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8/7/2019 OR Connection Magazine - Volume 6; Issue 1
1/124
Nurse LeadersRate PatientExperience
SpecialAORNIssue!
Breast Cancer
AwarenessSection Page 84
TheAligning practice with policy to improve patient care
FREE CE!
Man on aMission: HandHygiene Expert
ProfessorDidier Pittet
Turn up the heat on
HYPOTHERMIA
#1
Volume 6, Issue 1
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2/124
Subscribing to The OR Connection guarantees that youll continue to receive
this info-packed magazine and wont miss out on our industry updates andarticles addressing on-the-job issues and tips on caring for yourself!
We also welcome any suggestions you might have on how we can continue
to improve The OR Connection! Love the content? Want to see something
new? Just let us know!
To subscribe, simply go to
www.medline.com/orconnection.You will need to provide:
Your name
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Mailing address
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Never miss an issue of The OR Connection!Subscriptions are free and signing up is a snap!
Content KeyWe've coded the articles and information in this magazine to indicate which patientcare initiatives they pertain to. Throughout the publication, when you see these icons
you'll know immediately that the subject matter on that page relates to one or more of
the following national initiatives:
IHI's Improvement Map
Joint Commission 2009 National Patient Safety Goals
Surgical Care Improvement Project (SCIP)
We've tried to include content that clarifies the initiatives or gives you ideas and tools
for implementing their recommendations. For a summary of each of the initiatives,
see pages 8 and 9.
8/7/2019 OR Connection Magazine - Volume 6; Issue 1
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PATIENT SAFETY
6 Mission: Improving Hand Hygiene
8 Three Important Initiatives for Improving Patient Care
10 Patient Safety News
11 Provider Preventable Conditions
14 Turn Up the Heat: Avoiding Surgical Complications with
Adequate Patient Warming
30 ClearCount Clearly Makes a Difference in Patient Safety at
Hunt Regional Hospital
34 VAP: What is the Perioperative Nurses Role in Prevention?
47 The Quest to Improve Staff and Patient Safety: How One
Health District Converted to Latex-Free Surgical Gloves
61 Unity Hospital: Utilizing Medlines ERASE CAUTI Program
OR ISSUES
40 The Ins and Outs of Hernias and Ways to Repair Them
79 Upcoming Green Events & Green Facts
84 Study of Breast Biopsies Finds Surgery Used Too Extensively
101 Less Invasive Surgery Just as Effective for Some
Breast Cancer Patients
SPECIAL FEATURES
5 International Hand Hygiene Expert Urges U.S. to Use
Five Moments to Reduce Infection
56 Nurse Leaders Survey Results: Patient Experience Is #1
68 12 Ways to Reduce Hospital Readmissions
77 Medline Joins Greening the Operating Room Initiative78 Medline Launches Sustainability Program
88 Celebrating Six Years of Spreading Breast Cancer Awareness
92 Straight from the Heart: Quotes About the Pink Glove Dance
95 Beyond a Reasonable Doubt: Open Communication Helps
Jill Eikenberry Raise the Bar for Breast Cancer Awareness
CARING FOR YOURSELF
102 How to Energize Your Team
110 Recipe: Aunt Judys Tortilla Roll-Ups
FORMS & TOOLS
113 Highlights of AORNs Revised Recommended Practices
for Surgical Attire
120 CDC Hand Hygiene Poster
121 How Well Do You Know Pressure Points?
Editor
Sue MacInnes, RD, LD
Clinical Editor
Alecia Cooper, BS, MBA, RN, CNOR
Senior Writer
Carla Esser Lake
Creative Director
Mike Gotti
Clinical Team
Jayne Barkman, BSN, RN, CNOR
Lorri Downs, RN, BSN, MS, CIC
Margaret Falconio-West, BSN, RN, APN/CNS,
CWOCN, DAPWCA
Rhonda J. Frick, RN, CNOR
Anita Gill, RN
Kimberly Haines, RN, Certified OR Nurse
Rebecca McPherson RN, MSN
Carla Nitz, BSN, RN
Claudia Sanders, RN, CFA
Megan Shramm, RN, CNOR, RNFA
Angel Trichak, RN, BSN, CNOR
Perioperative Advisory Board
Larry Creech, RN, MBA, CDT
Carilion Clinic, Virginia
Sharon Danielewicz, MSN, RN, RNFA
Cedar Park Regional Medical Center, Texas
Tracy Diffenderfer, MSN, RN
Vanderbilt University Medical Center, Tennessee
Barb Fahey RN, CNOR
Cleveland Clinic, Ohio
Susan Garrett, RN
Hughston Hospital Inc., Georgia
Zaida I. Jacoby, MA, MEd, RN
NYU Medical Center, New York
Jackie Kraft, RN, CNOR
Huntsville Hospital, Alabama
Tom McLaren
Florida Hospital, Florida
Susan Phillips, RN, MSH, CNOR
University of North Carolina Hospitals
Donna A. Pritchard, BSN, MA, RN, CNOR, NE-BC
Kingsbrook Jewish Medical Center, New York
Debbie Reeves, MS, RN, CNOR
Hutcheson Medical Center, Georgia
Diane M. Strout, BSN, RN, CNOR
St. Joseph Medical Center, Washington
About Medline
Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospi tals, extended care facilities, surgery centers, home care dealersand agencies and other markets. Medl ine has more than 800 dedicated sales representatives nationwide to support its broad product line and cost management services.
2011 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
Page 14
Page 92
Page 102
Page 68
Page 77
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Last night I had the opportunity to have dinner with Professor
Didier Pittet (one of the foremost authorities on hand hygiene).
He spoke with great energy and passion about a number of
pertinent topics, including The World Health Organizations
Hand Hygiene Campaign, the Five Moments of Hand
Hygiene, and the hand hygiene compliance rates of mostfacilities in the United States as compared to other countries.
What a fascinating man he is. One of his achievements is
being appointed Commander of the British Empire (or CBE,
an international honor that includes knighthood). This honor
was awarded by Queen Elizabeth II in 2007 for his services
in the prevention of healthcare-associated infection in the
United Kingdom. He told the story, with great charm and
humility, of what is was like to be knighted by the Queen of
England for his contributions to safety and health care. He
said that while it was a great honor, it was also quite stressful,
as he was allowed to bring only two people with him to the
actual ceremony he chose his two daughters. You can
probably imagine their pride as they got to watch their dad
become only the second person from Switzerland ever to
be so honored.
I was enthralled, sitting across the table from this icon of
healthcare safety and listening to his stories of knighthood,
his early training and his current projects, which include
recording the English narration for the Hand Hygiene
Dance Video, originally performed and filmed at the
University of Geneva. (Our cover photo for this edition is from
the recording session.) Watch for an online link to the final
production to be printed in an upcoming issue ofThe OR
Connection!
Dr. Pittets visit was just one of the amazing experiences Ive
had in the last few weeks. Barely a week ago I met with Dr.
Haywood, Senior Vice President and Chief Medical Officer
of VHA, and his team to discuss research pertaining to
HCAHPS, the patient experience survey that is on the minds
of many nurse executives. I think it is so important to be
aware of the concerns and priorities of hospital administration,
so Ive included on page 56 very recent survey results on
whats most important to nursing leaders today.
Prior to Dr. Haywoods visit, I had met with Kaiser Perma-
nente on the West Coast to talk about healthcare innova-
tions that can be explored and tested. I dont mean
innovations that are made up in a lab or in some corporate
office, but real-life examples of how healthcare professionals,
thought leaders and industry can work together to make
your jobs simpler and to make the chaos of everyday
practice easier to navigate. Weve all been accustomed to
how things have always been done. But this is a new era of
change designed to support the healthcare worker while
improving care. And you are a very important part of this
model.
This edition ofThe OR Connection is being launched at the
AORN 58th Congress, March 18-24, 2011, in Philadelphia,
Pennsylvania my hometown. For those attending the Con-
gress, Medline has included a list of items on page 66 that
we will be featuring at our Booth #3408. If you dont get a
chance to attend, but you would still like information on any
of our programs or products, please give me a call at
847-643-4093. Although we would love to tell you more
about our products and programs, we are just as interested
in your ideas for innovation, so my line is open to you. This
is our biggest issue yet. There are so many things going on
in our industry, Im sure within these pages there is something
that will be of interest you.
Sincerely,
Sue MacInnes
4 The OR Connection
The OR ConnectionLetter from the Editor
VISIT MEDLINE BOOTH #3408 AT AORN CONGRESS
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Aligning practice with policy to improve patient care
International hand hygiene expert Professor Didier Pittet,MD, MS traveled from Geneva, Switzerland to Chicago this
spring to partner with U.S. healthcare workers to improve
hand hygiene compliance.
Dr. Pittet emphasized that despite hand hygienes proven ben-
efits in reducing infection, Its very frightening first to realize
that the compliance is so low, he said. On average its around
40%, at the best, and its not rare that when you come in a
unit or a ward the average compliance will be around 20%.
Dr. Pittet began his visit to Chicago at a recording studio where
he recorded English narration for a short film that promotes the
World Health Organizations (WHO) Five Moments for Hand
Hygiene. The film is called O Les Mains! translated in Eng-
lish it means Raise your Hands. Dr. Pittet currently uses
the film, which features professional dancers, to encourage
and teach proper hand hygiene techniques at his hospital in
Geneva. With Medlines help, Dr. Pittet hopes to get the video
to go viral to inspire healthcare workers in the U.S. and
around the world to learn proper hand hygiene.
Five Moments for Hand Hygiene defines the key times forhand hygiene, presents a unified vision on proper hand hygiene
technique and promotes a strong sense of ownership.
While in Chicago, Dr. Pittet, along with Mark Chassin, presi-
dent of The Joint Commission, also addressed more than 200
senior clinicians and infection preventionists at Loyola Univer-
sity Medical Center in Chicago. Their unified message was
clear a highly compliant and successful hand hygiene
program starts at the top of an organization with its leader-
ship. The event, called Safe Care Town Hall Forum was
co-hosted by Medline and Loyola, and is the first in a series of
patient safety forums to be held around the country.
Dr. Pittet also spoke before medical and nursing students at
Loyolas Stritch School of Medicine. Dr. Pittet believes teaching
healthcare professionals about proper hand hygiene techniques
early in their careers will instill good habits that will stay with
them long term.
Coming toAmerica:
International Hand Hygiene Expert Urges U.S.
to Use Five Moments to Reduce Infection
Special Feature
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6 The OR Connection
Joint Commission-accredited hospitals now have access to
an interactive tool that simplifies processes for solving
healthcare quality and safety. The Targeted Solutions
Tool (TST) encapsulates the work of the Joint Com-
mission Center for Transforming Healthcare and pro-
vides step-by-step processes to measure
performance, identify barriers to excellent perform-
ance, and implement proven solutions.
The first set of targeted solutions focuses on
improving hand hygiene. It was created by
eight of the countrys leading hospitals and
healthcare systems working with the
Center. The TST provides accredited
hospitals the foundation and
framework of an improvement
method that, if implemented well, will improve hand hygiene
compliance and contribute substantially to reducing health
care-associated infections.
The complimentary data-driven tool provides validated andcustomized solutions to address particular barriers to excel-
lent performance. Self-paced and confidential, the TST offers
instantaneous data analysis.
I encourage hospital leaders to use these tools to identify
very specific ways to improve their hand hygiene programs,
said Mark R. Chassin, MD, MPP, MPH, president of the Joint
Commission. Consistent excellence in hand hygiene is vital
to our larger aim of eliminating preventable health care-asso-
ciated infections. The Targeted Solutions Tool provides hos-
pitals with powerful new knowledge and methods they
can use right away to make substantial advances toward
this goal.
Data validates effectiveness of hand hygiene toolAt the start of the project in April 2009, the par-
ticipating hospitals were surprised to learn that
their rate of hand hygiene compliance aver-
aged 48 percent. By June 2010 they had
reached an average rate of 82 percent that
had been sustained for eight months.
Nineteen small, medium and large hos-
pitals across the country also collabo-
rated with the Center to test the work of the original eight
hospitals and provide guidance on the development of the
solutions that are now available through the TST. These
hospitals are experiencing similar gains as the original eight.
For a free electronic copy of the Targeted Solutions Tool for
hand hygiene, Hand Hygiene Factors and Solutions, go to
http://www.centerfortransforminghealthcare.org/tst.aspx.
Medline Industries, Inc. is a proud sponsor of the Center for
Transforming Healthcare Endowment Fund.
Joint Commission Center for Transforming Healthcare
Targeted Solutions Tool for Hand Hygiene
Mission:Improving hand hygiene
Measure
performance Id
entifyBa
rriers
Implement Proven Solutions
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No More Sticky Hands
Sterillium Rub Waterless Surgical Scrub
evaporates quickly for faster OR preparation.
Emollients leave hands feeling soft and silky
never sticky or tackyminimizing friction
and skin trauma when donning gloves. Its
also CHG, latex and non-latex compatible.
For a FREE Sterillium Rub
Waterless Surgical Scrub
trial, contact Lynsey Wolfe
at 847-643-4329
STERILLIUM
RUB:FAsTeR RUb TO GlOve
2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Sterillium is a registered trademark of Bode Chemie GmbH
1. Topical Antimicrobial Drug Products for Over-the-Counter Human Use;Tentative Final Monograph for Health Care Antiseptic Drug Products,59 FR 31042 (1994) (to be codified at 21 CFR 333)
2. Data on file
Exceeds FDA Requirements1
Sterillium Rub is the only waterless, brushless
surgical scrub with 80% (w/w) ethyl alcohol
the highest alcohol concentration of any surgicalrub available in the US. Its long-lasting, persistent
effect exceeds FDA requirements for surgical hand
antisepsis. Sterillium Rub provides a rapid and
comprehensive kill of transient and resident skin
flora, with a 6 log reduction within two minutes.2
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8 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 covers the entire landscape of outstanding hospital care to help hospitals make sense of countless requirements
and focus on high-leverage changes to transform care. There are 70 processes grouped into three domains: leadership and management,patient care and processes to support care.
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 2011; however, revisions to the NPSGs will be effective in 2011.
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 2011 National Patient Safety Goals2
Surgical Care Improvement Project (SCIP)3
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IHI Improvement Map: 73 Processes to Transform Hospital Care
Surgical Care Improvement Project (SCIP): Target Areas
Joint Commission 2011 National Patient Safety Goals
Aligning practice with policy to improve patient care
Patient Safety
Effective January 1, 2011:
Improve the accuracy of patient identification.
Improve the effectiveness of communication
among caregivers.
Improve the safety of using medications.
Reduce the risk of healthcare-associated
infections.
Accurately and completely reconcile medications
across the continuum of care.
The organization identifies safety risks inherent in
its patient population.
Universal Protocol for Preventing Wrong Site,
Wrong Procedure, and Wrong Person Surgery.
To learn more about National Patient Safety Goals, go to www.jointcommission.org.
The IHI Improvement Map is an online tool that distills the best knowledge available on the key process
improvements that lead to exceptional patient care.
To learn more about the IHI Improvement Map and the 73 processes to transform hospital care, go to www.ihi.org/imap/tool
1. Surgical infections
Antibiotics, blood sugar control, hair removal, perioperative
temperature management
Remove urinary catheter on Post Operative Day (POD) 1 or 2
2. Perioperative cardiac events Use of perioperative beta-blockers
3. Venous thromboembolism Use of appropriate prophylaxis
3 New Key Processes as of June 2010
1. Anticoagulation Management
2. Essential Care for Frail Older Patients
3. Glycemic Control in Non-Critically Ill Patients
Top 5 Key Processes Shared by Improvement Map Users
1. Central Line Bundle
2. CA-UTI
3. Anti-Biotic Stewardship
4. Falls Prevention
5. Heart Failure Core Processes
Visit www.qualitynet.org
By the numbers:
3,740 hospitals are submitting
data on SCIP measure #9, representing
75 percent of all U.S. hospitals
Currently, SCIP has more than 36
association and business partners
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10 The OR Connection
The Department of Health and Human Services recently
released its findings that about 134,000 Medicare patients
experienced adverse events in hospitals during a single
month in 2008. About 44 percent of the events were con-
sidered to be preventable. The cost to treat the affected
patients was estimated at $324 million.
The Centers for Medicare and Medicaid Services (CMS)
responded that it will aggressively pursue efforts to expand
adverse event reporting and the types of events that are
considered reportable. Only six states currently require
public reporting of medical errors.
New suggestions for blood glucose
management during outpatient surgery
The Society for Ambulatory Anesthesia (SAMBA) issued a
consensus statement at the end of 2010 outlining glucose
management suggestions for anesthesia providers. The
significant practice changes include:2
Preoperative advice to the patient regarding the use
of their anti-diabetic drug on the day of surgery
The use of rapid-acting insulin rather than regular
insulin during surgery
Use of the 1500/1800 formula for determining the
dose of insulin
Avoiding the temptation to normalize blood glucose
levels in patients with inadequately controlled levels
References1. Hospitals hurt 134,000 Medicare patients a month. Outpatient Surgery
Magazine. November 30, 2010.2. SAMBA issues suggestions for blood glucose management in diabetic
patients. Outpatient Surgery Magazine. December 2010.
National Patient Safety Foundation
launches new membership organization
for healthcare professionals
The American Society of Professionals in Patient Safety
(ASPPS) is a new membership organization launched by the
National Patient Safety Foundation (NPSF). It is seeking mem-
bers from across the spectrum of healthcare disciplines to
help extend the groups agenda of accelerating the delivery of
safe patient care and establishing consistency in safety prac-
tices and tools. The organization plans to implement a certi-
fication program to validate competencies and practices that
are proven to reduce medical errors. Information on mem-
bership and the May 2011 Patient Safety Congress can befound at www.npsf.org/hp/ASPPS.php.
PATIENT SAFETY NEWSPATIENT SAFETY NEWS
134,000 Medicare patients per month hurt at hospitals1
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Aligning practice with policy to improve patient care 1
Since the summer of 2008, the Centers for Medicare and
Medicaid Services (CMS) has encouraged states to model theirMedicaid payment rules after the federal Medicare program.
Now, the Affordable Care Act (ACA) has mandated that the
Medicare rules for withholding payment for never events now
be extended to state-run Medicaid programs. The Affordable
Care Act (ACA) requires the new rules extension be effective
July 1, 2011.
The eleven CMS-recognized preventable conditions are:
Retained items after surgery
Air embolism
ABO blood incompatibility
Catheter-associated urinary tract infection (CAUTI)
Pressure ulcers
Central line-associated bloodstream infection (CLABSI)
Surgical site infection (SSI)/mediastinitis
Falls and certain other traumas
SSI after certain elective procedures
Poor glycemic control manifestations
Deep vein thrombosis (DVT)/pulmonary embolism (PE)
This list is exhaustive for Medicare, but for Medicaid CMS has
intentionally granted states the flexibility for including other con-
ditions beyond the eleven that CMS has already identified.
The different nature of Medicaid and the services it pays for has
created a new set of terminology to learn. HAC, hospital-
acquired condition is now pass, as is HCAC, the more generic
healthcare-acquired condition. The preferred new term is
provider preventable condition, or PPC. The definition of a PPC
is a condition that could have reasonably been prevented
ProviderPreventableConditions:
ExpandingNever Event/No-Pay
Regulations
Patient Safety
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12 The OR Connection
through the application of evidence-based guidelines. PPCs
would encompass the same healthcare-acquired conditions as
defined for Medicare purposes, plus other PPCs defined by
states and approved by CMS.
Perhaps more significant than the what of a PPC is the
where it may occur. CMS proposes using PPC as an umbrella
term for both hospital and non-hospital conditions identified by
a state for nonpayment. PPCs would encompass hospital-acquired conditions, as defined for Medicare purposes, and
other PPCs applicable to service settings beyond the inpatient
hospital setting. CMS notes that preventable conditions can
occur in an outpatient hospital, nursing facility and ambulatory
care settings. The denial of claims for PPCs happening in any
of these environments is a significant expansion of the existing
regulations.
What does all this mean?Like any significant policy change such as this one, there will be
both expected results and unexpected consequences. The
original Medicare claims denials for HACs are running at
approximately $20 million per year. Over the next five years, the
Medicaid claims denials for PPCs are expected to total $35 mil-
lion, or an average of an additional $7 million per year. The Med-
icaid savings are divided approximately 60/40 between Federal
and state savings.
There will be costs associated with this new rule, too. CMS
estimates that both states and providers regulatory and
reporting compliance will be relatively small. Providers, however,
will incur additional costs to reduce PPCs. These costs may be
from hiring more nurses and infection control professionals aswell as training staff on best practices for PPC prevention.
Equipping staff with evidence-based products and programs
that help deliver better outcomes may be seen as an additional,
but very necessary cost as well. Most hospitals have taken
these PPC prevention steps to comply with Medicare rules.
However, most non-hospital health care settings will now find it
necessary to make expenditures to address the PPCs that
occur in their environment.
While the explicit purpose of the regulation is cost containment
through administrative action, the implicit purpose is the public
benefit of an overall reduction in PPCs and a correspondingincrease in healthy years of life. CMS is quick to point out, how-
ever, that the regulation itself is not responsible for the better
health of the population, but rather the responses made to it by
hospitals and other care providers.
For more information, visit: https://www.federaregister.gov/
artices/2011/02/17/2011-3548/medicaid-program-pament-
adjstment-for-provider-preventabe-conditions-incding-heath
CMS no pay for never events policy used to
be Medicare only. In July its set to be part ofall 50 state Medicaid plans.
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Promote Correct-Site Surgery
Our Surgical Time Out Procedure (S.T.O.P.)
safety products alert the surgical team to
perform a time-out verification and help reduce
the risk of wrong-site surgery.
Support Sharps Safety Practices
Transfer trays, scalpel holders and needle
counters with blade guards promote sharps
safety and help make you OSHA compliant.1
Improve Fluid Disposal Safety
The Safety-Splash fluid management system
converts biohazardous fluids into a solid,
minimizing the risk of exposure.
2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.Safety-Splash and S.T.O.P are trademarks of Medline Industries, Inc.
References:
1. Occupational Safety and Health Standards, Toxic and Hazardous Substances,
Bloodborne pathogens. Regulations (Standards - 29 CFR). Available at: http://
www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_
id=10051#1910.1030(d)(2)(i). Accessed October 13, 2010.
Medlines Gold Standard safety products stand out against thesea of blue in the OR to alert the surgical team to focus on safety.
For a FREE sample bundle, [email protected].
MEDLINE GOLD STANDARD SAFETY COMPONENTS
SAFETYDESERVES
ATTENTION
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Avoiding Surgical Complicationswith Adequate Patient Warming
14 The OR Connection
CE Article
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SCIP-Inf-101Measure: Surgical patients should be actively warmed during surgery or have at least
one recorded body temperature equal to or greater than 96.8 degrees Fahrenheit
within 30 minutes prior to the end of anesthesia to 15 minutes after anesthesia ends.
(Patients with intentional hypothermia are excluded from this measure.)
In 2003, the Joint Commission and the Centers for Medicare and
Medicaid Services (CMS) teamed up to align their common meas-
ures. In the process, they decided to add a set of measures for Sur-
gical Infection Prevention (SIP), which was quickly added as a core
measure set.2 In July, 2006, SIP was renamed the Surgical Care
Improvement Project (SCIP).
Members of the SCIP Steering Committee include the Association
of periOperative Nurses (AORN), the Joint Commission, the Centers
for Medicare and Medicaid Services (CMS), Agency for Healthcare
Research and Quality (AHRQ), American College of Surgeons
(ACS), American Hospital Association (AHA), American Society of
Anesthesiologists (ASA), Centers for Disease Control and Prevention
(CDC), Department of Veterans Affairs, and the Institute for Health-
care Improvement (IHI).3This national partnership of organizations
works together to improve the quality of surgical care.
To date, SCIP has introduced 10 measures, plus three others
specifically addressing cardiac patients and venous thromboem-
bolism. All measures are to be followed in order to reduce surgical-
site infections and other complications of surgery. (For the complete
list of all SCIP Measures, turn to the back of this article.)
SCIP-Infection (Inf.)-10, also known as SCIP Measure 10 Surgery
Patients with Perioperative Temperature Management, went intoeffect October 1, 2009.4 When the measure was first adopted, the
best available temperature management evidence was on patients
having colectomies while under general anesthesia. Consequently,
the measure initially focused on this population.
Currently, SCIP-Inf.10 applies to patients of any age undergoing
surgical or therapeutic procedures while under general or neurax-
ial anesthesia for one hour or more. It does not include patients
undergoing cardiopulmonary bypass.5
Contined on Page 17
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For protection from unintentional hypothermia in patients
undergoing surgery, PerfecTemp is an excellent alternative
to forced-air warming systems.
While other systems use disposable blankets to force
warm air on top of patients, PerfecTemps unique
surgical table pads offer.
Efficient underbody warming as effective asforced-air systems for preventing unintentionalhypothermia.1
More accurate patient monitoring
Complete patient access
Silent operation
Reduced staff time
No blowing air Energy conservation
PerfecTempOR Patient Warming System
Innovation in Patient Warming
2011 Medline Industries, Inc. Medline and PerfecTemp are registered trademarks of Medline Industries, Inc.
Flexible and durable carbon heating
element for uniform heating.
Underbody Warming for All
Patients and Procedures
References
1. Egan C, Bernstein E, Reddy D, et al. A Randomized Comparison of Intraoperative Warming With the LMA PerfecTemp
and Forced Air During Open Abdominal Surgery.
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Aligning practice with policy to improve patient care 1
Intraoperative core temperatures
about two degrees Celsius below
normal increase the incidence
of wound infection threefold and
prolong hospitalization by about
20 percent.5
Under SCIP-Inf-10 clinicians must either actively warm patients
during surgery or record a body temperature of 36 degrees C (96.8
degrees Fahrenheit) or higher within 30 minutes before or 15 minutesimmediately after the end of anesthesia. Clinicians must provide clear
documentation of the temperature during active warming or in rela-
tion to the end of anesthesia.
What causes perioperative hypothermia?As warm-blooded creatures, human beings organ systems are
designed to operate within a narrow temperature range. Hypother-
mia occurs when a persons body loses more heat than it can pro-
duce, leading to a core body temperature drop. In nature, we know
what makes us cold and we can respond. Exposure to cold air
encourages us to get out of the cold or bundle up. Being dampcauses us to seek drier conditions. We put on jackets or seek shel-
ter to get out of the wind. In the OR, perioperative hypothermia is
common, resulting from the effects of anesthesia on the bodys ther-
moregulatory control system.6
Many factors can contribute to unplanned perioperative hypother-
mia, including cool air temperature in the OR, length of surgery (the
longer the surgery, the greater the likelihood of hypothermia occur-
ring), blood and fluid loss, and effects from anesthesia, which alters
the patients ability to regulate body temperature. A patients body
type can also affect heat loss. Very thin, malnourished patients aswell as those who are very young or elderly are more susceptible to
perioperative hypothermia.7
Elderly patients are more susceptible to hypothermia for a number
of reasons. The body's ability to regulate temperature and to sense
cold may lessen with age. Comorbidities that affect temperature reg-
ulation are more likely in older adults, including conditions such as
hypothyroidism, stroke, severe arthritis, Parkinsons disease, and
neuropathies including diabetic neuropathy. They are also frequently
more dehydrated and malnourished than the general population.
Finally, medications including some antipsychotics and sedatives
(both of which are used more frequently in long-term care settings)
can impair the bodys ability to regulate its temperature.
Core body temperature changes occur in three stages, beginning
with the onset of general anesthesia. During the first hour, redistrib-
ution is the main cause of potential perioperative hypothermia.
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18 The OR Connection
0
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After indcing anesthesia, a patients
core bod temperatre drops rapid.9
Complications associated with perioperative hypothermiaHypothermia, which is defined as having a core body temperature
of less than or equal to 36 degrees Celsius or 96.8 degrees
Fahrenheit, is associated with several complications and an in-
creased risk of death. Perioperative hypothermia can result in: 11
three times the incidence of surgical site infection
increased bleeding and increased need for blood transfusions
three times the risk for cardiac complications
a higher risk for developing pressure ulcers
prolonged recovery after surgery
Surgical site infection. Hypothermia causes the blood vessels
to constrict, decreases blood flow to tissues and decreases oxy-
genation of surgical wounds, allowing a more favorable environ-
ment for bacterial growth. In 1996 Andrea Kurz, MD, andcolleagues published a study involving 200 colorectal surgery
patients; 100 were randomly assigned to undergo surgery with
warming and the other 100 without warming. For those who did
not receive warming, the final mean intraoperative core temper-
ature was 34.7 degrees Celsius. The final mean temperature for
those who were warmed was 36.6 degrees Celsius. Surgical
wound infections were found in 19 percent of the hypothermic
group and in six percent of the normothermic group. The
authors concluded that intraoperative core temperatures about
two degrees Celsius below normal increase the incidence of
wound infection threefold and prolong hospitalization by about20 percent.12
Melling et al. also conducted a study of wound infection rates
following surgery. The random controlled trial included 421
patients and resulted in a four percent infection rate among
patients who received local warming and 15 percent among
those who were not warmed.8
During this stage, warmer blood from the core is allowed to mix
with cooler blood from the rest of the body. The blood cools as
it circulates, and the cooled blood that returns to the heart cancause a decrease in body temperature8 of up to one degree
Celsius.7
Redistribution is followed by the second phase, which occurs
during the second and third hours of anesthesia, during which
heat loss exceeds the bodys ability to produce heat. During this
phase, warming the patient can effectively limit further heat loss.
Finally, after about three to five hours of anesthesia, the patients
temperature reaches a plateau, which usually remains constant
for the remainder of the surgery, regardless of how long the rest
of the procedure takes.
Did you know?
Some patients report that shivering and being
cold are worse than surgical pain. Hypothermia
can cause a vigorous shivering response, which
increases carbon dioxide production and increases
oxygen consumption 400 to 500 percent.10
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20 The OR Connection
Cardiac complications.A 1993 study by Johns Hopkins anes-
thesiologist S.M. Frank, MD, and colleagues revealed that a
greater number of hypothermic patients (36 percent) experi-
enced myocardial ischemia compared with normothermic
patients (13 percent). The incidence of angina postoperatively
was also greater among the hypothermic group (18 percent)
compared with the normothermic group (1.5 percent).15All 100
subjects in the study underwent a vascular reconstruction
procedure.
It is important to recognize the difference between unintended
hypothermia that leads to cardiac conditions, and the growing
practice of therapeutic, induced hypothermia in cardiac patients.
Unintentional hypothermia (perioperatively or otherwise) can lead
to an unusually slow or irregular heart rate, which manifests as
a weak or slow pulse or other arrythmias.16 Therapeutic hy-
pothermia is an evidence-based intervention that attempts to
lower core temperatures to around 33 degrees Celsius
for 24 hours after a cardiac event for the purpose of improving
neurological outcomes.
Perioperative pressure ulcers. Because of circulatory and
metabolic changes that occur during surgery, the etiology of
perioperative pressure ulcers is more complex than those that
One suspected cause of surgical site infections has been
understood to be a lack of oxygen, in particular bactericidal
oxide radicals. As a drop in core temperature leads to vaso-
constriction to preserve heat in the body, less oxygenated blood
flows to a wound site on the skin. That reduction in available
oxygen at the wound site makes it more conducive to bacterial
growth. One study found that dissolved oxygen (pO2) is a
strong predictor of infection. Measuring levels of subcutaneous
oxygen in post-surgical patients, he found that none with an
oxygen tension greater than 90 mmHg developed a SSI
whereas 43 percent of patients with an oxygen tension between
40 and 50 mmHg did develop a SSI.
Increased blood loss.A meta-analysis published in 2008 by
Daniel Sessler, MD, professor and chair of the Department of
Outcomes Research at Cleveland Clinic, and colleagues found
that less than one degree of hypothermia is enough to increaseblood loss by about 16 percent and increase the need for in-
traoperative transfusion by about 22 percent. Normothermia,
however, was associated with a reduced chance of blood loss
and a reduced need for transfusion.13 Similarly, an earlier study
by Schmied and colleagues in 1996 also found that mild hy-
pothermia can increase blood loss and the need for transfusion
during surgery.14
Published evidence shows
high rates of complications
among hypothermic surgical
patients, making it important
for perioperative professionals
to keep patients warm.
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Aligning practice with policy to improve patient care 2
occur in medical patients.17 In a 2001 study researchers
hypothesized that patients capacity to withstand mattress pres-
sures during surgery would increase if hypothermia were
prevented. They performed a randomized control trial to explore
the relationship between tissue viability and patient coretemperatures during surgery and to test the hypothesis that
patient warming would reduce the incidence of pressure ulcers.
Their trial involving 324 surgical patients resulted in an eight
percent pressure ulcer incidence among patients who were
warmed with a forced air over-blanket, versus a 65.4 percent
incidence among patients who were not warmed.18
Prolonged recovery. Rainer Lenhardt, MD, clinical director of
the Neuroscience-Anesthesia Intensive Care at the University of
Louisville School of Medicine, and colleagues hypothesized that
intraoperative hypothermia may prolong immediate surgicalrecovery by increasing the potency of the anesthetic, delaying
drug metabolism or depressing cognitive function. They followed
150 patients undergoing elective major abdominal surgery and
discovered that hypothermic patients required about 40 minutes
longer than normothermic patients to reach fitness for discharge.19
Length of stay in the post-anesthesia care unit (PACU) is an
important issue for health care managers. PACU nurses care for
a small number of patients because of the high level of attention
and care needed by a person recovering from anesthesia. Some
have calculated that the personnel cost for two-hours in thePACU stay is similar to the personnel cost for a full day on a general
care unit in a hospital.20 In an era of cost control, decreasing
recovery time is economically desirable for the institution.
Warming methodsAs summarized above, published evidence shows high rates of
complications among hypothermic surgical patients, making it
important to maintain normothermia. There are several kinds of
surgical warming devices available.
Types of warming devices include forced air over or under the
body; circulating warm-water devices; or conductive, active
warming devices, which include under-the-body warming
mattresses or over-the-body warming blankets. In addition to
requiring perioperative professionals to maintain normothermia
in patients, SCIP-Inf.-10 also requires clear documentation
regarding the use of active warming devices.11
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22 The OR Connection
Pulmonary artery.The most accurate measurement
of the core body temperature is through the pulmonary
artery, which is bathed in blood from the core. This
invasive form of monitoring, however, is not justified
solely for temperature assessment.
Recommendation IVThe core temperature of patients at risk for unplanned
hypothermia should be monitored pre-operatively,
intraoperatively and postoperatively.
Recommendation V
Interventions should be implemented to prevent
unplanned hypothermia.
Recommendation VI
Warming devices should be used in a manner that
minimizes the potential for patient injuries.
Recommendation VII
Competency
Personnel should receive initial education and competency
validation and updates on the prevention of unplanned
hypothermia and the use of warming equipment.
Recommendation VIII
Documentation
Patient assessments, the plan of care, interventions
implemented, and evaluation of care to prevent unplanned
perioperative hypothermia should be documented.
Recommendation IX
Policies and Procedures
Policies and procedures for prevention of unplanned
hypothermia should be developed in collaboration with
anesthesia care providers, reviewed periodically, revised as
necessary, and readily available in the practice setting.
Recommendation XQuality
A quality improvement/management program should
be in place to evaluate the structure, process, and
outcomes of interventions used to protect patients from
unplanned perioperative hypothermia.
How to prevent perioperative hypothermiaAlthough SCIP recommends keeping patients warm during
surgery, it does not recommend how to keep them warm.21
Nursing organizations, including the Association of
periOperative Registered Nurses (AORN) and the American
Society of Perianesthesia Nursing have developed standards
for preventing hypothermia during surgery. The followingare highlights from AORNs Recommended Practices for
Prevention of Unplanned Perioperative Hypothermia.22
Recommendation I
The perioperative registered nurse should assess the
patient for risk of unplanned perioperative hypothermia.
Recommendation II
The perioperative registered nurse should develop
a plan of care to minimize the risk of unplanned
perioperative hypothermia in patients identified at risk.
Recommendation III
Equipment to monitor core temperature should be
selected based upon reliability and access to the route.
III.a.1
There are four reliable sites for measurement of core
temperature:
Tympanic membrane.The tympanic membrane
temperature, measured by a thermocouple, is the
preferred method in many perioperative and postoperative
areas. This method is noninvasive, and the monitoring
site receives blood supply from the carotid artery, which
supplies the thermoregulatory center of the hypothalamus.
Distal esophagus.The distal esophagus is considered
a desirable site to measure temperature, particularly in
the operating room, and is less prone to artifact than most
others. It is an alternative to the pulmonary artery and is
widely used intraoperatively. Placement of the probe in the
lower fourth of the esophagus prevents artifactual cooling
of the probe by respiratory gases. Nasopharynx.The nasopharynx is another reliable
monitoring site for intraoperative measurement because it
approximates core temperature. A thermistor probe is
inserted through the nares to the nasopharynx.
Measurements may be influenced by the temperature
of inspired gases and often are 0.5 degrees Celsius
lower than pulmonary artery temperatures.
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Aligning practice with policy to improve patient care 2
near the patients skin to continuously monitor and control the
heat generation of the pad. Warming can begin as soon as the
patient is positioned on the OR table. The anesthesiologist can
select one of five preset temperatures of 37, 38, 39, 40, or 40.5
degrees Celsius. The heating element is placed below one inch
of viscoelastic memory foam to provide pressure redistribution
for the patient. The entire pad is encased in a fluid proof cover
and all seams are sealed to prevent penetration by spilled fluids,
meaning the mattress can be cleaned and reused, eliminating
unnecessary environmental waste. In addition, because the
patient is warming from underneath, blankets need not be
placed on top of the patient, allowing for greater surgical access.
The device also operates with no noise.
Warming blankets. Warming blankets are one option that is
portable, easy-to-use and effective. The downside, however, is
that nurses must make multiple trips to and from the blanket
warming cabinet to ensure the patient always has a warm blanket.
This can reduce efficiency and increase laundry costs.23
Also,adding too many layers of warmed cotton blankets is ineffective
in raising the patients body temperature. The first blanket can
reduce heat loss by 33 percent, however, adding another blanket
only adds another 18 percent reduction in heat loss. Adding
three or more blankets adds no further warming.8
Forced air warming.Another widely used option is forced air
warming. The system consists of a warming unit and a remov-
In an interview with OR Manager, perioperative hypothermia
expert Dr. Sessler stated that it doesnt matter which warming
method is used as long as the patients temperature is approx-
imately normal at the end of the surgery.21 Dr. Sessler is a lead-
ing researcher in surgical warming and has co-written many
studies on how hypothermia affects surgical patients and the
effectiveness of warming devices.
Warm IV fluids. Warming IV fluids is another way to increase
body temperature, but only under certain circumstances.
AORNs Recommended Practices for Prevention of Unplanned
Perioperative Hypothermia states:22
Warming intravenous (IV) fluids should be considered only if
large volumes (i.e., more than two liters/hour for adults) are
being administered. Warming IV fluids to near 37 degrees Cel-
sius (98.6 degrees Fahrenheit) prevents heat loss from the
administration of cold IV fluids and should be considered as an
adjunct to skin surface warming. When less than two liters ofvolume is given, fluid warming is of limited value because fluid-
induced cooling is minimal.
Conductive warming devices. One type of patient warming
pad on the market is an electrical resistive/conductive device
that warms underneath the patients body. It takes the place of
an existing OR table mattress pad. The device incorporates dual
fiber optic interface temperature sensors under the pad cover
Methods of Patient Warming
Warm IV Fluids
Conductive Warming Devices
Warming Blankets
Forced Air
Circulating Water Garments
Increased Operating Room Temperature
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24 The OR Connection
Differences in perioperative patient warming sstems rest
arge from what tisses are in contact with what heating ee-
ment and the avaiabe srface area. Heat transfer aso depends
on phsica characteristics of the heater-skin interface. For
exampe, the srface area of the ng is enormos, bt airwa
heaters and hmidifiers transfer trivia amonts of heat becase
the therma capacit of air is sma.
With an ctaneos warming sstem, heat transfer into the ther-
ma core depends on skin temperatre, tisse insation, and
circator convection of heat within the bod. Device efficac
ths depends on which srface area is heated becase the core
is reative isoated from dista skin srfaces. Bt most impor-
tant, ctaneos heat transfer depends on skin temperatre.
Near a commercia avaiabe patient-warming sstems are
eectrica powered; there is, therefore, no intrinsic phsica imit
to the caories that can be provided. Instead, the imitation is a-
was the skin temperatre that can be toerated withot nde
risk of brns.
Despite the high heat capacit and therma condctivit of water,
the efficac of conventiona circating-water mattresses is mod-
est. Poor efficac rests becase 1) the posterior srface is a
reative sma fraction of the bod srface area, 2) this area is
poor perfsed becase the weight of the bod compresses
ctaneos capiaries, and, 3) most heat is ost via radiation and
convection from the anterior srfaces rather than condction
able disposable blanket. The warming unit, which resembles an
industrial vacuum cleaner, draws in air from the room and
warms it to a specified temperature. The warm air is then
pumped through a hose into a disposable blanket that covers
the patient. According to Dr. Sessler, operating rooms tend to
use forced-air warming covers because they are effective, safe
and inexpensive. The blowers are often provided, and the blan-
kets are inexpensive.21
One difficulty with forced air warming is that it cannot always
sufficiently warm a large enough surface to maintain normoth-
ermia during very large procedures when the patient is not in
the supine position. For example, it can be difficult to maintain
normothermia in a patient undergoing a colectomy in the litho-
tomy position. So much skin is exposed that there is not enough
surface area to warm. In cases like this, a combination of patient
warming devices and an ambient operating room may be thesolution for maintaining normothermia.21
Some surgical staff reject the use of forced air warming because
it can contribute to field contamination and the unit itself can be
a source of pathogens. Another criticism of forced-air warming
is that it can create too warm an environment for the surgeon.8
The blowing can also create a considerable amount of noise in
the OR.
Circulating water garments.These devices circulate water
through a segmented garment that is wrapped around theanterior and posterior sides of the patient. This is in contrast to
circulating water mattresses, which the patient lies on in a
supine position, thereby warming the posterior side of the body.
Research conducted by Dr. Sessler has shown that circulating
water garments and energy transfer pads warm patients about
50 percent better than forced air because they warm both over
and under the body. These systems tend to be more costly,
however, experts argue the cost is justified by better patient out-
comes when compared with other warming methods.
The following is an excerpt from a study by Taguchi et al., which
compares the efficacy of circulating water garments versus
forced air to maintain perioperative normothermia.6To read the
study in its entirety, go to www.ncbi.nlm.nih.gov/pmc/arti-
cles/PMC1409744/?tool=pubmed. Akiko Taguchi, MD, is an in-
structor in the Department of Anesthesiology at Washington
University in St. Louis, MO.
Despite the high heatcapacity and thermalconductivity of water, the
efficacy of conventionalcirculating-watermattresses is modest.
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Aligning practice with policy to improve patient care 2
tner et a. who fond that periphera tisses isoate the core from
heat appied to the skin srface in the post-anesthetic period.
Simiar, Szmk et a. fond that core rewarming was sowed b
postoperative vasoconstriction. In contrast, periphera-to-core
heat transfer is nimpeded dring anesthesia, whether sbjects
are vasodiated or vasoconstricted. The critica distinction
amongst these stdies is that vonteers were f anesthetized
in the ater protocos whereas the were nanesthetized in the
former ones. Athogh or vonteers remained intbated, the
were ver ight anesthetized and f vasoconstricted. It is ths
nike that the were given sfficient anesthesia to case di-
rect arterioar vasodiation that seems to be critica for rapid pe-riphera-to-core heat transfer.
Athogh core temperatres were virta identica at onset of
warming, periphera tisse temperatre was sight cooer on the
circating-water da. This ower initia skin temperatre and greater
initia core-to-periphera tisse-temperatre gradient increases the
apparent efficac of circating water. However, the tisse tem-
peratre difference was on a few tenths of one degree Cesis
and ths nike to have sbstantia atered the rests.
Traditiona circating-water mattresses are associated with pres-sre-heat necrosis (i.e., brn) that rests when tisse com-
pressed b the weight of the patient is simtaneos warmed.
Gai et a. recent reported the case of a 67-ear-od woman who
deveoped brns on her back after 6.5 hors of srger whie
being warmed with the same circating-water garment we sed.
Ths, when sing this sstem, cinicians shod consider an risk
factors sch as age, ength of srger, and ntritiona stats,
which ma predispose a patient to skin injr.
In smmar, the circating-water garment transferred more heat
than forced air, especia dring the first hor of warming, with
the difference resting arge from posterior heating. Excessive
heating of periphera therma compartment indicates that pe-
riphera tisses insated the core, ths sowing heat transfer.
Increasing operating room temperature. When active skin
warming is not feasible or skin warming by itself is inadequate for
maintaining normothermia, increasing the room temperature is
into the operating-tabe mattress. As might ths be expected,
the circating-water garment transferred on 21 kca/h across
the posterior skin srface. This is more than reported previos
with a conventiona circating-water mattress, possib be-
case of a better interface materia. However, it is rogh the
same change in ctaneos heat transfer that is provided b a
singe cotton banket in a normothermic sbject.
Anterior srface heat transfer was comparabe with each warm-
ing sstem, and the change in anterior srface heat gain from 0
to 0.5 eapsed hors averaged 65 kca/h with each treatment.
Heat transfer per anterior nit area was ths simiar with eachsstem. A coroar of this observation is that virta the entire
difference between the two tested warming sstems rested
from heat transfer into posterior srfaces, that is from the portion
of the circating-water garment that acts as mattress. Core
temperatre increased 0.4 degrees Cesis/h faster with circ-
ating water than forced air, a rest that is consistent with Jan-
icki et a. Athogh not tested in this std, or rests sggest
that heat transfer and core rewarming with the circating-water
garment wod be simiar to that provided b combining a
forced-air cover and a conventiona circating-water mattress.
The core and periphera therma compartments were of simiar
size (e.g., weight). However, active warming increased periph-
era tisse heat content rogh three times as mch as the core
over the corse of the std. The differences were even more
prononced dring the initia warming phase. For exampe,
periphera heat content after one hor of circating water
increased 114 kca whereas core content increased on
34 kca. The anaogos vaes for forced air were 71 and 9 kca.
Periphera compartment heat content ths increased 60-80 kca
more than the core compartment with each device. These data
indicate that tisse insation restricted rapid flow of heat from
the peripher to the core. In other words, appied heat was
constrained b the insating properties of periphera tisses,
ths significant imiting the rate at which core temperatre
increased.
That periphera tisses insated the core and sowed heat
transfer in or vonteers is consistent with observations of Pat-
For most patients, raising the room
temperature to more than 73.4 F may
reduce the severity of hypothermia.
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26 The OR Connection
6 Taguchi A, Ratnaraj J, Kabon B, Sharma N, Lenhardt R, Sessler DI, et al. Effects
of a circulating-water garment and forced air warming on body heat content and
core temperature. Anesthesiology. 2004; 100(5):1058-1064.
7 Lynch S, Dixon J, Leary D. Reducing the risk of unplanned perioperative
hypothermia. AORN Journal. 2010; 92(5):553-562.
8 Weirich TL. Hypothermia/warming protocols: why are they not widely used in the
OR? AORN Journal. 2008;87(2):333-344.
9 Sessler D & Todd M. Perioperative heat balance. J Amer Soc Anesth. 2000;
92(2):578.
10 Paulikas CA. Prevention of unplanned perioperative hypothermia. AORN Journal.
2008; 88(3):358-364.
11 Wagner VD. Patient safety chiller: unplanned perioperative hypothermia. AORN
Journal. 2010; 92(5):567-571.
12 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the inci-
dence of surgical-wound infection and shorten hospitalization. The New England
Journal of Medicine. 1996;334(19):1209-1215.
13 Rajagopaian S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hy-
pothermia on blood loss and transfusion requirement. Anesthesiology.
2008;108(1):71-77.
14 Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases
blood loss and transfusion requirements during total hip arthroplasty. The Lancet.1996; 347(8997):289-292.
15 Frank SM, Beattie C, Christopherson R, Norris EJ, Perler BA, Williams GM et al.
Unintentional hypothermia is associated with postoperative myocardial ischemia.
Anesthesiology. 1993; 78(3):468-476.
16 Mayo Clinic Researchers Confirm Value of Therapeutic Hypothermia. February 18,
2011. Available at: http://www.mayoclinic.org/news2011-rst/6184.html. Accessed
March 4, 2011.
17 Rogan J. Pressure ulcer risk during the perioperative period focusing on surgery
duration and hypothermia. Wounds. 2007; 3(4):66-74.
18 Scott EM, Leaper DJ, Clark M, Kelly PJ. Effects of warming therapy on pressure
ulcersa randomized trial. AORN Journal. 2001; 73(5):921-938.
19 Lenhardt R, Marker E, Goll V, Tschernich H, Kurz A, Sessler DI, et al. Anesthesiol-
ogy. 1997;87(6):1318-1323.
20 Waddle JP, Evers AS, Piccirillo JF. Postanesthesia care unit length of stay: quanti-
fying and assessing dependent factors. Anesthesia and Analgesia 87. 1998;
87(3):628-633.
21 Mathias JM. Taking steps to keep OR patients warm. OR Manager.
2006;22(12):14-16.
22 Recommended Practices for Prevention of Unplanned Perioperative Hypothermia.
In: 2010 Perioperative Standards and Recommended Practices. Denver, CO: As-
sociation of PeriOperative Register Nurses; 2010.
23 Cantrell S. New normothermia measure heats up patient-temperature manage-
ment. Healthcare Purchasing News. March 1, 2010. Available at: http://www.hp-
nonline.com/inside/2010-03/1003-IC.html. Accessed February 25, 2011.
an option. For most patients, raising the room temperature to
more than 23 degrees Celsius (73.4 degrees Fahrenheit) may
reduce the severity of hypothermia.22
Combining warming techniques
Some have suggested the need for a holistic approach incor-porating several different warming techniques to adequately
warm a patient. Overall, depending on the surgeon, the surgi-
cal team, and patient and the circumstances, the best method
of active warming may vary.23
ConclusionLooking to the future, as surgical team awareness and further
research into normothermia continues to develop, even more
effective patient-temperature management devices are sure to
follow. Warming device experts predict the development of more
sustainable technologies that can be cleaned and re-used,unlike forced air warming which creates environmental waste
with its disposable blankets. In addition, developing effective
equipment that covers less of the body surface than forced-air
warming or circulating water devices can offer greater conven-
ience and access for anesthesiologists and surgical teams.23
References
1 Measure Information Form. SCIP-Inf-10. Available at:
http://www.hsag.com/App_Resources/Documents/SCIP_LS3_Inf10_MIF.pdf.
Accessed February 25, 2011.
2 Surgical Care Improvement Project. The Joint Commission Web site. Available at:
http://www.jointcommission.org/surgical_care_improvement_project/. AccessedMarch 4, 2011.
3 National SCIP Partnership Developing to Reduce Surgical Complications. The
Leapfrog Group website. Available at:
http://www.leapfroggroup.org/news/leapfrog_news/144968. Accessed February
27, 2011.
4 Gunn M. SCIP expanded normothermia measure to go into effect for all surgical
patients in October. AORN Management Connections. July 2009. Available at:
http://www.aorn.org/News/Managers/July2009Issue/Normothermia. Accessed
February 25, 2011.
5 Wagner VD. Patient safety chiller: unplanned perioperative hypothermia. AORN
Journal. 2010; 92(5):567-571.
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Aligning practice with policy to improve patient care 2
Patient Safety Quality Measures for theSurgical Care Improvement Project
Measure Rationale Strategy
SCIP-Inf-1
Prophylactic antibiotics areadministered one hour prior toincision.
Studies find that the lowest incidence of post-operative infection is associated withantibiotic administration during the one hourprior to surgery. The risk of infectionincreases progressively with greater timeintervals between administration of theantibiotic and the skin incision.
Include administration and documentation ofthe antibiotic in the surgical time out. For one-hour antibiotics, the antibiotic is hung
in pre-op, a surgical team member administersand documents the antibiotic infusion.
SCIP-Inf-2
Prophylactic antibiotics areconsistent with currentguidelines (specific to each typeof surgical procedure).
Use an agent that is safe, cost-effective, andhas a spectrum of action that covers most ofthe probable intraoperative contaminants forthe operation. First- or second-generationcephalosporins satisfy these criteria for mostoperations, although anaerobic coverage is
needed for colon surgery.
The use of pre-printed orders that include therecommended antibiotic will assist surgeonswith choosing appropriate antibiotics.
Vancomycin is appropriate if there is a risk ofMRSA.
SCIP-Inf-3
Prophylactic antibiotics are to bediscontinued within 24 hoursafter anesthesia end time.The discontinuation timeextends to 48 hours for cardiacsurgery patients.
Administration of antibiotics for more than afew hours after the incision is closed offers noadditional benefit to the surgical patient.Prolonged administration increases the risk ofClostridium difficile infection and thedevelopment of antimicrobial resistantpathogens.
Begin antibiotics in the PACU. Administer cephalosporins every 6 hours
rather than every 8 hours.
Antibiotics are not provided for more than 24hours after surgery without appropriatedocumentation.
SCIP-Inf-4
Cardiac surgery patients withcontrolled 6 a.m. blood glucose(0 mg/dL) for the first two
postoperative days.
Hyperglycemia in the immediatepostoperative phase increases the risk ofinfection in both diabetic and non-diabeticpatients; the higher the level of
hyperglycemia, the higher the potential forinfection in both patient populations.
Blood glucose levels are monitored from pre-op through 48 hours post operative.
The use of an insulin protocol for treatinghyperglycemia with an insulin drip is stronglyrecommended.
SCIP-Inf-6
Surgery patients withappropriate surgical site hairremoval. No hair removal, hairremoval with clippers, ordepilatory is appropriate.
There is no strong evidence to contraindicatepreoperative hair removal; however, there isstrong evidence against hair removal with arazor. Shaving is considered inappropriate.
Take ALL razors out of the peri-operative area Instruct patients not to shave the surgical site.
SCIP-Inf-9
Surgical patients with urinarycatheter removed onPostoperative Day 1 orPostoperative Day 2 with day of
surgery being day zero. (Thismeasure does not apply tocertain urological, gynecologicalor perineal procedures.)
It is well-established that the risk of catheter-associated urinary tract infection (UTI)increases with increasing duration ofindwelling urinary catheterization.
Create a system of alerts or reminders toidentify all patients with urinary catheters andassess the need for continued catheterization
Develop guidelines and protocols for nurse-directed removal of unnecessary urinarycatheters and management of postoperativeurinary retention.
Consider the use of external catheters forcooperative males
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Measure Rationale Strategy
SCIP-Inf-
10
Surgical patients should beactively warmed during surgeryor have at least one recordedbody temperature equal to orgreater than 96.8 F within 30minutes prior to the end ofanesthesia to 15 minutes afteranesthesia end time. (Patientswith intentional hypothermia areexcluded from this measure.)
Research has correlated impaired woundhealing, adverse cardiac events, altered drugmetabolism, and coagulopathies withunplanned perioperative hypothermia. A studyby Kurtz, et al. (1996), found that incidence ofculture-positive surgical site infections amongthose with mild perioperative hypothermiawas three times higher than the normothermicperioperative patients.
Use aggressive warming measures duringsurgery.
Ensure accurate documentation of post-operative temperature.
SCIP-
CARD-2
Surgery patients on beta-blockers prior to admissionshould continue beta-blockertherapy during the perioperativeperiod.
The American College of Cardiology and theAmerican Heart Association recommend
continuation of beta-blocker therapy in theperioperative period as a class I indication,and accumulating evidence suggests thattitration to maintain tight heart rate controlshould be the goal.
Instruct patients to take their beta blockers tday of surgery.
Educate in-house clinicians about theimportance of patients receiving their betablockers the day of surgery, even while thepatients are otherwise NPO.
Meet with physician office staff to ensureconsistent instructions to the patients.
SCIP-VTE-
1
Surgery patients withrecommended venousthromboembolism (VTE)
prophylaxis ordered anytimefrom hospital arrival to 48 hoursafterAnesthesia End Time.
Despite the evidence that VTE is one of themost common postoperative complicationsand prophylaxis is the most effective strategyto reduce morbidity and mortality, it is oftenunderused.The frequency of venous thromboembolism
(VTE), which includes deep vein thrombosisand pulmonary embolism, is related to thetype and duration of surgery, patient riskfactors, duration and extent of postoperativeimmobilization, and use or nonuse ofprophylaxis.
Use pre-printed orders that include nationalrecommended guidelines for VTE prophylax
A hard stop would be not to allow patientsleave the recovery area until VTE orders arecompleted by the surgeon.
Ensure that surgeon preference cards mirnational guidelines. Pharmacists should assist surgeons with
understanding the risk of bleeding withpharmacological interventions.
SCIP-VTE-2
Surgery patients who receivedappropriate venousthromboembolism (VTE)
prophylaxis within 24 hours priortoAnesthesia Start Time to 24hours afterAnesthesia EndTime.
Timing of prophylaxis is based on the type ofprocedure, prophylaxis selection, and clinicaljudgment regarding the impact of patient riskfactors. The optimal start of pharmacologicprophylaxis in surgical patients varies andmust be balanced with the efficacy-versus-
bleeding potential. Due to the inherentvariability related to the initiation ofprophylaxis for surgical procedures, 24 hoursprior to surgery to 24 hours post surgery wasrecommended by consensus of the SCIPTechnical Expert Panel in order to establish atimeframe that would encompass mostprocedures.
(Please note that rates for SCIP-VTE- 2 mabe lower than those for SCIP-VTE-1 as a reof more stringent criteria. SCIP-VTE-2 requdocumentation that prophylaxis was orderedand actually started, whereas SCIP-VTE-1requires only documentation of an order. )
Organizations with decreased VTE 2 ratesshould assess their processes to determinewhy physician orders are not beingimplemented.
This material was prepared by Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Arizona, under contract withe Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented donot necessarily reflect CMS policy. Publication No. AZ-9SOW-6.2.3-110609-01
28 The OR Connection
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True/False
1. Extremely thin and malnourished patients are more
susceptible to perioperative hypothermiaT F
2. SCIP Inf.-10 went into effect April 1, 2007. T F
3. Forced air warming is a widely used option for patient
warming. T F
4. Cool air temperature in the operating room can
contribute to unplanned perioperative hypothermia. T F
5. Perioperative hypothermia can cause a drastic drop in
blood pressure.T F
6. Some surgical professionals reject the use offorced air warming because it can contribute to
field contamination. T F
Multiple Choice
7. A 2008 study by Sessler and colleagues found that less
than one degree of hypothermia during surgery is
enough to increase blood loss by about ___ percent.
a. 25
b. 46
c. 16
d. None of the above
8. In the Scott study, what was the incidence of
pressure ulcers among patients who were not
warmed during surgery?
a. 72.5 percentb. 15.3 percent
c. 65.4 percent
d. 22.8 percent
9. Which of the following is NOT a known complica-
tion of perioperative hypothermia?
a. Surgical site infection
b. Prolonged recovery
c. Myocardial ischemia
d. Pneumonia
10. During anesthesia, core body temperature
changes occur in ____ stages.
a. Three
b. Five
c. Two
d. Seven
Visit www.medlineuniversity.com
and login or create an account.
Choose your course to take
the test and receive
1 FREE CE credit.
CE Test
Turn Up the HeatAvoiding Surgical Complicationswith Adequate Patient Warming
Corses approved for contining edcation b the Forida Board
of Nrsing and the Caifornia Board of Registered Nrsing.
Aligning practice with policy to improve patient care 2
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30 The OR Connection
The foowing is a tre stor shared b nrses Kath Magee andEmi Sndee from Hnt Regiona Hospita, Greenvie, TX.
Imagine this scenarioA patient arrives at the hospital for a scheduled abdominal sur-
gery. Everything is running on time. The patient is placed on the
operating room table, a Time Out is called, and anesthesia is
administered. The patient is intubated and placed on a
mechanical ventilator. The sponges are counted by the circulator
nurse and the scrub nurse. The surgery begins. The procedure
is going well; however, the surgery extends through a shift
change for the scrub nurses. Upon arrival of the second shift,
the patient experiences a large amount of blood loss and packs
of sponges are counted and quickly used. As the surgeon
focuses on recognizing the reasons for blood loss, the nurses
are instructed to order a back up blood supply for the patient.
The surgeon controls the bleeding and begins to close the
patients incision. The staff realizes there is an unreconciled
sponge count. The staff attempts to recover the missing sponge.
Many questions and concerns arise such as: Could it be in the patients cavity?
Was it thrown away in the linens?
Did we miscount?
Is it possible the previous shift made the error?
The surgeon quickly decides to use the SmartWand-DTX and is
able to locate and retrieve the missing sponge. The patient has
a good outcome.
Exploring technologyHunt Regional is community-based hospital with 192 beds
located in Greenville, Texas. The organization takes pride in a
culture of innovation and transparency. If any staff member says
this is a safety issue its viewed as very important and the lead-
ership team is committed to following up and resolving the con-
cern. Hunt Regional is dedicated to patient safety and quality
outcomes. That is one of the reasons they were the first hospi-
tal in the state of Texas to begin using ClearCount. Hunt Regional
realizes that retained objects is a standard problem for hospitals
nationwide.
ClearCount Clearly Makes a Difference
in Patient Safety at Hunt Regional HospitalBy Rebecca McPherson, MSN, RN
Contined on Page 32
Patient Safety
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Retained Surgical ItemsAORNs latest confidence-based learning (CBL) module.AORNs Confidence Based Learning (CBL) is a
unique educational program that is designed to
help you achieve mastery in both knowledge and
confidence of that knowledge when providing care
that meets AORN Standards and Recommended
Practices. CBL is used to train, teach and retainperioperative professionals. CBL supports the
learner in reducing time to master knowledge and
increasing retention of critical information.
I N T R O D U C I N G
Visit Medline booth # 3408 or Clear Count booth # 53at AORN Congress for a FREE DEMO of the Retained
Surgical Items module.2011 Medline Industries, Inc.
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32 The OR Connection
The retention of a foreign object is considered a serious and pre-
ventable event by the National Quality Forum.1The Centers for
Medicare & Medicaid Services (CMS) includes the retention of
foreign objects in its list of hospital-acquired conditions for which
reimbursement will not be provided.2The Joint Commission cat-
egorizes the unintended retention of a foreign object as a sentinel
event.3The Joint Commissions sentinel event statistics reported
360 instances of unintentional retention of a foreign body during
the period of 2005 through March 2010.4
National adverse event data demonstrates that retained surgical
items are the most frequent and costly surgical Never Events,
with surgical sponges representing the bulk of these incidents.
According to CMS, the cost of a retained foreign object (RFO)
after surgery is $62,631 per hospital stay.5 In addition to hospi-
tal costs, RFOs can produce major litigation expenses. The total
cost of an RFO, including legal defense, indemnity payments,
and surgical costs unreimbursed by CMS, would be approxi-
mately $166,135. At the previously quoted incidence of 1 in
5,500 operations, the cost of an RFO amortizes to approximately$30 per operation.
The concern of retaining sponges or foreign objects can occur
even when the staff follows procedures. The risk elevates with
emergency procedures, deviation from planned procedures, type
of procedure, patients with a higher mean body-mass index
(obesity), and failure to count or inaccurate counts during the
procedure.7The longer the patient spends on the operating
table, the greater the chance of developing pressure ulcers.
The incidence of postoperative pressure ulcers may be as high
as 66 percent.8The Institute for Healthcare Improvement (IHI)
estimates nearly one million people develop pressure ulcers eachyear, with some 60,000 deaths related to complications. The
cost of treatment ranges up to $11 billion annually.9
Hunt Regional made the commitment to reducing or eradicating
the incidence of retained surgical sponges by recognizing that
even one such event is one too many.
ClearCount benefits the patient and the organization by:
reinforcing safe, efficient, quality care
creating reassurance for the physician and staff that there
is another system they can rely on to account for all sponges
increasing staff productivity, avoiding time spent to
relocate sponges
Using ClearCount does not take the place of manually counting
sponges; however, it serves as reinforcement that the sponges
have all been accounted for. Practitioners should continually
check for RFOs before closing body cavities and develop safety
practices to minimize errors. Hunt Regional is committed to end-
ing retained lab sponges; they created a policy to use ClearCount
for all open abdominal cases in addition to the nurse counting.
Human error is a reality; however, Hunt Regional Hospital
accepted responsibility, and their objective is to address retained
surgical sponges head-on. They could not accept just any solu-
tion. Efficiency is important to them as well, particularly in the
healthcare reform climate.
The nursing team was highly focused on patient safety. After fur-
ther research, they discovered publications from AORN that
made them aware of new technology for the prevention of
retained sponges.
Surgeons also prefer using ClearCount and SmartWand.
According to Joshua K. Trussell, MD, board certified general sur-
geon, Primary Care Associates Affiliated and medical director of
the Trauma Program at Hunt Regional Medical Center in
Greenville, Texas, Using the lap sponge and raytec (X-ray gauze)
have not changed practice or the way I operate, in fact, they are
very user friendly and increase the level of confidence of the
physician.
About the author
Rebecca McPherson, MSN, RN, is vice president of clinical serv-
ices for Medline Industries, Inc. Prior to joining Medline, Rebecca
worked at Sherman Healthcare Systems as the director of opera-
tions for the immediate care centers. Her background also includes
emergency nursing.
1. Centers for Medicare & Medicaid Services. Hospital-acquired conditions
(present on admission indicator)[online]. 2009 Feb 19 [cited 2009 March11].
2. National Quality Forum. Serious reportable events in health-care 2006 update:
a consensus report. Washington (DC): National Quality Forum; 2007.
3. Joint Commission. Facts about the sentinel event policy [online]. 2008 Mar 20[cited 2009 Mar 11].
4. The Joint Commission. Sentinel event statistics: updated through March 31, 2010.
5. Centers for Medicare & Medicaid Services. C