ll wait until I get a better offer. after all, the father is probably not particularly keen to clean up
You: I’m sure you’d like to get it sold and I don’t really her vomit (Win-Lose).
like to haggle. I’ll give you $2,400, take it or leave it.
Seller: $2,600 and it is yours. Of course, the father could compromise with his daughter: “I
You: I tell you what, let’s just split the difference. I’ll tell you what, just drink half of your milk, and I’ll forget you are
give you $2,500. being so nasty to your old dad.” (Lose-Lose.)
Seller: You got yourself a deal.
If all else fails, he might bribe her: “If you drink your milk, I will
In this case, even though both parties compromised (Lose- take you to the movies.” (Of course, that is reinforcing various
Lose), they probably feel pretty good about the deal because undesired outcomes, such as: “If I rebel, good stuff happens.
they both got a better price than their WAP. So next time I can’t get what I want, I’ll just rebel.”)

Putting those unanticipated outcomes aside, all of these Separate Option Generation from Decision-Making
approaches will likely end up in either Win-Lose or Lose-Lose As you learned from the previous example, most of us tend to
outcomes, which neither the father nor his daughter are going focus on two mutually exclusive outcomes: either you get
to be particularly happy with. what you want and I lose, or I get what I want and you lose.
(Win-Lose.) If instead we learn to get in the habit of engaging
Now let’s take a look at how this might work if we focus on the brain power of both parties, many not-so-obvious ideas
interests, needs or wants instead of positions. can be generated that will meet or even exceed both parties’
Father: “I understand you don’t like milk. So please needs (Win-Win.). In other words, if we separate option gen-
tell me what you really want.” eration from decision-making, we can almost always make
Daughter: “I want food that tastes good, and milk just the pie bigger, and if we can’t, then we can establish objec-
doesn’t taste good to me.” tive criteria before attempting to reach an agreement (see the
Father: “I appreciate that. Now let tell you what I want. next section). Unfortunately, we tend to fall into the trap of
I would like you to get food that is nutritious and skipping the option generation step because most of us want
high in calcium. Why don’t we take a moment to get the negotiation process over with, and one way to do
and come up with a list of foods that meet both that is to come up with the answer
of our needs.” (This is separating option genera- both of us can agree on as fast
tion from decision-making. See the next section). as possible.
At this point, the father and daughter will probably be able to

come up with a long list of foods that meet both of their
objectives – food that tastes good, is nutritious and high in
calcium – such as cheese, ice cream, yogurt, pizza and the list
goes on. (Win-Win.)
In the Win-Lose approach, we saw how the parties’ egos

became identified with their position. Once that happens, the
negotiators have a new interest to satisfy – such as saving
face – which has nothing to do with the original interests. As
you discovered, the longer the parties attempt to reconcile
positions, the less attention they will devote to addressing their
real concerns, needs or wants. The result is it takes longer; it’s
likely to raise people’s negative emotions such as anger, and
is less likely to generate a Win-Win outcome. Plus, it will likely
damage the relationship between the bargaining parties.
At this point you might be saying: “That just doesn’t make any If All Else Fails Resort to Objective Criteria
sense.” Going back to the used car selling example, the only You will of course encounter real “fixed pie” scenarios. For
thing both parties are concerned with is price! Not necessar- example, if you have only one vacancy in your department
ily! It’s likely that both parties had other things that factored and there are three people applying, even after all the best ne-
into the sale. For example, if the buyer had said to the seller: gotiations in the world, there will still be two losers and only
“Before we talk about price, tell me what you want out of this one winner. To improve negotiation whenever you are involved
deal.” The seller might have said, “I’m interested in selling the in a true distributive negotiation process, where one party
car now, but keeping it for another two weeks because my must lose and the other win, it is wise to resort to objective
daughter’s new car won’t be delivered until then.” She might criteria such as standards, rules, independent mediators,
also have said, “I would like to get cash so I don’t have to arbitration, flipping a coin, drawing straws or other forms of
worry about a bounced check.” Or she might have said, “I chance, or any other criteria that produces a perceived fair
love this car like my own child and I would really like to sell it outcome. The classical example of this is the challenge of
to someone who will take really great care of it.” dividing one piece of cake between two siblings. If you have
children, I’m sure you can identify with this dilemma, and you
The buyer, on the other hand, might have said: “I would like to may remember how much potential bickering can ensue.
make sure I’m not buying a lemon; I would like a car that has There is of course a very elegant solution to that problem,
been well taken care of; I would like to drive it away today; I which dates back to biblical times. Have one child cut the
would like to deal with someone I can trust”…and the list goes cake and the other choose the piece she wants.
on. All of these may have economic value to either the seller
or the buyer and hence could have been used not only to in-
fluence the purchase price of the car, but could have resulted
in both parties getting far more than just a good price, i.e.,
getting a Win-Win outcome.
In the case of hiring a new employee, perceived fairness is

enhanced if you make the selection criteria and the selection
process public. There are other situations where it may be
beneficial for both parties to resort to objective criteria. Let’s
say for example, your best friend is interested in purchasing
your car. In this case, both of you express a desire to arrive at
a fair price without haggling because your relationship is more
important than getting the best price. As a result, you both
agree not to negotiate the price at all and instead abide by
the “Blue Book” value.
According to Fisher and Ury, there are three basic strategies

that will make resorting to objective criteria work:
1. Frame the proposal as a joint search for
objective criteria. In the case of selling our car to
your best friend, you both decided the “Blue Book”
value would represent a “fair” price for the car.
2. Reason and be receptive to the other person’s
reason regarding which standard is most applicable
and should be used to arrive at a “fair” outcome.
If you are selling your house, you may propose to
use an average sales price of three similar houses
that have sold in your neighborhood during the past
year as the “fair” price. The buyer, however, prefers
an average of three independent appraisals as a fair
price. In this case, it’s important to be receptive not
only to the proposal but also the underlying reason
for the proposal.
3. Don’t yield to pressure, yield to principles.
Pressure may come in a variety of forms: bribes,
About the author
side payments, threats or a refusal to budge. If the Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader,
other side uses these types of pressures, ask him to management consultant, executive coach and editor of the free elec-
tell you the reasoning behind his proposal, suggest tronic newsletters Make It a Winning Life and The Winning Manager.
To subscribe go to www.WolfRinke.com. He is the author of numer-
legitimate objective criteria and state why they
ous books, CDs and DVDs including Make It a Winning Life: Suc-
represent a fair outcome to both of you. If the other cess Strategies for Life, Love and Business, Winning Management:
party can’t do that, stick to your guns, and if that 6 Fail-Safe Strategies for Building High-Performance Organizations
fails you still have the option to ... you guessed it and Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways to
Improve Your Leadership Effectiveness. All are available at www.Wol-
. . . walk away.
fRinke.com. His company also produces a wide variety of quality pre-
approved continuing professional education (CPE) self-study courses
© 2010 Wolf J. Rinke including Win-Win Negotiation: Fail-Safe Strategies to Help You Get
More of What You Want, on which this article is based, available at
www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.
®
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Healthy Eating
Nutrition
Information
Servings: 8
Calories: 79
Fat: 3.3 g
Sodium: 273 mg
Fiber: 3.1 g
Syrian Salad (8 servings)

• 1 head romaine lettuce • 2 scallions, chopped Dressing:
• 1 cucumber, thinly sliced • 1 small red onion, sliced • ¼ c. olive oil
• 5 radishes, thinly sliced • 3 oz. feta cheese, sliced or crumbled • Juice of 1 lemon, or 3 tablespoons
• 1 red bell pepper, seeded and sliced • ½ cup fresh parsley, coarsely chopped lemon concentrate
• 1 green bell pepper, seeded and sliced • Several black olives • 1 tablespoon wine vinegar
• 2 large tomatoes, cut into wedges • 2 tablespoons capers (optional) • 1 clove garlic, pressed or minced
• Salt and pepper, to taste
Directions: She encourages experimenting with different ingredients and

Rinse the romaine, tear into bite-size pieces and put into salad herbs. “Add a little more garlic and different herbs. Fresh herbs
bowl. Arrange other vegetables attractively over the romaine, are always better than dried.”
topping with the feta, parsley, olives and capers. Combine the
dressing ingredients and drizzle over the salad. Vicki applies those same principles to
other recipes as well. “I tend to do a lot
Vendor data analyst Vicki Mirshak, who works at Medline’s with chicken, trying different herbs and
Vernon Hills, Ill., office, won a silver medal for this recipe in the spices and different cooking methods –
International Cookoff during Employee Appreciation Week 2008. poaching, grilling, baking. It’s best to stick
with a basic recipe, and then add a little to
“This is a light, very easy-to-make salad that’s very nutritious. It’s it here and there to change it up.”
especially good for people who are watching what they eat,”
Vicki said.
Forms & Tools
The following pages contain practical tools for implementing

patient-focused care practices at your facility.
Infection Control
2009 AAAHC/CMS Crosswalk for Infection Control . . . . . . . . . . . .85
Pressure Ulcer Prevention

Pressure Ulcer Prevention Checklist: Perioperative Services . . . .89
Surgical Safety
WHO Surgical Safety Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . .93

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iPhone and iPod Touch are registered trademarks of Apple, Inc.
Infection Control 416.51 Forms & Tools
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Forms & Tools Infection Control 416.51
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g is responsible
responsible
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The Accreditation
Accredita
ation Association for Ambulatory
Ambulatorry Health Care
C 2009 | Effective 5-18-09
TAKE THE PRESSURE OFF

YOUR SURGICAL PATIENTS
It’s estimated that up to 66 percent of pressure ulcers occur as a result of
surgery.1 What can you do to help prevent your patients from becoming statistics?
Medline’s pressure redistribution OR table and stretcher pads can help

redistribute the pressure that can occur before surgery while lying on
stretchers, on the table during surgery and while being transported
to the postoperative care unit.
All of our OR table and stretcher pads are designed

with state-of-the-art materials to offer an
advanced level of pressure redistribution.
Each pad offers a different level of pressure
redistribution and can be custom-made Completely conforms
to fit any OR table. Finally — product to the body
solutions to help you meet your pressure
ulcer prevention goals!
To sign up for a FREE webinar on perioperative pressure

ulcer prevention, go to www.medline.com/pupp-webinar.
Reference
1
AORN. Recommended practices for positioning the patient in the perioperative practice setting. Perioperative
Standards and Recommended Practices. 2008 Edition. Denver, Colo.: AORN Publications; 2008.
PERIOPERATIVE
PRESSURE ULCER EDUCATION
More important than ever before
Medline’s Pressure Ulcer Prevention Program now has a

component designed specifically for perioperative services.
The easy-to-use interactive CD addresses the following:
• Hospital-acquired conditions
• CMS reimbursement changes
• Best practices for pressure ulcer prevention
• Perioperative assessment tools
• Critical patient and equipment risk factors
To learn more about Medline’s Pressure Ulcer
“
Prevention Programs and FREE webinars for
I have seen an increase in the number of legal issues
acute care and perioperative services, call
linking facility-acquired pressure ulcers to post-surgical
your Medline representative or visit
patients. A pressure ulcer program for the OR is more
critical than ever.”
Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN
The AORN Seal of Recognition has been awarded to Pressure Ulcer Prevention for Perioperative Services
in June 2009 and does not imply that AORN approves or endorses any product or service mentioned in
any presentation, format or content. The AORN Recognition program is separate from the AORN, ANCC
Accredited Provider Unit and therefore does not include any CE credit for programs.
The AORN Seal of Recognition is a trademark of AORN, Inc., All rights reserved.
Pressure Ulcer Prevention Policy and Procedure Forms & Tools
Pressure Ulcer Prevention Checklist: Perioperative Services
Yes No Position Comments/Notes

Responsible
Do you have a policy and procedure for skin and risk assessment that addresses:
a. How and when a patient is considered at risk for
development of a pressure ulcer and in need of
prevention intervention(s)?
b. Who is responsible for developing, implementing
and monitoring the prevention care plan?
Do you have prevention protocols for staff to
implement when specific pressure ulcer risk factors
are identified?
Do you have a policy and procedure for positioning patients at risk for pressure ulcer that addresses:
a. Pressure redistribution OR table pads for
procedures lasting longer than two hours?
b. The use of gel table pads when indicated?
Do you warm your patients 30 minutes prior to the
surgical procedure to maintain core body
temperature intraoperatively?
Does the individualized care plan for each patient at
risk for pressure ulcers address the following
prevention interventions:
a. Pressure, friction and shear reduction
1. Pressure redistribution OR table pads or
overlays (foam, gel)?
2. Positioning/repositioning techniques?
3. Positioning devices (foam, gel, wedges, etc.)
to prevent pressure on bony prominences?
4. Mechanical aids (lifts, slide boards, sliding
sheets) for lifting, moving and
positioning/repositioning?
5. Protection for head, elbows and heels?
6. OR tables of sufficient sizes to fit your
patient population?
b. Skin care
1. Does skin inspection occur prior to and
immediately following the surgical procedure?
2. Is skin is kept dry during the surgical
procedure with minimal exposure to moisture,
perspiration and drainage?
3. Is it ensured that warming blankets are not
placed between the pressure redistribution
table pad and the patient in high-risk patients?

Forms & Tools Pressure Ulcer Prevention Policy and Procedure
Yes No Position Comments/Notes

Responsible
4. Is skin cleansed with a skin-cleansing agent

and thoroughly dried as soon as the surgical
procedure is complete (before moving to the
holding room)?
5. Do you minimize skin-drying factors?
Do your protocols address repositioning patients
whenever possible (head, heels, arms etc.) in long
surgical procedures at least every two hours?
Are there adequate supplies and equipment for staff to
provide prevention interventions to all patients who
require them?
Does the care plan include routine monitoring of the
effectiveness of the prevention interventions?
Is there a protocol for when the prevention care plan
should be evaluated and revised?
Sterillium® Comfort Gel™
Your hands will

love you
for it.
Sterillium® Comfort Gel™ is gentle on your hands but tough on bacteria.

You’ll want to reach for Sterillium Comfort Gel again and again. It includes a balanced
blend of moisturizing emollients that leverages technology shared with well-known
skincare products NIVEA® and Eucerin®. The result is a product proven to increase
skin hydration by 14 percent in just two weeks.1 Sterillium Comfort Gel delivers greater
efficacy than other alcohol-based hand antiseptics by virtue of its ethyl alcohol con-
centration. It does more for your infection control efforts by using up to 50 percent
less volume per application. Available in various sizes to suit any need.
Increased efficacy.
Incredible comfort.
Improved compliance.
To watch online interviews with international hand Sterillium®Comfort Gel™
hygiene experts Didier Pittet and Günter Kampf, go to
www.medline.com/media-room and choose featured
article number 3.
©2010 Medline Industries, Inc. Medline® is a registered trademark of Medline Industries, Inc.
Sterillium® is a registered trademark of BODE Chemie GmbH.
NIVEA and Eucerin are registered trademarks of Beiersdorf AG.
Sterillium® Comfort Gel® is a registered trademark of Bode Chemie GmbH. References 1. Data on file
Setting
a new
standard
in patient
safety.
Medline’s Gold Standard Safety Program—

a complete tool kit for surgical safety.
Designed to break down barriers to surgical safety
compliance by offering easy-to-use tools to help you
reach your safety goals, Medline’s Gold Standard
Safety Program offers three levels of safety options:
1. The Gold Standard Safety Bundle: Includes

six products to serve as visual safety reminders
to reduce needle sticks and wrong site surgery.
2. Innovative safety products: Surgical Time Out

Procedure (S.T.O.P.™) Flag and Dual Tip Marker
remind OR staff to take time to verify key information
Visit www.medline.com/goldstandard for a quick
before the first incision to reduce wrong site surgery.
video overview on how Medline’s Gold Standard
3. Med-Pack™: Electronic pack audit and a review Safety Program can help improve safety in your OR.
of safety components.
Surgical Safety Checklist
Body_65488_MedCal.qxp:Layout 1
Before induction of anaesthesia Before skin incision Before patient leaves operating room
(with at least nurse and anaesthetist) (with nurse, anaesthetist and surgeon) (with nurse, anaesthetist and surgeon)
4/14/10
Has the patient confirmed his/her identity, Confirm all team members have Nurse Verbally Confirms:
site, procedure, and consent? introduced themselves by name and role. The name of the procedure
Yes
5:30 PM
Confirm the patient’s name, procedure, Completion of instrument, sponge and needle
Is the site marked? and where the incision will be made. counts
Yes Has antibiotic prophylaxis been given within Specimen labelling (read specimen labels aloud,
the last 60 minutes? including patient name)
Not applicable
Page 93
Yes Whether there are any equipment problems to be

Is the anaesthesia machine and medication addressed
check complete? Not applicable
To Surgeon, Anaesthetist and Nurse:
Yes Anticipated Critical Events What are the key concerns for recovery and
Is the pulse oximeter on the patient and To Surgeon: management of this patient?
functioning? What are the critical or non-routine steps?
Yes How long will the case take?
Does the patient have a: What is the anticipated blood loss?
Known allergy? To Anaesthetist:
No Are there any patient-specific concerns?
Yes
Surgical Safety Checklist
To Nursing Team:
Difficult airway or aspiration risk? Has sterility (including indicator results)
No been confirmed?
Yes, and equipment/assistance available Are there equipment issues or any concerns?
Risk of >500ml blood loss (7ml/kg in children)? Is essential imaging displayed?

No Yes
Yes, and two IVs/central access and fluids Not applicable
planned
This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. Revised 1 / 2009 © WHO, 2009
Forms & Tools

Sterillium® Rub
Your hands will
love you even
more.
Sterillium® Rub’s surgical scrub with high alcohol content delivers

a devastating blow to microorganisms — not your skin.
Sterillium® Rub’s balanced emollient blend leaves hands
feeling soft and smooth, never greasy or sticky, and
makes gloving a breeze. But that doesn’t mean that Increased efficacy.
Sterillium® Rub makes any sacrifices in efficacy. In fact, Incredible comfort.
it meets FDA requirements for efficacy specifications. Improved compliance.
It’s also CHG, latex and non-latex glove compatible.
Sterillium® Rub.
Be one of the first 1,000 to try a

FREE sample of Sterillium Rub.
Send name/facility, address and e-mail
to handhygienecompliance.com.
©2010 Medline Industries, Inc. Medline® is a registered trademark of Medline Industries, Inc.
Sterillium® is a registered trademark of BODE Chemie GmbH.
FREE MEDICLIP TRIAL! ®
Why choose MediClip?

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

• User instructions are right on the handle for ease of use
• Ergonomic handle design provides a comfortable grip
• Hands-free blade disposal protects the user
• Clean-up is easy with the sealed, waterproof handle
• Smooth surface has no screws, crevices or engraving to trap dirt and debris
Sign up now to conduct your own extensive test of MediClip! Get up to 10 clippers and
five cases of blades FREE!* Visit www.medline.com/special/MediClip-Trial.asp today.
* This offer is good through 6/30/2010. It applies to new customers only and is good for up to 10 MediClip Clippers
and up to five cases of MediClip blades.
Untitled-2 1 4/16/10 12:27 PM

Covers_65488_MedCal.qxp:Layout 1 4/13/10 8:12 PM Page 1
VOLUME 5, ISSUE 2
Free Webinars
New Techniques for Pressure Ulcer Prevention,
Hand Hygiene and CAUTI Prevention
PERIOPERATIVE PRESSURE ULCER PREVENTION
Learn about pressure ulcer prevention in the perioperative arena and the implications
of the 2008 CMS inpatient hospital care “Present on Admission (POA)” indicator.
M AY JUNE J U LY AUGUST
4th 12:00 pm - 1:00 pm 3rd 11:00 am - 12:00 pm 7th 11:00 am - 12:00 pm 12th 1:00 pm - 2:00 pm
19th 1:00 pm - 2:00 pm 22nd 1:00 pm - 2:00 pm 20th 12:00 pm - 1:00 pm 17th 12:00 pm - 1:00 pm
27th 11:00 am - 12:00 pm 29th 12:00 pm - 1:00 pm 27th 1:00 pm - 2:00 pm 20th 11:00 am - 12:00 pm
Sign up at www.medline.com/PUPP-webinar
HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES
As the number one defense against healthcare-acquired conditions, hand hygiene plays
an important role in the prevention of infections. Learn how hospitals and healthcare
facilities are combining best-in-class products and education to achieve hand hygiene
THE OR CONNECTION
compliance while dramatically improving the skin condition of healthcare workers.
14 11:00 am - 12:00 pm
th th
14 11:00 am - 12:00 pm 8th 11:00 am - 12:00 pm 17th 2:00 pm - 3:00 pm
19th 12:00 pm - 1:00 pm 17th 12:00 pm - 1:00 pm 21st 2:00 pm - 3:00 pm 23rd 1:00 pm - 2:00 pm
Sign up at www.medline.com/handhygiene
INNOVATION IN THE PREVENTION OF CAUTI
Join your colleagues from around the country to learn more about strategies to prevent
catheter-acquired urinary tract infections as well as Medline’s ERASE CAUTI system.
5th 12:00 pm - 1:00 pm 7th
11:00 am - 12:00 pm 7th 11:00 am - 12:00 pm 12th 11:00 am -12:00 pm
10th 11:00 am - 12:00 pm 9th 2:00 pm - 3:00 pm 7th 2:00 am - 3:00 pm 12th 1:00 pm - 2:00 pm
11th 2:00 pm - 3:00 pm 11th 12:00 pm - 1:00 pm 8th 12:00 pm - 1:00 pm 16th 11:00 am -12:00 pm
18th 2:00 pm - 3:00 pm 18th 12:00 pm - 1:00 pm 20th 12:00 pm - 1:00 pm 16th 2:00 pm - 3:00 pm
21st 12:00 pm - 1:00 pm 21st 11:00 am - 12:00 pm 20th 2:00 pm - 3:00 pm 25th 11:00 am - 12:00 pm
24th 11:00 am - 12:00 pm 22nd 2:00 pm - 3:00 pm 21st 12:00 pm - 1:00 pm 25th 2:00 pm - 3:00 pm
Sign up at www.medline.com/erase/webinar.asp
Hosted by Alecia Cooper, RN, MBA, CNOR

and Lorri Downs, RN, BSN, MS, CIC
All schedules are based on Central Daylight Time

www.medline.com
MKT210091/LIT166R/20M/SLS
Untitled-2 1 4/16/10 12:25 PM

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VOLUME 5, ISSUE 2

Untitled-2 1 4/16/10 12:26 PM

Never miss an issue of The OR Connection!

Subscribing to The OR Connection guarantees that you’ll To subscribe, simply go to www.medline.com/orconnection.

Untitled-2 1 4/16/10 12:28 PM

Aligning practice with policy to improve patient care 3

THE OR CONNECTION I Letter from the Editor

Let’s Talk About Special Feature

Step 1: Complete the Survey!

Results of the survey will be published in the next

Step 2: Answer the Bonus Question!

MEDLINE HEALTHCARE SURVEY Let’s talk about you!

2. Where do you work? hair, etc.)

16. Do you currently have protocols in

18. What are your biggest barriers to

19. Has your organization ever been

20. Have you personally ever been

21. Which of the following technologies

❏ PDA (Blackberry®, Palm®, iPhone®)

Aligning practice with policy to improve patient care 7

Three Important National Initiatives

1 IHI Improvement Map

2 Joint Commission 2010 National Patient Safety Goals

3 Surgical Care Improvement Project (SCIP)

IHI Improvement Map: 70 Processes to Transform Hospital Care

Joint Commission 2010 National Patient Safety Goals

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

Surgical Care Improvement Project (SCIP): Target Areas

Aligning practice with policy to improve patient care 9

(Left to right) David Shapiro, MD,

Ambulatory Surgery Center

Aligning practice with policy to improve patient care 11

New Joint Commission Report

Improved quality saves lives, improves health and reduces costs

Surgical Care Measures

The Joint Commission

The Joint Commission introduced the tracer methodology into the

Aligning practice with policy to improve patient care 13

Tracer Methodology in Action

One example of a tracer that touches several hospital depart-

Now available from Joint

Tracer methodology is the most

Aligning practice with policy to improve patient care 15

Using a focused approach like the tracer

Use silver to fight bacteria.

Arglaes provides: The Arglaes family of products has something

To schedule a FREE demonstration of Arglaes

Indiana Surgeon Reduces

Dr. Turner explained that if an infection develops in an implant

“So infection avoidance is really very important to us,” Dr.

Optifoam Ag helps you manage both the wound and the

• Change the dressing less frequently

Non-cytotoxic and non-staining, Optifoam Ag conforms to

To receive a FREE trial of Optifoam® Ag,

Aligning practice with policy to improve patient care 21

#2 on the Joint Commission List:

By Alecia Cooper, RN, BS, MBA, CNOR

The Joint Commission considers retention of a foreign body

Aligning practice with policy to improve patient care 23

In another study that reviewed 191,168 operations per-

Integrated laparotomy pad/retractor.10 This device is

RFID.11 The RFID (radiofrequency identification) system

RF.12 The RF system is similar to the RFID system, but it