OR Connection Magazine - Volume 4; Issue 2

8/9/2019 OR Connection Magazine - Volume 4; Issue 2

1/84

TheAligning practice with policy to improve patient care

Volume 4, Issue 2

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OR ConnectionThe

Aligning practice with policy to improve patient care

Subscribing to The OR Connectionguarantees that

youll continue to receive this info-packed magazine

and wont miss out on our industry updates and

articles addressing on-the-job issues and tips oncaring for yourself!

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Never miss an issue of The OR Connection!Subscriptions are free and signing up is a snap!

We also welcome any suggestions you might have on how we can continue to improveThe OR Connection!Love the content? Want to see something new? Just let us know!

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

care initiatives they pertain to. Throughout the publication, when you see these

icons you'll know immediately that the subject matter on that page relates to one

or more of the following national initiatives:

IHI's Improvement Map

Joint Commission 2009 National Patient Safety Goals

Surgical Care Improvement Project (SCIP)

We've tried to include content that clarifies the initiatives or gives you ideas and

tools for implementing their recommendations. For a summary of each of the

initiatives, see pages 6 and 7.


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PATIENT SAFETY

6 Three Important National Initiatives for Improving Patient Care

20 Patient Safety Initiatives Across the United States

30 CAUTI Prevention: How Do You Rate?31 Back to Basics: Tell Me Again Why This Patient Needs

a Catheter?

51 Clean Up Your Act!

OR ISSUES

8 Breaking News

22 The Silent Treatment

42 Playing Traffic Control in the OR

SPECIAL FEATURES

10 Comparative Effectiveness Research

12 Prevention Above All Conference

13 Celebrating Nurses Accomplishments

14 OR Nurses Set Sail for Surgery

40 A Cost-Effective Alternative to Urinary Catheterization

46 Legal Issues in the Care of Pressure Ulcer Patients

CARING FOR YOURSELF

56 How to Communicate Effectively

65 Breast Cancer Awareness68 Recipe: 24-Hour Dill Pickles

FORMS & TOOLS

71 SCIP Prophylactic Antibiotic Regimen Selection for Surgery

73 VTE Prophylaxis Options for Surgery

75 What You Need to Know About Infections AfterSurgery: English

77 What You Need to Know About Infections AfterSurgery: Spanish

79 How to Handrub?81 CATS Decrease Surgical Site Infections: English82 CATS Decrease Surgical Site Infections: Spanish

Editor

Sue MacInnes, RD, LD

Clinical Editor

Alecia Cooper, RN, BS, MBA, CNOR

Senior Writer

Carla Esser Lake

Art Director

Mike Gotti

Clinical Team

Jayne Barkman, RN, BSN, CNOR

Rhonda J. Frick, RN, CNOR

Anita Gill, RN

Megan Shramm, RN, CNOR, RNFA

Kimberly Haines, RN, Certified OR Nurse

Jeanne Jones, RNFA, LNC

Carla Nitz, RN, BSNConnie Sackett, RN, Nurse Consultant

Claudia Sanders, RN, CFA

Angel Trichak, RN, BSN, CNOR

Perioperative Advisory Board

Larry Creech, RN, MBA, CDT

Carilion Clinic, Virginia

Sharon Danielewicz, RN, MSN, BSN, RNFA

St. Lukes The Woodlands, Texas

Barb Fahey RN, CNOR

Cleveland Clinic, Ohio

Susan Garrett, RN

Hughston Hospital Inc., Georgia

Zaida I. Jacoby, RN., M.A., M.EdNYU Medical Center, New York

Jackie Kraft, RN, CNOR

Huntsville Hospital, Alabama

Audrey Kuntz, EdD, MSN, RN

Vanderbilt University Medical Center, Tennessee

Tom McLaren, RN, BSN, MBA, CNOR

Florida Hospital

Donna A. Pritchard, RN, BSN, MA, CNOR, NE-BC

Kingsbrook Jewish Medical Center, New York

Debbie Reeves, RN, CNOR, MS

Hutcheson Medical Center, Georgia

Diane M. Strout, RN, BSN, CNOR

Chesapeake Regional Medical Center, Virginia

Margery Woll, RN, MSN, CNOR

North Shore University Health System, Illinois

About Medline

Medline, headquartered in Mundelein, IL, manufactures and distributes more than

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.

Meeting the highest level of national and international quality standards, Medline is

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.

Page 14

Page 31

Page 56

Page 42

Page 22

2009 Medline Industries, Inc. The OR Connectionis published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.


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Dear Reader,

As the summer of 2009 comes to a close, my

youngest child, Molly will be going to college. She is

the youngest of three so, my husband and I are now

officially empty nesters. I dont usually discuss mywork at home. By the time I get home, work is the last

thing I want to rehash, but Molly has had it in her head

for quite a while now that she wants to be a surgeon.

I havent said much to discourage or encourage her,

but earlier in the summer, I thought to myself, does

she have any idea what that means? And so, in typical

motherly fashion, I asked her if she wanted to watch

an actual surgery. My thinking was, if she is going to

commit the time and money into becoming a surgeon,

shed better make sure that is what she wants to do.

I dont know many eighteen-year-olds who are more

psyched about scrubbing in on a surgery than goingto Six Flags but Molly is one. I had promised to look

into it; the summer was flying by and every day Molly

would ask me if I had made any arrangements. I really

didnt think she would hold me to this. I was wrong.

My first dilemma was finding a mentor, someone who

would embrace the curiosity and naivet of youth and

allow Molly to watch a surgery. I contacted Margery

Woll, Director of Perioperative Services at North Shore

University Health System in Skokie, Ill., to ask her

advice and to see if this was even possible. Margery

embraced the project and invited Molly to her OR.

And that was that. All I really knew before the event

was that Molly had to get up much earlier than usual.

She had gotten directions to the hospital and was told

who to report to. I didnt hear anything until she was

on her way home.

That afternoon I received a call at the office. Molly said

it was the greatest day of her life! She spoke so fast

and so full of excitement I couldnt understand every-

thing she was saying. She said that surgery was a

marriage between art and science, and she felt she

could be good at both, so that is why this was meant

for her. She said the doctors told her she had great

hands. Celia (Celia Arrogante, RN, BSN, Clinical Nurse

Manager, Perioperative Services) and the nurses

treated her like she was one of them. She said it was

so cool because the surgeons were listening to music

from their iPods. She stood 18 inches from the

surgery. Her favorite part was the first cut. She saw 3

different surgeries starting with a breast biopsy, and

then proceeded to a total knee. She said that the total

knee was messy, but really cool. And, finally she saw

a total hip. The surgery team was so nice to her, they

told her what was going on and the chief of surgery

told her she could shadow him any time. Molly said,

Mom how many kids my age get a chance to actu-

ally go into surgery? I was right there. And, I was

invited back to see a heart.

Later Margery e-mailed me about the day. She said,

Dr. Velasco (Juan Velasco, MD, Vice Chairman of

Surgery) was so impressed with Mollys interest and

discipline in watching the cases. She continued, It

was a good day for Dr. Raab (David Raab, MD,

Orthopedic Surgeon), he taught both of us. He was so

honored

So, at a time that is so critical in health care, with

healthcare reform, patient safety initiatives at the fore-

front of every hospitals agenda and new guidelinesand evidence directing our actions, I have to stop and

say you make a difference. I got to experience

vicariously the love you have for what you do, the pas-

sion and teamwork you express at every opportunity.

Thank you. Youve just recruited another potential

surgeon who is telling all of her friends that they

simply have to work in the OR (and this kid has a lot

of friends).

Heres to you!

Sue MacInnes, RD, LD

Editor

4 The OR Connection

THE OR CONNECTION I Letter from the Editor

I got to experience

vicariously the love

you have for what you

do, the passion and

teamwork you expressat every opportunity.

Thank you.

(Left to right): Scott Pittman, MD, Anesthesiologist; Margery Woll,

RN, MSN, CNOR, Director of Perioperative Services and Molly

MacInnes at North Shore University Health System in Skokie, Ill.

Before observing three surgeries at the hospital, Molly said she

hadnt realized what a major role nurses play in the OR. The nurses

do so much. Nothing would happen without them, she said.


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6 The OR Connection

Three Important National Initiativesfor Improving Patient Care

Achieving better outcomes starts with an understanding of currentpatient-care initiatives. Heres what you need to know about national

projects and policies that are driving changes in care.

Origin: Launched by the Institute for Healthcare Improvement (IHI) in January 2009

Purpose: To help hospitals improve patient care by focusing on an essential set of processes needed to

achieve the highest levels of performance in areas that matter most to patients.

Hospitals sign up through IHI and can choose to implement some or all of the recommended interventions.

IHI provides how-to guides and tools for all participating hospitals.

The IHI Improvement Map will cover the entire landscape of outstanding hospital care, keeping the 12 changes from

the 100,000 Lives and 5 Million Lives Campaigns and expanding the agenda with three new interventions.

Origin: Developed by Joint Commission staff and the Patient Safety Advisory Group

(formerly the Sentinel Event Advisory Group)

Purpose: To promote specific improvements in patient safety, particularly in problematic areas

Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission offers

guidance to help organizations meet goal requirements.

Over the next year, the current National Patient Safety Goals (NPSGs) will undergo an extensive review process. As a result,

no new NPSGs will be developed for 2010; however, revisions to the NPSGs will be effective in 2010.

Crucial to understanding the 2009 NPSGs is a new method of numbering the goals, for which the Joint Commission has

created a crosswalk available at www.jointcommission.org.

Origin: Initiated in 2003 as a national partnership. Steering committee includes the followingorganizations: 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.

IHI Improvement Map1

Joint Commission 2009 National Patient Safety Goals2

Surgical Care Improvement Project (SCIP)3


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IHI Improvement Map: 12 Existing Interventions + Three New Ones

Surgical Care Improvement Project (SCIP): Target Areas

Joint Commission 2009 National Patient Safety Goals


Patient Safety

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

There are six new requirements for 2009:

Elimination of transfusion errors that are related

to misidentification of patients

Prevention of healthcare-associated infections

resulting from multiple drug-resistant organisms

(MDRO) using evidence-based practices

(one-year phase-in period applies)

Prevention of central line-associated bloodstream

infections using evidence-based practices (one-year

phase-in period applies) Prevention of surgical site infections using best

practices (one-year phase-in period applies)

When a patient leaves a facility, the patient and his

or her family receives a complete list of the patients

medications with an explanation of that list

In settings in which medications are prescribed

minimally or for a short time, modified medication

reconciliation processes are carried out

In addition to the new requirements, some of the NPSGs

already in place have been modified. Extensive changesalso have been made to the Universal Protocol (UP).

To learn more about the 2009 National Patient Safety Goals, go to www.jointcommission.org.

The Improvement Map is chartered with the following 15 interventions, and IHI will continue to add interventions

over time, clustering them by care setting and content area, and will help hospitals identify where they should

focus to maximize impact.

To learn more, turn to Page 8!

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 measureVisit www.qualitynet.org

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)

9. Deliver evidence-based care for acute myocardial infarction

10. Prevent surgical-site infections

11. Prevent central-line infections

12. Prevent ventilator-associated pneumonia

13. WHO Surgical Safety Checklist

14. Prevent catheter-associated urinary tract infections (CAUTI)

15. Link quality and financial management engage the chief

financial officer and provide value for patients

To learn more, visit www.ihi.org


8/84

8 The OR Connection

SCIP Adds Two New Measures

Effective October 1

Urinary catheter removal, normothermia

As part of its Surgical Care Improvement Project (SCIP), theCenters for Medicare & Medicaid Services (CMS) will begin

requiring hospitals to report quality data on two new meas-

ures effective October 1, 2009. The measures relate to

removal of urinary catheters and the documentation and reg-

ulation of patient body temperature.

SCIP Measure 9: Removal of urinary catheters

This new measure states that urinary catheters are to be

removed during the first or second day after surgery. The risk

of urinary tract infection and bacteremia increase when a

catheter remains in place for more than two days. Although

this measure pertains primarily to inpatient cases, surgerydepartments will need to establish protocols for a physician

order and a method of documenting catheter removals.

SCIP Measure 10: Normothermia requirements

This new measure requires the recording and reporting of

patient temperatures, documenting whether temperatures

dropped below 96.8 degrees F from 30 minutes before surgery

to 15 minutes after anesthesia ends. It also must be noted

whether forced-air or warmed-water patient warming devices

or garments were used. The measure applies to procedures

that last 60 minutes or longer, and employ general anesthesia

or neuroaxial blocks.

For more details on all of the SCIP measures,

visit www.qualitynet.org.

AORN Revises Hand Hygiene

Recommendations to Include

Use of Surgical Scrub Agent

Revised terminology in Recommended Practices for Hand

Hygiene in the Perioperative Setting, which was recently pub-lished by the Association of periOperative Registered Nurses

(AORN), advises use of a surgical hand scrub before donning

gloves for a surgical procedure. AORN recommends using an

antimicrobial or alcohol-based surgical hand rub product.

The following terminology was submitted

and approved by AORNs board of directors

on July 17, 2009:

A surgical hand scrub should be performed by health care

personnel before donning sterile gloves for surgical or other

invasive procedures. Use of either an antimicrobial surgical

scrub agent intended for surgical hand antisepsis or analcohol-based antiseptic surgical hand rub with documented per-

sistent and cumulative activity that has met US Food and Drug

(FDA) regulatory requirements for surgical hand antisepsis is

acceptable.

These changes will be made to the Recommended Practices

for Hand Hygiene in the Perioperative Setting, which is cur-

rently available electronically. AORNs electronic recom-

mended practices are available through AORNs new

eSubscription (www.aorn.org/eSubscription) and through

a pay-per-document platform (www.aorn.org/PracticeRe-

sourcees/AORNStandardsandRecommendedPractices/EDocuments/).

Reference

AORN board revises hand hygiene recommended practice. News Release. July

22, 2009. Available at http://www.aorn.org/docs/assets/A36FA8F4-046B-197F-

81B585C4FB6DF06E/HandHygieneAnnct.pdf. Accessed July 29, 2009.


9/84

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www.medline.com2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

For more information on Sterillium Rub, contact your Medline sales

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10 The OR Connection

Patient-centered researchTherefore, the healthcare research conducted under this

initiative will be patient-centered and apply to the real

world in order to help patients, clinicians and other deci-

sion makers assess the relative benefits and harms ofstrategies to prevent, diagnose, treat, manage or monitor

health conditions.1

In addition, the research should consider and include a

variety of patient populations (e.g., people with disabilities

and chronic illnesses, and different racial and ethnic back-

grounds) for the program to be effective.2

Federal Coordinating Council for ComparativeEffectiveness Research

The first step in the comparative effectiveness initiative wasto appoint a management council in March 2009. The Federal

Coordinating Council for Comparative Effectiveness

Research (the Council) is composed of 15 distinguished

leaders from key government healthcare-related agencies,

including the Veterans Health Administration (VHA), Centers

for Disease Control and Prevention (CDC), Centers for

Medicare & Medicaid Services (CMS) and the HHS, among

others.2 The Councils purpose is to coordinate compara-

tive effectiveness research and related health services

research across the federal government with the intent of

reducing duplication and encouraging the complementary

use of resources.1

The Council will oversee the $1.1 billion in funding, of which

$300 million is allocated to the Agency for Healthcare

Research and Quality (AHRQ), $400 million to the National

Institutes of Health (NIH) and $400 million to the Office of

the Secretary.1

Goals of Comparative Effectiveness Research

Reduce healthcare costs2

Build public interest2

Improve patient care2

Encourage development and use of clinical registries

and data networks1

Increase consistency of treatment provided in different

geographic regions1

Greater ability to tailor interventions to treat patients

specific needs1

Care based on evidence and best practices1

Legislators in the Senate and House have been busy

this year preparing and debating their versions of a

healthcare reform bill. Perhaps one of the bills, or a

hybrid, will be passed by the end of 2009. In the interim,

the launch of a new federally funded healthcare program on

comparative effectiveness research is well underway.

The American Recovery and Reinvestment Act of 2009allocated $1.1 billion to the U.S. Department of Health and

Human Services (HHS) for this initiative. What is compara-

tive effectiveness? The Institute of Medicine (IOM) defines it

as the extent to which a specific intervention, procedure,

regimen or service does what it is intended to do under real

world circumstances.1As HHS describes it, comparative

effectiveness research provides information on the relative

strengths and weaknesses of various medical interventions,

including drugs, devices and procedures.2

Comparative Effectiveness Research:

What It Is and How

It Can Help You andYour Patients

Whats Happening in Healthcare Reform


11/84

Aligning prac tice with po licy to imp rove pa tie nt ca re 1

High-Priority Topics for Federally FundedComparative Effectiveness Research3

The American Recovery and Reinvestment Act of 2009

called on the Institute of Medicine to recommend a list of

priority topics to be the initial focus of a new nationalinvestment in comparative effectiveness research.

The complete list contains 100 topics, prioritized into four

groups of 25 each. The following is a sampling of topics that

relate to surgical professionals. They are listed in order from

highest to lowest priority, as indicated by the Institute of

Medicine:

Compare the effectiveness oftreatment strategies for

atrial fibrillation, including surgery, catheter ablation

and pharmacologic treatment.

Compare the effectiveness of various screening,

prophylaxis, and treatment interventions in eradicating

methicillin-resistant Staphylococcus aureus

(MRSA) in communities, institutions and hospitals.

Compare the effectiveness ofstrategies (e.g.,

bio-patches, reducing central line entry, chlorhexidine

for all line entries, antibiotic-impregnated catheters,

treating all line entries via a sterile field) for reducing

healthcare-associated infections (HAI), including

catheter-associated bloodstream infection, ventilator-associated pneumonia and surgical site infections in

adults and children.

Compare the effectiveness ofrobotic assistance

surgeryand conventional surgery for common

operations, such as prostatectomies.

References

1. U.S. Department of Health and Human Services. Federal Coordinating Council

for Comparative Effectiveness Research: Report to the President and Congress,June 30, 2009. Available at http://www.hhs.gov/recovery/programs/cer/cerannu-

alrpt.pdf. Accessed August 3, 2009.

2. Zigmond, J. Healthy choices: industry wonders how $1.1 billion for comparative-

effectiveness research will be applied. Modern Healthcare. March 30, 2009:

6-7,16.

3. Institute of Medicine. 100 Initial Priority Topics for Comparative Effectiveness

Research. Available at http://www.iom.edu/?id=71032. Accessed August 3, 2009.

Brian Lee Morrison earned his registered nurse degree in

May 2009 from St. Petersburg College School of Nursingin St. Petersburg, Fla. He (and Medline nurse doll Alice)

graduated with honors. Brian is continuing at St. Peters-

burg College to complete a bachelors degree in nursing.

He currently works in the OR at St. Josephs Hospital in

Tampa. Before earning his RN, he had been a surgical

technologist and certified first assistant.

Graduation Day for Two!

Easier navigation to find

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Visit the redesignedwww

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12/84


Prevention Above All Conference,Washington, DC, August 16-18, 2009

Chief nursing officers, chief medical officers, directors of nursing

and other clinical executives from hospitals across the country

gathered in Washington, DC, August 16-18, 2009, for Medlines

popular Prevention Above All Conference. They learned new

strategies for delivering cost-effective, high-quality health care

and evidence-based solutions for improving patient care.

An impressive agenda

Tying in all that is top-of-mind on Capitol Hill these days, former

senator Tom Daschle opened the conference by discussing hisbook on healthcare reform and the delivery of cost-effective

health care. Following Daschle was Institute of Medicine President

Dr. Harvey Fineberg, who addressed the impact of comparative

effectiveness research on delivering cost-effective, evidence-

based health care. (See article on page 10 to learn more about

comparative effectiveness research.)

Emphasis on patient safety

As always, patient safety was a major focus, and world

renowned experts shared the latest innovations and evidence-

based practices in the prevention of catheter-associated urinary

tract infections (CAUTI), hand hygiene and pressure ulcerprevention.

CAUTI. Medline introduced its new evidence-based system

to help prevent CAUTI. The ERASE CAUTI program combines

innovative design, education and awareness to tackle catheter-

associated urinary tract infection the number one hospital-

acquired infection.

Hand hygiene. Internationally renowned professor and

epidemiologist Didier Pittet, of Switzerland, shared the latest

hand hygiene improvement strategies. Dr. Pittet is lead of the

World Health Organization (WHO) World Alliance for Patient

Safety and a member of the advisory board for the WHOsFirst Global Patient Safety Challenge, Clean Care Is Safe Care.

In addition, German epidemiologist Gunter Kampf presented

new discoveries and considerations in hand sanitizing tech-

niques. He is the author of 119 scientific papers published

in national and international infection control journals.

Pressure ulcers. Wound care expert Elizabeth Ayello provided

insight on CMS present on admission (POA) indicators as they

relate to hospital administrators and clinicians.

PREVENTIONABOVE ALL

TARTGETED INTERVENTIONS PRACTICAL SOLUTIONS

Also, two experts in wound care and healthcare law, who arealso members of the International Expert Wound Care Advisory

Panel, addressed the legal implications of caring for patients with

pressure ulcers, sharing ways healthcare professionals can pro-

tect themselves from litigation. Turn to page 46 for excerpts from

their new white paper, Legal Issues in the Care of Pressure

Ulcer Patients: Key Concepts for Healthcare Providers.

SCIP. The Surgical Care Improvement Project continues to

evolve, with two new measures coming in October. Highly

regarded quality improvement specialist Dale Bratzler, DO, MPH,

medical director of SCIP, discussed patient safety in the context

of SCIP and expanded on new and revised SCIP measures.

Prevention Above All Discoveries Grant recipients

Dr. Andrew Kramer announced the names of Prevention Above

All (PAA) Discoveries Grant award winners. Dr. Kramer, professor

of medicine at the University of Colorado, served as chair of the

PAA Discoveries Grant Review Committee. The committee also

included Dale Bratzler, DO, MPH, medical director of SCIP; Diane

Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN, wound & skin

care consultant; Michael Raymond, MD, chief medical officer,

North Shore University Health System and Heidi Wald, MD,

MPH, professor of medicine, University of Colorado. All grant

applications and proposals were independently reviewed and

approved by this committee. Watch for more information on therecipients and their research topics in upcoming issues of The

OR Connection.

Unable to attend the Prevention Above All Conference?

Visit medline.com for highlights from the meeting, including video

clips from the presentations.

Critical: What We Can Do About the

Health-Care Crisis, authored by for-

mer senator Tom Daschle, outlines the

healthcare reform strategies that are

the foundation of President Obamas

healthcare initiative. Evaluating where

p re v io u s a t te mp ts a t n a tional

healthcare coverage have succeeded,

and where they have gone wrong,

Daschle explains the complex social,

economic and medical issues involved in reform and sets

forth his vision for change. The book is available for purchase

at leading retail bookstores and online outlets.


13/84

Aligning practice with policy to improve patient care 1

OSF St. Joseph Medical Center

Achieves Magnet Recognition

OSF St. Joseph Medical Center in Bloomington, Ill.,

recently achieved Magnet Recognition for excellence in

nursing services by the American Nurses Credentialing

Center (ANCC).

The Magnet Recognition Program recognizes healthcare

organizations that demonstrate excellence in nursing prac-

tice and adherence to national standards for the organi-

zation and delivery of nursing services. The ANCCs

Commission on Magnet made a unanimous decision to

make OSF St. Joseph Medical Center a Magnet hospital.

Magnet applicants undergo a rigorous evaluation process,

including written documentation of 14 specific areas of

nursing practice called Forces of Magnetism. Hospitals

also participate in extensive interviews and an on-site

review of nursing services. OSF St. Joseph began work-

ing toward Magnet Recognition in 2004.

A magnet steering committee

was formed to create a docu-

ment proving that OSF St.

Joseph Medical Center met or

exceeded the 164 standards

that are part of the Forces of

Magnetism.

Each committee member was responsible for finding

sources of evidence to support the standards within one

force. Committee chair Sandra Scheidenhelm encouraged

all members to stay on task until the final documentation

was turned in all 15 volumes of it!

The committees hard work and dedication paid off.

OSF St. Joseph was awarded Magnet Recognition in

December 2008.

The OR ConnectionCelebrates

Nurses Accomplishments

OSF St. Joseph Medical Center CEO Ken Natzke presents

the ANCC Magnet Recognition obelisk to Chief Nursing

Officer Deb Smith.

OSF St. Joseph Medical Center Magnet Steering Committee.

Back row (left to right): Marcia Laesch, Dixie Reynolds,

Sue Herriott, Pat ODell, Barb Stevig. Front row (left to right):

Mark Dabbs, Deb Smith, Sandi Scheidenhelm, Phyllis McNeil.


14/84



15/84

OR NURSES SET SAILFOR SURGERY ONBOARD

MERCYSHIPS


Excellent nursing care for the underprivileged

Mercy Ships is a global charity

that has operated hospital ships

in developing nations since

1978. Mercy Ships brings hope

and healing to the forgotten poor

by mobilizing people and re-

sources worldwide and serving allpeople without regard for race,

gender or religion. Recently, a

partnership was formed between

AORN and Mercy Ships with the goal of increasing

awareness of the opportunities available to operating

room nurses wanting to serve the suffering poor.

The Africa Mercy is the worlds largest non-governmental

hospital ship. An entire deck functions as a complete

hospital with five wards, an intensive care unit, medical

lab, CT scanner and six operating rooms. There are 450crew members, and 130 are healthcare staff. Each year,

Mercy Ships welcomes more than 1,200 long-term

volunteers from over 40 nations and 2,000 short-term

volunteers.

Onboard the Africa Mercy, 12 surgeries, on average, are

completed each day, including maxillofacial, plastics,

general, orthopaedic, and vesicovaginal fistula (VVF). An

additional average of 30 cataract

removals and other eye-related

surgeries also take place daily. Tu-

mors are removed, burn contrac-

tures are released, limbs are

straightened, deformities are cor-

rected, sight is restored and,above all, dignity and hope are

given to thousands of previously

suffering individuals.

The work of highly skilled surgeons from around the

world allows for such tremendous healing to take place.

However, without the help of the operating room (OR)

nursing staff, none of it would be possible.

There are currently 15 OR nurses serving onboard the

Africa Mercy. Some have been onboard for more thantwo years (long-term); others will serve short-term for two

weeks or more. Both long-term and short-term commit-

ments are important and greatly appreciated. The dura-

tion of commitment may vary, but the standard of work

and care provided by all of the nurses is impeccable.

OR nurses from all walks of life serve with Mercy Ships

even those with families of their own. Before Jenny Rol-

Special Feature

by Mila Hightower


16/84

land, along with her husband and three children, joined Mercy Ships,

she worked as an OR nurse in the United States for 14 years, spe-

cializing in otolaryngology, ophthalmolics and plastics. She now

works as the assistant OR supervisor onboard the Africa Mercy. She

manages the daily surgery schedule, acts as a liaison between the

wards and the ORs, and provides orientation and assistance for new

nurses.

Apart from the factthat it is located on a ship, the

Africa Mercys OR is almost identical to the OR of a

regular hospital.

Remarkably, this hospital is very similar, Rolland said. Its encour-

aging to have short-term nurses who know how an OR functions,

and all they really need to know is where the supplies are kept. Then

they can do what they know how to do. Thats the beauty of it.

Every weekday morning, the OR staff meets at 7:30 a.m. for devo-

tions and a time of prayer. This is followed by a short briefing on the

days schedule. Thereafter, surgeries begin. Though it changes every

day, the OR usually doesnt end surgeries until around 6:00 p.m.

During nights and weekends, the OR is closed, although a weekly

team of three is on call in case of an emergency.


MERCYSHIPS

Melissa Brown of the USA is

currently serving with Mercy

Ships as an OR nurse for 3

months. An AORN member,Brown has found the

management and efficiency

of the Africa Mercys onboard

hospital similar to that of a First

World hospital.


17/84

Of course, running a First World facility in a Third World

environment has its challenges. As a not-for-profit organi-

zation, Mercy Ships resources are sometimes limited.

Surgical instruments and equipment have to be used more

than once. Effective methods of sterilization and a subse-

quently low infection rate make this feasible.

With an international staff represented by more than six

countries, language and communication can be problem-

atic. Theres a language that one has to get used to when

there are four different names for one instrument, Rolland

said. Thankfully the OR is sort of a universal environment.

A broad spectrum of nationalities and cultures also has its

benefits. Rolland explained, I think being able to work with

an international staff is very enlightening because there are

ways that people from different parts of the world do

things. Its nice to have that added to what we do.

Sometimes there might be a way that is more efficient.

Melissa Brown recently joined Mercy Ships as a short-term

OR nurse. My experience so far has been great! My first day

in the OR everyone was very welcoming, and they helped

me fit right in by explaining the procedures, she said.

Brown is a registered nurse and a member of AORN with

CNOR and first assistant certifications. She worked as a

travel nurse in the United States before joining the Africa

Mercy as an OR nurse for three months during the summer.

I have never been able to combine missions with my OR

nursing career, she said. Here with Mercy Ships is my first

opportunity to be able to do that, and that is very special to

me, Brown said.

Although the Africa Mercy is currently stationed in the West

African nation of Benin, the onboard hospital continues

to operate effectively. Its staff finds the conditions famil-

iar and comfortable.


Continued on Page 19


18/84

2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Medlines Gold Standard Safety Program is designed

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safety goals.

The program offers four levels of safety options:

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needle sticks and wrong site surgery.

2. Innovative safety products: Surgical Time Out

Procedure (S.T.O.P.) Flag and Drape remind OR

staff to take time to verify key information before

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3. AORN Checklist: Wrong site, wrong procedure,

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19/84


I worked a day shift at home so the hours here are very

similar, explained Brown. As far as how the OR is run and

the management and efficiency of things, I think its very

similar to a First World OR.

Although she is currently assisting with eye surgeries,

Brown will get the opportunity to work in all the surgical

specialties performed onboard the Mercy Ship.

Alison Green is a long-term volunteer who joined Mercy

Ships shortly after completing four years of nursing school

in Tyler, Texas. Although she has only been onboard theAfrica Mercy for a few months, she has already gained a

wealth of experience that will undoubtedly further her pro-

fessional career as an OR nurse.

Its great to see what I was a part of and

how Ive made a difference in their lives.

Ive found that Ive learned more here in five months than

I did in three years back home, Green said. Many of the

procedures and surgeries we do here are not normally done

back home because the cases are so unique. I have

learned so much as a scrub nurse. I get to be more

involved in assisting the surgeons, whereas back home I

had to do more paperwork.

Because Green has made a long-term commitment to

Mercy Ships, she is being trained in all the specialties. She

is currently undergoing six weeks of VVF scrub nurse train-

ing and has already completed training in ophthalmolics,

general and maxillofacial surgery.

In the United States I found surgeries were all about time

and getting things done, but here the surgeons are willing

to teach you more so that you are able to take better care

of the patients. They are humble and willing, she explained.

Green finds that a notable and positive difference is the

opportunity to spend more time with patients. I think that

here we get more connected with our patients. We have an

opportunity to pray with them, get to meet them face-to-face before surgery, see them afterwards in the ward and

watch how they heal, she explained. Its great to see what

I was a part of and how Ive made a difference in their lives.

Life here is very fast-paced and very busy, but at the same

time, its rewarding and life-changing. This work really

reminds me about why I became an OR nurse. I can see

the hope and healing brought to the patient firsthand. I think

if nurses are rundown and have forgotten why they are

doing what they are doing, they will be inspired if they come

here, Green said.

If you would like to be a part of bringing hope and healing

to the worlds poor, please visit www.mercyships.org or

contact the Mercy Ships human resources department at

(903) 939-7045. Mercy Ships headquarters is located in

Lindale, Texas.

MERCYSHIPS

Jenny Rolland of the USA lives onboard the Africa Mercy with

her husband and three children. With 14 years of experience,

she now works as the Assistant OR Supervisor for Mercy Ships.

Taking time for a little fun.


20/84


Rhode Island adopts protocol to

prevent wrong site surgery

Program implemented July 1, 2009

All 12 hospitals and 21 surgical centers in

Rhode Island have agreed to adopt a sur-

gical safety protocol designed to reduce

the risk of wrong site surgeries. According to the Hospital Associ-

ation of Rhode Island, the state is the first in the nation to have all

surgical providers voluntarily adopt the same safety protocol.1

The term wrong site surgery applies if the wrong procedure is per-formed or if a procedure is performed on the wrong person or the

wrong body part.

Rhode Islands protocol was developed over a period of 18 months

by state hospital and healthcare leaders in cooperation with the

Joint Commission.2 It is similar to surgical safety checklists created

by the World Health Organization and The Joint Commission.

With an emphasis on clear communication among surgeons, staff

and patients, the protocol is designed to prevent errors but also to

avoid the confusion that sometimes occurs when practitioners split

their time between facilities with different policies.

They have steps built into their protocol that allow all team mem-

bers to be accountable and responsible for speaking up if they

believe that something doesnt look right, said Mark Crafton,

the Joint Commissions executive director for state and external

relations.1

Four key features of the protocol include:2

Three-way pre-op consult. The surgeon, one other licensed

practitioner (such as a registered nurse) and the patient or patients

guardian all confirm the surgical site together before it is marked

with the surgeons initials.

OR team briefing.All team members introduce themselves and

their roles. The surgeon then briefs the team, identifying the patient,

procedure and site, and explaining plans for the surgery, including

any medications, documentation and equipment needed.

Time out. Led by the surgeon, all team members verify the

patient, procedure and site and confirm that the site marking is

visible after prepping and draping.

Post-op de-briefing.The surgeon leads a discussion of the post-operative plan of care and a review of how the surgery went and

what could have been done differently.

William Cioffi, MD, surgeon-in-chief at Rhode Island Hospital, said

that safety efforts must walk a fine line, requiring accountability with-

out overemphasizing blame; each member of the surgical team has

responsibilities to meet but also must feel free to acknowledge and

report errors.1

Cioffi added that the hospitals will train staff through lectures and a

video and also will devise ways to make sure the protocol is prop-

erly and uniformly adopted around the state. This is a great first

step. Its not the end of the process.1

Providers began implementing the protocol July 1, but it could be

as long as one year before staff at all facilities have received train-

ing on the new rules.1

Earlier this year, the federal government took steps toward pre-

venting wrong site surgery. As of January 15, 2009, the Centers

for Medicare and Medicaid Services (CMS) no longer reimburse

hospitals or surgery centers for wrong site surgery.3,4,5

Patient Safety Initiatives Across the United States


21/84


Near zero incidence of HAIs at

Monroe Hospital in Indiana

How do they do it?

Monroe Hospital in Bloomington, Ind. has

a near zero rate (0.06 percent) of hospital-

acquired infections among the more than

2,800 inpatients treated since the hospital opened in 2006.6 The

national average of healthcare-acquired infections in U.S. hospitals

is assumed to be five percent.7

So, how does Monroe Hospital stave off healthcare-acquired

infections? The following is a list of infection control measures used

at the hospital:6

1. Frequent handwashing with alternating products. Doctors

and staff are encouraged to wash their hands frequently particu-larly after having contact with a patient and before and after eating

or using the restroom. They are instructed to use three different

products soap and water, an alcohol-based hand foam and

an ammonia-based hand sanitizer on an alternating basis; each

one third of the time.

Hospital officials say this combination of products keeps the hands

clean, but also soft and pliable. Individuals with dry, cracked skin on

their hands tend to wash them less often.

2.A clean environment. Cleaning of all surfaces takes place

daily. Environmental services staff wipes down door handles, light

switches, patient beds, countertops and computer keyboards.

Deep cleaning, which includes cleaning behind computers and

under keyboards, occurs every Friday.

3. Isolation procedures. Patients with a history of MRSA are iso-

lated, and staff must wear gloves and protective gowns when they

come in contact with these patients. The patients remain in isola-

tion their entire hospital stay, regardless of subsequent negative

MRSA cultures.

4. Hospital-laundered scrubs.The hospital launders all doctors

and staff scrubs to make sure they are cleaned properly to remove

bacteria. No staff member enters or leaves the hospital wearingscrubs.

For further discussion on how scrubs may spread infection, turn to

page 51.

New Hampshire first state to

adopt surgical safety checklist

NH hospitals, ASCs lead the nation

in infection control

New Hampshire hospitals and ambulatory

surgery centers have voluntarily adopted

a safety checklist for surgeries and all other invasive procedures.

The protocol is based on a checklist developed by the World Health

Organization (WHO), which identifies three phases of a procedure

for which medical team members confirm appropriate tasks have

been completed. New Hampshire Gov. John Lynch applauded the

statewide collaboration, noting that reducing errors and infections

and improving quality all help in controlling the cost of health care.8

New Hampshire hospitals perform better than the national average

in each of the five Surgical Care Improvement Project (SCIP) meas-ures related to surgical care.9

Surgical Care Improvement Project (SCIP)

NH Nat. Avg.

Prophylactic Antibiotic Received Within One 96% 94%

Hour Prior To Surgery

Prophylactic Antibiotic Selection 98% 97%

Prophylactic Antibiotic Discontinued Within 94% 90%

24 Hours After Surgery

Recommended VTE Prophylaxis Ordered 94% 93%

Recommended VTE Prophylaxis Received 92% 90%

Controlled 6 am Postop Serum Glucose 91% 90%

Appropriate Hair Removal 99% 98%

References

1. Freyer FJ. R.I. hospitals agree on safety protocol for surgeries. The Providence Journal.

July 1, 2009. Available at

http://www.projo.com/health/conteent/SURGICAL_SAFETY_PROTOCOL_07-01-

09_QLETDSU_v10.3dce7cb.html. Accessed July 8, 2009.

2. Tsikitas I. R.I. adopts uniform surgery safety protocol. Outpatient Surgery Magazine.

Available at http://www.outpatientsurgery.net/news/2009/07/2.php. Accessed July 8, 2009.

3. Decision Memo for Wrong Surgery Performed on a Patient (CAG-00401N). Centers for

Medicare and Medicaid Services Web site. http://www.cms.hhs.gov/mcd/viewdecision-

memo.asp?id=223. Accessed July 8, 2009.

4. Decision Memo for Surgery on the Wrong Body Part (CAG-00402N). Centers for Medicare

and Medicaid Services Web site.

http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=222. Accessed July 8, 2009.

5. Surgery on the Wrong Patient (CAG-00403N). Centers for Medicare and Medicaid Services

Web site.

http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=221. Accessed July 8, 2009.

6. Denny D. Monroe Hospitals low infection rates draw national interest. Bloomington Herald

Times. January 19, 2009. Available at http://www.heraldtimeson-

line.com/stories/2009/01/19/news.qp-7992582.sto?1242057521. Accessed May 11, 2009.

7. Wenzel R, Edmond MB. The impact of hospital-acquired blood stream infections. Emerg Inf

Dis. 2001;7(2):174-177.

8. NH Health Care Quality Assurance Commission issues 4th annual report. News from the

Foundation for Healthy Communities. July 2009. Available at http://www.healthynh.com/

fhc/about/newsletter/FHCNewsletterJul09.pdf. Accessed July 21, 2009.

9. NH Quality Care Reports. New Hampshire Surgical Care Improvement Project (SCIP).

Available at http://nhqualitycare.org/reports.php?id=sip. Accessed July 22, 2009.

Patient Safety


22/84


THESILENTTREATMENT


23/84


Recently, a highly accomplished orthopedic sur-geon was scheduled to work on three consecutive

cases with his OR team. The operating rooms were

state of the art within the medical centers newly con-

structed orthopedic hospital, which had not yet cele-

brated its first birthday. A system of time outs including

use of the World Health Organization (WHO) surgical

checklist had been in place at the medical center for al-

most three years now, with multiple checklists for patient

identif ication, pre-op procedures and instrumentation.

The surgeon was scrubbing in for his second case when the

charge nurse approached him from behind and quietly

said, Doctor, I have something to tell you. The instru-

ments that you used for the first case were not sterilized.

With the second patient already under anesthesia, there

was no time for the surgeon to discuss the small bomb-

shell that had just been lobbed in his direction, but his

thoughts couldnt let it go: Wheres the checklist for whenthings go wrong? he thought sarcastically to himself,

having seen system error after system error despite the

apparent adaptation of techniques used by high reliability

organizations. Sharply, he gave an order for Gentamycin

for his first patient and turned his attention, as best he

could, to his next case. He dreaded the moment when he

would have to tell his patient a man who trusted him

implicitly for a second knee replacement. But things just

got worse.

His second case was a lawyer who had a long history of

surgeries due to rheumatoid arthritis. The physician had

literally spent hours selecting the best implants for this

complicated revision, talking to vendors at great length to

ensure the compatibility of the various systems and care-

fully relaying his recommendations to the patient, who

was extremely involved after five surgeries.

by Kathleen Bartholomew, RN, RC, MN

and John J. Nance, JD

OR Issues


24/84


Socket, he said at the appropriate moment with hand

extended, eyes still fixated on the open wound.

Socket, he said again, irritated after nothing had landed

in his hand.

From his peripheral vision he picked up on commotion. He

turned and looked up at the circulating nurse who quietly

said, Its not here doctor. Fully focused on getting the

piece he needed STAT, the surgeon immediately got on

the phone to the vendor, trying to negotiate the use of

another implant despite his careful planning.

Shes under a spinal it will be wearing off. I cant wait

that long why isnt it here? he said loudly over the phone.

Finally, after half an hour, the vendor arrived with the implant.

Both relieved and frustrated, the surgeon closed and turned

to his third case, which was uneventful and painfully, as

silent as the second case. In fact, despite the two major

mistakes of the day, not a single person in the operatingroom had mentioned either event.

The saddest thing was that no one said a word, the sur-

geon said soberly. I work with these people all the time and

you think someone could have at least said, Im sorry that

happened, or something like that. But instead, there was

nothing but this awkward silence. More than anything, Im

still bothered by the silence.

As well he should have been.

As noted communication expert Susan Scott says, The

conversation isnt about the relationship. It is the relation-

ship.1This orthopedic surgeon is an outstanding physician,

known and respected for his skill and compassion the

only surgeon who would actually drive to a patients house.

Yet, he could not communicate his disappointment to his

team and his team refused to reach out to him; or vocalize

any concerted team effort to make sure these errors would

never happen again. Despite the very best of intentions and

the adoption of standardized checklists and procedures,

this team has a long way to go. The level of trust and feel-

ings of personal safety in the group simply arent high

enough for anyone to risk being vulnerable and actually

address a painful truth that as a team they had systemi-

cally screwed up.

Worse, violating every premise of regarding mistakes as

important messages from the underlying system, they were

willing to squander and discard the obvious opportunity to

improve their own techniques, not to mention the opportu-

nity to share what had happened (and how to fix it) with

other surgical teams. Patient safety can only be enhanced

when bad experiences are shared, probed, understood,

and procedures changed. In fact, collegial interactive teams

groups of professionals dedicated to a common goal and

willing to care about each other and trust each other

enough to honestly report and evaluate any failure never

hesitate to put a failure on the table for discussion. Andnever never does an effective collegial team care so lit-

tle for their own that they permit silence to shroud the

human pathways of interaction between them.2

Three powerful forces impede communication in health

care: time pressures, knowledge and culture. Understand-

ing their impact is the first step to creating collegial and

effective teams in which relationships go deeper than the

mask of composure. Honest and meaningful relationships

can only happen if we are free to speak our truth at all times.

Culture the undertow of health care

There is no force more powerful in an organization than cul-

ture. As all business experts counsel: Culture kills the best

of strategies. In fact, the phrase and the concept of This

is the way weve always done it! is the mindless battle cry

of culture-resisting change. Culture is never written down

or spoken but known by everyone.

Three powerful forces impede

communication in health care: time

pressures, knowledge and culture.


25/84


For decades, operating room nurses were raised to be

humble; to care not only for the patient, but also for the sur-

geon. They monitored his/her moods and wondered if

he/she had gotten enough sleep. If necessary, they stroked

egos or took the blame for mistakes all for the sake of an

uneventful surgery. This is how many nurses were trained.

Instructors were often heard to say: If you want to work in

the OR, you better have thick skin. There were valid rea-

sons why a warning accompanied an invitation to work in

the OR.

Physicians were trained to lead in a hierarchical system and

taught to act and think as if their very education meant that

they were more important than any other member of the

team.3 Certainly they were, and are, more vulnerable. If the

patient died, the surgeon was faulted. And when all the

responsibility and liability is yours, then you had better have

total control over the situation.

In essence, this is the same drive for absolute physicianautonomy that according to healthcare governance expert

Jaime Orlikoff, originated about four thousand years ago

with the Code of Hammurabi, which decreed amputation of

a physicians fingers if his patient died after surgery. The

physician response, even in ancient Babylonia, was very

understandable: If I have total accountability, I demand total

autonomy in making decisions for my patients.4 In all the

millennia since, weve simply reinforced autonomy in our

medical culture. And that drive alone is frankly one of the

principal stumbling blocks in creating true collegial teams

in the OR rather than an iron-willed, all-knowing leaderand obedient followers (the old model).

Instructors were often heard to say,

If you want to work in the OR, you

better have thick skin.


26/84


Today, the massive profession-wide push for major improve-

ments in patient safety includes considerable pressure on

doctors to step away from the old model and shoulder theresponsibility of being an effective leader in building mean-

ingful, collegial relationships. But even the best leaders cant

lead if the members of the would-be team refuse to shoulder

their reciprocal responsibilities to be receptive and commu-

nicative and trusting. Thats what happened to the unhappy

orthopod left wondering why he got the silent treatment.

Whatever culpability he, as the surgeon, might have had for

not breaking the silence, his team also has a vital role.

The responsibility for a true team is a shared responsibility.

Start the conversation. What is the current culture of yourOR? Can you speak up at any time to ask a question or

stop the line? The culture of the operating room in the pre-

vious case was to lay low when things go wrong. No

member of the team ever acknowledged this, or said these

words out loud. As a team, they learned over the years to

hibernate until the storm passed. But until someone steps

forth and starts acting differently, nothing will change. Only

the courage to act differently over a long period of time,

even without the support of the group, can move cultural

inertia. If you can do this, you are a true leader regardless

of your position.

What is the single most important thing you can do

to impact culture on an individual level? Speak your

truth. But how?

Knowledge is power

Communication classes are noticeably absent from both

medical and nursing school curricula. Yet the number one

cause of adverse outcomes in a study of 2,400 sentinel

events by The Joint Commission was communica-

tion errors.

Communication omissions happen frequently. The operat-

ing room coordinator didnt know the bowel resection was

going to be lappy because nobody told him. The tech

didnt know that the surgeon switched systems for his

lumbar fusions because nobody told her. Likewise, the

orthopedic surgeon didnt know that his team cared, and

that they were just as upset as he was about the events of

the day, because nobody said anything. In the Silence Kills

study,5

fewer than 10 percent of physicians, registerednurses and clinical staff could directly confront their col-

leagues about their concerns. Why arent people talking?

A recent study of over 2,500 hospital nurses gives us some

answers.6 Nurses were asked to identify a conversation that

they needed to have in order to create a healthy

work environment.

When asked why they had avoided the crucial

conversation, they responded:

Fear of retribution Fear of retaliation (unfair assignment or schedule,

refusing to help, refusing a vacation)

Fear of being isolated or excluded from the group

Fear of being gossiped or talked about

Fear of being wrong

No time

Fear of upsetting the status quo; rocking the boat

Why bother? Nothing will change; its no use

The primary denominator here is fear. As long as we live in

fear, nothing will change. Healthcare workers share a pas-

sive-aggressive style of communication. They say why they

are upset to everyone in the department except the

person they are angry with. In addition, the most common

Continued on Page 28


27/84

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way nurses deal with confrontation is avoidance. Nothing is

worth upsetting the relationship. Noting this, it is imper-

ative that leaders teach assertive communication and

confrontation skills in the workplace.

One very simple model is called the D-E-S-C Communica-

tion Model. It provides a great framework for organizing your

thoughts and feelings.7

D - Describe the behavior

E - Explain the effect of the behavior

S - State the desired outcome

C - Say what happens if the behavior continues

For example, the physician could haveapproached the team this way afterthe surgeries:

DESCRIBE - I want to talk to all of you about the silence in

the operating room today. No one said a word all day.

EXPLAIN - The silence is what upset me the most. Having

to explain the unsterile instruments to my patient was

extremely upsetting; as was not having the right implant.

But the silence made me feel like I was alone, or surrounded

by strangers.

STATE - When something happens that is not normal

(unanticipated event or error), I would appreciate your

support or acknowledgement of what happened. I want to

create an atmosphere where every member feels sup-

ported, and today, I certainly did not.

CONSEQUENCE - If we continue to ignore issues as a

team, then we are not a team.

Time is money AND

For every good idea to improve patient safety and clinical

quality there is a voice reminding us that time is money.

Money governs healthcare in America. No surgeon, OR

scheduler, or CEO can refuse to be concerned about how

efficiently an OR can be used. Pressures have become so

intrusive on the surgical team that beepers and Blackber-

ries now provide a constant opportunity for interruption and

distraction that few patients on the table would appreciate

if awake. While only preliminary data is emerging to validate

what we already intuitively know, the fact is, the higher the

pressure on time, and the higher the level of distraction in an

OR, the less concentration on the procedure. To the extent

that a surgical team is constantly disrupted by mid-proce-

dure personnel substitutions, thoughtless intrusions, and


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Aligning prac tice with po licy to imp rove pa tie nt ca re 2

highly distracting communications, patient safety is com-

promised. Time pressures drive distractions that fragment

and fracture teamwork and the ability of a surgical team to

stay focused and supportive of each other.

How does the leader of a would-be collegial interactive

team respond to such pressures? By taking the time to

discuss issues outside the OR, tracking outcomes and

reviewing all outliers. A team cannot coordinate their

actions or responses if they dont make the time to come

together before the fact and at least go over the basics of

what theyre about to do; as well as openly discuss unin-

tended outcomes.2

Example: During a bariatric surgery the surgeon asked theanesthesiologist, Is the stomach clear? and the anesthe-

siologist answered Yes. And so the surgeon stapled the

stomach to the tube. For when the surgeon asked if the

stomach was clear, the anesthesiologist thought he meant

clear of fluids - and not the tube they had inserted for

decompression. After the event, the checklist was revised

to include teaching and now reads: Before stapling, I will

specifically ask, Is the stomach clear of the tube because

before I staple, I need the tube to be pulled. Respond clear

when the tube is pulled.

SCOAP (Surgical Care and Outcomes Assessment Pro-

gram) is the future of surgical quality improvement. It is a

physician-led voluntary collaborative creating an aviation-

like surveillance and response system for surgical quality.

SCOAP's goal is to improve quality by reducing variation in

process of care and outcomes at more than 40 hospitals in

the state of Washington. SCOAP is an engaged community

of clinicians working to build a safer, higher quality,

an d mo re cost-effective surgical healthcare system.

http://www.scoap.org/index.html.

Find your voice

In the opening case scenario, every team member failed to

communicate. The truth is that neither checklists, nor pro-

cedures, or process improvement will work in the absence

of meaningful, collegial relationships in which every member

of the team feels comfortable communicating what they

see, feel and know at all times. Silent cultures never change.

Find the courage. Find your voice.

References

1. Scott, S. (2004). Fierce Conversations. New York: The Berkley Publishing

Company.

2. Nance, J. (2008). Why hospitals should fly. Second River Healthcare Press,

Bozeman, MT.

3. Bartholomew, K. (2007). Stressed Out About Communication Skills,Marblehead, MA

4. Orlikoff, J. (2008). IHI Conference: From the top: the role of the board in quality

and safety, November 6-7, Boston, MA.

5. Silence Kills: The Seven Crucial Conversations for Healthcare study by

VitalSmarts available at www.silencekills.com.

6. Bartholomew, K. Presentation for Sigma Theta Tau International: Using a

communication model to identify barriers and increase self esteem November

2, 2009, Indianapolis, IN

7. Cox, S. (2007) Cox & Associates, Brentwood, TN.

Kathleen Bartholomew, RN, RC, MN, has

been a national speaker for the nursing pro-

fession for the past seven years. Her back-

ground in sociology laid the foundation forcorrectly identifying the norms particular to

health care specifically physician and

nurse relationships. For her masters thesis,

she authored Speak Your Truth: Proven

Stategies for Effective Nurse-Physician

Communication, which is the only book to date that addresses

physician-nurse communication. Stressed Out About Communi-

cation is a book designed for new nurses. Save 20 percent by

using source code MB84712A at www.HCMarketplace.com

or call customer service at (800) 650-6787.

John J. Nance, JD, author of the American

College of Healthcare Executive's 2009

Book of the Year, Why Hospitals Should Fly

(2008, Second River Healthcare Press,

Bozeman, MT), has been a dedicated mem-

ber of the healthcare profession for the past

20 years and an acknowledged leader in

adapting the most effective methods of

transforming human systems to high relia-

bility status. One of the founding board members of the National

Patient Safety Foundation, John is a licensed attorney, a 13-thou-

sand hour veteran airline captain, and an Air Force Reserve Lt.

Colonel, as well as the author of 19 best-selling books. He also

serves as the aviation analyst for ABC World News and the avi-ation editor for Good Morning America. Why Hospitals Should

Flycan be purchased online at www.whyhospitalsshouldfly.com.


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QUIZ YOURSELF!

CAUTI Prevention: How Do You Rate?

1. At my facility, we remove urinary catheters

within 48 hours after surgery.

a. Always

b. Sometimesc. Never

2. I follow strict aseptic technique when

inserting a catheter.

a. Always

b. Sometimes

c. Never

3. At my facility, we educate catheterized

patients about urinary tract infections.

a. Always

b. Sometimes

c. Never

4. At my facility, we keep track of how long

catheters are kept in patients.

a. Always

b. Sometimesc. Never

5. Before placing a catheter, I assess whether

the patient really needs it, and I document

the assessment in the chart.

a. Always

b. Sometimes

c. Never


Whats your score?

a _____ x 5 = _______

b _____ x 3 = _______

c _____ x 0 = _______

TOTAL _______

How do you rate?

25 Perfect score! Keep up the great work and educate others.

17 23 Great job. Read below for more helpful tips.

8 14 Youre doing OK. Turn to page 31 to find out more about CAUTI prevention AND earn a free CE!

0 5 Lots of opportunity to improve practices at your facility. Medline can help! Also review the strategies below.

We invite you to join the Race to ERASE CAUTI! With 100,000 nurses working together, we can do it!

CAUTI FACTS Evidence-Based Prevention Strategies The MOST effective way to prevent CAUTI is to AVOID inappropriate catheterization.1

Greater attention is REQUIRED to avoid inserting catheters in patients unnecessarily.2

Limiting urinary catheter use and, when a catheter is indicated, minimizing the duration the catheter remains

in place, are primary strategies for CAUTI prevention.3

Alternatives to catheterization should be considered.3

Documentation must include: indications for catheter insertion, date and time of catheter insertion,

individual who inserted catheter, date and time of catheter removal.3

Insertion using aseptic techniques and sterile equipment.4

Handwashing is the FIRST and most important preventive measure.5

Education must include appropriate indications for catheter placement and the possible alternatives to

indwelling catheters.5

Educating the patient can reduce readmissions6

and help to achieve higher patient satisfaction scores. SHEA/IDSA guidelines suggest that some common practices SHOULD NOT be used routinely to prevent

CAUTI including: Routine use of silver-coated or antibacterial urinary catheters.3, 4

References

1. Expert discusses strategies to prevent CAUTIs. Infection Control Today Web site. June 1, 2005. Available at http://www.infectionacontroltoday.com/articles/402/402_561feat2.html.

Accessed July 10, 2009.

2. Catheter-related UTIs: a disconnect in preventive strategies. Physicians Weekly. 25(6), February 11, 2008.

3. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute

care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41S50.

4. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008. Draft. Centers for Disease Control

and Prevention. Available at http://www.cdc.gov/ncidod/dhqp/pdf/pc/cauti_GuidelineApx_June09.pdf. Accessed July 10, 2009.

5. Gokula RM, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004;32:196-199.

6. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at

http://www.medscape.com/viewarticle/587464_4. Accessed July 6, 2009.


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Back to Basics Tenth in a Series

by Alecia Cooper, RN, BS, MBA, CNOR

Insertion of an indwelling urinary catheter is a common

procedure within perioperative services. In fact, as many

as 86 percent of patients undergoing surgery have urinary

catheters.1 In addition, 50 percent of these catheters remain in

place for more than two days.1 Have you ever thought about or

questioned if the catheter you were inserting was really neces-

sary and clinically indicated for your surgical patient? It has

become critically important that we evaluate the need for

urinary catheterization and no longer insert catheters for con-

venience or because there is a preference card telling us toinsert a catheter. Whats more, did you know that requests from

nurses to place a urinary catheter for nursing convenience are

not uncommon?2

New guidelines and recommendations tell us that we should

determine if there is an approved medical indication for

catheterization. This means that we evaluate and reconsider a

common practice occurring pre-, intra-, or postoperatively

insertion of an indwelling catheter prior to a certain surgical pro-

cedures. This evaluation may change how we have always

done things.

The Centers for Medicare & Medicaid Services (CMS),

as a result of the Medicare Modernization Act of 2003

and the Deficit Reduction Act of 2005, has identi-

fied catheter-associated urinary tract infec-

tion (CAUTI) as a healthcare-associated

infection (HAI) that can reasonably be

prevented through the application of

Tell Me Again Why This PatientNeeds a Catheter?

Patient Safety


32/84


evidence-based practice. CMS reported in the 2008 Fed-

eral Register that in 2007 there were 12,185 CAUTIs, costing

$44,043 per hospital stay.2 CAUTI is one of 10 hospital-

acquired conditions (HACs) for which CMS will no longer

provide reimbursement if it occurs during hospitalization.3

Brand-new CAUTI prevention guidelinesCAUTI is the number one healthcare-associated infection

(HAI), accounting for 40 percent of all hospital-acquired

infections.4 One in four patients receives an indwelling

urinary catheter at some point during their hospital stay.5

As a result of this data, leading industry experts, including

the Association for Professionals in Infection Control and

Epidemiology (APIC), the Society for Healthcare Epidemiol-

ogy (SHEA), the Centers for Disease Control and Prevention

(CDC), the Joint Commission and many others have joined

together to outline strategies and guidelines to prevent

catheter-associated urinary tract infections in acute care

hospitals.6 The CDCs Draft Guideline for Prevention of

Catheter-Associated Urinary Tract Infections 2008 (released

in June 2009) identifies new guidelines and recommenda-

tions to prevent CAUTI.

Barriers to CAUTI preventionThree distinct barriers to the prevention of CAUTI become

evident when analyzing the problem. In the perioperative

environment it is hard to imagine that there are errors in

aseptic technique because we are acutely aware of proper

technique. But remember that most nurses outside of the

perioperative environment do not routinely perform aseptic

technique and may not be aware when contamination

occurs. In fact, during most observations of nurses outsideof the perioperative environment, we have seen inconsis-

tent practice in setting up a sterile field and inserting

indwelling catheters aseptically. It is perfectly clear that in

perioperative services, two of the three barriers occur rou-

tinely too many catheters are inserted and catheters stay

in too long.

CAUTI incidence outside theperioperative environment

To help you further realize the magnitude and role of

perioperative services in preventing CAUTI, lets look at

additional statistics from outside the perioperative environ-

ment. Did you know that the emergency department (ED)

has the highest percentage of catheter placements?7 In the

ED, as well as in perioperative services, documentation of

the reason for catheter placement is poor and a written

physician order is frequently lacking. Without a physician

order, physicians are unaware that the patient has a

catheter.5 When physicians do not know that a catheter has

been inserted, it is no wonder that an order for timely

removal is lacking, and catheters stay in longer than med-

ically necessary.

Common catheter practices in perioperative servicesAdding to the problem, inappropriately placed catheters are

more often forgotten about.5 In 56 percent of hospitals there

is no system to keep track of which patients have catheters,

and 74 percent of hospitals do not keep track of how long

the catheter is in place.8 Shocking as this may be, lets

assess common practice in perioperative services and see

if any of these common occurrences occur at your facility.

1. Do you have preference cards that tell you to insert

an indwelling catheter for a specific procedures

performed by a particular surgeon?

2. Do you assess patients to determine if the standing

order to insert an indwelling catheter is medically

indicated?

3. When a patient comes to the OR with an

indwelling urinary catheter or when you insert oneintraoperatively, do you evaluate the need to keep

the catheter in place at the end of the surgical

procedure before transporting the patient to the

post anesthesia care unit (PACU)