An orientee comes to you

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1 The monthly publication for OR decision makers August 2012 Vol 28, No 8 ASC section on page 26 STANDARDS & REGULATIONS FDA proposes a UDI system for medical devices...5 OR PERFORMANCE Reducing variation in total knee replacements...12 OR PERFORMANCE Tying anesthesia salaries to on-time starts, turnovers...14 OR DESIGN & CONSTRUCTION Key OR design, construction changes proposed...20 STERILIZATION & INFECTION CONTROL Lumens and endoscopes: Meeting cleaning basics...22 AMBULATORY SURGERY CENTERS Sleep apnea: Identifying patients at risk in the ASC...26 AT A GLANCE...32 ECRI Institute Supplement Fecal microbiota transplantation for treating recurrent Clostridium difficile infection...15 Managing people Lateral violence: Tools managers can use to help shift the culture An orientee comes to you in tears saying a couple of tenured nurses have snapped at her or huffed impatiently when she asked a question. Several other staff have met with you individually about conflict and hurtful comments they say are happening on one of the specialty teams. You already have a lot on your plate. It s tempting just to hope the strife will blow over. There are good reasons why you shouldn t, says Jodi Koch, BSN, RN, CPAN. These nurseto-nurse attacks are examples of lateral violence, also known as horizontal violence or bullying. Patient safety Raising the bar for safety in the handling of surgical specimens Is this specimen fresh or frozen? Is it routine, or does it require a lung protocol? Does it go to the frozen section lab or the microbiology department? Proper labeling and handling of surgical specimens are critical to reduce the risk of misdiagnosis and the need for repeat surgery. Decreasing specimen-handling defects is one goal of the Michigan Health and Hospital Association There are strategies managers can use to help reduce the tension and shift the culture, suggests Koch, who is director of perianesthesia services for Lehigh Valley Health Network, Allentown, Pennsylvania. Reasons to stop it There are plenty of reasons why lateral violence needs to stop. The first effect is on the team and the ability to work cohesively. There is also a direct effect on patient safety, she says. Anxiety and distress caused by bullying can be a distraction, a risk factor for errors. Continued on page 6 (MHA) Keystone: Surgery collaborative, which aims to reduce surgical complications and mortality by 5%. The collaborative has made a difference: The defect rate declined by more than 50% from 3.18% to 0.46% from 2010 to Keystone: Surgery members from 3 hospital systems described their efforts to improve specimen handling. Continued on page 9

2 What do surgical smoke and cigarette smoke have in common? 1, 2 Carbon Monoxide - Formaldehyde - Hydrogen Cyanide - Methane - Toluene - Benzene Remove surgical smoke with SeeClear! Simply attach SeeClear to the side port of the trocar to filter out harmful toxins. Freestanding, no attachment to wall suction needed. If you can smell it, you are breathing it. Removes 99.99% of toxins including HIV, bacteria, viruses, dead and live cellular material Removes chemical byproducts including benzene, formaldehyde, carbon monoxide and more Absorbs noxious odors Optimal flow rate maintains pneumoperitoneum Easy setup requires minimal staff involvement No attachment to wall suction, unobtrusive functionality Find out how SeeClear can benefit your OR staff, Call or visit SeeClear is effective, easy to use and unobtrusive. Scan. View. Learn. Or go to coopersurgical.com/seeclear 1 Ulmer, B. C The Hazards of Surgical Smoke AORN Journal 87(4) U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease. A Report of the Surgeon General Rev. 09/11

3 Editorial PUBLISHER, AI HEALTHCARE GROUP Carol Brault PUBLISHER, OR MANAGER Elinor S. Schrader EDITOR Pat Patterson CLINICAL EDITOR Judith M. Mathias, MA, RN EDUCATION COORDINATOR Judy Dahle, MS, MSG, RN CONSULTING EDITOR Kathleen Miller, MSHA, RN, CNOR CONTRIBUTING WRITER Paula DeJohn SENIOR VP/GROUP PUBLISHER Jennifer Schwartz TRADE SHOW DIRECTOR Jenn Heinold ART DIRECTOR David Whitcher SENIOR PRODUCTION MANAGER Joann M. Fato ADVERTISING National Advertising Manager Ashley W. Kerwin Account Executive, OR Manager Fax: REPRINTS Wright s Media sales@wrightsmedia.com Vol. 28, No. 8, August 2012 OR Manager (ISSN ) is published monthly by Access Intelligence, LLC. Periodicals postage paid at Rockville, MD and additional post offices. POSTMASTER: Send address changes to OR Manager, 4 Choke Cherry Road, 2nd Floor, Rockville, MD Super subscription (includes electronic issue and weekly electronic bulletin) rates: $179 (plus $10 shipping for domestic and Canadian; $20 shipping for foreign). Single issues: $29. For subscription inquiries or change of address, contact Client Services, clientservices@accessintel.com. Tel: , Fax: Copyright 2012 by Access Intelligence, LLC. All rights reserved. No part of this publication may be reproduced without written permission. OR Manager is indexed in the Cumulative Index to Nursing and Allied Health Literature and MEDLINE/PubMed. SISTER Sites dorlandhealth.com patientadvocatetraining.com contexomedia.com Access Intelligence, LLC Chief Executive Officer Don Pazour Executive Vice President & Chief Financial Officer Ed Pinedo Exec. Vice President, Human Resources & Administration Macy L. Fecto Divisional President, Access Intelligence Heather Farley Senior Vice President, Chief Information Officer Robert Paciorek Senior VP, Corporate Audience Development Sylvia Sierra Vice President, Production and Manufacturing Michael Kraus Vice President, Financial Planning and Internal Audit Steve Barber Vice President/Corporate Controller Gerald Stasko 4 Choke Cherry Road, Second Floor Rockville, MD NSQIP you see those initials more and more in studies on surgical quality. NSQIP stands for the National Surgical Quality Improvement Program from the American College of Surgeons (ACS). NSQIP is gathering momentum, with 475 hospitals enrolled. Benefits are credible data for improving surgical outcomes and the buy-in from surgeons. By participating in NSQIP, a study found that a hospital each year, on average, has the opportunity to: prevent 250 to 500 complications save 12 to 36 lives reduce costs by millions of dollars. (Hall B L, et al. Ann Surg. 2009; 250: ) New quality measures A few recent examples of the momentum: ACS and NSQIP are partnering with the Centers for Disease Control and Prevention to develop measures for surgical site infections (SSI) and other complications. The National Quality Forum has endorsed 5 NSQIP outcome measures. Two measures, urinary tract infection after surgery and SSI, could be adopted as national measures as early as NSQIP s big database is being enlisted in a host of studies. A couple of highlights: A May report shed light on venous thromboembolism risk for surgical outpatients, an area that hadn t been studied well before. A group of Boston hospitals, all NSQIP participants, cut their complication rate for partial colectomy by a dramatic 23%. They compared data and came up with a list of best practices they called better colectomy Lite. A powerful tool for surgical quality. NSQIP data is being enlisted to study perioperative nursing. The Perioperative Outcomes Initiative (POI), an 18-hospital collaborative in Michigan, is using NSQIP data and other sources to study the link between perioperative processes and outcomes. Some areas POI is interested in studying are preop assessment, skin prep, and OR staffing patterns, says the lead researcher, AkkeNeel Talsma, PhD, RN, FAAN, of the University of Michigan. Despite benefits, the resources needed to participate in NSQIP give some hospitals pause. There is an annual fee, and hospitals have to provide a clinical reviewer full time to submit data on the 130 variables to report to NSQIP. ACS says there can be a significant ROI through improving care and saving lives. A NSQIP Lite could be coming. Researchers have piloted a model using as few as 3 NSQIP data points to predict risk-adjusted inpatient mortality. That would give NSQIP even greater momentum and give you and your colleagues a powerful way to learn what really makes a difference in the care of your patients. Pat Patterson Learn more about NSQIP at www. acsnsqip.org. For more about the Perioperative Outcomes Initiative, contact AkkeNeel Talsma at antalsma@umich.edu. August 2012 OR Manager Vol 28, No 8 3

4 25 the annual th The Premier Conference on Managing Today s OR Suite With the OR Business Management Conference and the Leadership Specialty Assembly Join us in fabulous Las Vegas to celebrate our 25th Anniversary! October 24-26, 2012 Caesars Palace Las Vegas, NV Early Bird pricing ends July 31 this is your last chance to receive the best price on the Conference! Register by July 31 with VIP Code: ORMSAVE to save with the Early Bird discount!

5 Standards & regulations FDA proposes a UDI system for medical devices The US Food and Drug Administration (FDA) released its long awaited proposed rule for a unique device identification (UDI) system on July 3, Comments will be accepted for 120 days after the proposed rule is published in the Federal Register, which was expected in early July. The rule would carry out a law passed in With some exceptions, under the proposed rule, a UDI would include: a device identifier specific to each device model an identifier with a device s current production information such as batch or lot number. The UDI would be marked on the device itself. The related information would be both in a plain text format and in a format readable by a bar code scanner or other technology. Examples of devices that would Advisory Board Mark E. Bruley, EIT, CCE Vice president of accident & forensic investigation, ECRI, Plymouth Meeting, Pennsylvania Stephanie S. Davis, MSHA, RN, CNOR Assistant vice president of surgical services, Hospital Corporation of America, Nashville, Tennessee Reuben J. DeKastle, BN, MSHA, RN, CNOR Administrative director, patient care services, Weiser Memorial Hospital, Weiser, Idaho Franklin Dexter, MD, PhD Professor, Department of anesthesia and health management policy, University of Iowa, Iowa City Brian Dolan, MHSA, RHIA, CHDA, SSGB Director, business operations, perioperative services, University of Kansas Hospital, Kansas City, Kansas Lorna Eberle, BSN, RN, CNOR Director, perioperative services, Providence St Peter Hospital, Olympia, Washington Linda R. Greene, MPS, RN, CIC Director of infection prevention, Rochester General Hospital System, Rochester, New York Devices could be identified more quickly. have to carry UDIs are implants and reusable devices intended to be reprocessed. Implementation is a long way off. Once final, the rule would be phased in over 7 years. Labeling for highrisk devices would take effect in 3 years with requirements for lowerrisk devices coming after that. Some low-risk devices would be exempt. The UDI information would be stored in a publicly available database, but no identifying patient information would be stored. The FDA says the proposed Jerry W. Henderson, MBA, RN, CNOR, CASC Assistant vice president, perioperative services, Sinai Hospital, Baltimore, Maryland Kathleen F. Miller, MSHA, RN, CNOR President, senior consultant, PeriopRx Consultants, Gilbert, Arizona Lisa Morrissey, MBA, RN Nursing director, Main OR, Massachusetts General Hospital, Boston, Massachusetts John Rosing, MHA, FACHE Vice president and principal, Patton Healthcare Consulting, Milwaukee, Wisconsin Kathryn Snyder, BSN, MM, RN, CGRN Nurse manager, endoscopy/bronchoscopy/motility departments, University of Virginia Health System, Charlottesville, Virginia Martha Stratton, MSN, MHSA, RN, CNOR, NEA-BC, Director of nursing, surgical services, AnMed Health, Anderson, South Carolina David E. Young, MD Medical director, perioperative services, Advocate Lutheran General Hospital, Park Ridge, Illinois rule reflects input from the device industry, clinicians, patients and consumers, and industry. The agency has conducted pilot tests with industry. The agency says the draft rule builds on standards and systems some companies already use. Benefits of UDI Benefits the FDA says a UDI system could have are: more accurate reporting and analysis of adverse events so problem devices can be identified and corrected more quickly fewer errors because users can identify a device more quickly and precisely; for example, distinguishing devices that require sterilization from those that do not and determining the kind of cycle required a consistent way to enter device information in electronic health records and clinical information systems more effective management of device recalls a more secure supply chain that could help address counterfeiting and device diversion and prepare for emergencies. With the UDI, the FDA notes that clinicians would be able to correctly identify a device even after it becomes separated from its packaging. They would be able to contact the database to access labeling and other information. The UDIs will also make it easier for the FDA to sort out the more than 400,000 adverse event reports it receives each year to determine exactly what devices are involved and which reports are duplicates. More information on the proposed rule, including a sample label, is at RegulationandGuidance/UniqueDeviceIdentification/default. August 2012 OR Manager Vol 28, No 8 5

6 Managing people Top 10 forms of lateral violence in nursing 1. Nonverbal innuendo 2. Verbal affront 3. Undermining activities 4. Withholding information 5. Sabotage 6. Infighting 7. Scapegoating 8. Backstabbing 9. Failure to respect privacy 10. Broken confidences. Source: Griffin M. J Contin Educ Nurs. 2004;35(6): Reprinted with permission from Slack Inc. Lateral violence Continued from page 1 An apt analogy is distracted driving, she says. A person who s angry, frustrated, and gets behind the wheel isn t likely to be paying full attention to the road. Likewise, a nurse who has a confrontation with a coworker is unlikely to be completely focused on patient care. Other effects linked to lateral violence are absenteeism, burnout, and resulting difficulties with recruitment and retention. Nursing units that gain a reputation for eating nurses alive have difficulty hiring new staff. And the staff on those units are more likely to suffer burnout and leave, creating a vicious cycle that raises costs and undermines patient care. Protecting new nurses Orienting and precepting new nurses are a lot of work not only for the manager but also for the It s the elephant in the room. staff, Koch acknowledges, particularly when everyone is being asked to do more. She suggests reframing the effort to orient new nurses as an investment in the future. It s an opportunity to help prepare someone to be an active member of the team and to contribute to the future of nursing. She says it s also important to educate new graduate nurses about lateral violence and give them the tools to manage it. Strategies for managers Part of a manager s role is engaging the staff, Koch notes. That includes setting the tone for healthy interactions and teaching the staff tools for heading off lateral violence. The best formula for bringing about change, she advises: Be consistent in addressing lateral violence. Let the staff know what to expect. And expect zero tolerance. Create a culture of respect Nursing leaders create a healthy climate for interactions through their own actions. The culture has to be driven by nursing leaders, she says. We have to be the role models. Don t be afraid to talk about it Many staff refer to lateral violence as the elephant in the room it s there, but we re not supposed to talk about it, Koch notes. Managers can bring the issue out into the open where it can be discussed and addressed. As managers, it s OK to acknowledge there may be a problem in our area, she says. If you sense something is wrong but can t put your finger on it, she suggests a frank open conversation with the staff. The manager might say: I m getting the sense there is some kind of tension. I can t help you manage it if I don t know about it. Once one person opens up, she finds, others usually follow. To take the pulse of the unit, Koch regularly asks at staff meetings, How are things going? How is the teamwork? How s the communication? She watches for signals, particularly from more reticent staff, indicating there may be issues to follow up on. Define the culture Let the team itself decide what it expects of its members and coworkers, Koch suggests. The staff is in the best position to set expectations for interactions because they are on the front lines with each other every day. A place to start is with the organization s code of behavior. Lehigh Valley s code is based on the acronym PRIDE: Privacy Respect Involvement Dignity Empathy. Employees are held accountable for the code as part of their performance appraisals. Educate on lateral violence Education needs to be ongoing, Koch advises. 6 OR Manager Vol 28, No 8 August 2012

7 Managing people First, make sure you ve educated yourself and other managers. Koch says she s been surprised that some nurse managers aren t familiar with the term lateral violence. But as soon as they hear the behaviors described, they get it. She suggests offering a presentation on lateral violence and repeating it at least annually as a refresher. The more we educate, the more we increase awareness. We have to understand lateral violence to be able to change it. Coach the staff Two skills Koch finds are especially helpful to teach the staff are: interrupting the violence cognitive rehearsal. Interrupt the violence. The most effective way of dealing with inappropriate behavior, she says, is to call it out as close as possible to when it happens and interrupt it. This real-time interruption is so much more effective than the nurse going to the manager. For example, when listening to gossip, a nurse could say: Timeout. I don t feel comfortable talking about someone when they re not here. If an incident happens during patient care, a nurse can say, Time-out. We need to focus on the patient. We need to talk about this later. Cognitive rehearsal. In this technique, a person who receives inappropriate behavior, stops, stays calm, and avoids processing the event as a personal affront. The person then responds calmly in a way that helps neutralize the situation. Martha Griffin, PhD, RN, tested cognitive rehearsal as a strategy for new nurses in her well-known Q&A: Managing lateral violence Responses to common questions from Jodi Koch, BSN, RN, CPAN, director of perianesthesia services, Lehigh Valley Health Network, Allentown, Pennsylvania. Q. What can you do about lateral violence that is under the radar? You hear it s a problem, but you don t witness it. JK: Typically, these behaviors take place nurse-to-nurse when no one is around (like a manager) to hold them accountable. That s why it s so important to educate the staff on the front lines to call out the behavior and to promote the type of behavior they expect. That s by far the number 1 way to address the problem. Q. How do you handle an employee who denies doing anything wrong, even when the staff continues to come to you about the behavior? JK: First, I document every conversation I have with a staff member, including if I can, quotes describing the behavior. Then I have this conversation with the initiator of the behavior: If I have one employee who comes to me to report a behavior, it is hard to differentiate one employee s word from another s (unless it s obvious). However, when 4 or 5 employees come to me about the same coworker, and the behaviors they describe independently of one another are similar, there is credibility. I then describe the behavior that has been reported, saying, I m not sure what s going on, but this is how your coworkers describe you. These are from several of your coworkers, so there is a problem. I add that I will be making my own observations and will meet with them regularly to discuss their progress. If the employee who reports is confident enough, I will have that person sit with me and the initiator to describe the behavior. That can be powerful. But it doesn t necessarily work well for the employee who is undermining and engages in retribution study of lateral violence. In the study, she gave the nurses cue cards they could use to practice responses to common types of lateral violence and tested their experiences in using them. For example, when a nurse hears someone betray a confidence, the nurse could say: Wasn t that said in confidence? Or He/she asked me to keep that confidential. Illustrating the approach Koch illustrates the approach with an anecdote from her own days as a staff nurse. One day, working in a charge role, she had to give an assignment to a tenured nurse who had a pattern of undermining and backstabbing. The manager hadn t addressed the problem even though the staff kept a calendar and circled the days this Continued on page 8 August 2012 OR Manager Vol 28, No 8 7

8 Managing people Continued from page 7 nurse had acted inappropriately. After Koch gave the assignment, as she walked away, she heard the nurse mutter about her under her breath. This time, Koch didn t let the incident pass. Having anticipated such a response, she had thought about it and rehearsed in advance what she would say. I made sure I was calm that s key. Then I walked up to her and said, I m sorry. I didn t hear what you said. The nurse responded, I didn t say anything to you. Koch then said: No, you actually did say something, and it was directed toward me. But I didn t hear what you said. The nurse stood her ground and said, I wasn t saying anything about you. I was just talking to myself. Koch responded. OK. I just want you to know that if you ever have anything to talk to me about, we can talk face-to-face. She then walked away. A colleague who d observed the exchange told Koch: I can t believe you said that to her. Koch confessed she couldn t believe she had actually done it either. But I knew that at that moment, something changed for me. Why? Because I had practiced. And she knew that the reason the nurse acted as she did was because others had let her. Support the staff Often, the number 1 reason the staff doesn t report lateral violence is fear of retribution by the initiator, Koch observes. She stresses privacy and confidentiality both in talking to staff members who come to her and in addressing the situation with Don t let bad behavior slip by. a person who may be initiating lateral violence. In counseling an initiator, I tell them our conversation is private and confidential. They may not discuss it on the unit or anywhere else with other staff or employees. That prevents the initiator from going around the unit and fishing for who might have reported the behavior. Be consistent Being consistent in addressing lateral violence takes energy and diligence, Koch advises. She encourages managers not to let bad behavior slip by even though they have a lot of competing priorities. The staff need to know that we take it seriously and are going to investigate promptly and follow up. Look at it as investment, she advises. Ultimately, the culture will begin to shift. It will become clear what the expectations are, and that will feed change. The team will grow as you lead them. It will get to the point where it becomes like maintenance. Jodi Koch presented an OR Manager webinar, Zero Tolerance for Lateral Violence. The recording is available for purchase at References Farrell G A. Aggression in clinical settings: Nurses views. J Adv Nurs. 1997;25: Farrell G A. Bobrowski C, Bobrowski P. Scoping workplace aggression in nursing: Findings from an Australian study. J Adv Nurs. 2006;55: Griffin M. Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. J Contin Educ Nurs. 2004;35: McKenna B G, Smith N A, Poole S J, et al. Horizontal violence: Experiences of registered nurses in their first year of practice. J Adv Nurs. 2003;42: New TJC tool for hand-offs The Joint Commission Center for Transforming Healthcare announced its new Hand-off Communications Targeted Solutions Tool in June The tool will assist organizations with the process of passing patient care information from one caregiver to another to prevent miscommunication. Organizations piloting the tool reduced readmissions by 50% and reduced by 33% the time it takes to move a patient from the ED to an inpatient unit. One universal experience of all the organizations that built and tested the tool was that senders and receivers had very different expectations of what constituted a successful hand-off, the commission says. The solutions use the acronym, SHARE, which addresses the specific reasons why hand-offs are unsuccessful. 8 OR Manager Vol 28, No 8 August 2012

9 Surgical specimens Continued from page 1 Ensuring a specimen chain of custody Sparrow Hospital in Lansing, Michigan, had begun improving specimen safety before joining Keystone: Surgery in Using failure mode and effects analysis (FMEA), a team had identified what needed to be fixed or improved. Becoming part of Keystone has enhanced our process even further, says Lynn Raynor, MSN, RN, CNOR, clinical nurse specialist, surgical services at Sparrow. One improvement is a process to ensure the chain of custody for a specimen: The chain begins when the surgeon hands a specimen to the surgical technologist (ST) and tells the ST what the specimen is and what process is needed in the lab. The ST hands off the specimen to the circulating nurse, repeating what the surgeon said. The nurse labels the specimen container and places the specimen in the container. The nurse completes the tissue requisition and initials it. The requisition is also initialed by the transporter and the lab person who accepts the specimen. During the debriefing at the end of the case, the circulating nurse announces all specimens obtained; if no specimens were obtained, that is also announced. A copy of the lab requisition is filed by date in a binder at the OR front desk, in a step suggested by an OR secretary. This helps ensure that all specimens intended to be delivered to the lab actually were delivered. The OR secretary makes sure the transporter brings a copy of Declaring a no distraction zone. each requisition back from the lab. The lab requisition was revised to include an extra copy for the binder. This has been helpful on a couple of occasions to clarify questions, notes Raynor. Tracking specimen data The Sparrow OR in collaboration with the lab tracks specimen data so the number and types of errors can be identified using a tool developed by Keystone: Surgery. If we see any trends, we can hone in on what s happening and correct it, says Raynor. Early in the collaborative, Raynor says the OR saw process errors decline to zero over a 6-month period because of improvements identified through the tracking information. We have learned we have to keep our finger on the pulse to spot and correct any errors, she says. It s also necessary to reinforce the new process with the staff and physicians. A safety board in the OR reports a running count of days without specimen errors and communicates any safety information and lessons learned from errors. Learning from defects A learning-from-defects tool has been instrumental in preventing errors, says Mary Pride, BSN, RN, department manager. The tool is part of the Comprehensive Unit- Based Safety Program (CUSP) and is provided by Keystone. The tool guides caregivers and leaders through a defect analysis to identify what contributed to the defect and how to prevent it from recurring. This tool helped identify a potential source of errors by the OR assistant who transports specimens to the lab. He noted that he often was distracted by a phone call to pick up a frozen section that must be delivered to the lab immediately while he was reconciling routine specimens in the specimen room to take to the lab. The solution was to declare a no-distraction zone when the OR assistant is reconciling specimens, says Pride. Before entering the specimen room, the assistant gives up his phone to focus on ensuring consistency between the specimen requisitions and the tissue log. He then takes those specimens to the lab and does not pick up his phone until he returns to the OR. Another OR assistant covers the phone while he is gone. The learning-from-defects tool has been super-helpful, says Pride. She notes that in discussing a defect, we make sure everyone understands that it s absolutely nonpunitive and is for our learning to prevent further errors. Standardizing processes At the Henry Ford Health System in Detroit, Michigan, the OR, pathology, and laboratory medicine have worked together to standardize processes, notes Rita D Angelo, MS, CQE, SSBB, manager, Quality Systems Division, Pathology and Laboratory Medicine. Continued on page 10 August 2012 OR Manager Vol 28, No 8 9

10 SURGICAL SPECIMEN SUBMISSION ROUTINE PROTOCOL FROZEN SECTION LYMPHOMA WORK-UP LUNG PROTOCOL MICROBIOLOGY SPECIMEN ROUTINE FROZEN LYMPHOMA LUNG MICRO No Fix No Fix No Fix No Fix No Fix NO FIXATIVE NO FIXATIVE NO FIXATIVE NO FIXATIVE NO FIXATIVE deliver to FROZEN SECTION LAB deliver to FROZEN SECTION LAB deliver to FROZEN SECTION LAB deliver to FROZEN SECTION LAB deliver to MICROBIOLOGY DEPARTMENT Mon-Fri, 8am-5pm: leave at frozen section window Off-hours and weekends: leave in frozen section refrigerator notify Pathology before Monday-Friday, 8am-5pm CALL Off-hours and weekends PAGE On-call staff: 3300 (Resident) or 2281 (Pathologist) No Fix Generic label for additional requests for assistance Mon-Fri, 8am-5pm: CALL Off-hours and weekends: PAGE On-call staff at 3300 (Resident) or 2281 (Pathologist) The specimens are labeled with a color-coded sticker for timesensitive or special-handling specimen streams A color-coded specimen submission form created by the Henry Ford Health System. Continued from page 9 D Angelo is managing 2 teams of nurses, pathologist assistants, and quality specialists with the goal to create one standard approach to collect, label, and deliver specimens to the lab. Henry Ford had begun looking at specimen defects long before it joined Keystone: Surgery and realized the pathology lab received a considerable amount of inaccurate or incomplete information from other departments, says D Angelo. We realized we didn t have a clearly defined standard of work or training on either side. We had defective processes, she says. In starting to working with Keystone: Surgery, We already had a good idea of what was missing and what was needed. Videos aid communication In their work, the Henry Ford teams learned surgeons and nurses did not necessarily communicate complete information about specimens. The surgeon identified the specimen as it was taken from the patient, but the nurse didn t always hear the surgeon or know how to spell the name of the specimen. To illustrate the correct process, D Angelo filmed a training video for the nurses on how to collect and label the specimens. The nurses were thrilled with it, but they suggested the surgeons also needed to see it, she says. She made a second video in which a surgeon spoke to the surgeons about what was required in handing off a specimen to make sure the circulating nurse knew the correct information. The surgeons pointed out that after they call out the specimen, they move on to another part of the procedure and may not have time to make sure the nurse heard the specimen information correctly. The nurses noted that they and the surgeons did not use the same nomenclature for specimens, leading to the realization that the 10 OR Manager Vol 28, No 8 August 2012

11 pathology department had not provided a list of specimen types for reference. Training the surgeons and getting them involved were milestones, but we re realizing other things we still have to do, says D Angelo. Developing standard work To develop standard work, 3 teams of nurses and pathology personnel are observing processes in both departments. The teams will then develop a standardized process to handle specimens in the OR and hand them off to the lab. At that point, they will include the surgeons. All will vote on the process to adopt. The physician steering committee will roll out the process to the rest of the clinicians and staff. The standardized process will be included in the OR s new Epic software, which will automate the requisition and submit it to the lab electronically. When the lab receives the specimen, the requisition will be waiting. Meanwhile, the IT department is creating a site using Microsoft s Sharepoint software. Circulating nurses will document their frozen sections, and the information will be viewed in the frozen section room so lab personnel know what specimens are coming out of each OR. As part of standard work, the OR has introduced a color-coded labeling system to denote the tissue type and test (illustration, p 10). When the lab receives the specimen, it knows what test is needed and where the specimen needs to go. Each OR has a poster of the color-coding system. Standardizing the process requires time and effort, D Angelo notes, but it has lowered the specimen defect rate to about 2 a week Color coding aids standard work. from about 40 a month before the Keystone project began. Steps to guide handoffs Marquette General Hospital in Michigan s Upper Peninsula has revised its specimen handoff communication protocol based on its involvement with Keystone, says Patricia Wills, BSN, RN, CNOR, director of clinical education for perioperative services. Although there had been a policy on handoff communication for specimens, it wasn t necessarily followed, Wills notes. She and team members educated the staff about the process and developed these steps: The surgeon calls out the name of the specimen; the ST repeats the name to the circulating nurse; the nurse repeats back the specimen name and receives verification from the surgeon. Music is to be turned down and conversation held to a minimum during specimen collection. If circulating nurses are gathering multiple specimens for frozen sections, they must call the OR desk to send help, which could be a floating RN, an ST, a manager, or an educator. Communicating with pathologists As the pathologists have begun requiring new tissue-handling processes for certain specimens, communication and education with the pathologists are doubly important, says Wills. An example is requiring certain specimens, such as lung tissue, to be transferred in a sterile manner, which had not been done before. The head of the pathology department gave an in-service session for the OR staff about the new processes. The OR had to determine which sterile containers to use to transfer specimens because some of the lung tissue samples were large. At the beginning, bone jars intended for large bone flaps were used, but the $10 cost was prohibitive. Instead, the staff decided to use a sterile basin covered with a sterile adhesive drape. Another staff idea was colorcoded specimen requisitions. Bright yellow requisitions are now used for specimens that require special handling, such as frozen sections and breast specimens sent fresh that need to be processed within an hour. The requisition for routine specimens is white. Included on the special-handling requisition are: reason for evaluation OR number name of circulating nurse name of surgeon who requested special handling time placed on dumbwaiter lift to the lab test requested. The goal is to decrease requisition errors to 0 to 1 per month, a goal that is being met in most months. Judith M. Mathias, MA, RN More on Keystone: Surgery is at August 2012 OR Manager Vol 28, No 8 11

12 OR performance Reducing variation in total knee replacements A new study in the journal Health Affairs of total knee replacement (TKR) confirms that wide variations in care exist among hospitals based on factors such as geographic location. 09 T h e H i g h Value Healthcare Collabora- 05 tive found significant variations in TKR among the 5 participating health care systems. Among these were length of stay (LOS), where patients were discharged after surgery, and complication rates (sidebar). The study also reports 3 practices for managing variability: a multidisciplinary approach to preop preparation, used by the hospital with the lowest inhospital complication rate dedicated OR teams for TKRs, used in hospitals with the fastest operating times managing patient expectations by engaging them in discharge planning even before admission, which started after the data were analyzed, has reduced LOS. OR Performance Best practices Variation, particularly in where patients are discharged after surgery, is not that surprising, says Mark Froimson, MD, an orthopedic surgeon at the Cleveland Clinic who is also president and CEO of Euclid Hospital in Ohio and one of the study s coauthors. Differences include cultural, personal, and professional preferences in various regions. The collaborative, helps to ferret out those differences, he says. All 3 practices for managing variability are at various stages of development in the Cleveland Clinic system, Dr Froimson says. He adds that care is highly personal with patients and professionals, which is a factor when working on more uniform acceptance of practices. Multidisciplinary preop approach At the Cleveland Clinic, the preop assessment/preparation team includes the physician, outpatient and inpatient nurse, physical therapist, anesthesiologist, pain management specialist, and an internal medicine physician. Much of this work is done in a classroom setting. Preop information should be organized and comprehensive, says Amy Storsveen, RN, orthopedic surgery nurse manager at the Mayo Clinic, a founding member of the collaborative. At the Mayo Clinic, patients receive information about what to expect before, during, and after surgery. Patients are offered assistance from social services if needed, and social services will work closely with the patients and their families, Storsveen says. Details are important; an example is a patient making sure a walker will fit through his front door at home. Power of a dedicated team It s a challenging balance to have dedicated OR teams and have OR personnel who can be cross-functional, Dr Froimson says. It requires a sufficient case volume. Storsveen credits a team approach for high efficiency in the 10 ORs dedicated to the adult orthopedic reconstructive practice at the Mayo Clinic. She hires staff specifically for the area, giving candidates a clear picture of roles and responsibilities. I stress that there are a lot of instruments to put together, she says. It s like a puzzle and takes a lot of specialization. Because team members know the surgeons they work with so well, they can anticipate the next step, Storsveen says. A surgeon may finish a surgery in one OR while another team sets up in another, further gaining time. The team approach is also used in other areas of the Mayo Clinic s ORs. If necessary, staff may work in other operative areas within the Mayo Clinic. We don t think in silos, Storsveen says. We take care of every patient. She notes, however, that the staff spend most of their time working within the reconstructive orthopedic specialty. Other benefits of a dedicated team are staff and surgeon satisfaction. Everybody likes to be part of a team, Storsveen says, which may be why many staff have stayed in orthopedic surgery for 15 years and longer. Rapid recovery program Dr Froimson says engaging patients in discharge planning before admission is based on a defining principle that we share the same goal, which is to discharge them safely back to their home. Once the mutual goal is established, patients are ready for education. The Cleveland Clinic uses a rapid recovery program, which includes a nurse who sets up the first postoperative home or outpatient physical therapist visit before the patient s admission. It gives patients the confidence they need, says Dr Froimson. They know they have someone to contact. Patients want to go home but are apprehensive. Extensive preoperative preparation and planning mitigate that apprehension. 12 OR Manager Vol 28, No 8 August 2012

13 OR performance The study collaborative The study included a wide age range of patients, not just those eligible for Medicare, from various locations, allowing the researchers to evaluate practices throughout the country. Eligibility criteria included: single (left or right) primary total knee replacement (TKR) age 18 to 89 as of January 1, 2008 discharged after TKR in 2008 or 2009 principal diagnosis of osteoarthritis. Findings Surgeons who performed more TKRs tended to have shorter lengths of stay (LOS), shorter operating times, and fewer complications. LOS was longer if the surgery was later in the week. Operating time was 80 to 105 minutes; longer time was associated with longer LOS, and operating time trended lower with high surgeon caseloads. The mean complication rate was 0.8% (range 0.2% to 1.6%). LOS was longer for older patients, men, those with more comorbidities, the morbidly obese, and Medicare enrollees. About the collaborative The High Value Healthcare Collaborative supports a distinct type of collaboration. The authors say the most important strength is open dialogue among experts who can look at variation in the data and come up with hypotheses to explain it. According to the authors, the collaborative s methodology has advantages over traditional research methods, including more insight into clinical practice; identification of low and high care value processes; and findings that can be rapidly determined, exported, and studied. Founding members Cleveland Clinic Denver Health Dartmouth-Hitchcock Medical Center Dartmouth Institute for Health Policy and Clinical Practice Intermountain Healthcare Mayo Clinic Education at the Mayo Clinic includes a booklet with instructions such as when to resume driving, postop pain medication management, physical therapy exercises, incision care, sexual activity after surgery, and when to contact a health care provider. If a patient needs extended care after hospitalization, it s important to evaluate the best location for that care, as Storsveen learned first hand when her mother had joint replacement surgery at the Mayo Clinic. Social services was able to locate a rehab facility in her mother s hometown, 2 hours away, to provide the best care in a familiar environment. My mother was not able to care for herself after surgery and probably wouldn t have done the exercises needed to recover if someone was not right there to help her, says Storsveen. Orchestrating success One of the collaborative s strengths is its ability to dig into the complex health care system by looking at multiple variables, Dr Froimson says. Creating the change needed to reduce variability and improve care delivery requires a conductor s skill to integrate approaches. For example, It s not just dedicated OR teams, it s how those teams are integrated into the system, Dr Froimson says. The complex variables have to be orchestrated to ensure success. The collaborative plans to study other conditions: diabetes, heart failure, asthma, weight loss surgery, labor and delivery, spine surgery, and depression. Cynthia Saver, MS, RN Cynthia Saver, a freelance writer, is president, CLS Development, Inc, Columbia, Maryland. References Tomek I M, Sabel A L, Froimson M I, et al. A collaborative of leading health systems finds wide variations in total knee replacement delivery and takes steps to improve value. Health Aff (Millwood). 2012;31(6): content.healthaffairs.org/ content/early/2012/04/30/ hlthaff Weinstein J N, Nesse R E, James B C, et al. The High Value Healthcare Collaborative (HVHC): Structure, process, challenges, and early lessons learned. Health Aff (Millwood). 2012;31(6). org/content/early/2012/04/30/ hlthaff Have an idea? OR Manager welcomes your ideas and contributions for articles. Contact Pat Patterson, editor, at ppatterson@accessintel.com. August 2012 OR Manager Vol 28, No 8 13

14 OR performance Tying anesthesia salaries to on-time starts, turnovers Better data coupled with an at-risk salary model for anesthesiologists have helped one academic medical center to improve its performance for ontime starts and turnover time between cases. The hospital s surgical volume was growing, and it had to make the most of its OR time. Yet a lot of the decisions were made based on feelings and perceptions, and not on data, says Brian Davidson, MD, assistant medical director for surgical services at the University of Colorado Hospital (UCH) in Aurora, Colorado. He is also associate department chair for quality and patient safety. The OR Committee s discussions centered on the familiar issues late first-case starts, turnover times, and block time utilization. Better data and a consensus on definitions were needed before the group could make headway. Dr Davidson, who completed a fellowship in perioperative services management, decided to start 2 projects: Define on-time starts and turnover time and begin collecting and sharing data. Create an at-risk salary model for the anesthesiologists. Results show quickly The program started to show results quickly. Within a week or so after data reporting began, he says, on-time starts in the outpatient surgery center were up to 68%-70% from a previous 35%- 38%. On-time starts for the inpatient ORs improved into the mid- 60% range from about 40%. The goal is to achieve on-time start rates of 65% for the inpatient ORs and 70% in the outpatient center, which would be in the top 10% to 15% of performers in the University HealthSystems The money is just a symbol. Consortium (UHC), Dr Davidson says. Time definitions The definitions UCH adopted are from the AACD Glossary of Times developed by the American Association of Clinical Directors (AACD), which have been endorsed by AORN and accepted by the American Society of Anesthesiologists. (The glossary is available in the AORN 2012 Perioperative Standards and Recommended Practices.) Accordingly, on time was defined as patient in the room by the scheduled start time plus 59 seconds. For example, a case with the patient in the room by 7:30:59 would be considered on time. Turnover time, as defined by AACD, is the time from the prior patient out of room to the succeeding patient in the room for sequentially scheduled cases. AACD advises that turnover time should be calculated only if a subsequent case is scheduled to follow immediately. Gaps should be recorded separately. At-risk salary model The anesthesiologists were chosen for the new model, not because the group thought they were responsible for long turnovers and late starts, he says, but because that is the department to which Dr Davidson belongs. Under the plan, 5% to 7% of anesthesiologists income is attached to the number of times, or percentage of cases, that start on time. The model applies to scheduled first cases and turnovers. The anesthesiologist earns the salary back if the case is on time or the anesthesiologist simply enters a valid reason for the delay in the electronic health record. The amount of the earn-back is calculated daily and reported electronically to the anesthesiologists. The amount is about $20 per inpatient case and $13 per outpatient case. Reasons for delays Collecting reasons for delays enables the department to collect data on causes for lateness. Credit is given to prevent teams from rushing patients into the OR before they are ready, which was a concern of the surgeons and nursing staff. The on-time start data is reported back to individual surgeons and anesthesiologists and to the nursing staff by service. Improvement was seen as soon as we started giving data back and saying, If you re not on time or don t state a reason, you are actually going to have a decrease in income, Dr Davidson says. The new salary model was introduced January 1, There was a hiatus from September through December 2011 as a new OR documentation system was implemented. During that time, he says, meeting on-time start and turnover time goals slipped. He says percentages have come back up since the program was reinitiated. Continued on page OR Manager Vol 28, No 8 August 2012

15 Fecal microbiota transplantation for treating recurrent Clostridium difficile infection u AUGUST 2012 ueditor s Note OR leaders are striving to make evidence-based decisions about new technology. OR Manager, Inc., and ECRI Institute have joined in a collaboration to bring quarterly supplements with summaries of the Institute s Emerging Technology Evidence Reports to OR Manager readers. ECRI Institute is an independent nonprofit organization that researches best approaches to improving patient care. It does its work by analyzing the research literature and data on clinical procedures, medical devices, and drug therapies. This summary provides a review of the literature through February Technology description Fecal microbiota transplantation (FMT) involves introduction of salinediluted fecal matter from a healthy donor into the gastrointestinal tract of a patient with recurrent Clostridium difficile infection (CDI). The procedure is intended to recolonize the patient s colon with nonpathogenic bacteria that will crowd out or otherwise make the environment in the bowel unfavorable for C. difficile colonization. No standardized guidelines exist on donor selection before FMT. Gastroenterologists recommend that fecal donors be healthy family members or spouses/significant partners who have common genetic and/ or environmental factors. However, universal donors have been recruited from healthcare workers to eliminate the need to identify and screen a new donor for each procedure. Prospective donors are screened by interview to identify risks for diseases and conditions for which there are no appropriate laboratory tests. Potential donors then undergo extensive laboratory screening for contagious transmissible diseases. Gastroenterologists can instill the donor fecal suspension by nasogastric tube, nasoduodenal/jejunal tube, upper tract endoscope, colonoscope, retention enema, or a combination of upper and lower approaches. Colonoscopic instillation allows direct simultaneous inspection of the mucosa and determination of preferential sites for infusing larger amounts of donor stool SUPPLEMENT TO OR MANAGER Vol 28, No 8, August 2012

16 Regulatory status FMT is not currently subject to U.S. Food and Drug Administration regulation, because centers that perform the procedure prepare the material in their institutions. Reported indications/contraindications FMT may be indicated for patients with: ZZrecurrent or relapsing CDI defined as at least three episodes of mild to moderate CDI and failure of a six- to eight-week taper with vancomycin with or without an alternative antibiotic or at least two episodes of severe CDI resulting in hospitalization and associated with significant morbidity ZZmoderate CDI not responding to standard therapy for at least one week ZZsevere CDI with no response to standard therapy after 48 hours. Some clinicians suggest FMT as a first-line treatment for severe CDI. FMT has a risk of transmission of diseases that are not screened for or cannot be detected during the preparation of the fecal material; thus, patients on major immunosuppressive agents or with decompensated liver cirrhosis, advanced HIV/AIDS, recent bone marrow transplant, or other cause of severe immunodeficiency could be at increased risk of adverse events. Hospital considerations Hospitals need dedicated laboratory facilities to process the donor stool and facilitate administration to patients. Consistent with universal precautions, staff members mixing and/or handling fecal material must wear fluidresistant gowns, gloves, and masks with goggles or eye shields. Because stool is a Level 2 hazard, using a fume hood during stool preparation is recommended. Centers need to modify current treatment protocols to add procedural steps to provide for patient counseling, donor testing, stool donation, and transplantation of processed fecal material. Credentialing/training Gastroenterologists who are experienced in upper and lower endoscopy techniques require minimal training to perform FMT. Laboratory technicians require minimal training to screen donor fecal material for pathogens and to prepare fecal material for transplantation. Competing/complementary technologies As a first-line therapy for recurrent or severe CDI, FMT competes directly with antibiotics used to treat CDI. As a treatment option for patients with relapsing CDI, FMT competes with other existing therapies, including vancomycin in tapered and pulsed doses, vancomycin plus probiotics, vancomycin plus rifaximin, fidaxomicin, pooled intravenous immunoglobulin, and monoclonal antibodies. Some clinicians have treated patients who have not responded to an initial FMT with a second FMT. Cost considerations Costs associated with screening donor blood and stool for contagious agents, preparation of the donor fecal sample, and placement of a nasogastric tube or retention enema tube can exceed $2,500. The estimated cost of a basic colonoscopy ranges from $2,912 to $6,293, depending on where it is performed. For FMT delivered via colonoscope, additional costs would include those for collection, evaluation, and transplantation of fecal material. Coverage/coding/payment The U.S. Centers for Medicare & Medicaid Services does not have a national coverage determination for FMT. Thus, coverage decisions are left to the discretion of local Medicare carriers. ECRI Institute searches of eight commercial third-party payers found no payer policies for FMT SUPPLEMENT TO OR MANAGER Vol 28, No 8, August 2012

17 Payers are not likely to cover the costs of donor screening, and in many cases, patients have to contribute to the cost of the procedure. The American Medical Association has not assigned a Current Procedural Terminology (CPT) code to describe FMT. Physicians performing this procedure typically report the CPT code that represents an unlisted procedure in the intestine. In the inpatient setting, payment is linked to one of more than 500 Medicare Severity Diagnosis-Related Groups. In the outpatient setting, the technical component is reimbursed under an Ambulatory Payment Classification (APC) as part of Medicare s Hospital Outpatient Prospective Payment System, and the professional component is reimbursed according to Medicare s National Physician Fee Schedule. The U.S. Centers for Medicare & Medicaid has assigned this unlisted procedure to APC 0153, which has a 2012 national unadjusted payment of $1, Medicare s National Physician Fee Schedule does not provide additional payment for professional services for this unlisted procedure. Evidence base ECRI Institute s searches did not identify any studies that compared FMT with other treatment options for CDI. However, our searches did identify eight retrospective case-series reports (Aas et al., 2003; Garborg et al., 2010; Kelly et al., 2012; MacConnachie et al., 2009; Mattila et al., 2012; Mellow et al., 2011; Rohlke et al., 2010; Yoon et al., 2010) and one prospective case-series report (Hamilton et al., 2012) that met the inclusion criteria for at least one of our key questions. These studies assessed a total of 256 patients. Key clinical questions/findings Does FMT for treating recurrent or relapsing CDI result in short-term and long-term resolution of CDI? Limited evidence from seven case series that reported data on 190 patients with 3-months follow-up indicates that FMT results in high rates of CDI resolution, ranging from 72.5% to 100%. Limited evidence from three of these case series suggests that patients who do not respond to FMT initially may benefit from receiving a second FMT. Limited evidence from five case series that reported data on 124 patients with >3-months of follow-up indicates that FMT results in high rates of CDI resolution, ranging from 77.1% to 100%. How does the efficacy of FMT for treating recurrent or relapsing CDI compare to the efficacy of possible treatments for recurrent and relapsing CDI (i.e., vancomycin, metronidazole, fidaxomicin, vancomycin in tapered and pulsed doses, vancomycin plus probiotics, vancomycin plus rifaximin, pooled intravenous immunoglobulin, monoclonal antibodies)? No studies addressed this key question. What adverse events have been reported in studies of FMT? Limited evidence suggests that FMT is safe and generally well-tolerated. Six of the seven case series that included assessment of adverse events reported that none occurred in 181 study patients. The remaining study that assessed 43 patients reported that about one-third of patients noted some irregularity of bowel movements and excessive flatulence the first 2 weeks following the procedure. Although these are reported as adverse events, some patients and clinicians may not consider these to be true or important events, given the impact of ongoing CDI. Excerpted with permission from ECRI Institute s database of Emerging Technology Evidence Reports. The complete report can be purchased from ECRI Institute s Health Technology Assessment Information Service at htais@ecri.org. ECRI Institute is an independent nonprofit health services research agency designated as an Evidence-based Practice Center by the US Agency for Healthcare Research and Quality. The Institute maintains the strictest conflict-of-interest standards in the health care industry to protect against biases and ensure the integrity of its information. Vol 28, No 8, August SUPPLEMENT TO OR MANAGER

18 State of Evidence Base Low Mod ECRI QUANTITY High Low Mod High ECRI CONSISTENCY Low Mod ECRI QUALITY High ECRI Institute 2012 Quantity of Evidence Base (Low) The evidence base consists of eight retrospective case series and one prospective case series that assessed a total of 256 patients who underwent fecal microbiota transplantation for recurrent or relapsing Clostridium difficile infection. Quality of Evidence Base (Moderate) The main limitation is a lack of studies directly comparing fecal microbiota transplantation (FMT) to standard therapies for recurrent Clostridium difficile infection (CDI) to determine relative efficacy. However, without any intervention, recurrent CDI does not resolve on its own; thus, case series reporting short- and long-term resolution of symptoms after FMT can provide some informative results (i.e., that the approach seems to work). Case series were primarily retrospective in design and reported singlecenter experience that may not be generalizable to a broader population. Studies had differing protocols for stool donors, stool preparation, route of administration, and definition of response. Consistency of Evidence Base (High) The included studies reported consistent results regarding the short and longer-term safety and found fecal microbiota transplantation to be effective treatment for recurrent Clostridium difficile infection in most patients (>70%). SELECTED RESOURCES Aas J, Gessert C E, Bakken J S. Recurrent Clostridium difficile colitis: case series involving 18 patients treated with donor stool administered via a nasogastric tube. Clin Infect Dis 2003 Mar 1;36(5): Garborg K, Waagsbo B, Stallemo A, et al. Results of faecal donor instillation therapy for recurrent Clostridium difficile-associated diarrhoea. Scand J Infect Dis 2010 Dec;42(11-12): Hamilton M J, Weingarden A R, Sadowsky M J, et al. Standardized Frozen Preparation for Transplantation of Fecal Microbiota for Recurrent Clostridium difficile Infection. Am J Gastroenterol 2012 Jan 31 (published online ahead of print). Kelly C R, de Leon L, Jasutkar N. Fecal microbiota transplantation for relapsing Clostridium difficile infection in 26 patients: methodology and results. J Clin Gastroenterol 2012 Feb;46(2): MacConnachie A A, Fox R, Kennedy D R, et al. Faecal transplant for recurrent Clostridium difficile-associated diarrhoea: a UK case series. QJM 2009 Nov;102(11): Mattila E, Uusitalo-Seppala R, Wuorela M, et al. Fecal transplantation, through colonoscopy, is effective therapy for recurrent Clostridium difficile infection. Gastroenterology 2012 Mar;142(3): Mellow M H, Kanatzar A. Colonoscopic fecal bacteriotherapy in the treatment of recurrent Clostridium difficile infection--results and followup. J Okla State Med Assoc 2011 Mar;104(3): Rohlke F, Surawicz C M, Stollman N. Fecal flora reconstitution for recurrent clostridium difficile infection: results and methodology. J Clin Gastroenterol 2010 Sep;44(8): Yoon S S, Brandt L J. Treatment of refractory/ recurrent C. difficile-associated disease by donated stool transplanted via colonoscopy: a case series of 12 patients. J Clin Gastroenterol 2010 Sep;44(8): SUPPLEMENT TO OR MANAGER VOL 28, NO 8, AUGUST ECRI Institute 5200 Butler Pike Plymouth Meeting, PA , USA Tel +1 (610) Fax +1 (610) Web Vol 28, No 8, August SUPPLEMENT TO OR MANAGER MS12366

19 OR performance Anesthesia salaries Continued from page 14 Data for improvement The data on late starts has shed light on where problems existed and has been a fruitful source for improvement projects. A few examples are missing histories and physicals, a surgeon arriving to talk with the family just 2 minutes before a scheduled 7:30 am start; a difficult epidural; complex patients with no preadmission testing visit; a patient waiting to see clergy; and a patient needing to go to the bathroom, a more common reason for delay than anyone had realized. We were able to take the data, categorize it, and create a dozen projects to try to reduce the causes of delays, he says. Nursing has led several of these initiatives. One improvement is to have patients who will receive a peripheral nerve block or epidural before surgery arrive 30 minutes earlier than previously. Staying on top of turnover The turnover time goal was set at 30 minutes for patient-out to patient-in. A tactic that has helped is to use a color-coded desktop timer to raise consciousness about the time between cases. The application was created by the IT department and tied to the electronic medical record. This got everyone to focus on the 30 minutes, Dr Davidson says. The timer, displayed on screens throughout the department, is started when a patient leaves the OR and counts down from 30 minutes. A nurse can look at the screen, for example, and see, I m in Room 14, and we are at 18:50. At that point, the timer is green. At 25 minutes, it turns yellow and at 30 minutes, red. Dr Davidson says that one realization is that turnover time goals need to be adjusted for different services. Some services with complex cases, such as orthopedics and neurosurgery, might have improved from 52 minutes to 37 minutes. But they weren t able to meet the 30-minute goal because of the necessary room cleaning and setups. For other less complex cases, such as hernia repair and basic laparoscopic surgery, the room was ready in 18 minutes. Initial hesitation The introduction of the at-risk salary model created some tension initially among nurses and surgeons, who felt they were being hurried, he notes. He responded by telling them, We are not trying to hurry. We are trying to get the cases started on time. If we don t, we want to know why. After what he says was some angst and with support of hospital, nursing, anesthesia, and surgeon leadership, each of the disciplines has made adjustments to improve its performance. It s now more widely accepted that being on time is an expectation. If you re going to tackle the problem, someone has to take the lead, Dr Davidson says. And everyone else has to realize we are going to keep going. How much of a difference has the salary model incentive made? My belief is that it s not about the money, he says. Money is just a symbol of what we think is important. Having individualized data is the key factor, in his view. More important than the money, surgeons and anesthesiologists are competitive. They don t want to be at the bottom of the list on any measure. He believes that makes a bigger difference than the small amount of salary they stand to lose for having a high percentage of late cases. Initially, he says, there was some pressure from his peers to stop the effort, but that was defused once the leadership saw the improvements in on-time starts and turnover times. --Pat Patterson Reference AACD glossary of times used for scheduling and monitoring of diagnostic and therapeutic procedures. Perioperative Standards and Recommended Practices. Denver, CO: AORN, in 5 hospital RNs is depressed The rate of depression in hospital employed nurses, at 18%, is twice the rate of the general population, finds a study. Body mass index, job satisfaction, number of health problems, mental well-being, and healthrelated productivity were significantly related to depression in the survey of 1,171 RNs. Advanced practice nurses and nurse managers are well positioned to help nurses recognize depression and get treatment, the authors suggest. The study, funded by the Robert Wood Johnson Foundation, was published in the May/June Clinical Nurse Specialist. Reference Letvak S, Ruhm C J, McCoy T. Depression in hospital-employed nurses. Clin Nurs Spec. 2012;26(3): August 2012 OR Manager Vol 28, No 8 19

20 OR design & construction Key OR design, construction changes proposed Key changes are being proposed in the OR design and construction guidelines that are used by the Joint Commission, federal agencies, and 42 states. OR leaders may wish to offer comments. Comments are accepted until November 22, 2012, on the draft 2014 Guidelines for Design and Construction of Health Care Facilities from the Facility Guidelines Institute (FGI). Among proposed changes related to surgery: OR design classifications based on infection risk, size of surgical team, quantity and size of equipment, and type of anesthesia updated guidance for pre and postoperative care areas new guidance for hybrid ORs deletion of office-based surgery chapter. There are 7 significant areas of change, notes Ramona Conner, MSN, RN, CNOR, a member of the FGI committee to revise the guidelines. She is AORN s manager of standards and recommended practices. Elimination of ABC classifications (General Hospitals ) The change with the most dramatic impact on ORs is the elimination of the ABC classifications for OR design, says Conner. They will be replaced with 2 classifications operating room and procedure room. The ABC classifications were based on the American College of Surgeons (ACS) Guidelines for Office Based Surgeries, which focused mainly on the type of anesthesia to be administered in the room. A classification was essentially for a standard operating room New classes simplify design. where general anesthesia was administered. B was a hybrid classification for rooms where general and local anesthetics were used. C was a classification for procedure rooms where no general anesthetic was administered. These guidelines, no longer in publication, were written in the 1980s and were not intended to be applied to all surgical settings. New classifications The proposal for 2 classifications simplifies design issues. In a room classified as an operating room, any kind of anesthesia can be administered, whether local, general, or regional. Notable is that minimal dimensions for an operating room in an ambulatory surgery setting dropped from a floor area of 400 sq ft to 360 sq ft (Outpatient Facilities, ). For inpatient operating rooms, minimum dimensions remain at 400 sq ft. Procedure room design requirements are less stringent than for an operating room with dimensions changed from a floor area of 400 sq ft to a minimum clear room width of 18 ft. It doesn t matter if the rooms are being built in an inpatient or ambulatory setting. The office-based surgery chapter was deleted from the proposed guidelines because with the new classifications, it doesn t matter where a procedure is performed; requirements are the same (Outpatient Facilities 3.8). Elimination of substerile rooms (General Hospitals ) Substerile rooms are proposed for elimination. The rationale is that if sterile processing or decontamination is being performed in the surgical suite, there should be a satellite sterile processing area with the necessary equipment and space required for proper decontamination and sterilization practices. The design of substerile rooms encouraged and almost required the placement of steam sterilizers between every couple of ORs, says Conner, noting that these sterilizers are expensive and take up lot of space. In addition, the term substerile is archaic. There is no such thing as substerile; either it is sterile or it is not, says Conner. New guidance for hybrid ORs (General Hospitals ) Hybrid operating rooms are complex and challenging spaces to build. Because of the storage requirements and imaging equipment used, the proposed minimum size for a hybrid OR is 640 sq feet. Also included in the draft guidelines is the requirement for a computer room for each hybrid OR. The room is to be large enough to contain transformers, power distribution equipment, computers, and associated electronic and electrical gear. A major emphasis is that there should be communication with the equipment manufacturer be- 20 OR Manager Vol 28, No 8 August 2012

21 OR design & construction fore the hybrid OR is designed, says Conner. We have run into a lot of problems with people designing a hybrid OR and then deciding what equipment they are going to put in it, she says. Team collaboration is emphasized, particularly between interventional radiology, the operating room, and equipment manufacturers. Defining what a hybrid OR is was a challenge for the steering committee, says Conner. The draft guidelines include a proposal for a glossary term for hybrid operating rooms. Elimination of central core terminology (General Hospitals ) The proposed language eliminates the terminology of central core from the guidelines. Storage areas need to be designed with clean storage in mind, but having a central core would not be a requirement. Elimination of anesthesia workrooms (General Hospitals ) Anesthesia workrooms are proposed to be eliminated as areas for cleaning, testing, and storing equipment. Decontamination of anesthesia equipment should be performed in an area designed for decontamination, such as a satellite decontamination area, not a workroom that also is used for storage, says Conner. The proposed guideline replaces anesthesia workroom with anesthesia storage a space for storing and testing clean anesthesia equipment. Requirements for unrestricted area moved (General Hospitals ) Guidance is offered for hybrid ORs. The language was changed to divide the surgical suite into only 2 designated areas semirestricted and restricted. Unrestricted areas are still needed in the design for a surgical suite, but those requirements are found in the general requirements section of the guidelines (General ). The committee determined that unrestricted areas such as locker rooms and entrance areas where street clothes are worn apply throughout the health care facility, not just the surgical suite, says Conner. Elimination of bariatric requirements in the OR (General Hospitals Appendix A ) Bariatric requirements in the operating room have been eliminated from the surgical suite guidelines and moved to the appendix. This still provides guidance for facilities that have bariatric patients as a large part of their patient population, but it is no longer a minimum requirement, says Conner. Judith M. Mathias, MA, RN An invitation to comment on the draft guidelines is at The proposed guidelines are at www. fgiguidelines.net/comments/draft.php Huge cost for total hip, knee surgical infection Readmission of patients who develop surgical site infections (SSIs) after total knee and hip replacement is common, adding more than $65 million to health care costs annually, in a new study. We found that the impact of these infections is not only significant and profound in the immediate diagnosis period but up to a year out, Keith Kaye, MD, MPH, who led the research team, said. Our analysis discovered huge amounts of previously unrecognized costs and duration of hospitalization, notes Dr Kay, who is from the Wayne State University School of Medicine and Detroit Medical Center. A challenge to prevention Analyzing claims data for 174,425 patients who had hip or knee replacement in 2007, he and his team found 2,134 (1.2%) were readmitted for an SSI within 1 year of surgery. Of those, 267 (12.5%) were readmitted again in the following year because of SSI-related issues. In addition, 870 (40.8%) of SSI patients were hospitalized for other reasons during the year after their SSI diagnosis. Subsequent SSI readmissions had an average hospital stay of 8.6 days, costing an average of $26,812. These findings really challenge us as health care providers to optimize prevention as much as we can and try and avoid these infections in the first place, Dr Kay said. The study was presented at the Association for Professionals in Infection Control and Epidemiology meeting in June 2012 in San Antonio, Texas. com/2012/apic/posterspresenters.asp August 2012 OR Manager Vol 28, No 8 21

22 Sterilization & Infection Control Lumens and endoscopes: Meeting cleaning basics Narrow-lumened instruments and endoscopes are one of your biggest reprocessing challenges. They have the highest risk of being improperly processed, notes Michelle J. Alfa, PhD, FCCM, a researcher in health care-associated infections. If the lumens and channels of endoscopes are not cleaned properly, high-level d i s i n f e c t i o n or sterilization may not be effective. This column addresses the cleaning basics for lumens and endoscope c h a n n e l s. I t should be noted that, in some cases, the design of the lumens and endoscopes makes them very difficult if not impossible to clean. In fact, AORN suggests using ophthalmic surgical instruments with single-use cannulae whenever possible because the lumens are so hard to clean. Dr Alfa, who is a professor at the University of Manitoba, Canada, and medical director for the clinical microbiology discipline with Diagnostic Services of Manitoba, reviewed cleaning advice at the Association for Professionals in Infection Control and Epidemiology conference in San Antonio, Texas, in June One of the clarion themes of the AAMI/FDA Medical Device Reprocessing Summit held in October 2011 was for medical device manufacturers to consider reprocessing requirements early in the design process so these devices can be effectively cleaned. Follow instructions for use Obtain the most up-to-date instructions for use (IFUs) and Review IFUs before purchase. follow them. If the instructions say to process the instruments through 2 ultrasonic cycles, then do not just use 1 ultrasonic cycle to save time because you can bet that those instruments will not be clean. IFUs can be obtained from corporate websites or by calling a company s sterility assurance or quality assurance services. Another option is the onesource document site ( com, 800/ ). For a minimal charge, this company will provide you with the most up-todate IFUs. If the IFUs are not understandable or incomplete, talk to the manufacturer. Review IFUs before purchase ECRI Institute suggests reviewing the IFUs before purchasing an endoscope to determine if: the device is more difficult to process the facility has the equipment and tools to process the device it will take longer to process the device. If the process will take longer, what effect will this have on the case schedule? Will the facility change the case schedule to allow proper processing of the endoscope? This same information could apply to more complex instrument sets that are usually loaned to a facility. Preclean instruments The OR staff needs to preclean instruments as soon as possible after use and keep them moist by using a commercially available presoak product (eg, enzymatic) and/or a towel moistened with water (but not saline) before transferring them to sterile processing. If instruments are not kept moist, blood and body fluids will dry on them within a short time, cause pitting, and will be hard to remove. This adds additional processing time to cleaning, which may, in turn, delay the return of instruments to the OR. This can have a big impact on OR workflow and customer service. Manual cleaning Manual cleaning is not as reproducible and effective as automated cleaning, Dr Alfa notes, but it does allow you to observe specific problem areas when cleaning. Don t take short cuts in manual cleaning. Also, look at the instrument manufacturer s IFUs because they may say automated cleaning with a washer/disinfector alone may not be effective, which means manual cleaning should be done first. Cleaning solution Follow the instrument manufacturer s IFUs to determine the type of cleaning solution to use. Follow the cleaning solution manufacturer s IFUs for the correct: dilution/concentration of the solution temperature of the water water quality to use for the dilution correct exposure time. Test the accuracy of the dilution process, including the automated dispensing and measure- 22 OR Manager Vol 28, No 8 August 2012

23 Sterilization & Infection Control Technologies to aid cleaning These technologies (probably not a complete list) may provide more effective cleaning of lumens and endoscope channels: Endoscope sheaths, which create a sterile barrier between the scope and patient by covering the exterior of the scope and providing a sterile, disposable channel for irrigation and tool passage Inserts for deep sinks or counter tops that replace syringes and internal brushing by pumping detergent and water through scopes, which reduces labor and errors Pull-through cleaning devices that provide a complete circumferential seal in the lumen tube Automated chemical delivery system/device or sink proportioner to ensure appropriate dilution of the cleaning agent Flushing aids used at the sink to provide continuous hands-free channel flushing Ultrasonic units with irrigation pumps for flushing cannulated instruments inside and outside Automatic endoscope reprocessors (AERs) with a cleaning claim. ment systems, to ensure you are correctly diluting the solution. The Joint Commission will be asking for this information during surveys. The optimal temperature of the water should be in the range of 27ºC to 44ºC (80ºF to 110ºF) not to exceed 60ºC (140ºF). This temperature should be monitored and documented. The cleaning solution should be discarded when soiled. Vertically soak instruments with lumens to prevent air bubbles from forming within the lumens, which will prevent the cleaning solution from contacting all surfaces of the lumens. Do not soak instruments horizontally. Thoroughly flushing lumens will also help with the solution contact. Brushes Brushing should be performed under water to avoid aerosolization of contaminants and splashing of infectious material while wearing the appropriate personal protective equipment (PPE). Cleaning brushes should be of the appropriate type, size (diameter and length), bristle type, and material. The brush should have the same diameter as the lumen or channel. If this information is not available in the medical device s IFUs, contact the manufacturer. Don t be stingy with the brushes. Use either single-use brushes, or if using reusable brushes, decontaminate them at least daily. If you continue to use the same brush during the day, the bristles may become worn and no longer contact the sides of the lumen or channel. If dirty, the brush may add more bioburden than it is removing. Also, brushing is only effective if the brush is long enough to exit the lumen or channel completely. Otherwise, dirt is just pushed to the spot where you stop. Water quality and rinsing In general, tap water may be used for the initial rinse, but the final rinse should be performed with treated water (eg, deionized or distilled water or water treated by reverse osmosis) that does not stain or contaminate the instruments. The water treatment process needs to be maintained to eliminate pyrogens, and the water quality should be tested. Mechanical cleaning equipment Mechanical cleaning equipment includes: utensil and cart washers washer-sanitizers and pasteurization equipment washer-disinfectors and washerdecontaminators ultrasonic cleaners. For mechanical cleaning, follow the IFUs for the instrument, the mechanical cleaning equipment, cleaning agents, and lubricants. This will ensure the correct dilution/concentration of the solution, water temperature, water dilution of the cleaning agent and rinsing, and correct exposure time. Review and initial each cycle printout on the mechanical cleaning equipment to ensure the equipment is functioning. Workers need to understand how to correctly operate equipment for efficiency, worker safety, and successful outcomes of the process. Perform the daily and preventive maintenance, such as descaling and cleaning the strainer, spray arms, and nozzles. Check the pumps and chemical feed rates and detergent feed lines to make sure that chemicals and detergents are being pumped into the system and ensure the correct chemicals and lubricants are being used. Check the cleaning solution between ultrasonic cycles and change if heavily contaminated. Degassing after filling with water Continued on page 24 August 2012 OR Manager Vol 28, No 8 23

24 Sterilization & Infection Control Continued from page 23 may be recommended. Keep the lid in place to prevent aerosolization of contaminants. Load instruments according to the IFUs from the instrument and mechanical cleaning equipment manufacturers to ensure the instruments are in contact with the cleaning agent. In general, remove instruments from containment devices and remove materials such as mats that could interfere with the cleaning agent contacting the medical device. In an ultrasonic unit, fully submerge instruments with lumens to remove air so the cleaning solutions can contact all surfaces or correctly connect if an irrigation pump is available. Verification of cleaning Historically, the effectiveness of manual and mechanical cleaning has been verified by visual inspection. The problem with visual inspection is that instruments may look clean but still be contaminated with biofilm, microbes, or biological residues. In addition, visual inspection does not work for lumens or endoscopes. Some instrument manufacturers have suggested using cameras. AAMI in its Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities (AAMI ST79 Annex D) discusses technologies available to verify the cleaning process by measuring levels of organic soil and microbial contamination. The most common methods test for adenosine triphosphate (ATP) or protein (sidebar, p 23). These tools can be used to monitor both the manual and mechanical processing of instruments and the cleaning of endoscope channels. The monitoring is done after the cleaning step and Test for water quality. before high-level disinfection or sterilization. Dr Alfa notes that if the monitoring is done after high-level disinfection or sterilization, the material left from inadequate cleaning will be fixed into the lumen or scope channel. The rapid test result may be negative even if cleaning was not effective, simply because the sampling method could not remove the fixed-on residuals. AORN recommends evaluating manual cleaning when new types of instruments are reprocessed and periodically as determined by the health care organization. AAMI ST79 states: Mechanical cleaning equipment should be tested upon installation, weekly (preferably daily) during routine use, and after major repairs. Testing cleaning AORN or AAMI do not have recommendations for testing of endoscopes. But because of the infection outbreaks associated with incorrect processing, hospitals are starting to test the cleaning process; in fact, some test each endoscope. Monitoring tools include: thermometers and remote sensing equipment to monitor water temperature (ie, to check if the water and detergent from the washer is contacting all surfaces) devices to verify sonic activity or effective cavitation devices to verify cleaning effectiveness of equipment, instrument surfaces, lumens, and endoscope channels (ie, ATP or a protein test). AORN and AAMI advise documentation of the entire cleaning process, as they do for the sterilization process. How often to test? How often should you test the effectiveness of the manual or mechanical cleaning of lumens and endoscope channels? A hospital I visited tested the lumen irrigation pump used in the ultrasonic unit for the DaVinci instruments and discovered the pump was not working. They did not know when the last lumen test was run. How many DaVinci instruments were not properly cleaned and used on patients? Do you want to risk that in your facility? As with biological-indicator monitoring of sterilizers, the more often you monitor the effectiveness of the manual and mechanical cleaning processes, the sooner cleaning failures are detected and corrected, and the fewer patients are placed at risk. No matter which technology is used, cleaning will improve because you will have a tool to establish a cleaning baseline and measure the effectiveness of cleaning before and after education and training. Conclusion Follow the medical device, mechanical cleaning equipment, and cleaning solutions IFUs. Without thorough cleaning and rinsing, it is not possible to achieve highlevel disinfection or sterilization of medical devices. Be sure to monitor the manual and mechanical cleaning processes to determine if they are effective. 24 OR Manager Vol 28, No 8 August 2012

25 Sterilization & Infection Control Ensure the competencies of those processing instruments and endoscopes by improving training, education, and certification. Review IFUs before you purchase medical devices to ensure you have the equipment, tools, and time to follow the IFUs. Patient safety is the top priority. Martha Young, MS, CSPDT President, Martha L. Young, LLC, providing SAVVY Sterilization Solutions for Healthcare Woodbury, Minnesota Martha Young is an independent consultant with long experience in medical device sterilization and disinfection. References Alfa M. Monitoring and Improving Effectiveness of Cleaning Medical and Surgical Devices. Presentations. Association for Professionals in Infection Control and Epidemiology. San Antonio, TX, June AORN. Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Association for the Advancement of Medical Instrumentation. Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. ANSI/ AAMI ST79:2010 & A1:2010 & A2:2011 (Consolidated text). Arlington, VA: AAMI, www. aami.org Association for the Advancement of Medical Instrumentation. Reprocessing 2011 Summit: Priority Issues from the AAMI/FDA Medical Device Reprocessing Summit. Materials/PDF/2011_Reprocessing_Summit_publication.pdf ECRI Institute. Top 10 technology hazards for Health Devices. 2011:40(11). org/products/pages/top-10- Hazards-Resources.aspx Schulz R. Inspecting Surgical Instruments: An Illustrated Guide. Chicago, IL: International Association of Healthcare Central Service Materiel Management (IAHCSMM), Create your legacy. Gresham, Oregon Whether we realize it, our legacy is something we create together every day. It s the way we live our lives and what we teach the next generation. It s what we do and why we do it. That s why, at Legacy Health, our legacy is doing what s best for our patients, our people, our community and our world. Our fundamental responsibility is to improve the health of everyone and everything we touch to create a legacy that truly lives on. Ours is a legacy of health and community. Of respect and responsibility. Of quality and innovation. It s the legacy we create every day at Legacy Health. And, if you join our team, it s yours. Nurse Manager, Operating Room, Central Sterile and Endoscopy - Legacy Mount Hood Medical Center Legacy Health, an Oregon-based not-for-profit corporation with more than 9,500 employees, is one of the largest private sector employers in the Portland Oregon/Vancouver Washington metropolitan area. Legacy consists of six hospitals, including a new state-of-the-art children s hospital, dozens of primary care and specialty clinics, a regional medical laboratory service, a research facility, and other components of a complete health system. We have an exciting opportunity for an experienced Operating Room Nurse Manager. As a key member of the leadership team, this position will report directly to the Director, Surgical Services and will provide leadership to the Operating Room, Central Sterile and Endoscopy services. We are seeking an experienced leader who has critical thinking skills, decisive judgment and the ability to develop effective relationships with staff, other departments, physicians, management and other customers. In this position, the qualified candidate will have overall responsibility for a 4 suite Operating Room, Central Sterile department and a 2 suite Endoscopy unit, in a community hospital setting. This is an exciting opportunity to be part of a larger dynamic organization within outstanding reputation locally and nationally. Qualified candidates will have: Bachelor s degree in Nursing required. MSN, MN or Master s in related field preferred. Current Oregon RN license or eligibility. A minimum of 3 years experience in a clinical nursing leadership role. Demonstrated growth in leadership responsibilities and breadth desired. Nursing experience relating to Surgical Services specialty area preferred. Operating Room nursing experience strongly preferred. Exceptional skills in team-building, communication, and accomplishing Have experience in the use of electronic documentation systems in planned change within a team oriented philosophy. procedure based setting. We are seeking someone with the ability to consistently model Experience with budget building, meeting productivity and budgetary goals. positive and progressive communication with staff, physicians and patients. Legacy Mount Hood Medical Center is in Gresham, between two of Oregon s premier recreational areas, Mt. Hood and the Columbia River Gorge, giving it easy access to activities from skiing to fishing to camping. Gresham gives residents the experience of a friendly community that is part of an exciting metropolitan area and just 30 minutes from downtown Portland. Our nursing staff care for a diverse patient population in a community hospital setting. Legacy Health is committed to diversity, inclusion and cultural competency. Competitive compensation and benefits package include relocation assistance! If you would like to join a progressive, quality-focused organization, then apply online at For additional information, please contact Barbara Becker, Legacy Employment Services, or bbecker@lhs.org. AA/EOE August 2012 OR Manager Vol 28, No 8 25

26 Sleep apnea: Identifying patients at risk in the ASC With obesity increasing across the country, it is not surprising that obstructive sleep apnea (OSA) also is on the rise. For ambulatory surgery centers (ASCs), obesity offers a major but not the only clue that a patient may have, or be at risk for, OSA. A common health risk of obesity, OSA disrupts sleep by constricting the airway and causing the sufferer to stop breathing briefly. The implications for surgery under anesthesia are that the patient is at risk for oxygen deprivation during and after the procedure. If the condition is serious enough, the patient should not undergo outpatient surgery, according to anesthesiology guidelines. New tools have emerged that have proved to be reliable as predictors of OSA. One, with the memorable name of STOP-BANG, is gaining acceptance as a way of identifying high-risk patients. In place of an expensive and timeconsuming clinical diagnosis, it combines screening questions and observation (sidebar, p 27). The question is which patients? At the same time, the anesthesia community is developing clinical guidelines designed to offer the best strategies to manage that risk, allowing more patients to experience the benefits of ASC procedures. Who has sleep apnea? Identifying patients with OSA is the first step in preventing postoperative complications due to OSA, says Frances Chung, MD, medical director of the Ambulatory Surgical Unit, Toronto (Ontario) Western Hospital. The condition results when a person stops breathing involuntarily and for long enough to deprive the brain of oxygen. Symptoms include snoring, daytime fatigue, and blood oxygen desaturation. Central sleep apnea (CSA) is less common than OSA and may be caused by stroke, congestive heart failure, narcotic use, or high altitude, where brain impulses that control breathing are disturbed. OSA is much more prevalent, and more likely to be encountered in ambulatory surgery patients. Dr Chung estimates that between 2% and 26% of the general population have OSA. The frequency and severity vary greatly depending on other characteristics, such age, sex, and how the condition is defined. Chung has found that for bariatric surgery in particular, 7 in 10 patients will have OSA. Which patients? The question for surgery centers is, Which ones? The only sure way to identify OSA is through polysomnography, an overnight sleep lab procedure. Few prospective patients are willing to do this, Dr Chung and other researchers have found. Another alternative is pulse oximetry in the patient s Ambulatory Surgery Advisory Board Lee Anne Blackwell, BSN, EMBA, RN, CNOR Vice president, clinical services, Practice Partners in Healthcare, Inc, Birmingham, Alabama Nancy Burden, MS, RN, CAPA, CPAN Director, Ambulatory Surgery, BayCare Health System, Clearwater, Florida Lisa Cooper, BSN, BA, RN, CNOR President, Surgery Center, Samaritan Medical Center, San Jose, California Rebecca Craig, BA, RN, CNOR, CASC CEO, Harmony Surgery Center, Fort Collins, Colorado and MCR Surgery Center, Loveland, Colorado Stephanie Ellis, RN, CPC Ellis Medical Consulting, Inc Brentwood, Tennessee Rikki Knight, BS, MHA, RN Clinical director, Lakeview Surgery Center, West Des Moines, Iowa Rosemary Lambie, MEd, RN, CNOR Nurse administrator, SurgiCenter of Baltimore, Owings Mills, Maryland LeeAnn Puckett Materials manager, Evansville Surgery Center, Evansville, Indiana Donna DeFazio Quinn, BSN, MBA, RN, CPAN, CAPA Director, Orthopaedic Surgery Center Concord, New Hampshire 26 OR Manager Vol 28, No 8 August 2012

27 Ambulatory Surgery Centers STOP-BANG scoring model for OSA STOP questions Questions for patients: S T O P Do you often snore loudly? Do you often feel tired during the daytime? Has anyone observed you stop breathing during your sleep? Do you have high blood pressure? BANG observations To be noted by staff: B A N G BMI >35 kg/m2? Over age 50 years? Neck circumference >40 cm? Male? Chung F, Yegneswaran B, Liao P, et al. Anesthesiology. 2008;108: home prior to surgery. Again, compliance cannot be assured. Chung estimates that 80% of men and 93% of women with moderate or severe OSA have not been diagnosed. The challenge for ASCs is to identify those individuals and then to assess the severity of their condition, which will determine if they can safely undergo surgery outside of a hospital with emergency facilities. Fortunately, there are clues. Obesity is the most obvious. According to Mia Zaharna, MD, in a presentation for the Stanford Center for Sleep Sciences and Medicine, 70% of persons with OSA are obese, while 40% of the obese population has OSA. Dr Zaharna speculates that OSA may contribute to obesity by lowering energy levels and increasing appetite. Another study found 75% of subjects with a body mass index (BMI) over 40 had OSA. For those with a BMI of 30, the OSA rate was 56%. In Dr Chung s study, the high-risk group had a BMI of 31 or more. Related to weight is neck circumference: 40 cm or more indicates a high risk, according to Dr Chung s study. Regardless of the patient s weight, other risk factors include blood pressure higher than 142 over 83; male gender, though some say the gender difference is declining; and age, with a high risk at age 58 and over. Children may have sleep apnea as well; it may be related to enlarged tonsils and is one reason for many tonsillectomies. Loud snoring is another symptom, defined as audible from another room. Daytime sleepiness, memory loss, depression, and low energy combine to create a reduced quality of life. Finally, a strong signal is observation by another person that the patient stops breathing while asleep. The need to screen None of the above symptoms alone is a sure sign of OSA. Research has shown, however, that as more are present, the likelihood of OSA increases. In 2008, Dr Chung and a team of researchers tested a checklist made up of the above symptoms against results of polysomnography in a group of preoperative patients. They found a strong correlation between the apnea-hypopnea index (AHI) and the number of items from the checklist that applied to each patient. From those results, they developed the questionnaire named STOP-BANG (sidebar). STOP-BANG is not the only screening tool. Many ASCs use a questionnaire issued by the American Society of Anesthesiologists (ASA). At the Algonquin Road Surgery Center in Lake in the Hills, Illinois, the ASA questionnaire forms part of an overall policy for managing OSA. Algonquin Road is a multispecialty center, but 40% of its volume is orthopedic procedures. You really don t want to transfer a patient, says director Lori Callahan, CASC. It costs the patient more, and lower reimbursement is coming. The questionnaire used by Algonquin Road Surgery Center is an algorithm, where a patient s Continued on page 28 August 2012 OR Manager Vol 28, No 8 27

28 Ambulatory Surgery Centers Continued from page 27 answer to one question prompts another. For instance: Ask if the patient has been officially diagnosed with sleep apnea. If the answer is Yes, the patient requires clearance from the medical director or anesthesiologist. If the answer is No, but BANG observations are affirmative, ask the STOP questions, along with several additional ones, such as past respiratory problems after surgery and the availability of a responsible adult during the first 24 hours after the upcoming surgery. Educating surgeons At the multispecialty Surgery Center of Fairbanks, Alaska, screening is the responsibility of the anesthesiologists, who meet with each patient 1 or 2 days prior to the scheduled surgery. Administrator Russell Uhrmacher, RN, CNOR, credits the policy with the center s strong track record for avoiding complications. It is important to make surgeons aware of screening procedures and policies, Algonquin Road s Callahan notes. Surgeons may not think about sleep Lee Anne apnea Blackwell, risk because BSN, EMBA, they RN, may be used CNOR to working at hospitals, Vice president, clinical services, Practice she says. At an ASC, we have a Partners in Healthcare, Inc, Birmingham, screening Alabama process. higher Educating the physicians has Nancy Burden, MS, RN, CAPA, CPAN helped reduce the number of Director, Ambulatory Surgery, BayCare patients Health rejected System, Clearwater, at the Florida time of screening. Lisa Cooper, BSN, BA, RN, CNOR On a recent day, Callahan President, Surgery Center, Samaritan recalls, Medical we Center, cancelled San Jose, 3 California cases because the BMI was too high or The challenge is identifying OSA. there was a history of apnea. That s only 1% or 2% of the caseload. If we did not educate our surgeons, it would be a lot more. Heightened risk OSA results from a compromised airway, whether from excess fat or swollen or collapsed soft tissue. According to Meena S. Desai, MD, managing partner at Nova Anesthesia Professionals in Villanova, Pennsylvania, patients with OSA are more sensitive to sedatives, which can lead to upper airway collapse. Both midazolam and propofol may cause upper airway obstruction, Desai warns, but recovery from propofol is more rapid. Sometimes, obese patients who showed no previous signs of sleep apnea develop airway obstruction during sedation. Therefore, Dr Desai recommends treating all obese patients as potentially having Rebecca sleep Craig, apnea. BA, RN, CNOR, CASC CEO, Harmony Surgery Center, Fort Collins, Colorado and MCR Surgery Stress of surgery Center, Loveland, Colorado The stress of surgery itself may increase Stephanie Ellis, the RN, risk CPC or severity of Ellis Medical Consulting, Inc apnea. Brentwood, Tennessee As Girish P. Joshi, MD, professor Rikki of Knight, anesthesiology BS, MHA, RN and pain Clinical director, Lakeview Surgery management at University of Center, West Des Moines, Iowa Texas Southwestern Medical Center in Dallas, explains, OSA, particularly unrecognized OSA, not obesity, is more likely to cause problems. Dr Joshi advises ASCs to screen all patients for signs of OSA. Where screening indicates the presence of OSA, he recommends using the ASA s follow-up questions to further pinpoint risk based on 3 criteria: estimated severity of the OSA invasiveness of the procedure need for opioids following the surgery. Score each criterion on a scale of 0 to 3. Consider a score of 5 or higher to indicate significant risk for difficult intubation, hospital admission, and postoperative complications. Admit the patient when in doubt, he adds. Patients ineligible for ASC procedures are those: with OSA and uncontrolled (nonoptimized) comorbidity who cannot substitute analgesics for opioids or regional anesthetics who cannot follow postdischarge instructions who refuse to use continuous positive airway pressure (CPAP) at night who live alone. Fewer drugs, more monitoring Rosemary The presence Lambie, (or MEd, strong RN, CNOR suspicion) of Nurse OSA administrator, requires SurgiCenter efforts to of minimize the risk of airway collapse. Baltimore, Owings Mills, Maryland LeeAnn The ASA Puckett recommendations and the Materials advice manager, of OSA Evansville specialists Surgery include reducing use of opioids and Center, Evansville, Indiana Donna sedatives DeFazio during Quinn, surgery BSN, MBA, because RN, they CPAN, will CAPA continue to depress respiration after surgery. Director, Orthopaedic Surgery Center Concord, New Hampshire To alert all health care providers to the risks of sedatives and 28 OR Manager Vol 28, No 8 August 2012

29 Ambulatory Surgery Centers opioids in the patient with known or suspected OSA, the charts of these patients will be flagged with OSA Precautions, the ASA advises. Among other recommendations are: In selecting anesthetics, where possible, use local anesthesia or peripheral nerve blocks or regional anesthesia. If a patient is given sedation, monitor ventilation with capnography (CO 2 measurement). Consider using nonsteroidal anti-inflammatory medications to reduce the need for opioids. In the recovery room, keep OSA patients fully or partially upright if possible. Monitor continuously with pulse oximetry following surgery. Give supplemental oxygen continuously until the patient can maintain baseline oxygen saturation while breathing room air; do not depend on traditional measures of respiratory rate to detect hypoxemia. If the patient repeatedly experiences airway obstruction or hypoxemia, consider transferring the patient to an inpatient facility for observation. CPAP before and after surgery may also reduce OSA risks. Clinicians report, however, that some patients who find CPAP uncomfortable refuse to use it even when informed of the medical benefits. Prescribe postdischarge narcotics in smaller-than-normal doses. Postop care It is essential to monitor ventilation, Dr Desai says, and to administer CPAP during moderate sedation. For patients already diagnosed with sleep apnea, general anesthesia may be preferable, she notes. Postoperatively, she warns of complications such as airway obstruction, oxygen desaturation, systemic hypertension, cardiac arrhythmia, and the need for reintubation. She recommends keeping such patients in a semi-upright position in the PACU. During recovery at home, she has found that despite the risk of oxygen desaturation in apnea patients, continued CPAP protects against further complications. Still, she warns, The risk of respiratory complications may last for several days after surgery because postoperative surgical stress response, anxiety, pain, and opioid use cause sleep deprivation and fragmentation, which may reduce REM sleep and exacerbate sleep disorders. It is important, she adds, that home caregivers be informed about how to recognize and treat complications. Postop instructions Before an OSA patient is discharged, an adult caregiver or family member will need special instructions for managing the postsurgical risks. Dr Joshi offers these instructions: Explain the dangers of opioids and the need to limit their use. Advise the patient to avoid sleeping in the supine position. Advise patients with CPAP equipment to use it at home. Suggest a sleep study for those patients who are believed to have OSA based on the STOP- BANG or other questionnaire. A group effort Finally, as Callahan notes, learn to use the growing number of tools and technologies to manage the risk. To make it work, you need to have a good anesthesia group that follows your guidelines, Callahan says. It s a group effort, with surgeons, anesthesia, and staff. Screening helps pinpoint the risks. Sleep apnea is on the increase, so there really is not a choice, she adds: Over time we re starting to see more and more of it, and that s why we created a policy. I think a surgery center wants every case it can get but not if it s at risk to a patient. Paula DeJohn References American Society of Anesthesiologists. Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea, Ankichetty S, Chung F. Considerations for patients with obstructive sleep apnea undergoing ambulatory surgery. Curr Opin Anaesthesiol. 2011;24(6): Chung, F, Yegneswaran, B, Liao, P, et al. STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108: Zaharna, M. The relationship of weight and obstructive sleep apnea. The Stanford Center for Sleep Sciences and Medicine. August 2012 OR Manager Vol 28, No 8 29

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