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Aligning practice with policy to improve patient care
www.medline.com
PATIENT SAFETY
Editor
Sue MacInnes, RD, LD
6 Three Important National Initiatives for Improving Patient Care
20 Patient Safety Initiatives Across the United States
Clinical Editor
Alecia Cooper, RN, BS, MBA, CNOR 30 CAUTI Prevention: How Do You Rate?
Senior Writer 31 Back to Basics: Tell Me Again Why This Patient Needs
Carla Esser Lake
a Catheter?
Page 14
Art Director
51 Clean Up Your Act!
Mike Gotti
Clinical Team
Jayne Barkman, RN, BSN, CNOR
OR ISSUES
Susan Garrett, RN
CARING FOR YOURSELF
Hughston Hospital Inc., Georgia 56 How to Communicate Effectively
Zaida I. Jacoby, RN., M.A., M.Ed 65 Breast Cancer Awareness
NYU Medical Center, New York
Jackie Kraft, RN, CNOR
68 Recipe: 24-Hour Dill Pickles
Huntsville Hospital, Alabama
Audrey Kuntz, EdD, MSN, RN FORMS & TOOLS
Vanderbilt University Medical Center, Tennessee
71 SCIP Prophylactic Antibiotic Regimen Selection for Surgery
Tom McLaren, RN, BSN, MBA, CNOR
Florida Hospital
Page 42
73 VTE Prophylaxis Options for Surgery
Donna A. Pritchard, RN, BSN, MA, CNOR, NE-BC 75 What You Need to Know About Infections After
Kingsbrook Jewish Medical Center, New York
Surgery: English
Debbie Reeves, RN, CNOR, MS
Hutcheson Medical Center, Georgia 77 What You Need to Know About Infections After
Diane M. Strout, RN, BSN, CNOR Surgery: Spanish
Chesapeake Regional Medical Center, Virginia
Margery Woll, RN, MSN, CNOR
79 How to Handrub?
North Shore University Health System, Illinois 81 CATS Decrease Surgical Site Infections: English
Page 56
82 CATS Decrease Surgical Site Infections: Spanish
Medline, headquartered in Mundelein, IL, manufactures and distributes more than Meeting the highest level of national and international quality standards, Medline is
About Medline
100,000 products to hospitals, extended care facilities, surgery centers, home FDA QSR compliant and ISO 13485 registered. Medline serves on major industry
care dealers and agencies and other markets. Medline has more than 800 dedi- quality committees to develop guidelines and standards for medical product use in-
cated sales representatives nationwide to support its broad product line and cost cluding the FDA Midwest Steering Committee, AAMI Sterilization and Packaging
management services. Committee and various ASTM committees. For more information on Medline, visit
our Web site, www.medline.com.
©2009 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
As the summer of 2009 comes to a close, my told her what was going on and the chief of surgery
youngest child, Molly will be going to college. She is told her she could shadow him any time. Molly said,
the youngest of three… so, my husband and I are now “Mom how many kids my age get a chance to actu-
officially empty nesters. I don’t usually discuss my ally go into surgery? I was right there. And, I was
work at home. By the time I get home, work is the last invited back to see a heart.”
thing I want to rehash, but Molly has had it in her head
for quite a while now that she wants to be a surgeon. Later Margery e-mailed me about the day. She said,
I haven’t said much to discourage or encourage her, “Dr. Velasco (Juan Velasco, MD, Vice Chairman of
but earlier in the summer, I thought to myself, does Surgery) was so impressed with Molly’s interest and
she have any idea what that means? And so, in typical discipline in watching the cases.” She continued, “It
motherly fashion, I asked her if she wanted to watch was a good day for Dr. Raab (David Raab, MD,
“
an actual surgery. My thinking was, if she is going to Orthopedic Surgeon), he taught both of us. He was so
commit the time and money into becoming a surgeon, honored …” I got to experience
she’d better make sure that is what she wants to do. vicariously the love
So, at a time that is so critical in health care, with you have for what you
I don’t know many eighteen-year-olds who are more healthcare reform, patient safety initiatives at the fore- do, the passion and
psyched about scrubbing in on a surgery than going front of every hospital’s agenda and new guidelines teamwork you express
to Six Flags … but Molly is one. I had promised to look and evidence directing our actions, I have to stop and at every opportunity.
”
into it; the summer was flying by and every day Molly say … you make a difference. I got to experience Thank you.
would ask me if I had made any arrangements. I really vicariously the love you have for what you do, the pas-
didn’t think she would hold me to this. I was wrong. sion and teamwork you express at every opportunity.
Thank you. You’ve just recruited another potential
My first dilemma was finding a mentor, someone who surgeon who is telling all of her friends that they
would embrace the curiosity and naiveté of youth and simply have to work in the OR (and this kid has a lot
allow Molly to watch a surgery. I contacted Margery of friends).
Woll, Director of Perioperative Services at North Shore
University Health System in Skokie, Ill., to ask her Here’s to you!
advice and to see if this was even possible. Margery
embraced the project and invited Molly to her OR.
And that was that. All I really knew before the event
Sue MacInnes, RD, LD
was that Molly had to get up much earlier than usual.
Editor
She had gotten directions to the hospital and was told
who to report to. I didn’t hear anything until she was
on her way home.
4 The OR Connection
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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.
Hospitals sign up through IHI and can choose to implement some or all of the recommended interventions.
IHI provides how-to guides and tools for all participating hospitals.
The IHI Improvement Map will cover the entire landscape of outstanding hospital care, keeping the 12 changes from
the 100,000 Lives and 5 Million Lives Campaigns and expanding the agenda with three new interventions.
Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission offers
guidance to help organizations meet goal requirements.
Over the next year, the current National Patient Safety Goals (NPSGs) will undergo an extensive review process. As a result,
no new NPSGs will be developed for 2010; however, revisions to the NPSGs will be effective in 2010.
Crucial to understanding the 2009 NPSGs is a new method of numbering the goals, for which the Joint Commission has
created a “crosswalk” available at www.jointcommission.org.
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.
6 The OR Connection
Patient Safety
• Elimination of transfusion errors that are related • When a patient leaves a facility, the patient and his
to misidentification of patients or her family receives a complete list of the patientʼs
• Prevention of healthcare-associated infections medications with an explanation of that list
resulting from multiple drug-resistant organisms • In settings in which medications are prescribed
(MDRO) using evidence-based practices minimally or for a short time, modified medication
(one-year phase-in period applies) reconciliation processes are carried out
• Prevention of central line-associated bloodstream
infections using evidence-based practices (one-year In addition to the new requirements, some of the NPSGs
phase-in period applies) already in place have been modified. Extensive changes
• Prevention of surgical site infections using best also have been made to the Universal Protocol (UP).
practices (one-year phase-in period applies)
To learn more about the 2009 National Patient Safety Goals, go to www.jointcommission.org.
8 The OR Connection
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What’s Happening in Healthcare Reform
Patient-centered research
Therefore, the healthcare research conducted under this
initiative will be patient-centered and apply to the “real
world” in order to help patients, clinicians and other deci-
sion makers assess the relative benefits and harms of
strategies to prevent, diagnose, treat, manage or monitor
health conditions.1
10 The OR Connection
High-Priority Topics for Federally Funded
Comparative Effectiveness Research3
The American Recovery and Reinvestment Act of 2009
called on the Institute of Medicine to recommend a list of
priority topics to be the initial focus of a new national
investment in comparative effectiveness research.
www.medline.com
Also, two experts in wound care and healthcare law, who are
Prevention Above All Conference, also members of the International Expert Wound Care Advisory
Washington, DC, August 16-18, 2009 Panel, addressed the legal implications of caring for patients with
pressure ulcers, sharing ways healthcare professionals can pro-
Chief nursing officers, chief medical officers, directors of nursing tect themselves from litigation. Turn to page 46 for excerpts from
and other clinical executives from hospitals across the country their new white paper, “Legal Issues in the Care of Pressure
gathered in Washington, DC, August 16-18, 2009, for Medline’s Ulcer Patients: Key Concepts for Healthcare Providers.”
popular Prevention Above All Conference. They learned new
strategies for delivering cost-effective, high-quality health care SCIP. The Surgical Care Improvement Project continues to
and evidence-based solutions for improving patient care. evolve, with two new measures coming in October. Highly
regarded quality improvement specialist Dale Bratzler, DO, MPH,
An impressive agenda medical director of SCIP, discussed patient safety in the context
Tying in all that is top-of-mind on Capitol Hill these days, former of SCIP and expanded on new and revised SCIP measures.
senator Tom Daschle opened the conference by discussing his
book on healthcare reform and the delivery of cost-effective Prevention Above All Discoveries Grant recipients
health care. Following Daschle was Institute of Medicine President Dr. Andrew Kramer announced the names of Prevention Above
Dr. Harvey Fineberg, who addressed the impact of comparative All (PAA) Discoveries Grant award winners. Dr. Kramer, professor
effectiveness research on delivering cost-effective, evidence- of medicine at the University of Colorado, served as chair of the
based health care. (See article on page 10 to learn more about PAA Discoveries Grant Review Committee. The committee also
comparative effectiveness research.) included Dale Bratzler, DO, MPH, medical director of SCIP; Diane
Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN, wound & skin
Emphasis on patient safety care consultant; Michael Raymond, MD, chief medical officer,
As always, patient safety was a major focus, and world North Shore University Health System and Heidi Wald, MD,
renowned experts shared the latest innovations and evidence- MPH, professor of medicine, University of Colorado. All grant
based practices in the prevention of catheter-associated urinary applications and proposals were independently reviewed and
tract infections (CAUTI), hand hygiene and pressure ulcer approved by this committee. Watch for more information on the
prevention. recipients and their research topics in upcoming issues of The
OR Connection.
CAUTI. Medline introduced its new evidence-based system
to help prevent CAUTI. The ERASE CAUTI™ program combines Unable to attend the Prevention Above All Conference?
innovative design, education and awareness to tackle catheter- Visit medline.com for highlights from the meeting, including video
associated urinary tract infection – the number one hospital- clips from the presentations.
acquired infection.
12 The OR Connection
The OR Connection Celebrates
Nurses’ Accomplishments
OSF St. Joseph Medical Center
Achieves Magnet Recognition
OSF St. Joseph Medical Center in Bloomington, Ill., A magnet steering committee
recently achieved Magnet Recognition for excellence in was formed to create a docu-
nursing services by the American Nurses Credentialing ment proving that OSF St.
Center (ANCC). Joseph Medical Center met or
exceeded the 164 standards
The Magnet Recognition Program recognizes healthcare that are part of the Forces of
organizations that demonstrate excellence in nursing prac- Magnetism.
tice and adherence to national standards for the organi-
zation and delivery of nursing services. The ANCC’s Each committee member was responsible for finding
Commission on Magnet made a unanimous decision to sources of evidence to support the standards within one
make OSF St. Joseph Medical Center a Magnet hospital. force. Committee chair Sandra Scheidenhelm encouraged
all members to stay on task until the final documentation
Magnet applicants undergo a rigorous evaluation process, was turned in – all 15 volumes of it!
including written documentation of 14 specific areas of
nursing practice called Forces of Magnetism. Hospitals The committee’s hard work and dedication paid off.
also participate in extensive interviews and an on-site OSF St. Joseph was awarded Magnet Recognition in
review of nursing services. OSF St. Joseph began work- December 2008.
ing toward Magnet Recognition in 2004.
OSF St. Joseph Medical Center Magnet Steering Committee. OSF St. Joseph Medical Center CEO Ken Natzke presents
Back row (left to right): Marcia Laesch, Dixie Reynolds, the ANCC Magnet Recognition obelisk to Chief Nursing
Sue Herriott, Pat O’Dell, Barb Stevig. Front row (left to right): Officer Deb Smith.
Mark Dabbs, Deb Smith, Sandi Scheidenhelm, Phyllis McNeil.
by Mila Hightower
land, along with her husband and three children, joined Mercy Ships,
she worked as an OR nurse in the United States for 14 years, spe-
cializing in otolaryngology, ophthalmolics and plastics. She now
works as the assistant OR supervisor onboard the Africa Mercy. She
manages the daily surgery schedule, acts as a liaison between the
wards and the ORs, and provides orientation and assistance for new
nurses.
Every weekday morning, the OR staff meets at 7:30 a.m. for devo-
tions and a time of prayer. This is followed by a short briefing on the
day’s schedule. Thereafter, surgeries begin. Though it changes every
day, the OR usually doesn’t end surgeries until around 6:00 p.m.
During nights and weekends, the OR is closed, although a weekly
team of three is on call in case of an emergency.
16 The OR Connection
Of course, running a First World facility in a Third World Melissa Brown recently joined Mercy Ships as a short-term
environment has its challenges. As a not-for-profit organi- OR nurse. “My experience so far has been great! My first day
zation, Mercy Ships’ resources are sometimes limited. in the OR everyone was very welcoming, and they helped
Surgical instruments and equipment have to be used more me fit right in by explaining the procedures,” she said.
than once. Effective methods of sterilization and a subse-
quently low infection rate make this feasible. Brown is a registered nurse and a member of AORN with
CNOR and first assistant certifications. She worked as a
With an international staff represented by more than six travel nurse in the United States before joining the Africa
countries, language and communication can be problem- Mercy as an OR nurse for three months during the summer.
atic. “There’s a language that one has to get used to when
there are four different names for one instrument,” Rolland “I have never been able to combine missions with my OR
said. “Thankfully the OR is sort of a universal environment.” nursing career,” she said. “Here with Mercy Ships is my first
opportunity to be able to do that, and that is very special to
A broad spectrum of nationalities and cultures also has its me,” Brown said.
benefits. Rolland explained, “I think being able to work with
an international staff is very enlightening because there are Although the Africa Mercy is currently stationed in the West
ways that people from different parts of the world do African nation of Benin, the onboard hospital continues
things. It’s nice to have that added to what we do. to operate effectively. Its staff finds the conditions famil-
Sometimes there might be a way that is more efficient.” iar and comfortable.
Continued on Page 19
G O L D S TA N D A R D S A F E T Y P R O G R A M
Medline’s Gold Standard Safety Program is designed 3. AORN Checklist: Wrong site, wrong procedure,
to break down barriers to surgical safety compliance wrong patient surgery prevention.
by offering easy-to-use tools to help you reach your 4. Med-Pack™: Electronic pack audit and a review
safety goals. of safety components.
The program offers four levels of safety options: To learn more about the Gold Standard Safety
1. The Gold Standard Safety Bundle: Includes six Program, contact your Medline sales representative,
call us at 1-800-MEDLINE or visit www.medline.com.
products to serve as visual safety reminders to reduce
needle sticks and wrong site surgery.
2. Innovative safety products: Surgical Time Out
Procedure (S.T.O.P.™) Flag and Drape remind OR
staff to take time to verify key information before
the first incision.
www.medline.com
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
MERCYSHIPS
Taking time for a little fun. Jenny Rolland of the USA lives onboard the Africa Mercy with
her husband and three children. With 14 years of experience,
she now works as the Assistant OR Supervisor for Mercy Ships.
“I worked a day shift at home so the hours here are very ing and has already completed training in ophthalmolics,
similar,” explained Brown. “As far as how the OR is run and general and maxillofacial surgery.
the management and efficiency of things, I think it’s very
similar to a First World OR.” “In the United States I found surgeries were all about time
and getting things done, but here the surgeons are willing
Although she is currently assisting with eye surgeries, to teach you more so that you are able to take better care
Brown will get the opportunity to work in all the surgical of the patients. They are humble and willing,” she explained.
specialties performed onboard the Mercy Ship.
Green finds that a notable and positive difference is the
Alison Green is a long-term volunteer who joined Mercy opportunity to spend more time with patients. “I think that
Ships shortly after completing four years of nursing school here we get more connected with our patients. We have an
in Tyler, Texas. Although she has only been onboard the opportunity to pray with them, get to meet them face-to-
Africa Mercy for a few months, she has already gained a face before surgery, see them afterwards in the ward and
wealth of experience that will undoubtedly further her pro- watch how they heal,” she explained. “It’s great to see what
fessional career as an OR nurse. I was a part of and how I’ve made a difference in their lives.”
“It’s great to see what I was a part of and “Life here is very fast-paced and very busy, but at the same
time, it’s rewarding and life-changing. This work really
how I’ve made a difference in their lives.”
reminds me about why I became an OR nurse. I can see
the hope and healing brought to the patient firsthand. I think
“I’ve found that I’ve learned more here in five months than
if nurses are rundown and have forgotten why they are
I did in three years back home,” Green said. “Many of the
doing what they are doing, they will be inspired if they come
procedures and surgeries we do here are not normally done
here,” Green said.
back home because the cases are so unique. I have
learned so much as a scrub nurse. I get to be more
If you would like to be a part of bringing hope and healing
involved in assisting the surgeons, whereas back home I
to the world’s poor, please visit www.mercyships.org or
had to do more paperwork.”
contact the Mercy Ships human resources department at
(903) 939-7045. Mercy Ships headquarters is located in
Because Green has made a long-term commitment to
Lindale, Texas.
Mercy Ships, she is being trained in all the specialties. She
is currently undergoing six weeks of VVF scrub nurse train-
Rhode Island adopts protocol to guardian all confirm the surgical site together before it is marked
prevent wrong site surgery with the surgeon’s initials.
Program implemented July 1, 2009 OR team briefing. All team members introduce themselves and
their roles. The surgeon then briefs the team, identifying the patient,
All 12 hospitals and 21 surgical centers in procedure and site, and explaining plans for the surgery, including
Rhode Island have agreed to adopt a sur- any medications, documentation and equipment needed.
gical safety protocol designed to reduce
the risk of wrong site surgeries. According to the Hospital Associ- Time out. Led by the surgeon, all team members verify the
ation of Rhode Island, the state is the first in the nation to have all patient, procedure and site and confirm that the site marking is
surgical providers voluntarily adopt the same safety protocol.1 visible after prepping and draping.
The term “wrong site surgery” applies if the wrong procedure is per- Post-op de-briefing. The surgeon leads a discussion of the post-
formed or if a procedure is performed on the wrong person or the operative plan of care and a review of how the surgery went and
wrong body part. what could have been done differently.
Rhode Island’s protocol was developed over a period of 18 months William Cioffi, MD, surgeon-in-chief at Rhode Island Hospital, said
by state hospital and healthcare leaders in cooperation with the that safety efforts must walk a fine line, requiring accountability with-
Joint Commission.2 It is similar to surgical safety checklists created out overemphasizing blame; each member of the surgical team has
by the World Health Organization and The Joint Commission. responsibilities to meet but also must feel free to acknowledge and
report errors.1
With an emphasis on clear communication among surgeons, staff
and patients, the protocol is designed to prevent errors but also to Cioffi added that the hospitals will train staff through lectures and a
avoid the confusion that sometimes occurs when practitioners split video and also will devise ways to make sure the protocol is prop-
their time between facilities with different policies. erly and uniformly adopted around the state. “This is a great first
step. It’s not the end of the process.”1
“They have steps built into their protocol that allow all team mem-
bers to be accountable and responsible for speaking up if they Providers began implementing the protocol July 1, but it could be
believe that something doesn’t look right,” said Mark Crafton, as long as one year before staff at all facilities have received train-
the Joint Commission’s executive director for state and external ing on the new rules.1
relations.1
Earlier this year, the federal government took steps toward pre-
Four key features of the protocol include:2 venting wrong site surgery. As of January 15, 2009, the Centers
for Medicare and Medicaid Services (CMS) no longer reimburse
Three-way pre-op consult. The surgeon, one other licensed hospitals or surgery centers for wrong site surgery.3,4,5
practitioner (such as a registered nurse) and the patient or patient’s
20 The OR Connection
Patient Safety
1. Frequent handwashing with alternating products. Doctors New Hampshire hospitals perform better than the national average
and staff are encouraged to wash their hands frequently – particu- in each of the five Surgical Care Improvement Project (SCIP) meas-
larly after having contact with a patient and before and after eating ures related to surgical care.9
or using the restroom. They are instructed to use three different
products – soap and water, an alcohol-based hand foam and Surgical Care Improvement Project (SCIP)
an ammonia-based hand sanitizer – on an alternating basis; each NH Nat. Avg.
one third of the time. Prophylactic Antibiotic Received Within One 96% 94%
Hour Prior To Surgery
Hospital officials say this combination of products keeps the hands Prophylactic Antibiotic Selection 98% 97%
clean, but also soft and pliable. Individuals with dry, cracked skin on Prophylactic Antibiotic Discontinued Within 94% 90%
their hands tend to wash them less often. 24 Hours After Surgery
Recommended VTE Prophylaxis Ordered 94% 93%
2. A clean environment. Cleaning of all surfaces takes place Recommended VTE Prophylaxis Received 92% 90%
daily. Environmental services staff wipes down door handles, light Controlled 6 am Postop Serum Glucose 91% 90%
switches, patient beds, countertops and computer keyboards. Appropriate Hair Removal 99% 98%
Deep cleaning, which includes cleaning behind computers and
under keyboards, occurs every Friday.
References
3. Isolation procedures. Patients with a history of MRSA are iso- 1. Freyer FJ. R.I. hospitals agree on safety protocol for surgeries. The Providence Journal.
lated, and staff must wear gloves and protective gowns when they July 1, 2009. Available at
come in contact with these patients. The patients remain in isola- http://www.projo.com/health/conteent/SURGICAL_SAFETY_PROTOCOL_07-01-
09_QLETDSU_v10.3dce7cb.html. Accessed July 8, 2009.
tion their entire hospital stay, regardless of subsequent negative 2. Tsikitas I. R.I. adopts uniform surgery safety protocol. Outpatient Surgery Magazine.
MRSA cultures. Available at http://www.outpatientsurgery.net/news/2009/07/2.php. Accessed July 8, 2009.
3. Decision Memo for Wrong Surgery Performed on a Patient (CAG-00401N). Centers for
Medicare and Medicaid Services Web site. http://www.cms.hhs.gov/mcd/viewdecision-
4. Hospital-laundered scrubs. The hospital launders all doctors’ memo.asp?id=223. Accessed July 8, 2009.
and staff scrubs to make sure they are cleaned properly to remove 4. Decision Memo for Surgery on the Wrong Body Part (CAG-00402N). Centers for Medicare
bacteria. No staff member enters or leaves the hospital wearing and Medicaid Services Web site.
http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=222. Accessed July 8, 2009.
scrubs. 5. Surgery on the Wrong Patient (CAG-00403N). Centers for Medicare and Medicaid Services
Web site.
For further discussion on how scrubs may spread infection, turn to http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=221. Accessed July 8, 2009.
6. Denny D. Monroe Hospital’s low infection rates draw national interest. Bloomington Herald
page 51. Times. January 19, 2009. Available at http://www.heraldtimeson-
line.com/stories/2009/01/19/news.qp-7992582.sto?1242057521. Accessed May 11, 2009.
7. Wenzel R, Edmond MB. The impact of hospital-acquired blood stream infections. Emerg Inf
Dis. 2001;7(2):174-177.
8. NH Health Care Quality Assurance Commission issues 4th annual report. News from the
Foundation for Healthy Communities. July 2009. Available at http://www.healthynh.com/
fhc/about/newsletter/FHCNewsletterJul09.pdf. Accessed July 21, 2009.
9. NH Quality Care Reports. New Hampshire – Surgical Care Improvement Project (SCIP).
Available at http://nhqualitycare.org/reports.php?id=sip. Accessed July 22, 2009.
22 The OR Connection
OR Issues
Recently, a highly accomplished orthopedic sur- thoughts couldn’t let it go: “Where’s the checklist for when
geon was scheduled to work on three consecutive things go wrong?” he thought sarcastically to himself,
cases with his OR team. The operating rooms were having seen system error after system error despite the
state of the art within the medical center’s newly con- apparent adaptation of techniques used by high reliability
structed orthopedic hospital, which had not yet cele- organizations. Sharply, he gave an order for Gentamycin
brated its first birthday. A system of time outs including for his first patient and turned his attention, as best he
use of the World Health Organization (WHO) surgical could, to his next case. He dreaded the moment when he
checklist had been in place at the medical center for al- would have to tell his patient – a man who trusted him
most three years now, with multiple checklists for patient implicitly for a second knee replacement. But things just
identification, pre-op procedures and instrumentation. got worse.
The surgeon was scrubbing in for his second case when the His second case was a lawyer who had a long history of
charge nurse approached him from behind and quietly surgeries due to rheumatoid arthritis. The physician had
said, “Doctor, I have something to tell you. The instru- literally spent hours selecting the best implants for this
ments that you used for the first case were not sterilized.” complicated revision, talking to vendors at great length to
With the second patient already under anesthesia, there ensure the compatibility of the various systems and care-
was no time for the surgeon to discuss the small bomb- fully relaying his recommendations to the patient, who
shell that had just been lobbed in his direction, but his was extremely involved after five surgeries.
“Socket,” he said at the appropriate moment with hand never happen again. Despite the very best of intentions and
extended, eyes still fixated on the open wound. the adoption of standardized checklists and procedures,
this team has a long way to go. The level of trust and feel-
“Socket,” he said again, irritated after nothing had landed ings of personal safety in the group simply aren’t high
in his hand. enough for anyone to risk being vulnerable and actually
address a painful truth – that as a team they had systemi-
From his peripheral vision he picked up on commotion. He cally screwed up.
turned and looked up at the circulating nurse who quietly
said, “It’s not here doctor.” Fully focused on getting the Worse, violating every premise of regarding mistakes as
piece he needed STAT, the surgeon immediately got on important messages from the underlying system, they were
the phone to the vendor, trying to negotiate the use of willing to squander and discard the obvious opportunity to
another implant despite his careful planning. improve their own techniques, not to mention the opportu-
nity to share what had happened (and how to fix it) with
“She’s under a spinal … it will be wearing off. I can’t wait other surgical teams. Patient safety can only be enhanced
that long – why isn’t it here?” he said loudly over the phone. when bad experiences are shared, probed, understood,
Finally, after half an hour, the vendor arrived with the implant. and procedures changed. In fact, collegial interactive teams
Both relieved and frustrated, the surgeon closed and turned – groups of professionals dedicated to a common goal and
to his third case, which was uneventful – and painfully, as willing to care about each other and trust each other
silent as the second case. In fact, despite the two major enough to honestly report and evaluate any failure – never
mistakes of the day, not a single person in the operating hesitate to put a failure on the table for discussion. And
room had mentioned either event. never – never – does an effective collegial team care so lit-
tle for their own that they permit silence to shroud the
“The saddest thing was that no one said a word,” the sur- human pathways of interaction between them.2
geon said soberly. “I work with these people all the time and
you think someone could have at least said, ‘I’m sorry that Three powerful forces impede communication in health
happened,’ or something like that. But instead, there was care: time pressures, knowledge and culture. Understand-
nothing but this awkward silence. More than anything, I’m ing their impact is the first step to creating collegial and
still bothered by the silence.” effective teams in which relationships go deeper than the
mask of composure. Honest and meaningful relationships
As well he should have been. can only happen if we are free to speak our truth at all times.
As noted communication expert Susan Scott says, “The Culture – the undertow of health care
conversation isn’t about the relationship. It is the relation- There is no force more powerful in an organization than cul-
ship.”1 This orthopedic surgeon is an outstanding physician, ture. As all business experts counsel: “Culture kills the best
known and respected for his skill and compassion – the of strategies.” In fact, the phrase and the concept of “This
only surgeon who would actually drive to a patient’s house. is the way we’ve always done it!” is the mindless battle cry
Yet, he could not communicate his disappointment to his of culture-resisting change. Culture is never written down
team – and his team refused to reach out to him; or vocalize or spoken – but known by everyone.
any concerted team effort to make sure these errors would
24 The OR Connection
Instructors were often heard to say,
“If you want to work in the OR, you
better have thick skin.”
Knowledge is power
Communication classes are noticeably absent from both
medical and nursing school curricula. Yet the number one
cause of adverse outcomes in a study of 2,400 sentinel
events by The Joint Commission was communica-
tion errors.
Continued on Page 28
26 The OR Connection
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way nurses deal with confrontation is avoidance. Nothing is STATE - When something happens that is not normal
worth upsetting the relationship. Noting this, it is imper- (unanticipated event or error), I would appreciate your
ative that leaders teach assertive communication and support or acknowledgement of what happened. I want to
confrontation skills in the workplace. create an atmosphere where every member feels sup-
ported, and today, I certainly did not.
One very simple model is called the D-E-S-C Communica- CONSEQUENCE - If we continue to ignore issues as a
tion Model. It provides a great framework for organizing your team, then we are not a team.
thoughts and feelings.7
D - Describe the behavior Time is money AND…
E - Explain the effect of the behavior For every good idea to improve patient safety and clinical
S - State the desired outcome quality there is a voice reminding us that time is money.
C - Say what happens if the behavior continues Money governs healthcare in America. No surgeon, OR
scheduler, or CEO can refuse to be concerned about how
For example, the physician could have efficiently an OR can be used. Pressures have become so
approached the team this way after intrusive on the surgical team that beepers and Blackber-
the surgeries: ries now provide a constant opportunity for interruption and
DESCRIBE - I want to talk to all of you about the silence in distraction that few patients on the table would appreciate
the operating room today. No one said a word all day. if awake. While only preliminary data is emerging to validate
EXPLAIN - The silence is what upset me the most. Having what we already intuitively know, the fact is, the higher the
to explain the unsterile instruments to my patient was pressure on time, and the higher the level of distraction in an
extremely upsetting; as was not having the right implant. OR, the less concentration on the procedure. To the extent
But the silence made me feel like I was alone, or surrounded that a surgical team is constantly disrupted by mid-proce-
by strangers. dure personnel substitutions, thoughtless intrusions, and
28 The OR Connection
highly distracting communications, patient safety is com- References
1. Scott, S. (2004). Fierce Conversations. New York: The Berkley Publishing
promised. Time pressures drive distractions that fragment Company.
and fracture teamwork and the ability of a surgical team to 2. Nance, J. (2008). Why hospitals should fly. Second River Healthcare Press,
Bozeman, MT.
stay focused and supportive of each other.
3. Bartholomew, K. (2007). Stressed Out About Communication Skills,
Marblehead, MA
How does the leader of a would-be collegial interactive 4. Orlikoff, J. (2008). IHI Conference: From the top: the role of the board in quality
and safety, November 6-7, Boston, MA.
team respond to such pressures? By taking the time to 5. “Silence Kills: The Seven Crucial Conversations for Healthcare” study by
discuss issues outside the OR, tracking outcomes and VitalSmarts available at www.silencekills.com.
6. Bartholomew, K. Presentation for Sigma Theta Tau International: “Using a
reviewing all outliers. A team cannot coordinate their
communication model to identify barriers and increase self esteem” November
actions or responses if they don’t make the time to come 2, 2009, Indianapolis, IN
together before the fact and at least go over the basics of 7. Cox, S. (2007) Cox & Associates, Brentwood, TN.
2. I follow strict aseptic technique when 5. Before placing a catheter, I assess whether
inserting a catheter. the patient really needs it, and I document
a. Always the assessment in the chart.
b. Sometimes a. Always
c. Never b. Sometimes
c. Never
3. At my facility, we educate catheterized What’s your score?
patients about urinary tract infections.
a. Always a _____ x 5 = _______
b. Sometimes b _____ x 3 = _______
c. Never c _____ x 0 = _______
TOTAL _______
We invite you to join the Race to ERASE CAUTI! With 100,000 nurses working together, we can do it!
References
1. Expert discusses strategies to prevent CAUTIs. Infection Control Today Web site. June 1, 2005. Available at http://www.infectionacontroltoday.com/articles/402/402_561feat2.html.
Accessed July 10, 2009.
2. Catheter-related UTIs: a disconnect in preventive strategies. Physician’s Weekly. 25(6), February 11, 2008.
3. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute
care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41–S50.
4. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008. Draft. Centers for Disease Control
and Prevention. Available at http://www.cdc.gov/ncidod/dhqp/pdf/pc/cauti_GuidelineApx_June09.pdf. Accessed July 10, 2009.
5. Gokula RM, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004;32:196-199.
6. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at
http://www.medscape.com/viewarticle/587464_4. Accessed July 6, 2009.
30 The OR Connection
Patient Safety
Back to Basics Tenth in a Series
evidence-based practice. CMS reported in the 2008 Fed- CAUTI incidence outside the
eral Register that in 2007 there were 12,185 CAUTIs, costing perioperative environment
$44,043 per hospital stay.2 CAUTI is one of 10 hospital- To help you further realize the magnitude and role of
acquired conditions (HACs) for which CMS will no longer perioperative services in preventing CAUTI, let’s look at
provide reimbursement if it occurs during hospitalization.3 additional statistics from outside the perioperative environ-
ment. Did you know that the emergency department (ED)
Brand-new CAUTI prevention guidelines has the highest percentage of catheter placements?7 In the
CAUTI is the number one healthcare-associated infection ED, as well as in perioperative services, documentation of
(HAI), accounting for 40 percent of all hospital-acquired the reason for catheter placement is poor and a written
infections.4 One in four patients receives an indwelling physician order is frequently lacking. Without a physician
urinary catheter at some point during their hospital stay.5 order, physicians are unaware that the patient has a
As a result of this data, leading industry experts, including catheter.5 When physicians do not know that a catheter has
the Association for Professionals in Infection Control and been inserted, it is no wonder that an order for timely
Epidemiology (APIC), the Society for Healthcare Epidemiol- removal is lacking, and catheters stay in longer than med-
ogy (SHEA), the Centers for Disease Control and Prevention ically necessary.
(CDC), the Joint Commission and many others have joined
together to outline strategies and guidelines to prevent Common catheter practices in perioperative services
catheter-associated urinary tract infections in acute care Adding to the problem, inappropriately placed catheters are
hospitals.6 The CDC’s Draft Guideline for Prevention of more often forgotten about.5 In 56 percent of hospitals there
Catheter-Associated Urinary Tract Infections 2008 (released is no system to keep track of which patients have catheters,
in June 2009) identifies new guidelines and recommenda- and 74 percent of hospitals do not keep track of how long
tions to prevent CAUTI. the catheter is in place.8 Shocking as this may be, let’s
assess common practice in perioperative services and see
Barriers to CAUTI prevention if any of these common occurrences occur at your facility.
Three distinct barriers to the prevention of CAUTI become 1. Do you have preference cards that tell you to insert
evident when analyzing the problem. In the perioperative an indwelling catheter for a specific procedures
environment it is hard to imagine that there are errors in performed by a particular surgeon?
aseptic technique because we are acutely aware of proper 2. Do you assess patients to determine if the standing
technique. But remember that most nurses outside of the order to insert an indwelling catheter is medically
perioperative environment do not routinely perform aseptic indicated?
technique and may not be aware when contamination 3. When a patient comes to the OR with an
occurs. In fact, during most observations of nurses outside indwelling urinary catheter or when you insert one
of the perioperative environment, we have seen inconsis- intraoperatively, do you evaluate the need to keep
tent practice in setting up a sterile field and inserting the catheter in place at the end of the surgical
indwelling catheters aseptically. It is perfectly clear that in procedure before transporting the patient to the
perioperative services, two of the three barriers occur rou- post anesthesia care unit (PACU)?
tinely – too many catheters are inserted and catheters stay 4. Do you date and time when the catheter was
in too long. inserted? This critical step helps the clinicians on
the patient care unit to remove the catheter within
48 hours or less following the surgical procedure.
32 The OR Connection
Perioperative nurses are positioned to significantly impact b. Appropriate urinary catheter use
the reduction and elimination of catheter-associated urinary Use indwelling catheters only when medically necessary.
tract infections by removing catheters when patients do not c. Aseptic insertion of urinary catheters
meet the approved indications. Take a peek at Table 1, which Use aseptic insertion technique with appropriate hand
lists when indwelling urinary catheters should and should not hygiene and gloves. Allow only trained healthcare
be used. providers to insert catheters.
d. Proper urinary catheter maintenance
What is a nurse to do? If your patient has no alternatives, - Properly secure catheters after insertion.
and you must insert a urinary catheter, is there anything you - Maintain a sterile closed drainage system.
can do to help prevent catheter-associated urinary tract - Maintain good hygiene at the catheter-urethral interface.
infections? Absolutely! - Maintain unobstructed urine flow.
- Maintain drainage bag below level of bladder at
CAUTI prevention methods all times.
a. Alternatives to urinary catheter use - Use portable ultrasound bladder scans to detect
Do not allow routine urinary catheter placement in the residual urine amounts.
OR. Remove as many urinary catheters as you can - Do not change indwelling catheters or urinary drainage
within 24 hours. Consider alternatives to indwelling bags at arbitrary fixed intervals.
urethral catheters, such as intermittent catheterization. e. Timely removal
- Remove catheters when
Table 1. Appropriate Indications for Indwelling Urethral Catheter Use 10,11 no longer needed.
Patient has acute urinary retention or obstruction - Document indication for
Need for accurate measurements of urinary output in critically ill patients urinary catheter on each
Perioperative use for selected surgical procedures: day of use.
• Patients undergoing urologic surgery or other surgery on contiguous structures - Use reminder systems
of the genitourinary tract to target opportunities
• Anticipated prolonged duration of surgery (catheters inserted for this reason to remove catheter.
should be removed in PACU)
The above list was combined from
• Patients anticipated to receive large-volume infusions or diuretics during surgery
recommendations in the CDC
• Operative patients with urinary incontinence guidelines and 2008 APIC CAUTI
• Need for intraoperative monitoring of urinary output Elimination Guidelines.
To assist in healing of open sacral or perineal wounds in incontinent patients
Patient requires prolonged immobilization (e.g., potentially unstable thoracic or Continued on Page 36
lumbar spine)
To improve comfort for end of life care if needed
Indwelling catheters should not be used:
• As a substitute for nursing care of the patient or resident with incontinence
• As a means of obtaining urine for culture or other diagnostic tests when the
patient can voluntarily void
• For prolonged postoperative duration without appropriate indications
• Routinely for patients receiving epidural anesthesia/analgesia
Design
The innovative one-layer tray design guides the clinician
through the process of placing a catheter to ensure
aseptic technique.
Education
The acronym ERASE is easy to remember, reminding
the clinician to:
Awareness
Join the Race to ERASE CAUTI! The current state of health
care demands that nurses play a leading role in identifying
and implementing CAUTI risk reduction strategies. Help us
reach our goal to introduce 100,000 nurses to the ERASE
CAUTI system.
www.medline.com
P
ww rem
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ed u
lin gu
e. st 1
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/e 09
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se
Education
Click here for
details on nursing
education materials
that promote
evidence-based
practice. Awareness
Visit this section
to join 100,000
nurses in the
Race to ERASE
CAUTI.
Reference
1. Catheter-related UTIs: a disconnect in preventive strategies.
Physicians Weekly. 25(6), February 11, 2008.
MAJOR BARRIERS TO CAUTI PREVENTION
Contamination occurs during insertion
Most nurses are aware of the importance of aseptic technique but it can take extra time.
Heavier nursing workloads contribute to poor compliance with aseptic technique.7
36 The OR Connection
Start the race to erase CAUTI in the operative arena by References
1. Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the
educating your patients and staff about CAUTI. Ensure all postoperative period: analysis of the national surgical infection prevention project data.
staff practice aseptic technique and remove catheters in a Arch Surg. 2008;143:551-557
2. Ribby KJ. Decreasing urinary tract infections through staff development, outcomes,
timely manner. and nursing process. J Nurs Care Qual. 2006; 21:272-276.
3. CMS, Proposed Changes to the Hospital IPPS and FY2009 rates; Available at
http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf. Accessed July 24, 2009
Join the Race to ERASE CAUTI! Talk about prevention, 4. Catheter-related UTIs: a disconnect in preventive strategies. Physician’s Weekly. 25(6),
February 11, 2008.
raise awareness, then implement solutions in your 5. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces
organization. urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf. 2005;
31(8):455-462.
6. 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 Epidemiology. 2008; 29:S41–
GO!
8. Saint S, Kowalski CP, Kaufman SR, Hofer PH, Kauffman CA, Olmsted RN et al.
Preventing hospital–acquired urinary tract infection in the United States: a national study.
Clinical Infectious Diseases. 2008; 46(2):243-250.
9. Magnall, J. Waterson, L. “Principles of aseptic technique in urinary catheterization.”
Nursing Standards. 2006 November 1 – 7; 21(8) 49 – 56;quiz. Available at
http://www.ncbi.nlm.nih.gov/pubmed/17111954. Accessed July 24, 2009
10. The CDC Guideline for Prevention of Catheter-Associated Urinary Tract Infections
2008, Draft
11. An APIC Guide to the Elimination of Catheter-Associated Urinary Tract Infections 2008
(CA-UTI) p. 22,35 -41 The Association of Professionals in Infection Control and
Epidemiology.
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. www.medline.com
CE Questions Back to Basics
3. One in three patients receives an indwelling urinary 12. It has been estimated that up to ____ percent of
catheter at some point during their hospital stay. T F indwelling urinary catheters are unnecessarily placed.
a. 85
4. Assistance in pressure ulcer healing for incontinent b. 10
patients is an approved indication for urinary c. 50
catheterization. T F d. None of the above
5. Allowing only trained healthcare providers to insert 13. Which of the following is a successful strategy
catheters is one method for preventing catheter- implemented by healthcare organizations to
associated urinary tract infections (CAUTI). T F reduce CAUTI?
a. Redesign patient care areas
6. A recent survey of U.S. hospital practices identified b. Utilize multidisciplinary teams to put
that no strategy is consistently or universally used to evidence-based changes in practice
prevent CAUTI. T F c. Serve cranberry juice to patients
d. Deploy rapid response teams (RRTs)
7. CAUTI is one of 10 hospital-acquired conditions for
which the Centers for Medicare & Medicaid Services 14. Which of the following organizations did not
(CMS) will no longer provide reimbursement if it participate in outlining strategies and guidelines
occurs during hospitalization. T F to prevent CAUTI?
a. American Medical Association (AMA)
8. Nurses rarely request to place a urinary catheter for b. Centers for Disease Control and Prevention (CDC)
nursing convenience. T F c. Association for Professionals in Infection Control
and Epidemiology (APIC)
Multiple Choice d. The Joint Commission
9. Which of the following is not an approved indication
for urinary catheterization? 15. One way to help prevent CAUTI is to use
a. To improve comfort during end-of-life care. ___________ systems to target opportunities to
b. Management of acute urinary retention and remove catheters.
urinary obstruction. a. infection control
c. The patient requires prolonged immobilization. b. emergency
d. The patient is incontinent and requires two or c. aseptic
three linen changes per shift. d. reminder
Knowing catheter-related urinary tract infections (UTIs) According to Rothfeld’s findings, catheters are needed in only
are the most common of all hospital-acquired infec- about half the cases in which they are used.
tions, Alan F. Rothfeld, MD, was looking for alternatives to
catheterizing patients at Hollywood Presbyterian Medical Before beginning the study, Rothfeld developed the
Center (HPMC), a 434-bed hospital in Los Angeles. following indications for the use of urinary catheters:
1. Written orders for hourly urinary output
Rothfeld noted that new incontinence management products 2. Inability to void spontaneously (usually due
offer less costly and more effective alternatives to catheteri- to obstruction)
zation. Restore ultra-absorbent disposable briefs, manufac- 3. Active urinary tract infection with Stage 3 or 4
tured by Medline, stay dry and hold significantly more urine pressure ulcer
per day.
If a patient had none of these indications, no catheter was
In order to document whether using disposable briefs in place requested. If a patient had a catheter already, a request to the
of urinary catheters would decrease UTIs, Rothfeld led a six- physician for discontinuance was initiated.
month study, from January to October 2008, at HPMC’s ICU
step-down units. The study observed the use of Restore An anonymous questionnaire conducted at the end of the
briefs during two three-month periods in two separate units of study revealed the disposable briefs were a welcome alter-
the hospital with a total of 60 beds, averaging 83 percent native among physicians and nurses. “In fact, no patient
occupancy. reported decreased comfort and most of the staff was sup-
portive of this program, indicating it increased overall satis-
50 Percent Reduction in UTIs faction among nursing personnel,” Rothfeld said.
There were five hospital-acquired UTIs during the three-month
control period, indicating an infection rate of 3.2 per 1,000 References
catheter days. During the three-month intervention period, Ditch the foleys, adopt diapers to address UTIs. Infection Control Today Web
site. Posted March 10, 2009. Available at
there were only two hospital-acquired UTIs, with an infection http://www.vpico.com/articlemanager/printerfriendly.aspx?article=23711. Ac-
rate of 2.4 per 1,000 catheter days. cessed May 22, 2009.
40 The OR Connection
Protection,
& performance,
comfort without compromise.
provides you with exceptional fit, feel • SensiCare® with Aloe – standard thickness,
smooth grip
and protection so that you can address
• SensiCare® LT with Aloe – standard thickness,
a rising concern in the OR community –
textured grip
latex allergies.
• SensiCare® Green with Aloe – 10% thinner for
enhanced tactile sensitivity
The American Latex Allergy Association estimates that
• SensiCare® Ortho – 40% thicker for extra protection
between 8 and 17 percent of all healthcare workers are
sensitized to natural rubber latex.1 Studies have suggested
Contact your local Medline representative
that the costs of healthcare workers’ disability compen-
for samples or e-mail us at glovedivision@
sation due to latex allergies justifies or significantly offsets
medline.com. Your staff will love you for it!
the cost of conversion to a latex-free environment.2
References:
1. American Latex Allergy Association. Latex Allergy Statistics. Available at:
www.latexallergyresources.org/topics/LatexAllergyStatistics.cfm.
Accessed November 5, 2008
2. Phillips VL, Goodrich MA, Sullivan TJ. Health care worker disability due to latex
allergy and asthma: a cost analysis. American Journal of Public Health.
1999:89(7):1024-28.
www.medline.com
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
by Lorri A. Downs RN, BSN, MS, CIC
Playing Traffic
Control in the OR
from contaminated materials, and to ensure that only
authorized personnel in appropriate attire enter the operat-
ing room.1
42 The OR Connection
OR Issues
10 QUICK TIPS
for controlling traffic in the OR2
References
1. Surgical Services. In: APIC Text of Infection Control and Epidemiology. Vol II. 3rd ed.
Washington, DC: Association for Professionals in Infection Control and Epidemiology,
Inc. (APIC); 2009
2. Recommended Practices for Traffic Patterns in the Perioperative Practice Setting. In:
2008 Perioperative Standards and Recommended Practices. Denver, CO: Association
of PeriOperative Registered Nurses; 2008.
3. Anderson DJ, Kaye KS, Classen D, Arias KM, Podgorny K, Burstin H, et al. Strategies
to prevent surgical site infections in acute care hospitals. Infection Control and Hospital
Epidemiology. 2008; 29:S51-S61.
4. Gagliardi A, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R.
Identifying opportunities for quality improvement in surgical site infection prevention.
AJIC. 2009; 37(4):398-402.
44 The OR Connection
S.T.O.P. for safety. ™
References
1 The Joint Commission. The Statistics page. Available at: http://www.jointcommis-
sion.org/NR/rdonlyres/D7836542-A372-4F93-8BD7-DDD11D43E484/0/SE_Stats_12_07.pdf.
Accessed March 13, 2008.
* Patent pending
www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Legal Issues in the Care
of Pressure Ulcer Patients
The International Expert Wound Care Advisory References
1. Voss AC, Bender SA, Ferguson ML, et al. Long-term care liability for pressure
Panel released a 23-page white paper in June ulcers. J Am Geriatric Soc. 2005;53:1587-1592.
2. Ayello EA, Capitulo KL, Fife CE, Fowler E, Krasner DL, Mulder G, et al. Legal
2009 identifying key concepts to help healthcare is sues in the care of pressure ulcer patients: key concepts for healthcare
professionals with preventative legal care providers. White paper. June 2009.
3. Aronovitch SA. Intraoperatively acquired pressure ulcers: are there common
practices taking into consideration the current risk factors? Ostomy Wound Management. 2007;53(2):57-69. Available at
pressure ulcer regulatory and legal environment. http://www.o-wm.com/article/6776. Accessed July 29, 2009.
46 The OR Connection
IJJJJJJJJJJJJI Special Feature
The unthinkable happened to me. of bruising or wounds. She developed sepsis, had
an altered mental status with bouts of confusion,
In my 46 years of nursing, I have always felt uncooperative behavior, lethargy, difficulty
that I was a patient advocate. In fact, I have told awakening and agitation; she was verbally abusive
many a patient, “If I were you, I would want me to the staff. Her hospitalization was fraught with
to take care of you.” I was shocked when I opened complications, including pneumonia with subsequent
the door one evening and was handed a subpoena need for intubation. Her behavior became combative.
to report for a deposition. She pulled out the nasogastric tube and intravenous
lines and had to be placed in restraints.
One of the patients I had cared for a few years
ago had brought a lawsuit against the hospital and Eight days after admission, two pressure ulcers
I was implicated as one of the wound care specialists (Stage I and Stage II) were noted in the sacral area.
who had rendered service. As per our protocol, photographs were taken. On post
op day 12, the orthopedic surgeon requested a wound
I was devastated. I have always done my best care consultation for recommendations regarding the
to keep patients in my charge clean, dry, comfortable management of the open fasciotomy incision. During
and safe. So how did this happen and what does it the skin assessment, the wound care nurse document-
mean for me? What would happen next? ed a 9 x 20 centimeter unstageable pressure ulcer
on the sacral area, 75% black, 20% yellow, 5% red.
I remembered the patient quite well. She was a The patient was on the bariatric air support surface.
very complex and difficult patient. Here’s what my
review of her medical record revealed. She was a The post-op leg wound continued to heal;
54-year-old morbidly obese (425 lbs.) female who however, the sacral pressure ulcer needed multiple
was admitted to the Emergency Department after surgical debridements. At the base of the pressure
three days of being febrile, unable to eat, experienc- ulcer, an abscessed area was found. Once the sacral
ing liquid stools and being lethargic. The paramed- area was clean, a negative pressure wound therapy
ics had been called to the home earlier, but she had closure device was applied over the wound.
refused to be taken to the hospital. Later that night,
her daughter was able to persuade her to go to the Upon discharge, she spent an additional six
Emergency Department. Her admitting diagnosis months in a skilled nursing facility for pressure ulcer
was right leg cellulitis. She had a history of multiple management. Eventually, she returned home with
co-morbidities including venous disease, diabe- a small open wound. Her lower leg cellulitis had
tes, morbid obesity, hypertension, chronic anemia, extended into an eight-month saga due to the com-
chronic kidney disease, asthma, and of non-adherent plication from the hospital-acquired pressure ulcer.
behavior. She had called the membership services
over 100 times during her years of coverage, Now what?
reporting various incidents regarding her care.
I was a fact witness (required to help relate the
A few hours after admission, she was taken specific facts of this one case) rather than expert
to the operating room, where she had a soft tissue witness (who is usually called in to offer an opinion).
incision and fasciotomy for compartment syndrome The hospital’s attorney represented me for the
of the right leg. On post-op admission to the inten- deposition. I was called by the defense and counseled
sive care unit, her initial skin assessment was clear not to give any opinions.
fact witness. A person testifying in court as to the facts or specifics of an individual case but not to offer opinions.
IJJJJJJJJJJJJI
expert witness. A person, typically with expert credentials, testifying in court and offering an educated opinion on the case.
Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers
After a few months, the case was settled out of court in favor of the patient.
I hope by my sharing my own story of doing a deposition, you will gain from my pain!
IJJJJJJJJJJJJI
Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers
48 The OR Connection
Are Your
What to Do Physicians
If This Happens Making
to You 2
the Grade?
Although finding out you are being sued can be shocking and A recent survey graded physiciansʼ abilities to
upsetting, it is crucial to stay calm and take some simple recognize, assess and document Stage III and
steps to allow for the best possible results. IV pressure ulcers at a “D” level. Medlineʼs new
Pressure Ulcer Prevention Program MD Education
• Notify your institution and malpractice carrier CD contains everything physicians need to brush
immediately for the name of your attorney (counsel). up on their skills and comply with the new CMS
Inpatient Prospective Payment System (IPPS).
• DO NOT create notes on your own – separate and apart
from a meeting with your lawyer. These notes could “The new MD Education component of Medlineʼs
easily be discoverable in litigation. Pressure Ulcer Prevention Program is critical for
acute-care facilities to ensure that physicians
• Avoid the temptation to talk to anyone about the case understand their role in recognizing and accurately
until you have discussed it with your attorney. Your documenting POA pressure ulcers.”
attorney will likely advise you to avoid talking to Michael Raymond, MD, Associate Chief Medical
colleagues about the case; this is important advice. Quality Officer, NorthShore University HealthSystem,
Skokie Hospital, Skokie, IL
• Your attorneys or legal department are your resources,
so ask them about terminology or procedures that are
unfamiliar to you.
Your shield
against
bacteria.
Your Act!
MRSA, C. diff, other harmful bacteria
lurk in unexpected places
52 The OR Connection
In one study, 65 percent of nurses who cared for St. Mary’s Health Center in St. Louis, Mo., reduced
patients with MRSA contaminated their uniforms with infections after cesarean births by more than 50 percent
MRSA.6 Staphylococci and Enterococci were found to by providing staff with hospital-laundered scrubs.5
survive for days to months after drying on commonly Similarly, Monroe Hospital in Bloomington, Ind., which
used hospital fabrics, such as scrubs made from 100 has a near-zero rate of hospital-acquired infections,
percent cotton or 60 percent cotton and 40 percent requires all staff to wear hospital-laundered scrubs and
polyester, as shown in a study conducted by the bans them from wearing scrubs outside the hospital
Shriners Hospital for Children and the Department of building.5
6
Surgery at the University of Cincinnati.
AORN recommendations further state, “Surgical attire On the other side of the debate, a 1997 state-of-the-art
should be changed daily or whenever it becomes visibly report (SOAR) compiled by the Association for Profes-
soiled, contaminated, or wet. Worn surgical attire should sionals in Infection Control and Epidemiology (APIC)
be placed in an appropriately designed container for states, “There is no scientific evidence to suggest that
washing or disposal and should not be hung or placed home laundering versus institutional laundering poses
in a locker for wearing at another time. This promotes any increased risk of infection transmission.” 9
high-level cleanliness and hygiene within the practice
setting. It has been reported that bacterial colony counts Yet the report also says, “OSHA holds employers
are higher when scrub clothing is removed, stored in a responsible for laundering any clothing, including scrubs
locker, and used again.” worn by health care workers, that becomes contami-
nated with blood or other potentially infectious body
Surgical staff are exposed to possible bacteria-contain- fluids, regardless of who owns the scrubs.”9
ing debris and fluid much more often than staff in other
areas of a hospital, however, microbial contamination The CDC supports home laundering of scrub uniforms
still can occur outside the surgical suite, in patient rooms in its Guideline for Isolation Precautions (2007), which
where patients have MRSA or VRE.8 states, “In the home, textiles and laundry from patients
54 The OR Connection
Perioperative Pressure Ulcer Education
The AORN Seal of Recognition is a trademark of AORN, Inc., All rights reserved.
By Wolf J. Rinke, PhD, RD, CSP 1. Reality Test
Most of us assume words have meaning. They do not! The
Do you have problems with communication in fact is all of us speak a different “language” because we all
have different values, beliefs and life experiences that impact
your facility and at home? Whenever I ask that
how we interpret everything. For example, what does the
question of my audiences virtually all hands go up. word “fast” mean to you? If you’ve been dieting, it probably
Why? Because we are all terrible communicators. means “to not eat.” If you are an amateur photographer, you
Here are 12 specific strategies that will help you might be thinking of the speed of film. If you do a lot of laun-
dry, you might be thinking of how stable a color is. If you like
communicate more effectively and get more of to race, you might think of the speed of a vehicle. And the list
what you want. goes on.
56 The OR Connection
Caring for Yourself
How to Communicate More Effectively and Get More of What You Want
To get around this, do a reality test, especially when a shared 2. Get Really Good at Asking Questions
understanding is critical. Here are several examples. When As an executive coach, I’ve learned the benefits of asking
your spouse tells you how much you irritate him, summarize questions. Here is what questions can do:
your conversation: “Sweetheart, let me just make sure that • Put you in control of the conversation. Questions elicit
you and I are on the same page. What I heard you say was . an almost Pavlovian response in the listener to find
. .” At the end of a complicated instruction to one of your pa- an answer.
tients: “Now Miss Eager, we went over a lot of technical in- • Establish rapport. Questions demonstrate interest, which
formation. To make sure you will be able to follow my causes others to like you. And people who like you
instructions, please repeat what you heard me say.” are more likely to comply with your wishes and requests.
• Build trust. Eliciting ideas from others causes them to
feel that you care about them, which helps build trust.
Continued on Page 59
The
choice
is yours.
Medline’s comprehensive line of facemasks was de-
signed to meet a variety of needs and preferences,
but all of our masks are united by a common trait —
quality. Every mask we manufacture—from our fluid-
resistant masks to our spearmint-scented masks—is
backed by Medline’s quality guarantee and designed
to exceed expectations for comfort and protection.
• Fluid resistant
• Fog free
• Spearmint scented
• Chamber style
• Isolation
• Procedure
• Face shield
• Protective eyewear
• Achieve deeper understanding. When you ask questions, My consistent advice is deceptively simply but extremely
you will help the other party focus on what you want powerful: If in doubt, check it out.
them to focus on.
• Provide for greater buy-in, higher motivation and 4. Utilize Adult Language
compliance. Questions allow individuals to come up According to Eric Berne and Thomas Harris, of the transac-
with their “solution,” and invariably their level of tional analysis (TA) fame, all of us utilize three different internal
commitment will increase. “recordings” that represent our “ego states”: child, parent
and adult.
3. Avoid Fundamental Attribution Errors
Someone is late for an appointment, and we perceive that The child ego state refers to the behavior pattern, thoughts
they don’t care or they are sloppy, when in fact they may and feelings we learned as children. They include helpless-
have had an accident. In psychology this is referred to as ness, blaming and emotional expressions such as “I can’t
making a fundamental attribution error. I refer to it as “we help it,” “Don’t blame me,” “It’s your fault,” etc. Nonverbal
are very good at running our own movies,” meaning that we cues of the child ego state include whining, whistling, laughing,
attach all kinds of meanings to behavior we observe that has teasing, expressing dejection, pouting, nail biting, moving
nothing whatsoever to do with the person’s actions. restlessly and looking rebellious, nervous or sad.
I see this all the time in my coaching practice. Our parent ego state was developed by observing parents
A manager tells me, “My boss does not care about me.” and other authority figures. When we are in a parent role we
I ask, “How do you know?” tend to be very judgmental, critical, controlling, comforting or
“Well, he never tells me anything.” nurturing, and use such phrases as “You can’t do that,” “You
I ask, “How do you mean?” have to,” “Always,” “Never,” etc. Nonverbal cues include
“Well, most of the time I find out stuff through finger pointing, looking at your watch while communicating,
the grapevine instead of from my boss.” finger tapping, pressing lips tight, grinding teeth, checking
I ask, “Have you ever asked him to keep you in the loop?” up on others, scowling, sneering, patronizing or expressing
“No, but you know, that is a very good idea. sympathy.
I should really do that.”
The third internal recording is that of the adult. An adult is a
fact finder, information seeker, analyzer and logical problem
solver. When you use your adult recording, you ask why? 6. Listen Actively
what? when? where? who? how? and say such things as “I Even though it’s been said by the prolific author Anonymous,
made a mistake,” “I changed my mind,” “I don’t know,” “It is better to remain quiet and be thought a fool than to
“I don’t understand,” “It’s my opinion,” “Let me check on speak and remove all doubt,” most of us are very good at re-
that,” and “What can we learn from this?” When you are in moving all doubt. One reason is that most of us are very
this ego state, you tend to be clear, calm and non-judg- good at “talking and telling” instead of “listening and learn-
mental. Your nonverbal expressions include straight but ing.” To become an active listener, remind yourself that there
relaxed posture, comfortable eye contact and a friendly face must be a reason that we were born with only one mouth
that says, “I’m interested in what you have to say. I’m alert, and two ears.
thoughtful and attentive.”
The better you get at listening, the more you’ll find out what
Communication effectiveness is dramatically enhanced the other party really wants. Once you know that, you are
when you express yourself in an adult ego state, especially communicating from a position of strength. Your husband
when both you and the other party are playing the same says: “For our next vacation I want to go to Phoenix.” Un-
recording. Since it is difficult to change other people, fortunately you are tired of Phoenix. Instead of telling him
I strongly urge you to get in the driver’s seat of your trans- why Phoenix is a bad idea, ask questions to find out what he
actions by using adult language whenever you are commu- really wants. “Please tell me what you would like to do in
nicating. If you would like more help with this, read my How Phoenix?” He might say, “I want to play golf where the air is
to Maximize Professional Potential CPE program available warm and dry.” Now you can put your thinking caps on to
from www.easyCPEcredits.com. identify lots of places that will meet both of your needs. Here
are several related strategies:
5. Accept 111 Percent Responsibility • When someone asks a question, keep your mouth shut
for the Entire Communication Process until the other person has finished speaking. Do this even
Most of us are experts at playing the blame game. Have you though you know the answer when the other person
noticed that when there is a breakdown in communication, begins to speak. Remember, when the mouth is
it’s almost always the fault of someone or something else, engaged, the ears are out of gear.
but seldom the person who is making the excuses! To make • Show the person speaking that you are listening actively
this point, ask someone who arrives late for a meeting, by totally focusing all of your mental energy on what the
“Would you have been on time if $1,000 were riding on it?” other person is saying, not only with her words but also
The typical answer is “Of course!” her body. You can achieve that by making strong eye
contact, leaning slightly forward and using your body
To achieve dramatic improvements in your communication language to acknowledge the message and
effectiveness, I strongly recommend that you buy 111 per- the messenger.
cent into the following axiom: If it is to be, it is up to me. (This
one works for all aspects of your life, so do try this at home.)
60 The OR Connection
• Listen to the “music” as well as the words. In order to would cause you to react negatively, PIN it. For example, your
really understand what’s being communicated, it’s team member says, “Boss, you know how morale has gone
important that you hear more than the words, which down the tube? Let’s close the hospital and go on a cruise.”
you can achieve by tuning into the mood, atmosphere
and emotional tone that put the words into context. Instead of NIPing anything “weird,” focus your mental energy
• Demonstrate empathy by getting inside the other first on the:
person’s thoughts and feelings. This can be expressed P - Positive. Ask yourself what could be positive about your
by saying “I see,” “I understand,” “I follow you,” “I’m with employee’s suggestion: “Well at least she seems interested in
you,” and so on. making things better.” After you’ve done that in your mind’s
• Take off your mask and be yourself. This engenders eye, next evaluate the …
trust, and trust is essential to effective communication. I - Interesting or Innovative. Ask what could be interesting
• Before ending your communication, summarize and do or innovative about your team member’s suggestion. “Maybe
a reality test, as previously discussed. there is a need for more celebration around here.” Once
you’ve evaluated that, and only after you’ve exhausted all the
7. Express Yourself in Positive Terms Ps and Is, then ask yourself: “What is the downside, or the
When we speak, we can say things negatively or positively. …”
For example, you can say, “I don’t have an answer for that,” N - Negative. Because in communication, just like in life,
or “I can answer that the next time we get together.” Which do nothing ever goes one way, there is yin and yang, health and
you think is easier to understand? Research has demon- sickness, life and death, high stock market and low stock
strated that positively worded statements are one-third eas- market and the list goes on. PINing it will enable you to eval-
ier to comprehend than their negative counterparts. The uate both the upside and downside of every conversation.
reason is that human beings are unable to move away However, if you NIP comments, ideas or suggestions in the
from the reverse of an idea. Instead, we move toward that bud, it’s like closing the proverbial shade, which prevents you
which we visualize in our minds. Don’t believe it? Let me ask from seeing opportunities.
you not to think of a green snake. What did you just think of?
A green snake, right? You see, none of us can move away 9. Convey Integrity at All Times
from the reverse of an idea. Take advantage of this phenom- People prefer to deal with communicators they can trust,
enon by expressing yourself in positive terms. rather than those they have to second-guess. The fact is that
without trust, relationships die and your ability to communi-
8. Master the PIN Technique cate is severely compromised. So be sure to be congruent,
The PIN technique is a powerful way to reframe your percep- which means that your body language, vocal patterns and
tions and turn the negatives into positives. Here is how it pitch support what you’re saying. And the way to achieve that
works. When you are confronted with anyone or anything that is to “tell it like it is,” even though it shows that you are not
omnipotent. Also be aware of self-defeating phrases some
Continued on Page 63
people use habitually without being aware of their implica- 12. Make Them Glad They Communicated
tions. For example, avoid saying, “Let me be absolutely with You
honest with you.” If you say that to me, I’m thinking: “What are To turbo-charge your communication effectiveness, pretend
you normally?” that all people you communicate with have printed across
their forehead a big bold sign that reads MAKE ME FEEL
10. Strive For Win-Win IMPORTANT! This phrase will remind you to always focus on
When you are communicating be on the lookout for things their needs first, because once they get the feeling you want
that will be beneficial to the other party. For example, if you are to help them, most people will do whatever they can to
talking with a team member, instead of saying “You have to reciprocate, which in the long run will help you get more of
yada, yada, yada,” use: “How can I help you with . . .?” When what you want.
you are talking to patients, instead of saying, “According to
hospital policy you have to . . .,” use, “What options can we
think of that will . . .” This attitude shows that you are inter-
ested in helping the other person get what he wants, which
in turn will make him more receptive to helping you get what
you want.
Support
Breast Cancer
Awareness
Month October 2009
5
Medline Breast Cancer Awareness Campaign
Celebrates Five Years
66 The OR Connection
Breast Self-Examination
1. In the Shower
Fingers flat – move gently over
every part of each breast.
Breast breast.
2. Before a Mirror
Cancer Inspect your breasts with your
arms raised high overhead. Next,
References
American Cancer Society, www.cancer.org
National Cancer Institute, www.cancer.gov
68 The OR Connection
Forms & Tools
Medline’s double-door and tabletop warming All of our blanket and fluid warmers have
cabinets are the perfect way to ensure that conveniently located keypads and digital
the warm blankets and fluids your patients controls for easy operation. The uniform
need before, during and after surgery are heating and open shelf design provide
right at your fingertips. greater temperature accuracy, and the
simplified control panel is a snap to use!
Studies have shown that hypothermia may To learn more about Medline
delay healing, predispose patients to wound Best of all, Medline blanket and fluid blanket and fluid warmers, contact
infections and increase the length of hospital warmers are so affordable that you can your Medline representative,
stays.1 Clearly, taking measures to prevent cover your needs on every floor! call 1-800-MEDLINE or visit us
hypothermia in the perioperative setting at www.medline.com.
is crucial.
Reference
1 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of
surgical-wound infection and shorten hospitalization. The New England Journal of Medicine.
1996;334:1209-1216.
The antibiotic regimens described in this table reflect the combined, published recommendations of
the Specifications Manual for discharges from 04-01-09 to 09-30-09.
The antibiotic regimens described in this table reflect the combined, published recommendations of
the Specifications Manual for discharges from 04-01-09 to 09-30-09.
72 The OR Connection
VTE Forms & Tools
Elective Total Hip Any of the following started within 24 hours of surgery:
Replacement • Low molecular weight heparin (LMWH)
*Patients who receive • Factor Xa Inhibitor (Fondaparinux)
• Warfarinnesthesia or have a documented reason for not the performance
measure if either appropriate pharmacological is ordered. Manual for
National Hospital Inpatient Quality Measures Discharges 4-01-09 (2Q09)
* Patients who receive neuraxial anesthesia or have a documented reason for administering pharmacological prophylaxis
may pass the performance measure if either appropriate pharmacological or mechanical prophylaxis is ordered.
* Patients who receive neuraxial anesthesia or have a documented reason for administering pharmacological prophylaxis
may pass the performance measure if either appropriate pharmacological or mechanical prophylaxis is ordered.
74 The OR Connection
Surgical Infections Forms & Tools
Most patients who have surgery do well. But sometimes patients get infections.
This happens to about 3 out of 100 patients who have surgery. Infections after
surgery can lead to other problems. Sometimes, patients have to stay longer in
the hospital. Rarely, patients die from infections. Patients and their family
members can help lower the risk of infection after surgery. Here are some ways:
This document is in the public domain and may be used and reprinted without permission provided
appropriate reference is made to the Institute for Healthcare Improvement.
Information provided in this Fact Sheet is intended to help patients and their families in obtaining effective
treatment and assisting medical professionals in the delivery of care. The IHI does not provide medical
advice or medical services of any kind, however, and does not practice medicine or assist in the diagnosis,
treatment, care, or prognosis of any patient. Because of rapid changes in medicine and information, the
information in this Fact Sheet is not necessarily comprehensive or definitive, and all persons intending to
rely on the information contained in this Fact Sheet are urged to discuss such information with their health
care provider. Use of this information is at the reader's own risk.
This document is in the public domain and may be used and reprinted without permission provided
appropriate reference is made to the Institute for Healthcare Improvement.
76 The OR Connection
Surgical Infections Español Forms & Tools
Lo Que Usted Debe Saber sobre las Infecciones después de las Cirugías:
Pagína de Informe para Pacientes y Sus Familiares:
La mayor parte de los pacientes que se operan, salen bien. Pero a veces al
paciente le da una infección. Esto ocurre en alrededor de 3 de cada 100
pacientes que se operan. Una infección después de una cirugía puede resultar
en otras complicaciones. A veces, el paciente debe permanecer más tiempo en
el hospital. Son raros los casos en que muere el paciente de una infección. El
paciente y sus familiares pueden ayudar a reducir el riesgo de una infección
después de una cirugía. Vea cómo, a continuación:
A la hora de la cirugía:
• Comunique al anestesiólogo (el médico o enfermera que lo duerme durante
la cirugía) cuales medicamentos usted toma. Una buena manera de hacer
esto es por medio de una lista de medicamentos, que esté al día.
• Diga al anestesiólogo si es diabético o si tiene el azúcar de la sangre
elevado. Las personas con el azúcar de la sangre alto tienen una mayor
probabilidad de adquirir una infección después de una cirugía.
La información que aparece en esta hoja se provee con la intención de ayudar a pacientes y a sus
familiares a recibir buen cuidado médico y para asistir a los profesionales médicos a prestar cuidado
médico. El Instituto para el Mejoramiento de la Salud no da consejos médicos ni presta servicios médicos
de ninguna clase, y no práctica medicina ni asiste en el diagnóstico, tratamiento, cuidado, o prognosis de
ningún paciente. A causa de los rápidos cambios en la medicina y la información, la información en esta
hoja no pretende estar completa ni tampoco es definitiva. Toda persona con la intención de usar la
información contenida en esta hoja, debe consultar con su proveedor médico. El uso de esta información
es a su propio riesgo.
Este documento es parte del dominio público y se puede usar y reproducir sin permiso con tal de que se
mencione apropiadamente al Instituto para el Mejoramiento de la Salud (Institute for Healthcare
Improvement).
78 The OR Connection
Handrub (Non-surgical) Forms & Tools
How to Handrub?
RUB HANDS FOR HAND HYGIENE! WASH HANDS WHEN VISIBLY SOILED
Duration of the entire procedure: 20-30 seconds
1a 1b 2
Apply a palmful of the product in a cupped hand, covering all surfaces; Rub hands palm to palm;
3 4 5
Right palm over left dorsum with Palm to palm with fingers interlaced; Backs of fingers to opposing palms
interlaced fingers and vice versa; with fingers interlocked;
6 7 8
Rotational rubbing of left thumb Rotational rubbing, backwards and Once dry, your hands are safe.
clasped in right palm and vice versa; forwards with clasped fingers of right
hand in left palm and vice versa;
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind,
either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.
May 2009
CATS Decrease
Surgical Site Infections
Clippers
Hair Removal:
If hair must be removed from the
surgical site, clippers are the best
option. Never use a razor.
Antibiotics
Prophylactic Antibiotics:
Antibiotics consistent with national
guidelines should be administered
within 1 hour of incision time and
discontinued within 24 hours (48
hours for cardiac surgeries) of surgery
end time.
Temperature
Normothermia:
Surgery patients should be normo-
thermic (≥ 96.8º F /36º C) within the
first 15 minutes after leaving the
operating room.
Sugar
Glucose Control:
Cardiac surgery patients should have
controlled 6 a.m. serum glucose
(d 200 mg/dL) on postoperative Day 1
and Day 2.
‘GATO’ Disminuye
Infecciones en el Sitio de Cirugía
Control de glucosa:
Pacientes de cirugía cardiaca deben
tener suero de glucosa controlado
(<200 mg/dL) por las seis de la mañana
en el Día 1 y el Día 2 después de la operación.
Antibióticos profilácticos:
Antibióticos consecuentes con directrices
Glucosa
nacionales deben ser administrados
dentro de una hora del tiempo de
incisión y discontinuados dentro de 24
horas (48 horas para cirugías cardiacas)
del fin de cirugía.
Antibióticos
Normotheremia:
Pacientes de cirugía deben tener una
temperatura llamada normothermia
( >96.8°F, 36°C) dentro los primeros 15
minutos después de salir del consultorio
de cirugía.
Temperatura
Removimiento de pelo:
Si el pelo debe ser removido del sitio de
cirugía, use crema depilatoria o una
maquinilla para cortar pelo—o no lo corte
si no es necesario. Nunca use navaja de
Opciones para
remover pelo
afeitar.
Este materiál fue preparado por Health Services Advisory Group (HSAG) bajo contrato con CMS (Centers for Medicare & Medicaid Services),
una agencia del departamento federal Health and Human Services. Esta información no viene de parte de CMS. HSAG es una organización
para mejorar la calidad de servicios de Medicare en Arizona. Número de Publicación AZ-9SOW-6.2.3-071909-02 www.hsag.com
82 The OR Connection
The
OR Connection
Aligning practice with policy to improve patient care
www.medline.com
VOLUME 4, ISSUE 2
The
Aligning practice with policy to improve patient care
Volume 4, Issue 2
FREE
Mercy Ships
Surgical Pros Donate
THE OR CONNECTION
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Join the Race to ERASE CAUTI™
The current state of health care demands nurses play
a leading role in identifying and implementing CAUTI
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Hospitals who join the race will receive free:
• Video podcast series hosted by John Nance
• Hospital press release announcing
OR Traffic
Control
educating and supporting nurses to help them rise to Awareness Campaign
this challenge. As part of raising awareness, Medline • Printed posters, flyers and literature to promote Are Your Scrubs
has set a goal to introduce 100,000 nurses to its
CAUTI prevention education program.
awareness to ERASE CAUTI
• Awareness wristbands for each member who
Spreading Infection?
joins the team
Ask your Medline representative about the new ERASE Race to ERASE CAUTI
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©2009 Medline is a registered trademark and ERASE CAUTI is a trademark of Medline Industries, Inc. MKT209323/LIT800/20M/HIG5