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Aligning practice with policy to improve patient care

Volume 3, Issue 3

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 The

OR Connection
Aligning practice with policy to improve patient care

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We've coded the articles and information in this magazine to indicate which patient
Content Key

care initiatives they pertain to. Throughout the publication, when you see these
icons you'll know immediately that the subject matter on that page relates to one
or more of the following national initiatives:
• IHI's 5 Million Lives Campaign
• Joint Commission 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 above
initiatives, see pages 6 and 7.
Sue MacInnes, RD, LD
Editor

Alecia Cooper, RN, BS, MBA, CNOR

Clinical Editor

Andy J. Mills, MBA

Contributing Editor

PATIENT SAFETY
Mike Gotti
Art Director
6 Three Important National Initiatives for Improving Patient Care
9 A Focus on Prevention
Laura Kuhn
Copy Editor

18 Back to Basics: Applying Evidence-Based Information to

Jayne Barkman, RN, BSN, CNOR
Clinical Team
Improve Hand-Off Communication in Perioperative Services
Rhonda J. Frick, RN, CNOR 30 Patient Safety in Surgery
Anita Gill, RN Page 18
Megan Giovinco, RN, CNOR, RNFA
32 A Spotlight on “Never Events”
Kimberly Haines, RN, Certified OR Nurse 50 Why Is Pressure Ulcer Risk Assessment So Important?
Jeanne Jones, RNFA, LNC
Carla Nitz, RN, BSN OR ISSUES
Connie Sackett, RN, Nurse Consultant
Claudia Sanders, RN, CFA
15 Targeting Zero Healthcare-Associated Infections
Angel Trichak, RN, BSN, CNOR 26 Care Bundle for Surgical Site Preparation
33 A Latex-Free Victory!
Gail Avigne, RN
Perioperative Advisory Board

Shands Teaching Hospital (UFL), Florida

42 Supply Management for Perioperative Services Page 30

Caroline Copeland, RN MPH 44 A New Way to “Pack” It All In

Southern Hills Hospital & Medical Center 58 Fluid Flow Disruption?
Cathy Crandall, RN
HealthTrust Purchasing Organization, Tennessee
SPECIAL FEATURES
Larry Creech, RN, MBA, CDT
Carilion Health System, Virginia
14 Prevention Above All Discoveries Grants
Pat DʼErrico, RN, CNOR 28 Measuring What You Manage
Medical Center of Central Georgia, Georgia
36 Organ Donation
Barbara Fahey, RN CNOR
Cleveland Clinic, Ohio 62 Why Can’t We All Just Get Along? Page 33

Zaida Jacoby, RN, MA, M.Ed 77 Mark Your Calendar: Linda Ellerbee
NYU Medical Center, New York
91 Ami Lends a Hand
Sherron Kurtz, RN, MSA, MSN, CNOR, CNAA
Wellstar Kennestone Hospital, Georgia
Wayne Malone, RN
CARING FOR YOURSELF
Physicians Hospital, Texas 66 Hot to Set Priorities and Get the Job Done
Lynda Mansfield, RN, CNOR 68 Conquer Stress During Tough Economic Times
Orange County Memorial, California
78 Recipe: Bruschetta Delizioso
Jackie Minor, RN CNOR
Huntsville Hospital, Alabama
Page 36

Jennifer Misajet, BSN, MHA, CNOR

FORMS & TOOLS
Exempla St. Joseph Hospital, Colorado 80 Summary of SCIP Measure Changes
Pricilla Ranseur, RN, MSN, CNOR 82 Hand-Off Communication in the Perioperative Setting
Duke University Hospital, North Carolina
Margie Voyles, RN, MS, CNOR
85 SBAR Hand-Off Communication
Lakeland Regional Medical Center, Florida 89 Pressure Ulcer Prevention Checklist: Perioperative Services
Margery Woll, RN, MSN, CNOR
Rush North Shore, Illinois
Page 66

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
care dealers and agencies and other markets. Medline has more than 800 dedi-
cated sales representatives nationwide to support its broad product line and cost
management services.
FDA QSR compliant and ISO 13485 registered. Medline serves on major industry
quality committees to develop guidelines and standards for medical product use in-
cluding the FDA Midwest Steering Committee, AAMI Sterilization and Packaging
Committee and various ASTM committees. For more information on Medline, visit
our Web site, www.medline.com.

© 2008 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,
October 1, 2008, seems like the distant past as we
break open the New Year with a new president, new
regulations, new goals and many new processes.
Many of you are addressing the 11 hospital-acquired
conditions that will no longer trigger higher DRG
payments if they are acquired during the hospital
stay. Those conditions include:
1. Objects left in surgery
2. Blood incompatibility
3. Air embolism
4. Catheter-associated urinary tract infections
5. Pressure ulcers
6.
7.
Vascular catheter-associated infections
Falls and trauma (including burns)
8. Surgical site infections – mediastinitis
after CABG
9. Surgical site infections following certain
elective surgeries
10. Certain manifestations of poor control of
blood sugar levels
11. Deep vein thrombosis of pulmonary
embolism following total knee replacement/hip
replacement procedure
Patient safety is not a trend, but a part of our daily
activities. 2009 will be a springboard for change as
more and more hospitals embrace the inevitable.
This edition of The OR Connection is all about pro-
viding solutions to help reduce hospital-acquired
conditions.
In reviewing Medlineʼs Prevention Above All cam-
paign (Pages 9-14), you will find one solution after
another on ways to reduce infections, programs to
reduce pressure ulcers and products to assist in the
This Editionʼs Question
What have you done
to improve patient safety
in your operating room?
4 The OR Connection
detection of foreign bodies left during surgery, to
name a few. Look on Page 32 for an index of arti-
cles offering solutions that will address many of the
11 conditions.
The best solutions come from those of you who are
in the trenches. For that reason, Medline wants to
support and encourage these great ideas through
the Prevention Above All Discoveries Grant Pro-
gram. Medline will be awarding $1 million in grant
money over several years. These awards are de-
signed to assist healthcare providers in developing
and testing creative solutions or interventions for re- This edition of
ducing or preventing hospital-acquired harms. For
more information on the Discoveries Grants, see
“
The OR Connection
is all about providing
Page 14.
solutions to help
Finally, STOP and take time for yourself. Destress reduce hospital-
and refocus. Read how you can communicate acquired conditions.”
peacefully with other departments, set priorities and
conquer stress. Let 2009 be the start of a great year!
Best Regards,
Sue MacInnes RD, LD
P.S. Take a look below at the Reader Question for
this edition. The winning response will receive a
copy of Take Big Bites by Linda Ellerbee, our
keynote speaker at our breast cancer awareness
breakfast at AORN Congress in March.
Please submit your response to orconnection@medline.com. Each
issue will feature a new question of the month and a winner will be
chosen for the best submission. Please submit early and often as
the best solutions are created by those who deliver patient care
every day!
 News Flash
DNV Joins Joint Commission and AOA
for Accreditation for CMS Payment
The Centers for Medicare & Medicaid Services (CMS)
has approved the first new hospital accreditation organi-
zation in more than 40 years, giving hospitals another
choice when seeking to participate in Medicare or Medi-
caid. The approval by Det Norske Veritas Healthcare Inc.
for conferring deemed status on hospitals adds to
accreditation programs by the Joint Commission and the
American Osteopathic Association, or certification by a
state survey agency.
To learn more about DNV go to:
http://www.dnv.com/news_events/index.asp
Older Blood Raises Infection Risk
A study conducted at Cooper University Hospital, Cam-
den, NJ, and presented at the annual scientific meeting
of American College of Chest Physicians in late Octo-
ber, found that those who received a transfusion of
blood stored for 29 days or longer were twice as
likely to develop pneumonia, sepsis and other serious
infections compared with those who received stored
blood kept for 28 days or less. Additional studies are
needed to determine the optimal storage period for blood to
prevent infections. Rules currently permit blood to be
stored for 42 days.
To learn more about this study, go to:
http://www.chestnet.org/about/press/releases/200
8/CHEST/PDF/BloodStorage.pdf?zbrandid=3032&zid-
Type =CH&zid=1342800&zsubscriberId=751519175
Aligning practice with policy to improve patient care 5
UCLA study reveals smoking's effect
on nurses' health, death rates
A new UCLA School of Nursing study is the first to reveal
the devastating consequences of smoking on the nursing
profession. Published in the November- December edition
of the journal Nursing Research, the findings describe
smoking trends and death rates among U.S. nurses and
emphasize the importance of supporting smoking cessation
programs in the nursing field.
The current UCLA research explored changes in smoking
trends and death rates among female nurses enrolled in the
Nurses' Health Study between 1976 and 2003, a span of
27 years.
According to the most recent data, the smoking
rate among registered nurses nationwide is
nearly 12 percent.
The rate of smoking among women in the Nurses' Health
Study declined from 33.2 percent in 1976 to 8.4 percent in
2003. The number of cigarettes smoked per day also
dropped. However, the daily number among current
smokers still averaged more than 15 cigarettes, or over half
a pack.
The entire story can be found at:
http://newsroom.ucla.edu/portal/ucla/new-ucla-study-
reveals-smoking-71590.aspx?link_page_rss=71590
 Three Important National Initiatives
for Improving Patient Care
Achieving better outcomes starts with an understanding of current
patient-care initiatives. Here’s what you need to know about national
projects and policies that are driving changes in care.

1 5 Million Lives Campaign

Origin: Launched by the Institute for Healthcare Improvement (IHI) in December of 2006
Purpose: To prevent unintended physical injury resulting from or contributed to by medical care that requires
additional monitoring, treatment or hospitalization, or that results in death
Goal: To prevent five million incidents of medical harm over the next two years and to enroll more than
4,000 hospitals and their communities in the project.

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

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

2 Joint Commission 2008 National Patient Safety Goals

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

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

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

3 Surgical Care Improvement Project (SCIP)

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

SCIP aims to reduce surgical complications in 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

5 Million Lives Campaign: Twelve Interventions
1. Prevent pressure ulcers
2. Reduce methicillin-resistant staphylococcus
aureus (MRSA) infection
3. Prevent harm from high-alert medications
4. Reduce surgical complications
5. Deliver evidence-based care for congestive heart failure
6. Get boards on board
7. Deploy rapid response teams
8. Prevent adverse drug events (ADEs)
An IHI forum, “Celebrating 20 Years: The Future
of Health Care is Ours to Imagine,” was held in
Nashville on December 8-11, 2008. www.ihi.org
Joint Commission 2009 National Patient Safety Goals
• Improve accuracy of patient identification
• Improve effectiveness of communication
among caregivers
• Improve medication safety
• Reduce risk of healthcare-associated infections
(Expanded in 2008 to include either WHO
or CDC Hand Hygiene Guidelines)
• Reduce risk of patient harm from falls
• Reduce risk of influenza and pneumoccocal
disease through immunization
To learn more about the 2009 National Patient Safety Goals, go to www.jointcommission.org. New in 2009: New numbering system for
sorting in new electronic manuals and minor language changes for consistency.
Surgical Care Improvement Project (SCIP): Target Areas
1. Surgical-site infections
• Antibiotics, blood sugar control, hair removal, normothermia
2. Perioperative cardiac events
• Use of perioperative beta-blockers
3. Venous thromboembolism
• Use of appropriate prophylaxis
SCIP is targeting two new measures for October 2009:
• Removal of urinary catheters within 48 hours post surgery
• A new, updated normothermia measure
To learn more, go to Page 9.
Visit www.qualitynet.org
Aligning practice with policy to improve patient care 7
Patient Safety
9. Deliver evidence–based care for acute
myocardial infarction
10.Prevent surgical-site infections
11. Prevent central-line infections
12.Prevent ventilator-associated pneumonia
By the numbers:
• Over 4,000 hospitals currently enrolled
• The Top 4 Interventions:
1. Adverse Drug Events (ADEs) – 3,152
2. Surgical Site Infection (SSI) – 3,047
3. Acute Myocardial Infarction (AMI) – 3,016
4. Rapid Response Teams – 2,853
• Reduce risk of surgical fires
• Encourage patientʼs active involvement in their care
• Prevent healthcare-associated pressure ulcers
(decubitus ulcers)
• Identify safety risks inherent in patient population
(suicide, home fires)
• Improve recognition and response to changes in a
patients condition
• Implementation of Universal Protocol for preventing
wrong-site, wrong-person, wrong-procedure surgery
By the numbers:
• 3,740 hospitals are submitting
data on SCIP measures, representing
75 percent of all U.S. hospitals
• Currently, SCIP has more than 36
association and business partners
A Focus on Prevention
Highlights from the Prevention Above All Forum
At the Prevention Above All Forum in August, nearly 100
chief nursing officers, chief medical officers and healthcare
quality executives from across the U.S. came to Chicago to
hear some of health careʼs top thought leaders discuss
policy changes, patient safety strategies and targeted,
evidence-based solutions for improving patient outcomes.
There was a lot of information and excitement around the
new reimbursement regulations that CMS put into practice
October 1, as well as the patient safety themes that the
quality improvement organizations are working on.
If you didn't get a chance to attend this yearʼs meeting, here
are five key things that you missed hearing about:
The key to cultural change:
mutual cooperation built on real
mutual respect
With CMS revamping reimbursement
for hospital-acquired conditions (HACs)
and expanding implementation of the
Quality Indicator Survey for long-term
Nance care facilities into more states, it wasnʼt
too surprising to hear Keynote Speaker John J. Nance, JD
open the Prevention Above All Forum by saying “the core
culture of medical practice has to be drastically changed.”
Nance, founding member of the National Patient Safety
Foundation and author of Why Hospitals Should Fly: The
Ultimate Flight Plan to Patient Safety and Quality Care,
touched on how the October 1 CMS reimbursement mile-
stone for HACs provides the opportunity for healthcare
providers to “re-commit” to improving patient safety by
becoming engaged professionals dedicated to barrierless
communication.
“Youʼre not only going to solve the CMS problems (of HAC
prevention),” said Nance. “But you are going to get to the
point of asking doctors ʻWhy donʼt we have 100 percent
compliance on handwashing?ʼ and ʻIs it okay if my nurses
remind you?ʼ That consistent cross-checking of each other,
completely devoid of professional defensiveness, and a real
caring for each other as full members of a team dedicated to
the patientʼs best interests, is the key to safe practice.
Why Hospitals Should Fly by John Nance is available at
www.whyhospitalsshouldfly.com.
Aligning practice with policy to improve patient care 9
“This conference was absolutely terrific,
My knowledge has been increased
greatly. Our ‘assigned row rep’ was
terrific, very helpful, anticipated our
needs before we knew them and was
overall great!”
Karin L. Boylard, Clinical Nurse Educator
Johnson Memorial Hospital
CMSʼ new community approach
to pressure ulcers
In terms of healthcare policy changes
and their implications for care, one with
an astounding impact discussed at the
forum was CMSʼs new community
approach to pressure ulcer prevention
Bratzler and care as outlined in the 9th Scope
of Work. Dale Bratlzer, DO, MPH, Med-
ical Director of the Oklahoma Foundation for Medical Qual-
ity, provided some early information on how the epidemic of
the “ambulance acquired” pressure ulcer will be something
of the past and how this is the number one initiative for the
Quality Improvement Organizations (QIOs) right now.
Previously, CMS
reviewed cap-
tured MDS data
to help identify
nursing homes
that have high
rates of pressure
ulcers. With the
CMS 9th Scope
Be sure to visit the Prevention Above All Web
of Work, which
site at www.medline.com/special/PAA/ for
took effect on
continued updates and additional resources.
August 1, CMS now directs QIOs to focus not only on nurs-
ing homes with a high incidence of pressure ulcers, but to
take a closer look at hospitals in the same county and hold
them accountable as well. So the QIOs are tasked with
going in and working with both the hospital and the nurs-
ing home to reduce the rates of pressure ulcers. You
can learn more about the 9th Scope of Work by visiting
www.providers.ipro.org/index/9SOW_summaries - 39k.
 A Focus on Prevention
Highlights from the Prevention Above All Forum
According to Bratzler, CMS is actively working on building
performance measures that will publicly report hospital pres-
sure ulcer rates, and once they complete that there will be
a strong incentive for nursing homes and hospitals to work
together to figure out the best way to prevent pressure
ulcers. This new community focus represents how CMS is
starting to look at data outside of the hospital to see what is
happening in the hospital. For example, they are looking at
things that happen in surgery and the effects 30 days and 60
later, so the tracking systems from whether you are in the
acute care setting or leave is going to ultimately look at
every setting of healthcare not just one.
Learn more about Medlineʼs Pressure Ulcer Prevention
Program on Page 13.
“I want to take the [Medline] pressure
ulcer program to our executive nursing
team – this program would be excellent
in helping us to prevent pressure ulcers
and to improve our overall patient care
delivery.”
Debra Williams, Vice President/CNO
Garden City Hospital
Implications of the CMS Guide-
lines on pressure ulcer prevention
and treatment
Thereʼs a great variability in terms
of how organizations prepared for the
October 1 deadline and where they are
at on that continuum of preparation.
Krasner According to Diane Krasner, PhD, RN,
CWCN, CWS, BCLNC, FAAN, Wound and Skin Care Con-
sultant. A lot of that preparedness comes down to education.
“If you just look at the pressure ulcer part of the CMS ruling,
thereʼs a high training and education component that each
facility is going to have to grapple with,” said Krasner.
Krasnerʼs presentation highlighted the need for nurses
to receive more education on:
• Risk assessment (interpretation of Braden Scale)
• Pressure ulcer staging
• Proper positioning (including bed and chair)
• Effects of moisture on the skin (including incontinence,
humidity and maceration)
10 The OR Connection
• Pressure-relieving products
• Proper application and usage of prevention products
The following documents – currently in use at Krasnerʼs
facility, Rest Haven-York – are also available:
• Pressure Ulcer Protocol
• Pressure Ulcer Protocol – Avoidable versus
Unavoidable Pressure Ulcers
• Pressure Ulcer Notification Fax
• Pressure Ulcer Risk Factors tracking chart
• Wound Photo Documentation
If you are interested in receiving any of these documents,
please email us at orconnection@medline.com.
“This was the ultimate forum,
unsurpassed, professional, phenomenal
speakers with the most up-to-date reliable
education with statistical evidence. Kudos
to Medline.”
Charles Gizara, Director, Clinical Operations
Atlantic General Hospital
A proposed new SCIP measure
for October 2009 on timely
catheter removal.
The proposed performance measure
focuses specifically on whether the
healthcare provider attempted to
remove the catheter by the second
post operative day (with surgery being
Wald
day zero). This important performance
measure that is now National Quality Forum endorsed will
be rolling out in October of 2009. A main driver behind this
measure was a study led by Heidi Wald, MD, MPH, who
discussed the connection.
Wald, along with her co-authors of the study “Indwelling
Urinary Catheter Use in the Postoperative Period,” reviewed
data from 35,904 Medicare patients at 2,965 acute care hos-
pitals across the United States to determine the relationship
between catheter use and postoperative outcomes. From
that large number of patients that were operated on, they
found that 86% of the patients had been catheterized, and
that half of them had their catheter for more than two days –
a concern since patients whose catheters are in for a long pe- Warye distributed copies of APICʼs MRSA guidelines and a
riod of time post-operatively are at an increased risk of infection. DVD on hand hygiene geared toward patients. To download a
copy of the DVD video, please visit www.cdc.gov/handhy-
Previously research had already demonstrated the doubling giene. For more APIC resources, please visit www.apic.org.
of mortality rate with something as simple as a urinary tract in-
fection, but Dr. Wald and her colleagues were able to confirm
that indwelling urinary catheters that are left in place for longer
than two days postoperatively may result in catheter-acquired Medline
urinary tract infections (CAUTI) as well as an increase in 30- President
day mortality and an increased length of stay (to view the Andy Mills
confers with
study, please visit http://archsurg.ama-assn.org/cgi/content/ presenter
short/143/6/551). Dea Kent

How big of an issue is this? There are an estimated 26-36 mil-

lion operations performed in the United States each year and
Bratzler notes that every single study looking at patients with
similar risks, having the same operation, shows the mortality
rate doubling if they get a surgical infection. And in fact, a Uni-
versity of Pennsylvania study reviewing a large number of
operations performed demonstrated that when a patient has
a major complication of surgery, the risk of death is
increased by threefold within the next 60 days.

“I didn’t know Medline had these types of

products. And the supportive evidence was
excellent, how can we work together?”
Mary R. Lopez, Vice President, Quality Initiatives
Hospital Council Northern & Central California Guests get involved at the Prevention Above
All Presentation

APIC: Spreading knowledge,

preventing infection
Sometimes a few changes need to be
made in order to clarify goals and con-
tinue to move toward them. Kathy Warye,
CEO of the Association for Professionals
in Infection Control and Epidemiology,
Warye Inc. (APIC) shared the associationʼs rec-
ommendation of changing the title of Infection Control Pro-
fessional to Infection Preventionist with Prevention
Above All forum attendees.
A sampling of the items presented at the forum
“Language creates culture, and if the goal is around prevention,
then our name needs to incorporate prevention,” Warye said.

Aligning practice with policy to improve patient care 11

 Prevention Above All
Targeted interventions, practical solutions
Medlineʼs six practical and targeted interventions
to help improve outcomes.
There is compelling evidence that many hospital-acquired con-
ditions (HACs), specifically those targeted by CMS as “never
events,” are preventable. And there are plenty of great prod-
ucts and evidenced-based solutions available. The challenge
is implementing these solutions. There is a need to educate
caregivers, organize data and assist the healthcare provider
with process improvement.
Combining innovative products with evidence-based solutions,
Medline strategically integrated a portfolio of focused and
achievable evidence-based solutions designed to fit into the
everyday processes and systems most healthcare providers
already have in place. The six conditions targeted by Preven-
tion Above All and their complementary Medline product and
program solutions are:
Target: Catheter-Associated
Urinary Tract Infection (CAUTIs)
The Prevention Above All
Intervention: Silvertouch Catheters
A bundled solution of advanced silver technology with
Medlineʼs Silvertouch™ Foley catheters and educational
training to reduce CAUTIs.
Silvertouch Foley catheters incorporate the power of silver
through a patented process that binds silver ions to the
catheterʼs lubricious coating, delaying the onset of biofilm for-
mation. Educational materials provide summarizations of the
major recommendations from the CDC, SHEA, APIC and others
provide a policy and procedure template guide for proper
catheterization. Also included are validation tools that can be
utilized during training or re-education classes, and a trou-
bleshooting guide book and a poster to help caregivers work
through issues.
Target: Harm Avoidance
and Patient Satisfaction
The Prevention Above All Inter-
vention: Educational Packaging
To help reduce medical errors, Medline redesigned its Advanced
Wound Care packaging in a format that allows each package
to serve as a 2-minute course on advanced wound care.
12 The OR Connection
The innovative packaging design is an improved delivery and
communication system to help healthcare professionals better
understand and more easily deliver wound care at the patient's
bedside. It replaces confusion with clear, step-by-step
information, eliminating the clutter and highlighting
critical information.
Target: Objects
retained after surgery
The Prevention Above All
Intervention: RF Detect
RF system designed to alert the OR nurse when a RF-tagged
surgical item remains in the patient before closing the procedure.
This provides an added level of safety and an adjunct to the
counting procedure.
The system consists of three components: a micro RF tag
embedded in gauze, sponges and towels and a sterile hand-
held wand that is connected to the third component, an easy-
to-use, self-calibrating console. By passing the wand back and
forth and side to side over the patient, hospital personnel will be
able to accurately detect, within seconds, retained surgical
disposables before site closure and rectify incorrect counts.
Target: Hospital-
Acquired Infections
The Prevention Above
All Intervention: Hand
Hygiene Compliance Program
A program of products that stresses appropriate application
techniques and education to achieve hand hygiene compli-
ance while dramatically improving the skin condition of health-
care workers.
The Hand Hygiene Compliance Program contains three
products – Sterillium Comfort Gel™, Medline Remedy™ Skin
Repair Cream and Aloetouch® exam gloves – clinically proven
to nourish dry skin. The program includes an intensive edu-
cational module developed by an expert panel of infection
control professionals. Healthcare workers can earn up to four
continuing education credits by completing the training program.
Additional components include testing for skill and competency
validation through the use of Visirub and a UV light box. Pa-
tient education pamphlets, facility posters and a rewards pro-
gram are also included to reinforce positive behavior change.
Target: Pressure Ulcers
The Prevention Above
All Intervention: Pressure
Ulcer Prevention Program
Medline offers a Pressure Ulcer Prevention Program to fit
all disciplines, from physicians and OR nurses to CNAs,
RNs and LPNs. A program of products, tools and
resources to implement an effective prevention program
and immediately begin reducing the incidence of pres-
sure ulcers.
The Pressure Ulcer Prevention Program is a strategic prod-
uct bundle to assist in reducing or preventing pressure ul-
cers and incontinence-associated skin conditions, which
may include dermatitis and skin tears. Products include
Remedy™ Advanced Skin Care Products, Ultrasorbs® AP
Dry Pads, Restore®/Remedy™ Adult Brief, and Supra DPS
alternating pressure and low-air-loss mattresses.
Target: Wrong Site Surgery
The Prevention Above All
Intervention: S.T.O.P. Drape
A surgical drape that incorpo-
rates a “Time Out” sticker strip
that must be removed prior to the surgical case and provided to
the circulating nurse to be placed on the patientʼs chart.
The Medline S.T.O.P drape has a sticker in the shape of a red
stop sign and tells the staff to stop, forcing them to remember
to perform the time-out procedure required prior to beginning
surgery. The sticker provides a location to write and confirm the
patientʼs name, procedure, site and side, date, time and
surgeonʼs initials. By requiring the surgeon to initial the sticker,
the surgical team is again reminded to perform the time-out
immediately prior to the incision.

The Perioperative Pressure Ulcer Prevention Program in-

cludes an educational DVD addressing pressure ulcer risk
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vice president of
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Maryland asks
a question during
The comprehensive program also packages together edu- a session.
cation and training tools so a healthcare team can implement
an effective pressure ulcer prevention program and immedi-
ately begin reducing the incidence of healthcare-acquired
pressure ulcers. Included are workbooks, patient and Dr. Andrew Kramer
family education brochures and a rewards program. speaks to attendees
about patient safety.

Attendees review Medlineʼs Medline Chief Marketing Officer Sue MacInnes addresses attendees during the
Pressure Ulcer Prevention Prevention Above all Forum.
Program materials.

Aligning practice with policy to improve patient care 13

Special Feature
PREVENTION ABOVE ALL DISCOVERIES GRANTS:
Supporting the adoption of solutions
into everyday clinical practice
Medline is committing up to $1 million in over several years
to stimulate the gathering of solid evidence that supports the
adoption of solutions into clinical practice. A review panel, whose
members represent a breadth of research and practice knowl-
edge, will select grant recipients to be awarded up to $25,000
each for pilot studies or $100,000 each for empirical studies.
Objectives
To stimulate research that will lead to the development of new
targeted interventions aimed at reducing medical risks and
harms associated with hospital-acquired conditions (identified
by CMS in 2008 IPPS final rule).
• To test the costs and effectiveness of interventions and
programs designed to reduce the incidence of hospital-
acquired conditions.
• To disseminate practical, evidence-based solutions
within and across hospitals, leading to a reduction in
hospital-acquired conditions.
These awards are designed to assist healthcare providers in
developing and testing creative solutions or interventions for
reducing or preventing hospital-acquired conditions. Recipients
of grant awards will be paired with a research mentor/consul-
tant through the grant program to develop methods and guide
the conduct of the study, ensuring that a rigorous research
process is followed. These studies can be small pilot studies
aimed at developing and testing the feasibility of new solutions
or larger evaluation studies to more fully test the costs, effec-
tiveness or dissemination of evidence-based solutions.
Award Process
1. In response to our request for applications (RFA),
providers will submit a 2-3 page letter of intent providing
the following information:
• The HAC(s) that the study will address
• Whether the letter is for a pilot or
empirical study
• The proposed solution
• The objective of the study
• The proposed approach in as much detail as
you have thought it through at this point
• Expected output of the study
• Brief biography about the individuals involved,
including any experience in the area of focus
• Budget estimate, including the major expenditure
categories
2. The review committee will review letters of intent on a
rolling basis (see list of review committee members).
Acceptable letters will be assigned to the most appro-
priate research mentor, who will contact the applicant
and work with him/her to develop the letter into a full
proposal of 5-7 pages in length, including a complete
budget. Proposal and budget guidelines will be sent
after approval of letter of intent.
3. The review committee will review full proposals and
budgets on a rolling basis. Most of the projects that are
chosen for full proposal submission will be funded;
however, this process may involve a subsequent
resubmission of a revised proposal so that the funded
research plan is clear.
4. Pilot studies will generally be up to six months in duration
with a budget of about $25,000. Empirical studies can
be up to $100,000 and last up to a year or more in duration.
Pilot study grantees can go on to submit an empirical
study proposal at the successful conclusion of the pilot project,
or applicants can apply for a full empirical study grant
based on their initial letter of intent if they have an
existing practice with evidence that they wish to evaluate.
5. The final report for a pilot grant study should be a brief
paper written for a Medline publication (Healthy Skin,
The OR Connection or Infection Prevention Now)
whether the grant is successful or not. The final report
for an empirical study is a paper to be submitted for
publication in a peer-reviewed journal.
GRANT PROGRAM SCHEDULE
Nov. 15 to Jan. 31, 2009
Accept and review letters of intent on a rolling basis
Dec. 1 to Feb. 28, 2009
Notification of acceptance and authorization to begin full
proposal (due one month after notification of letter of intent)
Jan. 1, 2009 to Apr. 30, 2009
Full proposals funded and projects started within
two months of proposal submission

Targeting
ZERO
Healthcare-Associated Infections
An exclusive report from APIC
By Kathy Warye, APIC executive director
In January of 2006, the Association for Professionals
in Infection Control and Epidemiology published APIC
Vision 2012, a strategic approach to the future of the
practice and profession. The first goal of the plan stated
that APIC will “promote prevention and zero tolerance for
healthcare-associated infections (HAIs).”1 Since that time,
APICʼs approach has evolved and focused instead on pro-
moting a culture where targeting zero healthcare-associated
infections is fully embraced.
Insertion of the word “culture” was an important addition, as
APICʼs intent is to promote a cultural change within health
care wherein providers strive to eliminate preventable HAIs.
OR Issues
While few organizations in the early 2006 time frame were
contemplating the possibility of reaching zero HAIs, zero
tolerance first emerged in 2000 when Julie Gerberding,
director of the CDC, introduced the concept. She noted that,
over time, the goal of elimination had been applied to other
public health concerns, such as TB and polio. Elimination
might not have occurred, but ambitious goals drove positive
change and dramatic reductions.
Making prevention a priority
As APICʼs strategic plan was taking shape, a small but
influential group of healthcare organizations were discovering
that many more infections are preventable than previously
 thought. They were setting goals to reduce HAIs significantly
below previously accepted benchmarks, reaching and sus-
taining them. With a declining arsenal of antibiotics to treat
infections, it was increasingly clear that the traditional
orientation toward control of HAIs needed to shift to one
where preventing the occurrence was the priority throughout
the institution. APIC was hearing from leaders across the
spectrum of health care, from providers to patients and
patient safety advocates. It was in this context that APICʼs
leaders agreed that the Association should be at the fore-
front in promoting significant and sustained reductions in
preventable healthcare-associated infections.
Since that time, APIC has moved forward to promote pre-
vention and provided members with a host of resources to
help them set and reach ambitious goals for the reduction of
HAIs. Targeting Zero encourages all organizations to set the
goal of elimination rather than remain comfortable when
local or national averages or benchmarks are met. Every
single HAI impacts the life of a patient and family – even one
should feel like too many.
“Zero tolerance” explained
APIC also believes that willful non-adherence by healthcare
workers with proven infection prevention and control measures
should be unacceptable. References to “zero tolerance”
today are generally intended as a response to unsafe
behaviors and practices that place patients and healthcare
workers at risk. In the context of HAIs, zero tolerance doesnʼt
mean that people or organizations should be penalized for
infections that might not be preventable, but this language
may be used to stress the need for accountability and a cul-
ture built on inquiry and learning as opposed to punishment.
A culture of targeting zero healthcare-associated infections
and zero tolerance for unsafe practices is characterized by
the following:
• Setting the theoretical goal of elimination of HAIs;
• An expectation that infection prevention and control (IPC)
measures will be applied consistently by all healthcare
workers, 100 percent of the time;
• A safe environment for healthcare workers to pursue 100
percent adherence, where they are empowered to hold
each other accountable for infection prevention;
• Systems and administrative support that provide the
foundation to successfully perform IPC measures;
• Transparency and continuous learning where mistakes
and/or poor systems and processes can be openly
discussed without fear of penalty;
16 The OR Connection
• Prompt investigation of HAIs of greatest concern to the
organization and/or community and
• Focus on providing real-time data to front line staff for
the purpose of driving improvements.
Culture change in the OR
Creating the culture change required to eliminate surgical
site and other infections that begin in the OR will require
commitment on the part of the entire OR team, from
surgeons and anesthesiologists to operating room man-
agers, nurses and technicians. The institutionʼs infection
prevention experts can assist in the provision of real-time
data, application of performance improvement concepts
(such as root cause analysis) and ongoing education and
training for OR staff in the consistent application of key
infection prevention measures.
New technologies and procedures, more virulent pathogens
and increasing resistance will continue to challenge the
healthcare community in its efforts to reduce HAIs. Because
of this, even where large-scale cultural change and consis-
tent application of IPC measures exists – even when no
break in practice can be identified – healthcare-associated
infections will still occur. However, where the goal of zero
has been set and the culture is consistent with this goal,
APIC is confident that new approaches will emerge to bet-
ter protect patients from healthcare-associated infections.
To view APICʼs evidence-based guides on the elimination
of infection, archived webinars and other resources in the
Targeting Zero program, please visit www.apic.org.
1 Association for Professionals in Infection Control and Epidemiology, Inc. APIC Vision
2012. Available at: http://www.apic.org/AM/Template.cfm?Section=About_APIC&Tem-
plate=/CM/ContentDisplay.cfm&ContentFileID=4688. Accessed October 31, 2008.
About the author
Kathy Warye is the executive director of the Association for
Professionals in Infection Control and Epidemiology, Inc., (APIC),
a worldwide membership association providing 11,500 infection
prevention professionals legislative and/or public relations strategies
on issues impacting the infection prevention and control profession.
APIC advances its mission through education, research, collabo-
ration, practice guidance, public policy and credentialing.
 More than an ounce of prevention.

CAUTI PREVENTION
Top Ways to Prevent Catheter Associated Urinary Tract Infections

Maintain Secure
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?
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needed A B when possible
86 percent, 50 percent have catheters for longer than two days (intermittent catheters,
male external catheters)
after surgery, which is associated with increased likelihood of
urinary tract infections, 30-day mortality and longer hospital stays.1
Insert using Utilize bladder
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Clearly, we should make every effort to halt CAUTIs in their tracks. technique appropriate

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or visit us at www.medline.com. 1 Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use
in the postoperative period. Archives of Surgery. 2008;143(6):551-557.

©2008 Medline Industries, Inc. Medline and Silvertouch are registered trademarks of Medline Industries, Inc. www.medline.com
 Back to Basics Ninth in a Series
Applying Evidence-Based Information
to Improve Hand-Off Communication
in Perioperative Services
By Alecia Cooper, RN, BS, MBA, CNOR
There are three very significant hand-offs that occur in
perioperative services for each patient who undergoes a
surgical procedure. The first one is from the pre-operative
patient care area to the holding room staff. The second one is
from the OR team to OR team members. The third one is from
the OR team to the post-anesthesia care team.
There are also additional hand-offs that result for data gathered
within each unit or area, depending upon information gath-
ered during assessment periods. There can be hand-offs from
holding room staff to anesthesia and the assigned circulator
as well as from circulator to circulator when being relieved for
breaks, lunch and at shift change. The last hand-off occurs
when the PACU nurse hands off to the post-op caregiver.
18 The OR Connection
Obviously, there are many opportunities to gather and
communicate critical information that can affect and improve
patient care, prevent injuries and medical errors and ensure
that your patient has the safest and highest-quality surgi-
cal outcomes.
Adverse events during surgery
The list of what can go wrong during a surgical experience is
long and intimidating. Foreign bodies, mislabeled pathology
specimens, operative fires, transfusion and medication errors
and wrong site, wrong procedure, wrong person surgery are
just some of the preventable hazards associated with surgery.1
Adverse events occur more often in surgery than in any other
specialty, and disproportionately greater harm results from
surgical errors.2
In the surgical setting, a premium is placed on efficiency.
There are strict schedules that must be kept despite constant

interruptions from emergencies, add-ons, delays and compli-
cations. Time becomes a barrier to communication.2 Rushing
the hand-off can lead to small, yet critical mistakes that can
ultimately harm patients.2
Example: A patient who has been in an accident and requires
surgery also has a severe shoulder sprain. However, the staff
members who transfer the patient to preoperative holding
forget to mention this, so no one else – including the OR,
anesthesia, PACU or the floor – is aware of the shoulder
sprain. Throughout the care, nurses repeatedly manipulate
the patientʼs arm during repositioning, causing distress to the
patient and worsening the patientʼs injury.2
National Patient Safety Goal 2E
According to the Joint Commission, communication issues are
the leading factor in root causes of sentinel events.3 For this
reason, the National Patient Safety Goal 2E (NPSG.02.05.01)
was added in 2006. This goal reads as follows: “The [organi-
zation] implements a standardized approach to hand-off com-
munications, including an opportunity to ask and respond to
questions.”3 The elements of performance that are measured
by the Joint Commission in an organizationʼs hand-off
process include3:
Aligning practice with policy to improve patient care 19
Patient Safety
1. Interactive communication that allows for the opportunity
for questioning between the giver and receiver of
patient information.
2. Up-to-date information regarding the patientʼs condition,
care, treatment, medications, services and any recent
or anticipated changes.
3. A method to verify the received information, including
repeat-back or read-back techniques.
4. An opportunity for the receiver of the hand-off information
to review relevant patient historical data, which may include
previous care, treatment or services.
5. Interruptions during hand-offs are limited to minimize
the possibility that information fails to be conveyed or
is forgotten.
The goal further states that an organization should implement
a standardized approach to hand-off communication. Is your
process standardized?
Standardizing hand-off communication
Hand-off communication is defined as the “transfer of infor-
mation (along with authority and responsibility) during transi-
tions in care across the continuum for the purpose of ensuring
the continuity and safety of the patientʼs care.”4 It is the inter-
active delivery of accurate and current information about a
patient exchanged from one provider/caregiver to another. To
improve the reliability of workflows accomplishing their desired
goals, and to reduce the risk to patient safety, researchers
 recommend structured communications and clear agree-
ments about roles and responsibilities in a hand-off.5
A clear barrier to hand-off communication is the sheer number
of individuals involved in the care of surgical patients. In a
recent study, it was revealed that the typical surgical patient
sees an average of 26.6 health professionals during their
hospital stay, compared with the mean of 17.8 health profes-
sionals seen by medical patients.2 Therefore a standardized
process for hand-off communication becomes critical in peri-
operative services to ensure that communication is thorough
and complete among all of the perioperative team members.
Choosing a standardized hand-off method and tool
Healthcare providers have looked at other high-risk, high-
stakes industries such as aviation, aerospace, nuclear power
and the military for new approaches that can be applied to
healthcare hand-offs.2 Organizations have also used the Six
Sigma methodology framework to try and better understand
the process for hand-off communication.6 The development
of a standardized hand-off communications tool is a dynamic
process that allows continued opportunities for improving the
delivery of patient care.4 AORN has developed a Perioperative
AORNʼs nine recommendations for standardized hand-off policy development4
Recommendation One
Leadership should respond to the Joint Commission man-
date to improve hand-offs by initiating a program within each
facility, setting the priority and identifying the timeline.
Recommendation Two
Consider using structured tools that can facilitate consis-
tency in communication exchanges. Examples include, but
are not limited to, the “I PASS THE BATON,” “I-SBAR,”
“PACE” or the “Five Ps.” Each mnemonic is developed to
guide medical hand-offs and optimize information transfer.
Recommendation Three
When implementing training and process changes, use a
broad definition for hand-offs to include most care transitions
and information handling across the continuum of care.
Recommendation Four
Use a system, checklist, template or mnemonic that includes
updated information, recent changes in condition or circum-
stances and any anticipated changes or aspects of care that
need to be observed or watched closely.
Recommendation Five
Redesign the hand-off and shift change processes to pro-
tect against unnecessary interruptions, and allocate suffi-
cient time to the process.
20 The OR Connection
Patient “Hand-Off” Tool Kit that includes nine recommenda-
tions for standardized hand-off policy development.4
Popular hand-off communication systems
Here are four widely used hand-off communication systems:
• “I PASS the BATON” (Introduction, Patient, Assessment,
Situation, Safety Concerns, Background, Actions, Timing,
Ownership, Next)
• “I-SBAR” (Introduction, Situation, Background, Assessment,
Recommendation)
• “PACE” (Patient/Problem, Assessment/Actions, Continuing
[treatments]/Changes, Evaluation)
• “Five Ps” (Patient, Plan, Purpose, Problem, Precautions,
Physician [assigned to coordinate])
All four systems are effective as long as there is adherence
to the following rules4:
1. Conduct the hand-off face-to-face.
2. Be certain that the hand-off is two-way, with both participants
taking joint responsibility for ensuring accurate
communication.
3. Use verbal and written means of communication.
4. Give as much time as necessary to ensure accurate
communication.
Recommendation Six
Design methods that facilitate instruction on and implemen-
tation of effective communication and teamwork skills, as
provided in TeamSTEPPS, which verify information transfer
with closed-loop communication tools (including check-back,
read-back, call-out, etc.) for transferring important informa-
tion, such as critical actions, medication doses and urgent
actions.
Recommendation Seven
To meet this requirement, charts, written information and
reports/results should be available for review (as appropri-
ate) by the oncoming provider(s).
Recommendation Eight
While developing hand-off policies and protocols, include a
clear statement of how and when responsibility is transferred
during healthcare transitions.
Recommendation Nine
Teach and practice communication using established clear,
common language among care providers during hand-offs.
 10 barriers to effective hand-offs
1. Lack of education at nursing and medical schools
2. Healthcare system that historically has supported
individual autonomy and performance
3. Lack of engagement of patients and families in the
care process
4. Resistance to change among staff
5. Lack of time for providers to devote to handoffs
6. Problems in the physical setting, including
background noise and interruptions
7. Language barriers between clinicians and between
the clinician and the patient. Itʼs also important for
clinicians to avoid abbreviations and ambiguous
terminology
8. Failures in mode of communication, such as fax
machine or email or the inability to locate the
patient record
9. Lack of definitive scientific research and data to
identify accepted hand-off best practices
10. Lack of financial resources to implement
standardized hand-off processes
TeamSTEPPS
TeamSTEPPS (Team Strategies and Tools to Enhance Per-
formance and Patient Safety) is an evidence-based team-
training curriculum used by the Department of Defense (DoD).
It was developed by the Agency for Healthcare Research and
Quality (AHRQ).
The DoD Patient Safety Program extended permission to
AORN to customize its existing materials with a focus on
perioperative settings. This is what was used in the develop-
ment of AORNʼs tool kit. The TeamSTEPPS program is an op-
portunity for the surgical team to diminish the risk of error and
improve patient outcomes by creating a structure to support
standardized hand-offs and improve communications during
care transistions.4 Within this kit are numerous tools,
mnemonics and strategies to be used as templates. The
AORN tool kit is available for free and can be downloaded
from www.aorn.org.
One healthcare organization utilizing the TeamSTEPPS
curriculum developed a team hand-off model. To minimize
interruptions and distractions during the hand-off process, this
organization modified a concept championed by the aviation
industry – the “sterile cockpit.” In response to the increasing
number of commercial airline accidents involving the cockpit
Aligning practice with policy to improve patient care 21
10 tips for effective hand-offs
1. Allow for face-to-face hand-offs whenever possible.
2. Ensure two-way communication during the
hand-off process.
3. Allow as much time as necessary for hand-offs.
4. Use both verbal and written means
of communication.
5. Conduct hand-offs at the patient bedside whenever
possible. Involve patients and families in the hand-off
process. Provide clear information at discharge.
6. Involve staff in the development of hand-off
standards.
7. Incorporate communication techniques, such as
SBAR, in the handoff process Require a verification
process to ensure that information is both received
and understood.
8. In addition to information exchange, hand-offs should
clearly outline the transfer of patient responsibility
from one provider to another.
9. Use available technology, such as the electronic
medical record, to streamline the exchange of timely,
accurate information.
10. Monitor use and effectiveness of the hand-off.
Seek feedback from staff.
crewʼs attention being diverted from more critical tasks, the
Federal Aviation Administration enacted regulations to prohibit
crew members from performing nonessential duties or activities
(including conversation) while the aircraft is involved in the
phases of flight most commonly associated with error: taxi,
takeoff and landing.6
This healthcare organization interpreted the sterile cockpit
concept for the clinical setting during the verbal transfer of
patient information. Specifically, only patient-specific conver-
sation or urgent clinical interruptions were permitted to occur
during the hand-off process. They measured their perform-
ance improvement after implementing the system and found
they were able to reduce hand-off turnaround time from 15.3
minutes to 9.6 minutes.
Formula 1 hand-offs
Another healthcare organization has initiated a new hand-off
process modeled after routine pit stops in racing, which typically
take less than 10 seconds. Each crew member has a specific
job that they know very well. The crew is prepared down to
the smallest detail. Safety is the number one concern because
the consequences of errors can be life-threatening for both
driver and crew. In contrast to pit stops, hand-offs can be
chaotic events involving multiple simultaneous conversations.
Continued on Page 23
Searching for that
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manually counting surgical sponges and instruments before, objects retained during surgery. Several major insurers
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Reference
1. Popovic JR, Hall MJ. 1999 National Hospital Discharge Survey. Advance data from vital and health
1-800-MEDLINE.
statistics. No. 319. Hyattsville, Md.: National Center for Health Statistics, 2001. (DHHS publication no.
(PHS) 2001-1250 1-0287.).

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This organization utilized a human factors expert along with
members of the medical staff to study the unique maneuvers
of Formula 1 pit crews. They witnessed many behaviors that
they then applied to patient hand-offs following surgery. Before
the hand-off, the surgical team notifies the receiving care-
givers of any specific equipment that the patient will need so
that there is no scrambling to get it set up. The equipment can
be ready and waiting upon arrival.
When the patient arrives, there is a routine process that is
standardized and takes place in the same order every time.
First, all lines and tubes are untangled and reconnected qui-
etly and efficiently. Then, the team ensures that the patientʼs
condition is stable before the report begins. The final phase is
the report, which utilizes a handover checklist and surgeonʼs
summary. This occurs without distraction from transfer activi-
ties or competing conversations because the receiving team
is able to give their full attention to the transferring team as
the report is given. The hand-off is smooth, efficient and –
most important – safe.2
Battling lost data in nursing hand-offs
In a study done by Pothier, Monteiro et al, the hand-off of 12
simulated patients was observed over five consecutive hand-
off cycles. Three hand-off styles were used and the amount of
data loss was recorded for each style. The purely verbal hand-
off style resulted in the loss of all data after three cycles. A
note-taking style resulted in only 31 percent of data being
transferred correctly after five cycles. When a printed form
was included with the verbal hand-off, data loss was minimal.
The authors recommend that nursing and medical staff
include a printed data sheet as part of the hand-off process.4
AORN describes the preoperative brief as a powerful tool to
“bring the entire OR team onto the same page”; remove
incorrect assumptions; clarify the intended plan and contin-
gency plans; obtain key information from surgeons, anesthe-
sia providers, circulating nurses and surgical technologists or
scrub nurses that enhances patient care safety and quality
and develop counter-strategies for avoiding common pitfalls,
errors and complications.4
the recipient is prepared to mentally process. Because of this,
many organizations have developed structured communica-
tion techniques such as checklists and read-back techniques.6
The use of a checklist serves two purposes. It ensures that
critical information necessary for patient care is not over-
looked and it provides a consistent order in which infor-
mation is communicated.
These tools serve to address those unique issues or critical
pieces of information related to continuity of patient care
between specialty areas.4 The hand-off checklist or docu-
mentation tool will help ensure a standardized method for
everyone to use. Although checklists can enhance memory,
longer lists might not be as effective. A checklistʼs content and
design must be prudent and strategic to gain its desired results.
When providing the hand-off communication, remember these
important communication techniques to ensure that there is
two-way interaction:
• Get the personʼs attention
• Make eye contact
• Face the person
• Use the personʼs name
• Express concern
• Use a standardized communication technique
• Use a standardized communication tool/checklist
• Re-assert as necessary
• Escalate if necessary
Transitions in care are prime targets for improved patient
safety efforts. There are several strategies that have been
developed in high-reliability organizations that can be applied
to health care and have been successfully implemented with
positive results. For a sample hand-off policy and procedure
as well as checklists and other tools from Trinity Medical
Center in Rock Island, IL, please refer to Pages 82-83
and 85-86 in the Forms & Tools section. Trinity has been
recognized by the Joint Commission as a model for
hand-off communication.

AORN recommends using four different Pre-Operative Intra-Operative Post-Operative Discharge Brief/Home
hand-off briefs, the Pre-Op Brief, Hand- Pre-Op Brief Hand-Off Post-Op Discharge
Off Briefs for Continuity, Post-Op Brief Briefs for Brief Brief
and Discharge Brief. The diagram to the Continuity
right displays the operating room briefs “Bring the OR Nurse-nurse Anesth to To the patient and
from the OR to discharge home. team onto the Anesth-anesth PACU nurse family for home
same page” by Tech-tech to inpatient care or home
Forms and checklists stating the plan provider health nurse with
To facilitate an individualʼs comprehen- clear diagnosis
sion of what is communicated, informa- and post-op plan
tion must be organized in a format that

Aligning practice with policy to improve patient care 23

 Topics for hand-off checklists
Anesthesia provider may report: Perioperative nurse may report:
• Patient name, gender, age, procedure, physician • Baseline patient assessment
• History of present illness • Positioning during procedure
• History of chronic illness • Skin prep
• Relevant pre-op lab tests • ESU pad placement and removal assessment
• Type of anesthesia administered • Use of special equipment (laser, endoscope)
• Patient response to anesthesia agents • Intraoperative irrigation fluids
• Duration of anesthesia • Administration of medications or dyes from
• Reversal agents surgical field
• Narcotics • Implants, transplants, explants
• Antibiotics • Dressing
• Fluid replacement and type (I & O) • Drains, stents, catheters
• Invasive monitoring line • Sensory or motor limitations
• Vital signs • Prosthesis presence
• Allergies • Pressure ulcer risk assessment
• Other conditions • Other pertinent patient information
• Medications given • Information about the family or others waiting
• Complications related to the procedure for the patient
• Orders

Surgeon may report: Be sure to complete the CE

• Immediate orders
• Diagnostic tests for PACU
credit crossword puzzle on
• Interventions needed in PACU
Page 26!

References
1 Makary M, Sexton J, Freischlag J. et al. Patient safety in surgery. Ann Surg.
2006;243: 628-635.
2 Stokowski L. Perioperative Nurses: Dedicated to Safe Surgical Care. Available at:
http://www.medscape.com/viewarticle/562998. Accessed November 4, 2008.
3 The Joint Commission. National Patient Safety Goals: History Tracking Report 2009-
2008. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafe-
tyGoals/09_hap_npsgs.htm. Accessed November 4, 2008.
4 AORN. Perioperative Patient “Hand-Off” Tool Kit. AORN. Available at:
http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/. Accessed No-
vember 4, 2008.
5 Agency for Healthcare Research and Quality. Patient Safety and Quality: An Evi-
dence-Based Handbook for Nurses. AHRQ Publication No. 08-0043. April 2008.
6 Mistry K, Jaggers J, Lodge A et al. Using Six Sigma® Methodology to Improve Hand-
off Communication in High-Risk Patients. Available at: http://www.ahrq.gov/down-
loads/pub/advances2/vol3/advances-mistry_114.pdf. Accessed November 4, 2008

24 The OR Connection
Care Bundle for Surgical
Site Preparation
Following these steps for best practice
can help reduce the incidences of
surgical site infections.1

• Glucose control
• Preoperative CHG shower
• Appropriate hair removal
• Hand hygiene
• No razors
• Skin antisepsis
• Antimicrobial prophylaxis
• Normothermia

Reference
1. Mangram AJ, et al. The hospital
control practices advisory committee.
Guidelines for prevention of surgical site
infection. Infect Control Hosp Epidemiol.
1999;20(4): 250-278. Information
contained on this site pertains only
to the United States of America.

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 Back to Basics Crossword Puzzle

Applying Evidence-Based Information

to Improve Hand-Off Communication
in Perioperative Services
1

4
5

7 8 9

10 11
12

13

14
15

16 17

18

19 20 21

22

23

24 25

26 27 28 29

30
31

32

33

34

1. Register (free) or log in

www.medlineuniversity.com

2. Click Free Courses tab

3. Locate the puzzle and click Learn
More, then Begin Course
4. Certificates are available online
after puzzle completion

26 The OR Connection
Across
1 Consider using structured _____ that can facilitate
consistency in communication exchanges.
5 When providing the hand-off communication,
express _____.
7 Teach and practice communication using
established clear, common _____ among care
providers during hand-offs.
9 According to the Joint Commission, communication
issues are the _____ factor in root causes of
sentinel events.
12 _____ the hand-off can lead to small, yet critical
mistakes that can ultimately harm patients.
13 A clear _____ to hand-off communication is the
sheer number of individuals involved in the care of
surgical patients.
16 The National Patient Safety Goal 2E states that an
organization should implement a _____ approach
to hand-off communication.
18 Redesign the hand-off and shift change processes
to protect against unnecessary interruptions, and
allocate sufficient time to the process.
21 Give as much _____ as necessary for the hand-off
to ensure accurate communication.
22 Time becomes a barrier to _____.
23 In the surgical setting, a premium is placed on _____.
24 A healthcare organization initiated the sterile _____
concept for the clinical setting during the verbal
transfer of patient information.
2 7 _____ must be organized in a format that the
recipient is prepared to mentally process.
31 _____ should respond to the Joint Commission
mandate to improve hand-offs by initiating a
program within each facility.
32 When providing the hand-off communication, make
_____ contact.
33 Adverse events occur more often in _____ than in
any other specialty, and disproportionately greater
harm results from surgical errors.
34 A checklistʼs content and design must be prudent
and strategic to gain its desired _____.
To receive one hour of CE credit, enter your answers
online at www.medlineuniversity.com
Aligning practice with policy to improve patient care 27
Down
1 A standardized process for hand-off communication
becomes critical in perioperative services to assure
that communication is _____.
2 Be certain that the hand-off is two-way, with both
participants taking _____ responsibility for ensuring
accurate communication.
3 When providing the hand-off communication,
_____ the person.
4 _____ in care are prime targets for improved
patient safety efforts.
6 When providing the hand-off communication,
use a standardized communication _____.
8 Healthcare providers have looked at other
high-risk, high-stakes industries such as _____ for
new approaches that can be applied to hand-offs.
10 The use of a checklist ensures that critical
information necessary for patient care is not _____.
11 The _____ brief brings the OR team on to the same
page by stating the plan.
14 When providing the hand-off communication, get
the other personʼs _____.
15 “I-SBAR” stands for introduction, _____,
background, assessment, recommendation.
17 While developing hand-off policies and protocols,
include a clear statement of how and when _____
is transferred during healthcare transitions.
19 TeamSTEPPS is an evidence-based team-training
_____ used by the Department of Defense.
20 Another healthcare organization has initiated a new
hand-off process modeled after routine _____ stops
in racing.
25 Researchers recommend _____ communications
and clear agreements about roles and
responsibilities in a hand-off.
26 There are _____ very significant hand-offs that
occur in perioperative services for each patient
who undergoes a surgical procedure.
28 The use of a checklist ensures a consistent
_____ for information.
29 When providing the hand-off communication,
use the personʼs _____.
30 _____ communication is defined as the “transfer
of information during transitions in care across
the continuum.”

We have all heard the old adage “If you canʼt measure
it, you canʼt manage it.” Most folks in health care
strongly believe in this concept. So it will come as no sur-
prise to you that when I speak to healthcare executives
about the work of LifeWings, I am always asked, “How do
you measure this?”
I think what they are really asking is, “What are the results
we can expect to see?” and “How can you document
that?” Consequently, we spend quite a bit of time and effort
helping hospital executive teams create realistic data
collection and analysis plans to help them paint the
“before” and “after” pictures for their teamwork-based
patient safety initiatives. Of course, by gathering and
analyzing data that builds the “after” picture, the client can
see in their measurement tool if the steps they are taking
are actually changing anything – are they hitting their
goal(s)? If not, they can take management action and
change or adjust the methodology to reach their goal(s).
Teamwork: the key to patient satisfaction
One common goal of most hospitals today is getting great
HCAHPS scores. CMS now publishes the results of these
patient satisfaction survey scores on their Web site. What
patients think about the care they received in your hospital
is now available for the whole world to see on the Internet.
28 The OR Connection
Measuring
What
You
Manage
So, the goal of the facility is great patient satisfaction.
The measurement tool is the satisfaction survey.
Based upon recent research from a large hospital in the
mid-South, if your goal is to improve patient satisfaction,
the management action should be to improve the team-
work of the healthcare team.
Whether your goal is reduced mortality,
to eliminate bloodstream infections or to
improve patient satisfaction, providing
your caregivers with excellent teamwork
skills should play an important part in
your improvement equation.
What management action should an institution take if the
satisfaction score is not where theyʼd like it to be? By
adding a question to their satisfaction survey asking the
patient to rate the level of teamwork they experienced dur-
ing their stay, the hospital mentioned above was able to
analyze the results of almost 30,000 surveys to discover
a .97 correlation between the “teamwork” rating and the
patientʼs willingness to give a “Would Recommend” and
an “Overall Excellent” rating on their survey responses.
 Special Feature

Patients may not be expertly trained teamwork assessors,

but they seem to know good teamwork when they see it.
When your caregiversʼ teamwork is first rate, your patients
are going to give you an “Overall Excellent” rating and
“Recommend” your facility to their friends and family.

Using teamwork to improve your mortality rate Based upon recent research
This same research also showed a correlation between a from a large hospital in the
patientʼs “teamwork” rating and the mortality rate of the mid-South, if your goal
is to improve patient
hospital. The teamwork of the facilityʼs caregivers, as
satisfaction, the management
rated by the patient, controls approximately one third of
action should be to improve
the variation in mortality in that institution. If your goal is the teamwork of the
to provide better care and one of the measurement tools healthcare team.
for that goal is your mortality rate, then one of the man-
agement actions you should take to help reach that goal
is to improve your providersʼ teamwork skills.

Hereʼs one more example of these principles. The state of

Michigan began a state-wide initiative called the Keystone
Project to reduce or eliminate bloodstream infections in
patients in their hospitalʼs ICUs. To achieve this, one of
the tactics the facilities adopted was the use of a standard
protocol, accomplished with the aid of a checklist, to insert
a central line. The checklist and the training process on
how to use it were pretty near identical for every institu- Whether your goal is reduced mortality, to eliminate blood-
tion. Yet despite the similarity in protocol, process and stream infections or to improve patient satisfaction, providing
training, ICUs saw variability in their results. your caregivers with excellent teamwork skills should play
an important part in your improvement equation.
What causes the variability? Further analysis revealed the
most successful ICUs were those with a better safety cul-
ture as evidenced by a greater willingness to cross check
one another and to speak up to hold one another account-
able to abide by the protocol. In short, better teamwork.
If your goal is fewer bloodstream infections, and your
measurement tools are the level of compliance with the
protocol and the number of infections, the management
action you should take to help reach your goal is to
About the author
improve the teamwork of the folks in the ICU.
Stephen W. Harden is President of LifeWings Partners LLC and
co-founder of Crew Training International, Inc. (CTI), the parent
One of my favorite quotes about measurement is from the company of LifeWings. Prior to his position at LifeWings, he was
author Robert Heinlein. He says, “If it canʼt be expressed the principal courseware designer of CTIʼs Crew Resource Man-
in figures, it is not science; it is opinion.” One thing we agement (CRM) training for the U.S. Air Combat Command, Air
know about teamwork is there is a “science” to it. Team- National Guard, Air Force Reserve Command, Italian Air Force,
work has been clearly shown, by expression in “figures” Swiss Air Force, Belgian Air Force, domestic and commercial
(or numbers), to improve outcomes in health care. airlines, construction crews and hospital surgical teams.

Aligning practice with policy to improve patient care 29

 Patient Safety in Surgery
Learning from aviation safety:
a call for formal "readbacks" in surgery
By Philip F. Stahel
The first fatal airplane crash in history occurred exactly 100
years ago, on September 17, 1908, when Army lieutenant
Thomas Selfridge died in a failed flight attempt with the
aviation pioneer Orville Wright. Since that time, aviation safety
standards have significantly improved. Currently, the risk for an
American dying in an airplane crash is about 1:500,000, com-
pared to a 1:20,000 chance of dying in a car accident. In
the field of medicine, it was not until the shock-
ing report by the Institute of Medicine in
1999 revealed that 100,000's of pa-
30 The OR Connection
tients die in the United States every year as a consequence of
medical errors [1], when we began to realize that there is some-
thing "wrong with the system". While this unacceptably high
number has been chronically underrated in public recogni-
tion, an extrapolation of these statistics to professional aviation
equals to about 200 jumbo jet crashes per year, or one 747
crash every other day. This dramatic insight
led to the design of the "100,000 lives
campaign" by the Institute for
Healthcare Improvement in

2004 [2]. By 2006, the campaign had surpassed its initial goal by
saving more than 120,000 lives through the implementation of
increased patient safety standards and algorithms [2]. These
include the recent implementation of a standardized surgical
"time-out" to ensure the correct patient identity and correct pro-
cedure performed at the correct surgical site [3]. In addition,
the implementation of formal, structured perioperative briefings
in the operating room have been shown to significantly reduce
the incidence of wrong site surgeries [4].
Despite those recent improvements, the analysis of the Ameri-
can College of Surgeons' closed claims study revealed that a
breakdown in communication before, during, or after surgery still
represents a significant source of errors which lead to patient
Aligning practice with policy to improve patient care 31
Patient Safety
complications [5]. Of these, 85% of adverse events related to
communication breakdown occurred by verbal communication,
while only 4% were attributed to communication in written form
[5]. This notion provides the basis for a call for written checklists
and formal verbal "readback" orders among healthcare profes-
sionals who care for surgical patients, in order to avoid or
reduce the high incidence of perioperative complications related
to a breakdown in communication. Interestingly, pilot readbacks
represent a hallmark safety concept in professional aviation.
While the current debate in aviation safety is related to optimiz-
ing and correcting the modality of readbacks [6,7], this crucial
form of communication is still virtually nonexistent among sur-
geons. Dr. Eddie Hoover has characterized the issue to the
point, in a recent editorial: "Getting surgeons to readback orders
and instructions will age you 10 years, yet the Navies of the
world have demonstrated for eons that it improves efficiency,
promotes safety, and saves lives." [8].
 I wish to emphasize that the implementation of verbal read-
back orders represents the 2nd National Patient Safety Goal
(NPSG) for 2009, as defined by the Joint Commission [9]. The
NPSG #02.01.01, aimed at improving the effectiveness of A Spotlight
communication among caregivers, is defined as such: "For
verbal or telephone orders or for telephone reporting of critical
on “Never Events”
test results, the individual giving the order or test result verifies
the complete order or test result by having the person receiv-
ing the information record and 'read back' the complete order As you know, as of October 1, 2008, CMS is no longer
or test result." [9]. reimbursing at a higher DRG for 11 conditions deemed
“never events.” Those conditions are listed below, along
with articles in this magazine that relate to them. We hope
In conclusion, I urge all healthcare professionals involved in
they help you enhance your facilityʼs prevention measures!
the care of surgical patients to contribute to improved patient
safety and reduced complications and sentinel events in 2009 1. Retained foreign object after surgery
by addressing the most frequent root cause for adverse out- “A Focus on Prevention” ..............................................Page 9
come in surgery: Ineffective communication. The implemen-
tation of formal standardized "readbacks" is a promising start. 2. Air embolism

Competing interests
The author declares that he has no competing interests.
Acknowledgements
I would like to thank Ms. Jan Minifie, Dr. Ted Clarke, and Dr.
Kagan Ozer for helpful discussions related to this editorial.
References
1. Institute of Medicine: To Err is Human: Building a Safer Health System. National
Academy Press, Washington D.C.; 1999.
2. Wachter RM, Pronovost PJ: The 100,000 lives campaign: a scientific and policy
review. Jt Comm J Qual Patient Saf 2006, 32(11):621-627.
3. Michaels RK, Makary MA, Dahab Y, Frassica FJ, Heitmiller E, Rowen LC, Crotreau
R, Brem H, Pronovost PJ: Achieving the National Quality Forum's "never events":
prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg
2007, 245:526-32.
4. Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E, Rowen
L, Behrens DC, Marohn M, Pronovost PJ: Operating room briefings and wrong site
surgery. J Am Coll Surg 2007, 204:236-43.
5. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner
MJ, Gawande AA: Patterns of communication breakdowns resulting in injury to sur-
gical patients. J Am Coll Surg 2007, 204:533-40.
6. Anderson DZ: Correcting readbacks. Aviation Safety 2008, 28(3):3.
7. Correcting readbacks – letters to the editor. Aviation Safety 2008, 28(4):.
8. Hoover EL: Patient safety and surgeons – why the resistance? Arch Surg 2007,
142:1127-8.
3. Blood incompatibility
“Organ Donation”........................................................Page 36
4. Stage III and IV pressure ulcers
“A Focus on Prevention” ..............................................Page 9
“Why Is Pressure Ulcer Risk Assessment
So Important?” ..................................................................Page 50
“Fluid Flow Disruption?” ....................................................Page 58
“Pressure Ulcer Prevention Checklist” ......................Page 89
5. Falls and trauma (fractures, dislocations, intracranial
injuries, crushing injuries, burns)
6. Catheter-associated urinary tract infections
“A Focus on Prevention” ..............................................Page 9
“Targeting Zero” ..........................................................Page 15
7. Vascular catheter-associated infections
“Targeting Zero” ..........................................................Page 15
“Care Bundle for Surgical Site Preparation” ...............Page 26
8. Surgical site infection – mediastinitis after coronary
artery bypass graft (CABG)
“Targeting Zero” ..........................................................Page 15
“Care Bundle for Surgical Site Preparation” ...............Page 26
“SCIP Fact Sheet” ......................................................Page 80

9. Surgical site infections following certain elective

9. [http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/].

procedures, including certain orthopedic surgeries,

Published: 17 September 2008
Patient Safety in Surgery 2008, 2:21 doi:10.1186/1754-9493-2-21
This article is available from: http://www.pssjournal.com/content/2/1/21
and bariatric surgery for obesity
“Targeting Zero” ..........................................................Page 15
“Care Bundle for Surgical Site Preparation” ...............Page 26
“SCIP Fact Sheet” ......................................................Page 80

© 2008 Stahel; licensee BioMed Central Ltd. 10. Certain manifestations of poor control of blood
sugar levels
This is an Open Access article distributed under the terms of the Creative Com-
mons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, pro-
vided the original work is properly cited. 11. Deep vein thrombosis or pulmonary embolism
following total knee replacement and hip
replacement procedures
Address: Department of Orthopaedic Surgery, Denver Health Medical Center,
University of Colorado School of Medicine, 777 Bannock Street,
Denver, CO 80204, USA “SCIP Fact Sheet” ......................................................Page 80
Email: Philip F Stahel - philip.stahel@dhha.org

32 The OR Connection

A Latex-Free Victory!
One OR’s success
An interview with members of the River Oaks Hospital OR Team
Kim Gordon, RN, BSN, CNOR, is the products nurse
at River Oaks Hospital, a 14-room OR in Jackson,
Mississippi. In her role, Kim was constantly ordering
replacement gloves for all of the services and special needs
of the medical and surgical staffs. She was responsible for
the inventory of approximately 12 different types of gloves
in sizes 5 ½ to 9.
At best, it was a difficult task. Kim knew
that her facility needed to standard-
ize glove types and reduce their
inventory. At the same time, she saw
an opportunity for the hospital to ad-
dress a rising concern in the OR com-
munity – latex allergies.
Latex allergies among
healthcare workers
The American Latex Allergy Association
estimates that between 8 and 17 percent of
all healthcare workers are sensitized to natural
rubber latex.1 Studies have suggested that the
costs of healthcare workersʼ disability compen-
sation due to latex allergies justifies or signif-
icantly offsets the cost of conversion to a
latex-free environment.2
Aligning practice with policy to improve patient care 33
OR Issues
When facilities contemplate where to start combating latex
intolerance, one of their most frequently ordered commodities
pops into mind: gloves. Latex gloves have the highest con-
centration levels of allergenic proteins and therefore are the
greatest threat to staff members and patients who are intol-
erant to latex.3
What worked at
River Oaks
To help consolidate gloves and convert River Oaksʼ OR to a
latex-free environment, Kim asked product representatives to
initiate a glove trial. When selecting new gloves, it is impor-
tant to establish criteria for the
decision. Examples include
product availability, viral pen-
etration test results, color, tex-
ture, finish, length, primary
material, pinhole levels and
elongation levels.4
Kimʼs product representative
set up a station in a high-traffic
area and asked the medical and
surgical staff to try on latex-free
polyisoprene gloves with and
without an interior aloe vera coating.
 These gloves were made readily available to the staff for pro-
cedures while the likes and dislikes were addressed by the rep-
resentative.
The evaluations were tallied and the majority of the surgical
staff approved the conversion and 100 percent are now using
latex-free gloves. Through the conversion, Kim reduced her
massive inventory to four types of gloves – two types of latex-
free gloves and two gloves that a handful of surgeons re-
quire.
Addressing cost concerns
Facilities have a tendency to believe that synthetic gloves are
not cost effective. However, conversion and simplification can
lead to cost savings through inventory management. Kim was
able to demonstrate this by minimizing her glove stock from
12 to four different types of gloves. Although Kimʼs glove
usage did not decrease, she was able to minimize waste and
increase efficiency.
Kim summarizes the overall impact of
converting to latex free gloves to be:
1. “We improved our patient care by providing a safer,
latex-free environment without increasing costs.”
2. “The conversion has created new, much needed space
for us. Eliminating so many different kinds of gloves freed
up three storage system carts in our central supply area.”
3. “The majority of our staff has been pleased with the
conversion. It has certainly cut down on confusion.
There is a comfort in knowing that there are two types
of gloves to choose from in our OR and both will
provide safe care for our patients.”
Other latex-free options
Gloves are not the only items purchased by medical facilities
that contain latex. Some hospitals are beginning to purchase
latex-free surgical packs. Other facilities have created a latex-
safe unit or latex-safe rooms. This does not mean, however,
that these rooms are 100 percent latex-free because there are
still some products on the market without a latex-free option.
The “latex-safe” designation simply means that there is a
severely limited or small amount of latex that is kept or allowed to
enter into the room. At River Oaks, Kim also focused on convert-
ing to latex-free Foley trays, tubing and arthroscopic cannulas.
Another option for assisting patients with latex sensitivity is cre-
ating a latex-free cart. This cart could be easily transported to
patients with latex allergies without having to convert and en-
tire room or unit to a latex-free environment. Medical staff will
then only be permitted use the latex-free supplies on the cart
while working with the patient.
34 The OR Connection
Left to right: Doug Morrison, Sharon Grisham, Kim Gordon and Dwayne
Braxton – members of the Surgical Services Team at River Oaks
Hospital who assisted with the latex-free conversion.
What is a latex allergy?
It is estimated that more than three million people in
the United States suffer from a latex allergy.5 The
Mayo Clinic defines “latex allergy” as “a reaction to
certain proteins found in natural rubber latex, a prod-
uct manufactured from a milky fluid derived from the
rubber tree (Hevea brasiliensis) found in Africa and
Southeast Asia.”6 When people have latex allergies,
their bodies mistake latex for a harmful substance.6
Milder reactions to latex include skin redness, rash,
itching and hives. More serious reactions include sneez-
ing, itchy eyes, scratchy throat and asthma. In severe
cases, sinusitis, rhinoconjunctivitis, anaphylaxis and gas-
trointestinal problems can also occur.7
References
1 American Latex Allergy Association. Latex Allergy Statistics. Available at:
http://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.
3 Lenehan GP. Latex allergy: separating fact from fiction. Nursing. 2004
Feb;Suppl:12-7; quiz 17-8.
4 Lillis K. Hospitalʼs latex-free program fits like a glove – what works. Healthcare
Purchasing News. 2002 Sept.
5 Dyck RJ. Historical development of latex allergy. AORN Journal. 2000
Jul;72(1):27-9, 32-3, 35-40.
6 MayoClinic.com. Latex allergy. Available at: http://www.mayoclinic.com/health/latex-
allergy/DS00621. Accessed November 5, 2008.
7 Stout G. Creating a latex-safe environment. Infection Control Today Magazine.
Available at: http://www.infectioncontroltoday.com/articles/051feat2.html. Accessed
November 5, 2008.
You have too much on your hands...
to worry about bacteria.
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www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
36 The OR Connection

Overcoming obstacles and objections
By Jeanne M. Jones, RN
As nurses, we know firsthand that when you are
in the emergency room and a massive injury
comes through those doors, a multitude of
decisions are being made very quickly. One of the
important decisions is often organ donation and
unfortunately, many of our patients have not made
their wishes known beforehand. Organ donation is
important for obvious reasons, and millions of people
believe in its value. However, problems can crop up
when itʼs actually time for the donation.
Victims of trauma were not planning on dying – and
they might have very strong feelings on whether they
want to participate in this final act. But, unless they
inform their family members of their wishes, the
decision-making quest can be terrible.
Aligning practice with policy to improve patient care 37
Special Feature
Organ Donation
A personal experience
My niece, Diane, lost her husband, Joe, two years
ago after battling the waiting list. For patients to
receive a transplant, they must be “sick enough” but
not “too sick” to receive a healthy organ. Every time
Joe was on the list, we prayed for a match. Every
time he was too sick, we prayed that modern medicine
could buy us more time. Joe and Dianeʼs children
always said things like, “When Daddy gets his trans-
plant, we can go to Disney” or “When Daddy gets his
transplant, we can do the things we used to do.” Joe
never got that organ and their lives have changed
more than any of us could imagine.
Diane and her two children have joined forces with
Joeʼs parents and siblings to educate everyone they
can on the value of this potentially life-saving decision.
Continued on Page 39
S.T.O.P. for safety.

It could be the difference If you would like to receive a free sample

between life and death. of the S.T.O.P. Drape system to evaluate for
Wrong site surgery has recently moved into the yourself, ask your Medline representative or
number one position as the most frequently call us at 1-800-MEDLINE.
reported hospital error.1 STOP!!!
STOP!!!
Perform
P erform “TIME
“TIME O OUT”
UT”
This is despite a conscientious effort to eliminate this Verify
V erify ccorrect:
orrect:
problem before it occurs. What is needed is another layer Person
Person
Procedure
P rocedure
of safety...something that will improve our chances of Site
S ite & Side
S ide
correcting the mistake before it happens. Date:
Date: _______
_____ Time:
Time: ______
______
Surgeon’s
S urgeon’s Initials:
Initials: ______
____
Enter S.T.O.P. Surgical Drapes* from Medline.
We just made a good idea even better. S.T.O.P. (Surgical
Time Out Procedure) drapes are available in a variety of
configurations, and include a “S.T.O.P.” strip across the
fenestration. As a result, you can’t forget to take a time
out to verify the correct patient, procedure, side and site.
Then all that is left is to hand the sticker off to the circulating
nurse to include in the medical record, documenting that
the verification process was completed. S.T.O.P. strip and sticker

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.

www.medline.com
* Patent pending

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
They have worked with insurance companies, the
senate in New Jersey, local citizen groups and other sup-
porters throughout the state to spread the word.
In July of 2008, Bill S755/A2083, known as the New Jer-
sey Hero Act, was signed by Acting Governor Richard
Codey. New Jersey is the first state to require organ do-
nation decisions before applying for a driverʼs license and
mandatory high school education regarding organ donation.1
It is hoped that other states will follow the example of this
first-in-the-nation initiative. You can learn about your
stateʼs policies on organ donation by visiting
http://www.donatelife.net/CommitToDonation/.
Who is on the transplant waiting list?
According to information from the Department of Health
and Human Services (DHHS), there were 100,238 waiting
list candidates as of October 20, 2008.2 Kidneys are the
organs needed by the largest number of waiting list can-
didates, accounting for 76 percent of all organ needs.3
Other commonly needed organs include lungs, hearts,
intestines, livers and the pancreas.3
Organ donation myths
“I canʼt donate because Iʼm too old/young/sick.”
According to the DHHS, there are no strict upper
or lower age limits when it comes to organ dona-
tion.5 There are very few illnesses that completely
exclude people from donating. The exceptions are
HIV, active cancer and systemic infections.5
“My religion prohibits it.”
Most religions encourage organ donation or leave
the decision to be made by the individual. To view
a listing of the official stances taken by churches,
please visit http://organdonor.gov/donation/
religious_views.htm.
“I have to donate my whole body.”
The DHHS details four different types of donation.
They are6:
• Organ and tissue donation from living donors
• Donation after brain death
• Donation after cardiac death (DCD)
• Whole body donation

What can be donated?

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

How to encourage donation at your own facility

In 2003, the DHHS created the Organ Donation Break-
through Collaborative with the goal of “saving or enhancing
thousands of lives a year by spreading known best practices
to the nationʼs largest hospitals, to achieve donation rates
of 75 percent or higher in these hospitals.”7

The Collaborativeʼs members represent all members of

the organ donation and transplant community – critical
care nurses, organ procurement and transplant coordina-
tors, hospital administrators, physicians, clergy, social
workers, family members of organ donors and transplant
recipients.7

Aligning practice with policy to improve patient care 39

 References
1 The State of New Jersey Office of the Governor. Acting Governor Codey Signs
New Jersey Hero Act. Available at: http://www.nj.gov/governor/news/news/2008/
Victims of trauma approved/20080722a.html. Accessed October 20, 2008.
2 OrganDonor.Gov. Waiting list candidates. Available at: www.organdonor.gov.
Accessed October 20, 2008.
were not planning 3 Transplant Living: Organ Donation and Transplantation Information for Pa-
tients. Organ Facts. Available at:
on dying – and they http://transplantliving.org/beforethetransplant/organfacts/default.aspx. Accessed
October 20, 2008.
might have very strong 4 OrganDonor.Gov. What Can Be Donated. Available at:
http://organdonor.gov/donation/what_donate.htm. Accessed October 20, 2008.
5 OrganDonor.Gov. Who Can Donate. Available at: http://organdonor.gov/dona-
feelings on whether tion/who_donate.htm. Accessed October 20, 2008.
6 OrganDonor.Gov. Types of Donation. Available at: http://organdonor.gov/dona-
they want to participate tion/typesofdonation.htm. Accessed October 20, 2008.
7 Tamburri LM. The role of critical care nurses in the Organ Donation Break-
in this final act. through Collaborative. Critical Care Nurse. 2006;26(2).

Critical care nurses are an integral part of the donation

process. In this spirit, the Collaborative made the follow-
ing recommendations to critical care nurses to aid them
in turning best practices into common practice in their
intensive care units7:
• Refer all potential donors: Identify potential donors in
your unit, familiarize yourself with your facilityʼs criteria
for clinical triggers and promptly get in touch with your
organ procurement organization (OPO).
• Partner with your OPO: Introduce yourself to OPO
coordinators and help them become part of your team.
• Become a donor “champion”: Talk to your fellow
nurses and colleagues about the importance of organ
and tissue donation.
• Advocate for your patients and their families: Honor
your patientsʼ last wishes, including those related to
organ donation. Be sure that families are aware of the
donation option.
• Educate yourself and your colleagues: One option
for education is to invite your OPO to conduct in-service
training sessions in your unit.
• Be a change agent: Focus on system issues, examine
what your facility is doing right and determine what
needs to change to better your organ donor policies.
• Understand the data: Compare your hospitalʼs data
on organ donation to national benchmarks.

About the author

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

40 The OR Connection
Customized solutions.

Anesthesia Supply
Management Solutions
Does your anesthesia storage need help? When you part-
ner with Medline, your anesthesia supply management
world will be revolutionized.

With Anesthesia Complete Delivery System (ACDS*), all

anesthesia supplies will be par level packaged in a stan-
dardized drawer insert, which is then used to restock the
anesthesia case carts. This decreases the time it takes
staff to order, receive and stock shelf supplies.

Taking care of your needs every step of the way

Each program is custom designed based on your facility’s
anesthesia supply requirements. Medline’s® ACDS will …
• Increase staff productivity and satisfaction
• Improve inventory control
• Increase space utilization
• Improve charge/cost capture
• Eliminate outdated product
• Enhance supply standardization For your free cost-savings analysis,
• Enhance compliance with the Joint Commission, contact your sales representative or
AORN and SCIP call 1-800-MEDLINE.

* Patent pending

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

Supply Management for

Perioperative Services
How to get your inventory
under control

42 The OR Connection
By Ned Turner

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

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

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

Getting your inventory under control

When hospital CFOs mentions the word “inventory” to key hospital directors, theyʼre often
talking about inventory reduction. While many ORs doubtless have the capability to reduce
inventory, itʼs still crucial that the right products are in the right place, at the right time. Simply
cutting back on inventory might not make your OR more cost effective and might even
create a situation that could affect patient care, patient and staff safety and surgeon and
staff satisfaction.

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

1. Organization
Orderly and organized supplies are often more effectively managed.

2. Systems
An effective OR materials management system and accurate reporting tools are critical
for effective inventory management.

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

4. Consignment
Consignment can be a great tool for high-cost supplies such as implants, grafts and
custom packs.

5. Annual inventory counts

Although annual inventory counts can be time-consuming and a task that volunteers rarely
line up to help with, these counts are vital to managing inventory and identifying obsolete
supplies.

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

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

About the author

Ned Turner has spent the past 29 years working in surgical supply
manufacturing and supply management consulting. Ned joined Medline in
2003 after a lengthy career at Cardinal Health that included serving as Area
Manager of the Western U.S. He is currently the vice president of
Medlineʼs Sterile Procedure Tray Division – Sales and Supply Manage-
ment Consulting Services.

Aligning practice with policy to improve patient care 43

44 The OR Connection

A New Way to “Pack” It All In
An interview with members of St. Vincentʼs perioperative team
Think about the last time you put a surgical pack
together. You probably had a lot to think about. Could you
lower costs? Increase productivity? Are all of the products
youʼre ordering latex-free? Is there any way to standard-
ize it all?
On average, operating room supplies account for more
than 50 percent of a hospitalʼs budget.1 It makes
sense that youʼd want to get as much bang for your
buck as possible!
In the spring of 2008, Medline launched a program to
reduce the headaches typically associated with pack
management. Med-Pack is a Web-based, real-time pack
management tool that was created following intense input
from focus groups and advisory boards.
Med-Pack, which is available to any
Medline pack customer, operates
through a series of iViews, which are
essentially microsites supplying specific
information to users. Examples of iView
topics include Safety, Analysis Tools,
Alerts, Savings, Standardization and
Supply Management, plus many more.
The goal of each of these iViews is to
quickly provide critical information in a
hassle-free format. Users simply click on
an iView icon to get the material they
need, eliminating the need to jump from
Web site to Web site to track down
information on latex-free options, St. Vincent Carmel Hospital
industry initiatives, etc.
Aligning practice with policy to improve patient care 45
OR Issues
Each Med-Pack user also has an online “eBook” created
for them. This eBook contains:
• Component lists
• Pack history
• Documents
• Pack images
• Pack changes
• Eco-friendly components
As you can see, the eBook is a great way to keep critical
documents together – without creating a mountain of paper.
Since its launch, hospitals throughout the country have
adopted Med-Pack at their facilities. We wanted to share
one facilityʼs success story with you.
St. Vincentʼs story
St. Vincent Health is the largest health-
care employer in the state of Indiana,
with 17 health ministries serving 45
counties in the central portion of the
state. It is also a member of the
Catholic Healthcare System and As-
cension Health, the nationʼs largest
not-for-profit.
St. Vincent Indianapolis Hospital is
ranked nationally for cardiac, stroke,
orthopedic and gastrointestinal care. It
is also Indianaʼs only hospital to be
recognized for excellence in four spe-
cialty areas by HealthGrades, the
leading provider of independent hos-
pital ratings in the U.S.2

Left to right; Vicky Smith, Gussie B. Johnson, Barb
Weimer, Karen Fox, Sondra Jones and Francie Dolder
Becky Hodson is the OR Materials Team Leader at St.
Vincent and estimates that the facilityʼs 10 operating
rooms perform around 150 bariatric surgeries a month in
addition to other types of procedures. With the hospitalʼs
high volume of surgeries, Becky has found Med-Packʼs
time-saving features especially beneficial.
Simplifying pack changes
Before using Med-Pack, Becky recalls that surgical
packs would have to be built by arranging to have a
sales rep visit the facility and complete paperwork. Mak-
ing pack changes required more back-and-forth with pa-
perwork. Now, Becky can view her packs online and
request changes with a few clicks of her computer
mouse. This comes in handy because team leaders at
St. Vincent meet once a month to discuss any changes
they would like to make
with packs, which could
create more time-drain-
ing paperwork with an-
other system. All pack
changes are approved by
the management team.
Vicky Smith, CST, Spine
Team Lead at St. Vincent
Indianapolis, appreciates
how Med-Pack enables
Vicky Smith her to see when a pack
change is about to occur.
46 The OR Connection
Easy to use
The goal was to make Med-Pack so intuitive
that users would be up and running in min-
utes. The program is made up of a series of
icons called iViews. Each iView is a microsite,
supplying data specific to your account. Here
are some of the most popular iViews.
eBook OR Corner Safety
Analysis Tools Alerts Savings
Spend Standardization Supply
and Trend Management
This gives her time to alert staff that a change is coming
and prevent potential frustration. Itʼs also easy to identify
the most recent pack versions on St. Vincentʼs
shelves because Med-Pack automatically changes the
last letter in the packʼs product number each time a pack
is altered.
Standardization
Becky has also used Med-Pack to help make strides
toward St. Vincentʼs goal of pack standardization
across its multiple facilities.
“When you can have one pack, why have three out
there?” she said.
In one instance, Becky was able to use Med-Pack
to view the pack used at a sister facility by one of St.
Vincentʼs top-volume orthopedic doctors. Since that
surgeon was also practicing at the Carmel location,
Becky was able to standardize using his pack at both
locations.
Continued on Page 48
Everything you need to
know about your packs
at your fingertips.

Introducing Med-Pack, an interactive, Talk to your sales representative to obtain

real-time data management tool for sur- a Med-Pack login and experience Med-Pack
gical procedure pack management. for yourself.
Whether you’re an OR director, materials manager or
GPO administrator, Med-Pack has many different
“iViews” that provide specific information to help you
manage your surgical packs and your OR.

• View photographs of your packs and components

• View inventory in real time
• Get alerts for pack changes
• Run safety and latex analyses on your packs
• Run reports by component, pack or discipline

Featuring OR Corner, where

you can find the latest indus-
try news, hot topics and
industry calendar of events.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 Cost savings
Both Vicky and Becky praised Med-Pack for its ability to call
attention to cost savings options.

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

To learn more about how Med-Pack could benefit your own

facility, please contact your Medline sales representative.

References
1 Davis E. Educating perioperative managers about materials and financial manage-
ment. AORN Journal. 2005;81(4):798-812.
2 St. Vincent Health. St. Vincent Indianapolis Hospital. Available at: http://www.stvin-
cent.org/ourlocations/hospitals/indianapolis/default.htm. Accessed November 13, 2008.

Clinical Logistical Financial

eBook

Pack Detail

Pack Image

Safety Center

Safety Analysis

Lu McKee and Becky Hodson

Latex Analysis

Safety Articles

Supply Management

Alerts

Inventory

Savings

Analysis Tools

Standardization

Component Utilization

OR Corner

Hot Topics

Link to Industry Experts

Note: iViews can host clinical, operational or financial information.

Which iViews would be most helpful to you?

48 The OR Connection
 We’re
setting
a new
standard
in patient
safety.

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 is proud to introduce our Gold Standard Safety 3. AORN Checklist: Wrong site, wrong procedure,
Program, designed to break down barriers in surgical wrong patient surgery prevention.
safety compliance by offering products, analysis tools 4. Med-Pack™: Electronic pack audit and a
and checklists to help you reach your safety goals. review 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 represen-
products to serve as visual safety reminders to reduce tative, call us at 1-800-MEDLINE or visit
needle sticks and wrong site surgery. www.medline.com.
2: Innovative safety products: Surgical Time Out
Procedure (S.T.O.P.™) Drapes (patent pending),
RF Surgical® Detection System and Universal
Electrosurgical Pads.

www.medline.com

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 Why is
Pressure Ulcer
Risk Assessment
So Important?

Letʼs examine what a patient and nursing student have to say!

By Alecia Cooper, RN, BS, MBA, CNOR
My name is Euretha and I have a story to tell you. I think it
could help folks like you who work in hospitals and nursing
homes alike. My granddaughter is studying to become a nurse
and she thinks what she and I have learned about my experi-
ence can help everyone. So I agreed to help.
I am 79 years old and have been in pretty good health all of my
life until I started getting feeble these last few months. Since
the passing of Theodore, my beloved husband, three years
About 70 percent of
ago this past September, I have lived all pressure ulcers
alone and got along pretty well caring occur in people 70
for myself. But as of late, I have been years and older.1
getting “blue” more often than not. I
donʼt have much of an appetite and I canʼt get around as well
as before. I become dizzy in the early mornings and I have
taken a fall several times. Most of my friends are either too sick
to get out much or they have passed on.

50 The OR Connection

Then things got worse. I tripped walking back from the mailbox
a few months back and skinned my arm, my nose and bruised
my left hip. My whole body was bruised up pretty bad. My
daughter June insisted that I go see my doctor, Dr. Hill. I have
been cared for by Dr. Hill for more than 30 years and pretty much
think he is one of the smartest doctors I know of, so when he told
me that he thought it was time for me to go live in a nursing
home, only for a while, so I could get stronger, eat better and
find out what was causing all these dizzy spells, I didnʼt much
argue with him.
Aligning practice with policy to improve patient care 51
Patient Safety
On November 1, I went to stay at Happy Valley Nursing Home
for what I thought was only temporary, no more than a couple of
months. Today is Christmas Day and I hope the kids get here
soon as I just cannot bear the thought of being away from
home on my favorite holiday. As hard as I tried to persuade
him otherwise, Dr. Hill said I am not ready to leave yet. You see,
what I have not told you yet is that I had one of those dizzy spells
14 days after I came to Happy Valley.
It was early that morning when I got out of bed to go to the bath-
room. I lost my footing, slipped and fell hard on my right hip and
it broke. We were not sure it was broken at first, but once I got
to the hospital, they were sure. I had surgery and a stay in the
hospital and then came back
Why is pressure ulcer risk
to Happy Valley with this
doggone bedsore on my assessment so important?
other hip. It is not healing too Because it helps identify which
well. In fact, it just keeps get- patients or residents may benefit
ting worse. Those “blue” most from preventable measures.2
days have just been getting
worse. I thought I would cry The best way to prevent pressure
all day when Dr. Hill let me ulcers may be through the use of
know that he now thinks that evidence based of pressure ulcer
this bedsore could be risk assessment tools.3
infected.
This whole situation worried my poor granddaughter, so she
talked to one of her nursing instructors who gave her an idea
for a school research proj-
ect. She said she needed my Confinement to a bed or chair
help. Imagine that. I get to for a week has been found to
help her figure out what could increase the prevalence of pres-
have prevented my bedsore sure ulceration by 28 percent.4
from developing after I broke
my hip.
I asked her how could I possibly help, and she told me that we
needed to go through every event from the time my injury
occurred until the bedsore developed. She explained that she
would take every part of the story and research the prevention
measures that, if they had been done, might have prevented that
bedsore from developing. To prove her point, she brought me an
article to read that she found in one of her nursing journals. That
article said that the experts say bedsores can be prevented in
most cases. If all this is true, then I think we need to all work
together to prevent them from happening. Oh, I know that mis-
takes can happen unintentionally. People can forget when they
are working so hard, under stressful situations, Lord knows I
have nothing better to do to occupy my time these days. Hereʼs
a look back at what was going on when that bedsore developed.
November 15, 2007
5:47 a.m.
I remember that I had tossed and turned all night, and even
though I was still so tired, I just could not fall back to sleep no
Continued on Page 53
 No pressure, just support.
Recent studies have shown that pressure ulcers can start to
form in as little as 20 minutes in the operating room.1 When
every second counts, the surfaces used for positioning and
transporting patients need to be chosen carefully.

Medline’s gel positioners are designed to help reduce pressure

while providing exceptional support during surgical procedures.
They’re latex- and silicone-free, antimicrobial, antibacterial and
radiolucent. They’re also reusable and can easily be cleaned
and disinfected with standard hospital disinfectants.

Our gel positioners are available in a wide variety of

shapes and sizes to meet your needs. To learn more
about Medline’s comprehensive Pressure Ulcer
Prevention Program, contact your sales representative
or visit www.medline.com/pressureulcerprevention.

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

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. www.medline.com
matter how hard I tried. So I One pressure ulcer can cost
got up to use the bathroom an average of $43,180. CMS
and fix my dentures so I and other providers
could go to breakfast. Maybe will not reimburse for the
I got up too fast, or I was additional costs associated
dizzy for some reason, but as
with hospital-acquired
soon as my feet hit the floor,
pressure ulcers.5
I slipped and fell hard on my
right hip. I think I remember
hearing something snap, but Iʼm not certain. I yelled for help
and that nice girl Sheila ran in and found me lying on the floor.
She told me not to move if possible and she quickly ran to get
some help. The head nurse came in and they got me stretched
out as best they could and said they called my doctor and an
ambulance was on the way to come get me and take me to
Mercy Medical Center so I could be checked out.
7:46 a.m.
The ambulance came to take me to the hospital (1 hr and 59
minutes after the incident occurred). I looked at the very
small stretcher with that tiny mattress – I donʼt think it could have
been more than one or two inches thick – and worried how they
were ever going to get me on and off that safely, but they did.
And trust me, it was one of the most uncomfortable beds that I
have ever laid on. They
strapped me in and got me Pressure ulcer incidence is
into the ambulance. I was in over 60 percent for high-risk
so much pain, but the emer- patients with femoral fractures
gency medical personnel told and/or hip fractures.1
me they could not give me
anything to dull it until I was checked out at the hospital. I could
not even have anything to drink. I think that was the worst part,
but they said if I needed to have surgery it could hurt me.
8:37 a.m.
I am rolled off the ambulance and rolled into the hospitalʼs emer-
gency room. Finally, after some confusion, I am moved from that
tiny stretcher to a bigger bed that was a little wider, but that mat-
tress was not much better than the one before. They nurses and
doctors told me that I had to lie still while they checked me out,
otherwise I might further injure my hip. For what seemed like for-
ever, they checked me out.
Then they told me they had Pressure ulcers are defined
called Dr. Hill and that he was as areas of localized damage
on his way, but had given to the skin and underlying
them orders over the phone tissue caused by pressure,
for me to have an EKG, a shear, or friction.6
chest X-ray and an X-ray of
my hip. Also, June and the kids had arrived by now and they
let June come back to sit with me for a while until it was
time for me to go to the X-ray department.
For consideration:
1. Was a pressure ulcer risk and skin assessment
performed and documented on admission
to the nursing home?
Aligning practice with policy to improve patient care 53
2. Was an admission pressure ulcer risk and skin
assessment performed, documented and compared
to the assessment performed at the nursing home?
9:57 a.m.
I am rolled down the hallway to the X-ray department for the X-
rays that Dr. Hill ordered. The boys moved me from my
stretcher to a very hard and very cold table in a darkened room.
A very nice lady came in and
explained what was going to 70 percent of nurses consider
happen. Pictures were taken their basic wound education
of my chest and hip and then to be insufficient.7
those sweet boys came back
and moved me off that hard table and back to that uncomfort-
able stretcher and I was rolled back to the emergency room.
When I got back, Dr. Hill was waiting on me and the first thing I
asked for was a drink of water as I was so parched. I remem-
bered that I had not had anything to drink since before 8 p.m. the
night before and nothing at all to eat since dinner. He said he
knew that I was dry, but it was unsafe to give me anything to drink
until we knew whether I needed surgery. I asked if they could
please hurry and find out.
Nurses need more education in: 8
• Risk assessment (interpretation of Braden Scale)
• Pressure ulcer staging
• Proper positioning
• Effects of moisture on the skin (including incontinence,
humidity and maceration)
• Pressure relieving products
• Proper application and usage of prevention products
11:02 a.m.
The nurse comes in to tell me that the X-rays show that my right
hip was indeed broken and that the surgeon, a Dr. Cloud, or one
of his assistants would be here
soon to discuss the plan for sur- The incidence of pressure
gery with me. I was getting so ulcers occurring as a result
tired of just laying in one spot for of surgery may be as high
so many hours, but she explained as 66 percent.8
to me that they had to keep my
body straight so I did not injure
my hip more. I asked her what time it was, and when she said
11:02, I realized that it had been over six hours since I fell and
that I had been in one position for as many hours. No wonder I
was getting so stiff. If I could have only turned over and had a
glass of water.
For consideration:
1. Did the stretcher pads used in the ambulance
and in the emergency room have pressure
redistribution capability?
2. Were pressure-relieving devices used to frequently
reposition the patient?
 11:35 a.m. an immobilizer was positioned Pressure ulcers can develop
Dr. Cloud comes in, intro- Key causes of OR-related between her legs to keep her within two to six hours of the
duces himself and explains pressure ulcers8: in proper body alignment, she onset of pressure.1
that I need to have surgery. was rolled onto her bed and
• Immobility during the
He was dressed in what taken to the recovery room,
procedure While AORN guidelines
looked like pajamas with a where she remained for two
white coat and a blue cap.
• Pressure on bones close recommend pressure relief
hours until she was stable
He told me that he had been to the skin surfaces for surgeries lasting
enough to be taken back to
in surgery all morning and • Diminished tissue tolerance her own room. Iʼll let Granny longer than 2 hours, pressure
that he had one more proce- • Excessive moisture tell you how she was feeling ulcers can start to form in as
dure to finish and then he when she got out of surgery. few as 20 minutes.9
would be able to get me all
fixed up. I told him how sore I The most frequent predictors For consideration:
was and how much pain that of perioperative pressure 1. Was the OR table pad a pressure redistribution pad?
hip was giving me, so he told ulcers have been found to be8: 2. Were all bony prominences and pressure points
the nurse to give me a shot • Increasing age of the padded appropriately to minimize pressure that might
for pain and that he would go occur during a surgical procedure?
patient
ahead and have me moved
• A patient diagnosed with
to the surgery holding area, 6:00 p.m.
where they could get me
diabetes or vascular
June and the kids were all waiting for me when I got to my room.
ready for surgery. About 20 disease
There was a pitcher of water waiting and that was the first thing
minutes later, a boy who was • Vascular procedures I wanted – a cold drink. My nurse for the evening came in and in-
dressed like Dr. Cloud came troduced herself and checked me out. They gave me some broth
in and told me he was there to roll me up stairs to where the Sur- to eat a little later. My hip was beginning to hurt again, so they
gery Department was located. I said my goodbyes to June and gave me some more pain medicine and I drifted back to sleep.
the kids and they told me not to worry, that I was going to be I guess I was really tired because I slept more that evening than
fine. I told them I knew that, I just wanted to get this over with. I had in weeks. I woke up a few times during the night and
needed some more pain medicine, but then I went right back
1:08 p.m. to sleep.
I am finally being rolled According to AORN, surfaces
back to the operating room in the OR for both positioning For consideration:
to get this old hip fixed. and transporting patients 1. Was the patientʼs skin thoroughly cleansed and
They started an IV in the should be smooth and intact inspected after surgery before leaving the operating
holding area and gave me because surfaces that hold room to ensure that there was no pooled blood or prep
some medicine that was moisture or wrinkle contribute solutions under bony prominences?
making me very drowsy. I to skin breakdown.8
now had on one of those November 16, 2007
blue hats, too. They moved 7:00 a.m.
me over to a table that looked just as uncomfortable as that Breakfast arrives and I am The greatest incidence of
gurney I had been lying on for the past five or six hours. After awake and ready to eat. new-onset postoperative
that, I donʼt remember much, so I have to turn the story over Soon afterward, the day shift pressure ulcers for elderly
to my granddaughter to explain what happened in surgery. nurse comes in and says she patients with hip fractures
has to check me out head to
occur within the first two
For consideration: toe. In doing so, she finds a
1. Each time the patient was moved from stretcher postoperative days.4
big red mark on my left hip
to stretcher and table to table, were the staff well and asked me if it had been
trained in transfer and positioning techniques there before I arrived at the hospital. I told her it hadnʼt been as
that reduce friction and shear? far as I knew, but that I had been falling easily and bumping into
things so it was possible that I was there and I didnʼt know it.
Granny was positioned on her left hip, prepped and draped with There was still some paint from surgery and a few blood spots on
a full-body drape and only her right hip exposed to the op- my skin, so she got some soap and water and cleaned me up
erative field. The procedure started at 1:45 p.m. and was com- real good. My granddaughter can tell you what came out of all
pleted at 3:30 pm., lasting one hour and forty-five minutes. of this.
During the surgery, Granny has some reasonable blood loss
and the hip was irrigated with antibiotic fluid. At 3:45 p.m., after
Continued on Page 56

54 The OR Connection
 The program
you need ...

right when you need it most.

Pressure Ulcer Prevention Program For the OR
“In many of the recent legal cases I have reviewed following Topics addressed in
facility acquired pressure ulcers, I have seen that an increasing the program include:
number are occurring in post surgical patients. A pressure I. Implications of the New CMS
ulcer prevention program for perioperative services that Payment Provision
addresses risk assessment as well as comprehensive II. Incidence of Perioperative Pressure Ulcers
prevention measures is more critical than ever.” III. Perioperative Risk Factors
– Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN, IV. Perioperative Assessment
Wound and Skin Care Consultant
V. Perioperative Prevention Measures

Studies suggest that the incidence of pressure ulcers occurring

To learn more about Medline’s Perioperative Pressure
as a result of surgery may be as high as 66 percent.1 With
Ulcer Prevention Program, contact your Medline
that in mind, Medline has developed a companion program
representative, call 1-800-MEDLINE or visit us at
to its highly successful Pressure Ulcer Prevention Program
www.medline.com.
especially for perioperative services.

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

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 For consideration:
1. Should soap and water be used to cleanse patients
at high risk for development of pressure ulcers?
By now, you must know the rest of the story. Granny was in the
hospital for five days after surgery and then returned to Happy
Valley Nursing Home. The reddened area eventually devel-
oped into a Stage III pressure
ulcer that is now infected. When a Stage I pressure
From my research, we have ulcer develops, the risk for
developed a protocol for additional ulcers on the
the prevention of pressure same individual is reported
ulcers that includes a com- to increase tenfold.4
munity effort between the
nursing home and acute-care facility to prevent facility-acquired
pressure ulcers. In Grannyʼs case, the ulcer could have devel-
oped due to pressure, moisture, friction, shear, poor nutri-
tion, tissue injury or tearing, but most likely from a combination
of all of these factors. Not all pressure ulcers are avoidable, but
many are. I encourage you to work closely within your medical
community to make sure your pressure ulcer prevention meas-
ures and protocols are up to date and that everyone is fully
trained to execute them appropriately.
Critical steps
Critical steps in pressure ulcer prevention and healing include8:
• Identifying the individual resident at risk for
developing pressure ulcers
• Identifying and evaluating the risk factors and
changes in the patientʼs condition
• Identifying and evaluating factors that can be
removed or modified
• Implementing individualized interventions to attempt
to stabilize, reduce or remove underlying risk factors
• Monitoring the impact of the interventions
• Modifying the interventions as appropriate
Risk factors
Risk factors for pressure ulcer development include8:
• Impaired/decreased mobility
• Decreased functional ability
• Co-morbid conditions
• Drugs that may affect wound healing
• Impaired diffuse or localized blood flow
• Resident refusal of some aspect of care and treatment
• Cognitive impairment
• Exposure of skin to urinary or fecal incontinence
• Under-nutrition, malnutrition and hydration deficits
• History of a healed ulcer
For Happy Valley Nursing Home, they not only had to provide
care for Eurethaʼs mending hip, they also had to deal with her fa-
cility-acquired pressure ulcer, which had become infected.
Euretha was now a much more complex resident with a much
56 The OR Connection
higher acuity, requiring more All members of the healthcare
resources and services to be team need to know their
provided and at a higher cost responsibilities and how their
burden for both the payer tasks relate to each other in
and the provider. Added on the prevention and manage-
top of this is the at-risk con- ment of pressure ulcers.
dition for the development of
additional complications, such as additional pressure ulcers,
deep vein thrombosis, pulmonary embolism and additional
infections.
Prevention is paramount. It begins with proper risk and skin
assessment, combined with proper prevention measures
(including the appropriate prevention products). The cement that
holds it all together is proper education and training of personnel
across the complete continuum of health care, including the
community of hospitals, nursing homes and emergency
medical professionals.
Refer to the Forms & Tools section to learn more about how
you can prevent pressure ulcers at your facility.
This story is a fictional account based on the real-life experiences
of the author.
References
1 Medical News Today. Clinical Trial Shows 96% Improvement In Pressure Ulcer
Healing Among Nursing Home Residents. Available at: http://www.medicalnewsto-
day.com/articles/39327.php. Accessed September 3, 2008.
2 Ayello E, Braden B. Why is pressure ulcer risk assessment so important? Nursing.
2001;31(11):74-80.
3 Walsh K, Bennett G. Pressure ulcers as indicators of neglect. Nursing & Residential
Care. 2000;2(11):536-539.
4 Maklebust J. Pressure ulcers: The great insult. Nursing Clinics of North America.
2005;40(2):365-389.
5 CMS, Proposed Changes to the Hospital IPPS and FY2009 rates;
http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf accessed October 24, 2008.
6 Lepisto M, Eriksson E, Hietanen H, Lepisto J, Lauri, S. Developing a pressure ulcer
risk assessment scale for patients in long-term care. Ostomy/Wound Management.
2007;53(10):34-38.
7 Zulkowski K, Ayello E, Wexler S. Certification and education: Do they affect pres-
sure ulcer knowledge in nursing? Advances in Skin & Wound Care. 2007;20(1):34-38.
8 AORN 2008 Perioperative Standards and Recommended Practices, “Recom-
mended Practices for Positioning the Patient in the Perioperative Practice Setting.”
9 Akridge J. Pressure ulcers hit a sore spot in the OR. Healthcare Purchasing
News. August, 2007.
It all adds up. The Pressure Reducing OR Table P

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

throughout. It is also antifungal, fluid proof, stain, fungal and fire
resistant—making it reusable and easy to clean.

To learn more about our

pressure reducing table
pads, contact your Medline
representative, call
1-800-MEDLINE or visit
Pressure Free, Medline’s new OR table pad features 3 layers of www.medline.com.
foam covered in our exclusive Nirvana “Memory” Foam which not
only completely conforms to the patient’s body contours and
Pressure Free
gently cradles delicate bony prominences but keeps its shape
OR table pad
throughout even the longest procedure. All of this is encased in
our state-of-the-art Proknit ticking to eliminate the “hamocking
effect” seen in other vinyl pads.

www.medline.co
 Fluid
Flow
Keep your surgical patient desert dry

Disruption?

By Jayne Barkman RN, BSN, CNOR

As Joe and Sandy walked down the hall

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

They assisted the paramedics and anesthesiologist in lifting

the patient from the stretcher onto the operating room bed.
Joe then grabbed a gown and a pair of gloves from the
room stock supply to scrub in and help Tom, the scrub
nurse, finish setting up. Sandy secured the patient to the
bed with the safety strap and began cutting off the young
manʼs clothing. The attending poked his head into the
room. “Letʼs go!” he barked. Sandy inserted a temperature-
sensing Foley and Laura, the room circulator, poured be-
tadine over the patientʼs chest and abdomen. Sandy tied
up the attending and two surgical residents as Joe and

58 The OR Connection

Tom draped the patient. Within in a minute, the young
manʼs abdomen was opened. Blood immediately began
pouring out.
“Get me another cell saver. Come on, I need more
suction!” the surgeon yelled. Sandy delivered another cell
saver tubing to the field and Joe handed it off to the perfu-
sionist as the whirl of the second cell saver machine filled
the room. Sandy and the anesthesiologist checked five
units of emergency release blood as a CRNA squeezed
the packed cells into the patient. Sandy and Joe then
counted the additional packs of lap sponges that Sandy
had tossed onto the field and began placing the soiled
sponges from the kick bucket into the sponge counter
bags. Next, Sandy carefully wiped up the blood that had
pooled around the surgeonʼs feet and showed the anes-
thesiologist the blood-soaked bath towels so that he could
incorporate the blood on the towels into the blood loss es-
timate. Soon, the attending had the bleeding under con-
trol.
“Clamps on,” the surgeon said as the anesthesiologist
noted the time. The attending asked for an 18 woven graft.
Before opening the graft to the field, Sandy and Joe verified
the graft size. Jim, the senior resident, and the attending
surgeon changed sides of the table. Jim asked for some
3-0 prolene suture and began sewing the graft into the
patientʼs ruptured aorta. The anesthesiologist motioned for
Sandy to come to the head of the bed. He asked her to
check the warming blanket, as both the bladder and
esophageal temperatures registered at 35 degrees.
Sandy checked the hypo/hyperthermia machine. The low
Aligning practice with policy to improve patient care 59
OR Issues
fluid light was blinking on the machine. Sandy grabbed a
bottle of sterile water and added the fluid to the machine.
The low fluid light continued to blink an amber warning.
Sandy called the control desk and requested an additional
hypo/hyperthermia machine. When the machine arrived,
she disconnected the faulty machine, inserted the warm-
ing blanket tubing into the new machine, plugged it into the
wall and turned the machine on. The low fluid light began
blinking on the new machine. Sandy went to the anesthe-
siologist and explained what was happening. Mike, the
anesthesiologist, asked for some warm blankets that he
then wrapped around the patientʼs head.
According to a report from the ECRI
Institute, an evidence-based practice
center, injuries related to the use of
a warming/cooling blanket tend to
occur in lengthy procedures in which
the aorta is cross clamped.
When things slowed down, Sandy read the accident
details provided by the paramedics. The patient had suf-
fered an aortic injury due to deceleration when he
slammed into another vehicle while running a red light.
When Joe asked to do the initial counts, Sandy was sur-
prised at how quickly the past three hours had gone. At the
end of the case, Laura brought the ICU bed into the oper-
ating room. Sandy stood by the OR bed with warm blan-
kets to cover the patient as Joe removed the drapes and
Lisa secured the dressing. As she was placing the blan-
kets on the patient, Sandy realized the draw sheet and the
linen on the OR bed were saturated with fluid. She asked
Laura to get a couple of bath towels to dry off the patient.
A dry draw sheet was placed under the patient, who was
Continued on Page 61
Keep your surgical patients desert dry.
Medline’s Sahara® Super Absorbent OR table sheets 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 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 learn more about Sahara OR table sheets and
your OR turnover time and help reduce cross contamina- Medline’s comprehensive product line, contact your
tion risk through a combination of disposable products. Medline representative, call 1-800-MEDLINE or visit
us at www.medline.com.
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.

www.medline.com
then lifted onto the ICU bed. The patient was gently turned
so Sandy and Laura could assess the patientʼs skin, which
was intact with no redness noted. As the patient was being
transported out of the OR, Sandy pulled the fluid-saturated
sheets off the OR bed and placed them in the laundry
hamper. She examined the reusable warming/cooling
blanket and realized there was no fluid left in the blanket.
She could not see a hole in the blanket, but nonetheless
disconnected the blanket from the machine and placed it
in the trash.
A couple of days later, after she had transported a patient
to the CVICU, Sandy decided to check on the young man
with the ruptured aorta. She poked her head into the
CVICU room. The patient was lying on his side, asleep.
His nurse, Jennifer, was in the room doing her charting.
Sandy asked how the patient was doing. Jennifer replied
that he was progressing remarkably well, and his main
complaint was pain on his back where it appeared pres-
sure ulcers were developing. Jennifer and Sandy gently
lifted the blankets off the patientʼs back. There were red-
dened areas on both scapulae as well as a four-inch long
red area on his thoracic spine. They covered the patient.
Back in the OR, Sandy found Joe. She gave him an update
on the patientʼs condition and the pressure ulcers devel-
oping on the patientʼs back 48 hours postoperatively, quite
possibly related to lying on the fluid-saturated operating
room bed linens.
Preventing pooling fluids and pressure ulcers
Great care is taken by preoperative nurses to avoid the
formation of pressure ulcers in surgical patients. Bony
prominences are padded and towels are placed to avoid
pooling of solutions under the patient. The use of water-
based hypo/hyperthermia systems in the operating room
should not be overlooked as a potential cause of pressure
ulcer formation in operative patients.
Minute holes in water-based hypo/hyperthermia blankets
might not be evident until the pressure from the weight of
a patient is placed onto the blanket, causing the fluid in the
coils to leak out. According to a report from the ECRI
Institute, an evidence-based practice center, injuries
Aligning practice with policy to improve patient care 61
As with
any surgical
complication,
prevention
is the key.
related to the use of a warming/cooling blanket tend to
occur in lengthy procedures in which the aorta is cross
clamped. ECRI recommends the following when using a
hypo/hyperthermia blanket in the operating room1:
• The blanket should be covered with a sheet.
• The circulating water temperature as well as the patient
temperature should be monitored.
• The thermostat on the unit should be set at a maximum
temperature of 42 degrees Celsius.
• The machine should be used and maintained according
to the manufacturerʼs recommendations.
Additional recommendations from the ECRI Institute to
avoid skin injuries in the operating room include1:
• Check the OR bed mattress for sufficient padding
and thickness.
• Verify that the patient safety strap is not placed too tightly,
restricting circulation or placed over a grounding pad or
ECG electrode.
• Lift anesthetized patients rather then rolling or
tugging them.
• Avoid pooling of solutions under the patient.
Todayʼs technology offers impervious disposable fabrics to
cover the operating room bed. Some of these fabrics trap
fluid, wicking moisture away from the patient. This helps
to reduce the possibility of the patient lying on wet bed
linens during the operative procedure, potentially resulting
in the formation of a pressure ulcer.
Keep your patient desert dry. As with any surgical compli-
cation, prevention is the key.
Reference
1 ECRI Institute. Skin Injury in the OR and Elsewhere. Available at:
http://www.mdsr.ecri.org/summary/detail. aspx? doc_id=8185. Accessed Novem-
ber 4, 2008.
 Two out of three
employees feel that the flow
of communication between
the departments of their
facility is poor.

All information is
important, but different
disciplines value and prioritize
it in different ways.

62 The OR Connection
 Special Feature

Why Can’t We All

Just Get Along?
Improving relationships within
healthcare facilities

By Dayna Lowe, Clinical Instructor

Does your facility have a failure to communicate?

If it does, youʼre not alone. Surveys show that two out of three employees
feel that the flow of communication between the departments of their facility
is poor.2

First and foremost, healthcare providers, no matter what their discipline,

want to give their patients the best possible care. If this is true, why are
there so many problems? It all comes down to communication.

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

Although important, communication takes time – time that many people

simply do not feel they have.

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

How can you help your own facility?

So what can you do? There is no one simple solution for breaking down the
barriers of communication between healthcare providers of different
organizations. Improvements need to be tailored to the needs of each
facility. However, there are some basic guidelines that we can all follow.

First of all, the information that is truly important and necessary needs to be
identified. So often, time is wasted sifting through documents and repeating
the same piece of information over and over. All information is important,
but different disciplines value and prioritize it in different ways. Communi-
Continued on Page 65

Aligning practice with policy to improve patient care 63

We take
blood pressure cuffs
personally.

A study found that 77 percent of blood pressure cuffs
wheeled from room to room in a hospital were contami-
nated.1 Choosing Medline disposable blood pressure
cuffs is great way to battle those bugs.
Medline’s Blood Pressure Cuff Standardization Program,
which helps ensure that virtually all blood pressure
monitors accept the same
cuff connector, allows the
cuff to follow the patient
throughout their stay and
then be discarded. This
focus on their primary concern – the patient – instead of
hunting down connectors.
To learn more about Medline disposable blood
pressure cuffs and our Blood Pressure Cuff Stan-
dardization Program, please contact your Medline
representative, call us at 1-800-MEDLINE or visit
www.medline.com.
1 De Gialluly C, Morange V, de Gialluly E, Loulergue J, van der Mee N,
Quentin R. Blood pressure cuff as a potential vector of pathogenic microor-
ganisms: a prospective study in a teaching hospital. Infect Control Hosp
Epidemiol. 2006 Sept;27(9):940-3.

helps to reduce the likelihood

of cross contamination and
also frees up caregivers to

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. www.medline.com
cation checklists for different departments could be devel-
oped so that only necessary information is shared and
nothing is missed. They would ensure the sharing of “need to
know” rather then “nice to know” information.2
Properly conducted team-building
exercises can dramatically improve how
well department heads and staff mem-
bers work with each other. Typically, this
Communication checklists
another. They must communicate in an efficient and proper
manner. Last but not least, they need to ensure that the best
possible communication tools are available and that their staff
has adequate training on their use. Staff must learn to work
with new technology and with each other. They must
remember that this is all done for the
good of the patient.
References

requires the use of an outside profes-

sional with experience getting fellow
employees to unite as a team. Part of
these exercises could also include staff
rotating to other facilities to see “how the
other half lives.” Not only does this give
everyone a better understanding of what
other facilities do, it also gives employ-
ees a more rounded perspective of how
the work of the organization is con-
ducted and the importance of sharing
information between departments. It
is also a great way for different or-
ganizations to get to know one another.2
Facilities need to look into available com-
munication technology and train their
staff how to use communication tools
properly. Without adequate education,
these tools can be used incorrectly,
causing more problems then they solve.
for different departments
could be developed so
that only necessary
information is shared
and nothing is missed.
1 Plsek P. Interdepartmental communication in a
large hospital. Available at: http://www.plexusinsti-
tute.org/ edgeware/archive/think/main_tales9.html.
Accessed September 2, 2008.
2 Katcher BL. How to improve interdepartmental
communication. Available at: www.discovery-
surveys.com/articles/itw-017.html.
Accessed September 2, 2008.
3 Spring Valley Hospital Medical Center. High marks
for prompt ER care. Available at: http://valleyhealth.
uhspublications. com/winter2007/story2.html.
Accessed September 2, 2008.
About the author
Dayna Lowe has been a surgical tech-
nologist for six years. She currently
works at a hospital in Florida and as an
Instructor of Surgical Technology at
Central Florida Institute.

As we plunge headlong into the 21st

century, health care will only continue to
get bigger and more complex. Staff will
be expected to provide skilled services faster then ever
before. Administrators and managers of these organizations
must set good examples for their staff. They must be able
to put aside any personal differences and work with one

Aligning practice with policy to improve patient care 65

 How to Set Priorities
and Get the Job Done
When you donʼt set priorities, you tend to follow the path
of least resistance. Youʼll pick and sort through the things
you need to do and work on the easiest ones, leaving the
more difficult and less fun tasks for a “later” that, in many
cases, never comes. Or, worse, the “later” may come just be-
fore the action needs to be finished, throwing you into a whirl-
wind of activity, stress and regret. There are three basic
approaches to setting priorities, each of which probably suits
different kinds of personalities.
The first is for procrastinators, people who put off unpleas-
ant tasks.
If you are a procrastinator – eat a frog!
Thereʼs an old saying that if you wake up in the morning and
eat a live frog, you can go through the day knowing that the
worst thing that can possibly happen to you that day has
already passed. The day can only get better!
66 The OR Connection
Popularized in Brian Tracyʼs book Eat That Frog!, the idea
here is that you tackle the biggest, hardest and l e a s t
appealing task first thing every day. Just knuckle down and
do it, and the rest of the day will be a breeze.
The second approach is for people who thrive on accom-
plishment, who need a stream of small victories to get through
the day.
If you thrive on accomplishments – move big rocks
Maybe youʼre someone who fills your time fussing over little
tasks. Youʼre busy all the time, but somehow, nothing impor-
tant ever seems to get done. You need the wisdom of the
pickle jar. Take a pickle jar and fill it up with sand. Now try to
put a handful of rocks in there. You canʼt, because thereʼs
no room.
If itʼs important to put the rocks in the jar, youʼve got to put
the rocks in first. The pickle jar is all the time you have in a
 Special Feature

If you thrive on
accomplishments –
move big rocks

day. You can fill it up with meaningless little busy-work tasks,

leaving no room for the big stuff, or you can do the big stuff I. Important and Urgent
II. Important and Not Urgent
To put it into practice, sit down tonight before you go to bed III. Not Important but Urgent
and write down the three most important tasks you have to IV. Not Important and Not Urgent
get done tomorrow. In the morning, take out your list and
attack the first “big rock.” Work on it until itʼs done or you canʼt If youʼre really on top of your time management, you can
make any further progress. Then move on to the second, and minimize Q1 tasks, but you can never eliminate them – a car
then the third. Once youʼve finished them all, you can start in accident, someone getting ill, a natural disaster. These things
with the little stuff. all demand immediate action and are rarely planned for.

The third approach is for the more analytic types, who need
to know that theyʼre working on the objectively most important
thing possible at this moment.
If you are analytical – use the Covey quadrants
If you just canʼt relax unless you absolutely know youʼre working
on the most important thing you could be working on at every
instant, Stephen Coveyʼs quadrant system might be for you.
After youʼve plotted out your tasks on the Covey quadrant
grid, according to your own sense of whatʼs important and
what isnʼt, work as much as possible on items in quadrant II
(and quadrant I tasks when they arise).
Spend some time trying each of these approaches on for size.
Itʼs hard to say what might work best for any given person.
In the end, setting priorities is an exercise in self-knowledge.

Covey suggests you divide a piece of paper into four Reprinted with permission from www.mercola.com.
sections, drawing a line across and a line from top to bottom.
Into each of those quadrants, you put your tasks according to
whether they are:

Aligning practice with policy to improve patient care 67

 Conquer Stress During
Tough Economic
Times
By Wolf J. Rinke, PhD, RD, CSP

68 The OR Connection
 Caring for Yourself

Housing market imploding? Your 401(k) down

the tubes? Uncle Sam bailing out everyone ex-
cept you? No wonder stress is at an all-time high,
to the point that many stress-related diseases are
increasing logarithmically. (Things are so bad that
the Occupational Safety and Health Administration
has classified stress as a workplace hazard.) Even
though some stress is good for us – for example,
the excitement (stress) you experience when you
are getting ready to go on vacation or start a new
project – most other forms of stress, especially the
type that you experience when you feel out of con-
trol, are bad for us (dysfunctional stress). It turns on
your fight or flight response and causes your body to
produce more adrenaline and hormones such as
cortisol, norepinephrine, epinephrine and DHEA-S,
which increase your blood pressure and pulse,
tense your muscles and diminish the effectiveness
of your immune system. Dysfunctional stress will
lead to fatigue, frequent headaches and upset
stomach. Long-term dysfunctional stress con-
tributes to chronic health problems such as
high blood pressure, heart disease, depres-
sion and memory loss. It may also lead to
family breakdowns and injuries, especially on
the job. To manage stress during tough eco-
nomic times, I recommend you master the most
powerful stress reduction technique of all time. It
consists of just three steps:

Three steps to stress reduction

1. Change the changeable
Donʼt like something? Change it! Your stocks driv-
ing you nuts? Sell them! Is the media giving you acid
indigestion with their incessant stream of bad news?
Turn off the TV! Donʼt fret, complain or whine … just
do it! Remember, you donʼt have to do anything you
donʼt want to do. All right, you caught me. There is
one thing you have to do – die. Everything else is a
choice. So what can you do? Get rid of the words “I
have to.” Using these three little words generates
“victim” behavior patterns. And victims experience
dysfunctional stress, which will make you sick.

2. Remove yourself from the unacceptable

Find something unacceptable? Get out of the way!
Your credit card debt interfering with your sleep?

Aligning practice with policy to improve patient care 69

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

2. Recognize that you are not your job

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

3. Get your life in balance

If youʼre experiencing problems at home and at work, youʼll
accelerate the burnout process. So think creatively, and
develop a strategy for balancing personal and professional
demands. For example, if you know youʼll be working late
all week, arrange to meet your family for dinner one of
those evenings at a nearby restaurant or plan a weekend
Start paying them off now and cut up all your credit cards
outing. Recognize that the most important things in life are
except one for true emergencies. Being followed by some-
relationships – not stuff! So make time for the real important
one who is overdosing on road rage? Move out of her way
things in your life: your spouse, your children, your parents
and let her have a “coronary” without your help. Working
and your friends.
for a toxic boss? Start shopping for a new one. Whatever
you do, just do it without fretting, whining … I know youʼre
4. Cut the electronic umbilical cord
catching on!
Too many of us simply no longer know how to relax. When
we leave work to go home or on a vacation, we not only
3. Accept the unchangeable
take work with us, we are still tied into the office via pager,
There are lots of things beyond your control – for example,
email, cell phone or our “crackberries.” Discipline yourself
the crashing global economy. Regardless of how much you
to turn those things off. (Heads up: you are not nearly as
stress yourself, you will likely not be able to change it. So
important as you think you are.) Better yet, donʼt even give
let it go. And then there are your parents. No matter how
out your cell phone number. I use mine only for bona-fide
much you would like them to be different, they wonʼt be. So
emergencies. Also, leave work at work so that you can set
love them the way they are, not the way they ought to be.
aside time to relax and recharge – recreate yourself.
(By the way, that is a great prescription for getting along
with all people!) Getting older – accept it. You are beautiful
5. Reduce your commuting time
just the way you are! Donʼt sweat your chronological age –
If you are commuting more than one hour a day, itʼs time to
something that you canʼt change. Instead, take care of your
move. One hour a day means that you are wasting about
body. Thatʼs something you can have a positive impact on
30 working days per year. Plus, you are already stressed by
right now.
the time you get to work. If you must commute, get in the
habit of listening to motivational and educational CDs – it
15 stress-reduction strategies will reduce your perceived commuting time dramatically. (If
Once you have mastered the basic three, here are 15
you donʼt know where to start, go to www.WolfRinke.com.
additional stress-reduction strategies to help you kiss stress
We have several powerful CDs to choose from.)
good-bye once and for all.
Continued on Page 73

70 The OR Connection
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6. Find a boss who knows how to MBA – manage
by association
If you report to a toxic boss, someone who constantly
“builds you down,” or who practices seagull management,
itʼs time to look for a new boss, or at least stay away from
your current boss as much as you can. (Seagull manage-
ment is when the boss flies in, makes a lot of noise, eats
your lunch, craps on you and flies back out.) If you are a
manager and the shoe fits, you owe it to yourself to read –
no, wait, devour – my book Winning Management: 6 Fail-
Safe Strategies for Building High-Performance Organizations.
7. Move your body
Weʼve made our lives too simple. Make yours more difficult
by conducting your next meeting while walking (walk and
talk), use a stand-up desk, park in the farthest spot from
the door, take the stairs, walk into the bank instead of using
a drive up window, mow your lawn with a push mower, and
so on.
8. Exercise
Do approximately 30 minutes of aerobic exercise every
other day, such as jogging, biking or fast walking. Alternate
that with resistance exercise like lifting weights or using a
“gym” machine. And be sure to start every exercise session
with light warm-up exercises and end with a comprehen-
sive stretch routine.
9. Take breaks
Youʼll be surprised how refreshed you feel just by taking
brief stretch breaks throughout the day. Simple actions such
as taking three very deep breath and exhaling slowly, going
for a short walk or just standing up and stretching at
your desk are a powerful way to alleviate stress and
boost productivity.
Aligning practice with policy to improve patient care 73
10. Get eight hours of sleep a day
If you find you donʼt have eight hours, reduce TV viewing by
one hour per day. (Good advice even if you do get enough
sleep.) That will give you – are you ready for this? – 15
extra days per year. Just think how much fun stuff you could
do if you had 15 extra days!
11. Manage priorities
You canʼt manage time. We all get the same 24 hours every
day. But you can manage your energy and your priorities.
(Have you ever noticed that all of us make time for all the
important things in our lives?) Each day, figure out what
your high pay-off items are and do them when you are at
your best. For most of us, thatʼs in the morning. And donʼt
forget to make vacation and play time a priority.
12. Get rid of conflict
If youʼre having problems with a family member or someone
at work, arrange to meet and discuss the situation. By
opening the lines of communication, youʼll set the stage for
a fair resolution. You might even find out that what seemed
like a major and stressful conflict was actually a minor
misunderstanding. And donʼt forget to master the most
powerful conflict and stress reduction phrase in the world:
“You are right about that.” Try it any time conflict rears its
ugly head and conflict will vaporize.
13. Celebrate more often than you think is wise
Set attainable and measurable goals for each of your
projects, whether they are at home or at work. Then cele-
brate each baby-step accomplishment with small rewards,
such as taking time to go out to lunch with your spouse
or colleagues. It will keep you motivated and increase
your productivity.
14. Reduce information
Most of us suffer from TMI – too much information. So when
you need to make a decision, avoid whatʼs referred to as
“decision optimization” in systems language. (A friend of
mine refers to it as contemplating your navel.) Instead, go
for decisions that are minimally acceptable. Itʼs faster and
leads to better decision outcomes in the long term. I truly
believe that most of us need lots more reminding and less
information. In other words, I believe most of us know how
to do the right thing – we just forget what we already know.
If youʼd like help with this, I have just the right tool for you.
It is my Make It a Winning Life: Success Strategies for Life,
Love and Business perpetual calendar, available at
 www.WolfRinke.com. Every day, it provides you with an
inspirational message – a reminder of what you probably
already know. However, then it takes you to the next level
by providing you a specific action step that helps you
implement what you already know in a dramatically new
and different way. When you get to the end of the year, you
can start the calendar all over again.
About the author
15. Ask for help Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar
If you still have dysfunctional stress after all this, itʼs time to leader, management consultant, executive coach and editor of
ask for help. (Remember that asking for help is a sign of the free electronic newsletters Make It a Winning Life and The
strength, not weakness.) While sometimes it might seem Winning Manager. To subscribe, go to www.WolfRinke.com. He
is the author of numerous books, CDs and DVDs, including
like itʼs you against the world, keep in mind that this is rarely
Make it a Winning Life: Success Strategies for Life, Love and
the case. Often the help you need is available simply by Business; Winning Management: 6 Fail-Safe Strategies for
asking for it. Reach out to family members, colleagues or Building High-Performance Organizations and Donʼt Oil the
your boss by letting them know of your challenges. You can Squeaky Wheel and 19 Other Contrarian Ways to Improve Your
avoid being perceived as a complainer by objectively out- Leadership Effectiveness, available at www.WolfRinke.com. His
lining how others can help. If that still does not do the trick, company also produces a wide variety of quality pre-approved
continuing professional education (CPE) self-study courses
talk with your mentor or coach (you do have one, donʼt
available at www.easyCPEcredits.com. Reach him at
you?) or a professional counselor. Because they are WolfRinke@aol.com.
removed from a situation, they are more likely to provide
you with a fresh perspective that will enable you to develop
new strategies for conquering stress once and for all.

74 The OR Connection
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Special Feature Mark Your Calendar

Medline Industries, Inc. will be hosting

its annual AORN Breast Cancer Aware-
ness Breakfast, by invitation only, at the
2009 AORN Congress. The event will take
place at the Hyatt Regency McCormick
Place in Chicago on Monday, March 16,
2009. We are honored to announce that
this yearʼs speaker will be Linda Ellerbee,
an outspoken journalist, award-winning tel-
evision producer, bestselling author, breast
cancer survivor, mother and grandmother.

About Linda Ellerbee

Ellerbee began her career at CBS, and
then moved to NBC News where, after
years covering national politics, she
pioneered the late-night news program
NBC News Overnight, which she wrote and
anchored. Overnight was cited by the
duPont Columbia Awards as "the best writ-
ten and most intelligent news program
ever." In 1986, Ellerbee moved to ABC
News to anchor and write Our World, a
weekly primetime historical series. Her
work on Our World won her an Emmy.

In 1987, Ellerbee and Rolfe Tessem, her

partner, quit network news to start Lucky
Duck Productions, first producing docu-
mentaries for PBS. In 1991, Lucky Duck
began producing Nick News for Nick-
elodeon with Ellerbee writing and hosting.
Seventeen years later, Nick News is
watched by more children than watch all
other television news shows put together—
and has earned honors traditionally associ-
ated with adult programming. Known for the
respectful and direct way it speaks to chil-
dren about the important issues of our time,
Nick News has collected three Peabody Ellerbeeʼs first foray into books for kids, an As a breast cancer survivor, Ellerbee
Awards (including one personal Peabody eight-part fiction series titled Get Real, pub- travels thousands of miles each year
given to Ellerbee for her coverage of the lished in 2000, won her raves among mid- giving inspirational speeches to others.
Clinton investigation), a duPont Columbia dle school readers. Both of Ellerbeeʼs She is as direct with women as she is with
Award and six Emmys. previous adult books—And So It Goes, a kids; they understand that she understands
humorous look at television news, and their lives.
These days, Ellerbee and her work can be Move On, stories about being a working
seen all over the television universe. Lucky single mother, a child of the ʻ60s and a Although Ellerbee has won all of televi-
Duck has and continues to produce prime- woman trying to find some balance in her sion's highest honors, she says itʼs her two
time specials for ABC, CBS, HBO, PBS, life—have been national best sellers. Eller- children whoʼve brought her the richest
Lifetime, MTV, Logo, A&E, MSNBC, SOAP- beeʼs recent book, also a best seller, Take rewards. Ellerbee spends her personal time
net, Trio, Animal Planet and TV Land, Big Bites: Adventures Around the World in New York City and Massachusetts with
among others. Ellerbee was honored with and Across the Table, a tribute to her love of Rolfe, her partner in work and life and their
an Emmy for her series, When I Was a Girl, travel, talking to (and eating with) strangers, dogs, Daisy and Dolly.
which aired on WE: Womenʼs Entertain- and, according to Ellerbee, “oh, just making
ment network. trouble in general.”

Aligning practice with policy to improve patient care 77

 Healthy Eating

Bruschetta Delizioso
A delicious and easy appetizer!

5 tomatoes (chopped)
Ingredients

1/2 cup extra-virgin olive oil

2 tablespoons balsamic vinegar

5 fresh basil leaves (julienne cut)
1 bulb of garlic
1 loaf of French bread
Salt and pepper to taste

Preheat oven to broil. Combine the tomatoes, extra-virgin

Directions

olive oil, balsamic vinegar, basil, salt and pepper in a

medium bowl. Set the bowl aside. Slice the loaf of French
bread so that each slice is about one-half inch thick. Place
the bread on a cookie sheet and toast on the top rack of the
oven. Once the bread has turned a golden-brown color, flip
each piece in order to toast the other side. Remove the
bread from the oven once both sides have been toasted.
Peel the garlic cloves and rub directly on each side of the
toast. Spoon the tomato mixture on top of the bread Note: This recipe, created by Emily MacInnes, won an award at
and serve. Medlineʼs Employee Appreciation Week International Cook-Off!

78 The OR Connection
 Forms & Tools

The following pages contain practical tools for implementing

patient-focused care practices at your facility.

SCIP
Fact Sheet ..................................................80

Policy and Procedure ..................................82

Hand-Off Communication

Perioperative SBAR ....................................85

Endoscopy SBAR........................................86

Pressure Ulcer Prevention

Checklist ................................................89

Aligning practice with policy to improve patient care 79

 FACT SHEET
Summary of SCIP Measure Changes for 10/1/08+ Discharges

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

VTE-1 and VTE-2:

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

Data Element and Table Changes

Data Element
New Clarification Change
or Table
Beta-Blocker ¥ x Documentation of a time associated with the last dose of
Perioperative the beta-blocker is necessary to verify that it was taken
within the perioperative time frame. If the patient arrives on
the day of surgery and there is documentation that the
beta-blocker was taken on that same day prior to
admission, the abstractor can select “Yes.”

Beta-Blocker ¥ x The data element Sex will be used in the algorithm to

During exclude male patients.
Pregnancy

Contraindication ¥ x Physician documentation of a bleeding risk associated with

to VTE surgery, such as the normal risk described in the operative
Prophylaxis permit, will not be considered a contraindication to
pharmacological prophylaxis.

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

Other Surgeries ¥ x Implanted or pocketed cardiac devices that are performed

without general anesthesia will be abstracted as “Yes” for
Other Surgeries because the antibiotic prophylaxis given
for these procedures could interfere with the prophylaxis
for the principal procedure.

Summary of 10/1/08 SCIP Manual Revisions Page 1 of 2

Hospital Interventions QIOSC/Hospital Quality Measures Special Study

80 The OR Connection
September 2008
 Data Element
New Clarification Change
or Table
Preoperative Hair ¥ x Documentation that does not reflect actual hair removal,
Removal such as surgeon documentation in the operative report
that the patient was “shaved and prepped,” should not be
considered when answering this data element.
x Hair removal that is documented as performed with
scissors will be collected with Value 3 – Clippers.
x Exclusions were added for non-surgical site hair removal
and hair removal performed during the patient’s daily
hygiene routine.

Surgery End ¥ x The inclusion terms are now prioritized as 1st, 2nd and 3rd.
Time The data sources are no longer prioritized.
x Priority order applies to items in the inclusion table, not to
source document. Also, the synonyms in the lists are
alphabetized, not prioritized.

x The Notes for Abstraction were modified to be consistent

with the instructions for Surgical Incision Time.

Surgical Incision ¥ x The priority lists were changed to more accurately reflect
Time the wording commonly found in operating room
documentation.
x Priority order applies to items in the inclusion table, not to
source document. Also, the synonyms in the lists are
alphabetized, not prioritized.

x The Notes for Abstraction were modified to be consistent

with the instructions for Surgery End Time.

Vancomycin ¥ x Allowable Value 2 was revised to include MRSA

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

Table 1.3 Beta- ¥ x 5 medications were added to the table of beta-blockers.

Blockers

Table 2.1 ¥ x Doripenem was added to the antibiotic table.

Antimicrobial
Medications

For a complete list of changes please see the “Release Notes,” located in the Specifications Manual for National
Hospital Quality Measures for discharges 10/1/2008. The manual can be found at
http://www.qualitynet.org/dcs/ContentServer?cid=1192804535739&pagename=QnetPublic%2FPage%2FQnetTier3
&c=Page

This material was prepared by Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for
Oklahoma, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services. The contents presented do not necessarily reflect CMS policy. 4-728-OK-0908

Aligning practice with policy to improve patient care 81

Summary of 10/1/08 SCIP Manual Revisions Page 2 of 2
Hospital Interventions QIOSC/Hospital Quality Measures Special Study
September 2008
 Forms & Tools Hand-Off Communication

Hand-Off Communication in the Perioperative Setting

Policy • Holding area RN reports to anesthesia, the surgeon

• “Hand-offs” are interactive communications that allow and the circulating RN
the opportunity for questioning between the giver and • Circulating RNs report to the PACU RN and/or the
receiver of patient information. patient care unit RN
• Anesthesiologists report to the PACU RN and/or to
• Hand-off communication includes: the patient care unit RN
• Accurate patient information regarding care, • Surgical team (surgeon, nurse, surgical technologist)
treatment and services transfer of on-call responsibility
• Patientʼs current condition and diagnosis • Surgeon hand-off from the perioperative area to
• Recent or anticipated changes in the patientʼs inpatient units
condition • Critical laboratory and radiology results
• What to watch for in the next interval of care disseminated to the surgical team

• Specific examples of times when the transfer of Procedure:

responsibility for the surgical patient, i.e., hand-offs,
occur include, but are not limited to, the following:
• Shift change or break relief
• Physician to surgeon/nurse to nurse/surgical
technician to surgical technician transfer of
patient responsibility
• When surgeons and nurses are transferring the
patient to another level of care within or outside of
the organization
• Patient care unit RN/ambulatory care RN report to
the holding area RN
• Healthcare professionals shall be allotted the time
for hand-off patient communication and to ask and
answer questions with minimal interruption. It is
hoped that this will lessen the amount of information
that might be forgotten or simply not conveyed.
• Healthcare professionals shall find a quiet area to give
a verbal report (hand-off communication) to ensure
accurate, clear and concise information is given with
a minimum of interruptions.

I-SBAR: An example of hand-off communication

Introduction Situation Background Assessment Recommendations

State name Pre-op diagnosis History/past Vital signs Pain control

and unit hospitalization
NPO status Isolation required IV pump
State patient (# of hours) Infection control/
name, age, isolation Pain assessment Family communication
gender Procedure
Primary language Medications EKG
Mental status
Sensory impairment Activity/mobility/ Treatments
Patient stable/ falls risk
unstable Special needs: spiritual, Radiology
cultural, learning, Risk factors
Allergies communication
Other issues
Advance Directive Religious needs:
refuses blood
Code status
transfusion
Family (location,
Disposition of patient
contact person/
belongings
number)

82 The OR Connection
 Hand-Off Communication Forms & Tools

• Hand-off communication shall be conducted
face-to-face.
• Healthcare professionals shall give each other the
opportunity to ask questions, answer questions and
read-back or repeat-back information, as needed.
• The following is an example of a generic hand-off
communication that may be used.
Perioperative hand-off communication:
• At specific points within the perioperative continuum,
specific communications shall occur and shall include,
but are not limited to:
Patient care unit/holding area to operating room:
• Patient identification
Operating room team to post anesthesia care unit:
• Surgical procedure (completed vs. planned)
• Anesthesia
• Estimated blood loss
• Input and output (i.e., straight catheter, Foley)
• Allergies
• Medications (received intra-op)
• Significant medical history (i.e., contact precautions)
• Family contact information
• Equipment needs (i.e., sequential
compression devices)
• Other issues (i.e., blood products, anesthesia
concerns)
References
Joint Commission. Improving Hand-off Communications: Meeting National
Patient Safety Goal 2E. Joint Perspectives on Patient Safety. 2006;6(8):9-15.
http://www.jcipatientsafety.org/15427/. Accessed May 8, 2007.

• Planned surgical procedure

AORN. “Perioperative Patient 'Hand-Off' Tool Kit, http://www.aorn.org/
PracticeResources/ToolKits/PatientHandOffToolKit/.
• Site marking Last Accessed September 28, 2007.
• Planned anesthesia type
• Allergies Reprinted with permission from Medical Consultants Network, Inc.

• Antibiotics to be given
• Significant medical history
• Family contact information
• Other issues (i.e., NPO, blood products available)
• Last voided
• Equipment needs
• Pre-operative medications

Change of shift/breaks/lunch relief:

• Procedure
• Surgeon plan and preferences (where we are in
the case)
• Anesthesia
• Allergies
• Significant medical history
• Counts
• Irrigation
• Medications
• Instrumentation on and off field
• Specimens on and off field
• Tubes, lines, equipment

Aligning practice with policy to improve patient care 83

 Why pay more
for suction
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When you choose GENTEC® suction regulators from
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TheisOR
Medline Connection
©2008 Medline Industries, Inc.
84 a registered trademark of Medline Industries, Inc.
www.medline.com
 SBAR Hand-Off Communication Forms & Tools
Label

TMC Perioperative Hand-Off Communication Date:

Family MD: DNR: Yes No Modified Method of transfer: IV Fluids:
Wheelchair Cart
Isolation/Infection: Ambulatory
Surgeon: IV Access: PICC
Mobility: Bedrest Assist

S
MRSA ! VRE ! Saline Lock
Ambulatory
Anesthesia: C Diff ! Other ! Central Line
Peripheral
Fall Risk:
Admitting Diagnosis: NPO: Yes No Mental Status:
Low ! High ! Alert
O2 Needs: Restless
NKA Communication: Confused
Allergies: HOH R L Combative
Core Measures Vision Impairment: Speech Clear: Yes No
Unresponsive
Contacts Glasses !
SCIP/SIP CHF Non-English speaking
Past Medical History: Initial vitals: TPR _____________ Pre-op Antibiotic:
Diabetes HTN CAD PVD B/P_________02 Sat_____________ Time:
CVA Arthritis Renal disease Height________Weight__________

B
COPD Asthma Seizure Admission Blood Glucose___________ Med Given:____________Time______
Pacer/AICD
Med Given:____________Time______
ASA Score __________
Other: ETOH Smoker Med Given:____________Time______
H&P Yes No
Dentures/Partials/Loose teeth

*No B/P ______ arm* Pre-procedure verification: Yes No

Site Marking: Yes No N/A Last pain med:
Anesthesia: MAC Local Foley: Yes No Pain Control: (circle one)
General Spinal Block Epidural Straight Cath: Yes No PCA Epidural Intermittent IV
PO N/A
Procedure/Operation: OR Intake: Medication:
Blood/Blood Products:
Duramorph: Yes No
__________________________ OR Output:

A
EBL: PACU discharge pain score_______

Dressings: Pertinent Assessment Findings: Med Reconciliation completed !

Operation End Time:____________
Penrose: Yes No Packing: Yes No PACU Vitals: PACU Intake:
Drains: JP Hemovac Cardiac Rhythm________________
NG gravity suction G-tube IV #____IV credit on Transfer_________
Stryker Reinfusion start time: Treatments: TEDS SCD’s CPM
Chest Tube: Suction Water Seal Heimlich ASA________ PACU Output: Foot Pumps Polar Care Binder

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

Intraop RN Sig:___________________________

R Postop RN Sig:___________________________

Call______________for any
questions @ ext.___________.

This document is not a part of the permanent medical record

Aligning practice with policy to improve patient care 85

 Forms & Tools SBAR Hand-Off Communication
Label
TMC Endoscopy Hand-Off Communication Date:
Room/location:
DNR: Yes No Method of transfer: IV Fluids:
Admitting MD: Modified Wheelchair Cart Ambulatory
IV Access: PICC
Mobility:

S
Surgeon: Isolation/Infection: Saline Lock
Bedrest Assist Ambulatory Central Line
MRSA ! VRE !
Peripheral
C Diff ! Other ! Fall Risk:
Admitting Diagnosis: Low ! High ! Mental Status:
NPO since: _________ Alert
Communication: Restless
NKA HOH R L
Confused
O2 Needs:
Speech Clear: Yes No Combative
Allergies: Unresponsive
Vision Impairment: Non-English speaking !
Contacts Glasses

Past Medical History: Initial vitals: TPR _____________ Do home meds include:
B/P_________02 Sat_____________
Diabetes HTN CAD PVD Height________Weight__________ B/P ____

B
CVA Arthritis Renal disease Cardiac_____
COPD Asthma Seizure ASA Score __________ Diabetes: oral____ insulin_____
Pacer/AICD MAO inhibitor_____
H&P Yes No
Other: ETOH Smoker Pain Status:____________________
Pre-procedure verification: Yes No
*no B/P ______ arm*
Site Marking: Yes No N/A
Anesthesia: MAC Medications given:
Procedural Sedation
Demerol __________
Procedure/Operation: Aldrete Score:__________________
Fentanyl __________

EGD Versed ____________ Cardiac

A ERCP Rhythm:________________________
Peg Tube
Bronchoscopy Cetacaine Spray: Time____________
Colonoscopy Endo discharge pain score_________

Polypectomy: Yes No Other Med:______________________

Reversal agent: Yes No Med Reconciliation Completed !

__________________________ ________________________________

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

Procedural RN :___________________________

R Postop RN: ______________________________

Call______________for any
Questions @ ext.___________.

This document is not a part of the permanent medical record

86 The OR Connection
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Bovie is a registered trademark of Bovie Medical Corporation.
 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?

Aligning practice with policy to improve patient care 89

 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?

90 The OR Connection
•••••••••••••••••••••••••••••••••
Ami Lends a Hand
By Laura Kuhn
The OR Connection staff writer
When Ami arrived at work and obtained her
assignments for the day, she learned that
the patient in Room 210 had contracted
Clostridium difficile. She proceeded to
the isolation cart to obtain her personal
protective equipment before entering
the room.
The patientʼs name was Jeffrey, and
he was three days post inguinal
hernia repair.
“How are you feeling today, Jeffrey?”
Ami asked him. “Iʼm so sorry to hear
about the infection. Weʼre going to do
everything we can to make sure that
you donʼt pick up any other infections.
Iʼm sure Dr. Payton will be by soon to
check in on you.”
Ami had no more than said his name when Dr.
Payton walked into the room. He had been a surgeon at
the hospital for as long as anybody could remember and
was beloved by his patients for his gentle bedside manner.
“Hello there, Jeffrey,” Dr. Payton said. “You should be able
to get back to skiing in six to eight weeks, if you take care of
yourself. Now, letʼs get a look at my handiwork.” He peeled
Jeffreyʼs bandage back to inspect his wound. Then, satis-
fied, he placed the bandage back over the wound.
“Everything looks good,” Dr. Payton told Jeffrey. “We need
to get this nasty infection cleared up so that we can get you
home. Iʼll stop by later and check in on you again.” He stood
to leave, and Ami followed him from Jeffreyʼs room.
“Dr. Payton, I noticed you didnʼt sanitize your hands before
touching Jeffrey,” she said to him quietly once they were in
the hallway.
Dr. Payton sighed. “I know, Ami, but this cold weather is
really wreaking havoc on my skin. If I sanitized my hands
all the times weʼre supposed to, they would be unbearably
sore. And letʼs face it, this is a job where I need my hands
to be in good condition!”
Aligning practice with policy to improve patient care 91
“I agree,” Ami said. “But maybe using lotion
would help moisturize your hands so sani-
tizing them wouldnʼt hurt. You know, itʼs a
myth that the alcohol in those sanitizers
makes them sting. It only stings if
your skin is already compromised.
And you could always find a little
bottle of it to carry around with you
so itʼs always available.”
Dr. Payton sighed. “Look, Ami, I
know. Iʼll talk to you later, okay?”
With that, he was off to his next patient.
Ami stood in the hallway for a
moment, deciding what to do. Then
she smiled to herself and walked to the
nursesʼ lounge. She picked up the phone
and dialed the facilityʼs hand hygiene
product vendor.
A few days later, Dr. Payton entered his office to find
sample-sized bottles of hand lotion and the same hand
sanitizer that the hospital used. He laughed to himself and
tucked the bottles inside his coat pocket.
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
The next day, Ami saw Dr. Payton in the hallway. He
caught her attention, took the bottle of hand sanitizer out of
his pocket, applied it to his hands and waved at her before
entering a patientʼs room.
Ami smiled and gave him a thumbs-up.
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
Stay tuned for the continued adventures of Medline’s family
of nurse dolls, Ami, Angel, Alice Aurora and Anastasia!
The Hottest Debut at AORN!

Want to meet the NEWEST ADDITION

to Medline’s family of nursing dolls?
You’ll have to stop by our booth at AORN Congress
in Chicago! We’ll give you just one hint to the newest
doll’s identity … you asked for it!

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MKT208305/LIT167R/15M/SEL5