or connection magazine - volume 6; issue 1

8/7/2019 OR Connection Magazine - Volume 6; Issue 1

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Nurse LeadersRate PatientExperience

SpecialAORNIssue!

Breast Cancer

AwarenessSection Page 84

TheAligning practice with policy to improve patient care

FREE CE!

Man on aMission: HandHygiene Expert

ProfessorDidier Pittet

Turn up the heat on

HYPOTHERMIA

#1

Volume 6, Issue 1


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Content KeyWe've coded the articles and information in this magazine to indicate which patientcare initiatives they pertain to. Throughout the publication, when you see these icons

you'll know immediately that the subject matter on that page relates to one or more of

the following national initiatives:

IHI's Improvement Map

Joint Commission 2009 National Patient Safety Goals

Surgical Care Improvement Project (SCIP)

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

for implementing their recommendations. For a summary of each of the initiatives,

see pages 8 and 9.


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PATIENT SAFETY

6 Mission: Improving Hand Hygiene

8 Three Important Initiatives for Improving Patient Care

10 Patient Safety News

11 Provider Preventable Conditions

14 Turn Up the Heat: Avoiding Surgical Complications with

Adequate Patient Warming

30 ClearCount Clearly Makes a Difference in Patient Safety at

Hunt Regional Hospital

34 VAP: What is the Perioperative Nurses Role in Prevention?

47 The Quest to Improve Staff and Patient Safety: How One

Health District Converted to Latex-Free Surgical Gloves

61 Unity Hospital: Utilizing Medlines ERASE CAUTI Program

OR ISSUES

40 The Ins and Outs of Hernias and Ways to Repair Them

79 Upcoming Green Events & Green Facts

84 Study of Breast Biopsies Finds Surgery Used Too Extensively

101 Less Invasive Surgery Just as Effective for Some

Breast Cancer Patients

SPECIAL FEATURES

5 International Hand Hygiene Expert Urges U.S. to Use

Five Moments to Reduce Infection

56 Nurse Leaders Survey Results: Patient Experience Is #1

68 12 Ways to Reduce Hospital Readmissions

77 Medline Joins Greening the Operating Room Initiative78 Medline Launches Sustainability Program

88 Celebrating Six Years of Spreading Breast Cancer Awareness

92 Straight from the Heart: Quotes About the Pink Glove Dance

95 Beyond a Reasonable Doubt: Open Communication Helps

Jill Eikenberry Raise the Bar for Breast Cancer Awareness

CARING FOR YOURSELF

102 How to Energize Your Team

110 Recipe: Aunt Judys Tortilla Roll-Ups

FORMS & TOOLS

113 Highlights of AORNs Revised Recommended Practices

for Surgical Attire

120 CDC Hand Hygiene Poster

121 How Well Do You Know Pressure Points?

Editor

Sue MacInnes, RD, LD

Clinical Editor

Alecia Cooper, BS, MBA, RN, CNOR

Senior Writer

Carla Esser Lake

Creative Director

Mike Gotti

Clinical Team

Jayne Barkman, BSN, RN, CNOR

Lorri Downs, RN, BSN, MS, CIC

Margaret Falconio-West, BSN, RN, APN/CNS,

CWOCN, DAPWCA

Rhonda J. Frick, RN, CNOR

Anita Gill, RN

Kimberly Haines, RN, Certified OR Nurse

Rebecca McPherson RN, MSN

Carla Nitz, BSN, RN

Claudia Sanders, RN, CFA

Megan Shramm, RN, CNOR, RNFA

Angel Trichak, RN, BSN, CNOR

Perioperative Advisory Board

Larry Creech, RN, MBA, CDT

Carilion Clinic, Virginia

Sharon Danielewicz, MSN, RN, RNFA

Cedar Park Regional Medical Center, Texas

Tracy Diffenderfer, MSN, RN

Vanderbilt University Medical Center, Tennessee

Barb Fahey RN, CNOR

Cleveland Clinic, Ohio

Susan Garrett, RN

Hughston Hospital Inc., Georgia

Zaida I. Jacoby, MA, MEd, RN

NYU Medical Center, New York

Jackie Kraft, RN, CNOR

Huntsville Hospital, Alabama

Tom McLaren

Florida Hospital, Florida

Susan Phillips, RN, MSH, CNOR

University of North Carolina Hospitals

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

Kingsbrook Jewish Medical Center, New York

Debbie Reeves, MS, RN, CNOR

Hutcheson Medical Center, Georgia

Diane M. Strout, BSN, RN, CNOR

St. Joseph Medical Center, Washington

About Medline

Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospi tals, extended care facilities, surgery centers, home care dealersand agencies and other markets. Medl ine has more than 800 dedicated sales representatives nationwide to support its broad product line and cost management services.

2011 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Page 14

Page 92

Page 102

Page 68

Page 77


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Last night I had the opportunity to have dinner with Professor

Didier Pittet (one of the foremost authorities on hand hygiene).

He spoke with great energy and passion about a number of

pertinent topics, including The World Health Organizations

Hand Hygiene Campaign, the Five Moments of Hand

Hygiene, and the hand hygiene compliance rates of mostfacilities in the United States as compared to other countries.

What a fascinating man he is. One of his achievements is

being appointed Commander of the British Empire (or CBE,

an international honor that includes knighthood). This honor

was awarded by Queen Elizabeth II in 2007 for his services

in the prevention of healthcare-associated infection in the

United Kingdom. He told the story, with great charm and

humility, of what is was like to be knighted by the Queen of

England for his contributions to safety and health care. He

said that while it was a great honor, it was also quite stressful,

as he was allowed to bring only two people with him to the

actual ceremony he chose his two daughters. You can

probably imagine their pride as they got to watch their dad

become only the second person from Switzerland ever to

be so honored.

I was enthralled, sitting across the table from this icon of

healthcare safety and listening to his stories of knighthood,

his early training and his current projects, which include

recording the English narration for the Hand Hygiene

Dance Video, originally performed and filmed at the

University of Geneva. (Our cover photo for this edition is from

the recording session.) Watch for an online link to the final

production to be printed in an upcoming issue ofThe OR

Connection!

Dr. Pittets visit was just one of the amazing experiences Ive

had in the last few weeks. Barely a week ago I met with Dr.

Haywood, Senior Vice President and Chief Medical Officer

of VHA, and his team to discuss research pertaining to

HCAHPS, the patient experience survey that is on the minds

of many nurse executives. I think it is so important to be

aware of the concerns and priorities of hospital administration,

so Ive included on page 56 very recent survey results on

whats most important to nursing leaders today.

Prior to Dr. Haywoods visit, I had met with Kaiser Perma-

nente on the West Coast to talk about healthcare innova-

tions that can be explored and tested. I dont mean

innovations that are made up in a lab or in some corporate

office, but real-life examples of how healthcare professionals,

thought leaders and industry can work together to make

your jobs simpler and to make the chaos of everyday

practice easier to navigate. Weve all been accustomed to

how things have always been done. But this is a new era of

change designed to support the healthcare worker while

improving care. And you are a very important part of this

model.

This edition ofThe OR Connection is being launched at the

AORN 58th Congress, March 18-24, 2011, in Philadelphia,

Pennsylvania my hometown. For those attending the Con-

gress, Medline has included a list of items on page 66 that

we will be featuring at our Booth #3408. If you dont get a

chance to attend, but you would still like information on any

of our programs or products, please give me a call at

847-643-4093. Although we would love to tell you more

about our products and programs, we are just as interested

in your ideas for innovation, so my line is open to you. This

is our biggest issue yet. There are so many things going on

in our industry, Im sure within these pages there is something

that will be of interest you.

Sincerely,

Sue MacInnes

4 The OR Connection

The OR ConnectionLetter from the Editor

VISIT MEDLINE BOOTH #3408 AT AORN CONGRESS


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Aligning practice with policy to improve patient care

International hand hygiene expert Professor Didier Pittet,MD, MS traveled from Geneva, Switzerland to Chicago this

spring to partner with U.S. healthcare workers to improve

hand hygiene compliance.

Dr. Pittet emphasized that despite hand hygienes proven ben-

efits in reducing infection, Its very frightening first to realize

that the compliance is so low, he said. On average its around

40%, at the best, and its not rare that when you come in a

unit or a ward the average compliance will be around 20%.

Dr. Pittet began his visit to Chicago at a recording studio where

he recorded English narration for a short film that promotes the

World Health Organizations (WHO) Five Moments for Hand

Hygiene. The film is called O Les Mains! translated in Eng-

lish it means Raise your Hands. Dr. Pittet currently uses

the film, which features professional dancers, to encourage

and teach proper hand hygiene techniques at his hospital in

Geneva. With Medlines help, Dr. Pittet hopes to get the video

to go viral to inspire healthcare workers in the U.S. and

around the world to learn proper hand hygiene.

Five Moments for Hand Hygiene defines the key times forhand hygiene, presents a unified vision on proper hand hygiene

technique and promotes a strong sense of ownership.

While in Chicago, Dr. Pittet, along with Mark Chassin, presi-

dent of The Joint Commission, also addressed more than 200

senior clinicians and infection preventionists at Loyola Univer-

sity Medical Center in Chicago. Their unified message was

clear a highly compliant and successful hand hygiene

program starts at the top of an organization with its leader-

ship. The event, called Safe Care Town Hall Forum was

co-hosted by Medline and Loyola, and is the first in a series of

patient safety forums to be held around the country.

Dr. Pittet also spoke before medical and nursing students at

Loyolas Stritch School of Medicine. Dr. Pittet believes teaching

healthcare professionals about proper hand hygiene techniques

early in their careers will instill good habits that will stay with

them long term.

Coming toAmerica:

International Hand Hygiene Expert Urges U.S.

to Use Five Moments to Reduce Infection

Special Feature


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6 The OR Connection

Joint Commission-accredited hospitals now have access to

an interactive tool that simplifies processes for solving

healthcare quality and safety. The Targeted Solutions

Tool (TST) encapsulates the work of the Joint Com-

mission Center for Transforming Healthcare and pro-

vides step-by-step processes to measure

performance, identify barriers to excellent perform-

ance, and implement proven solutions.

The first set of targeted solutions focuses on

improving hand hygiene. It was created by

eight of the countrys leading hospitals and

healthcare systems working with the

Center. The TST provides accredited

hospitals the foundation and

framework of an improvement

method that, if implemented well, will improve hand hygiene

compliance and contribute substantially to reducing health

care-associated infections.

The complimentary data-driven tool provides validated andcustomized solutions to address particular barriers to excel-

lent performance. Self-paced and confidential, the TST offers

instantaneous data analysis.

I encourage hospital leaders to use these tools to identify

very specific ways to improve their hand hygiene programs,

said Mark R. Chassin, MD, MPP, MPH, president of the Joint

Commission. Consistent excellence in hand hygiene is vital

to our larger aim of eliminating preventable health care-asso-

ciated infections. The Targeted Solutions Tool provides hos-

pitals with powerful new knowledge and methods they

can use right away to make substantial advances toward

this goal.

Data validates effectiveness of hand hygiene toolAt the start of the project in April 2009, the par-

ticipating hospitals were surprised to learn that

their rate of hand hygiene compliance aver-

aged 48 percent. By June 2010 they had

reached an average rate of 82 percent that

had been sustained for eight months.

Nineteen small, medium and large hos-

pitals across the country also collabo-

rated with the Center to test the work of the original eight

hospitals and provide guidance on the development of the

solutions that are now available through the TST. These

hospitals are experiencing similar gains as the original eight.

For a free electronic copy of the Targeted Solutions Tool for

hand hygiene, Hand Hygiene Factors and Solutions, go to

http://www.centerfortransforminghealthcare.org/tst.aspx.

Medline Industries, Inc. is a proud sponsor of the Center for

Transforming Healthcare Endowment Fund.

Joint Commission Center for Transforming Healthcare

Targeted Solutions Tool for Hand Hygiene

Mission:Improving hand hygiene

Measure

performance Id

entifyBa

rriers

Implement Proven Solutions


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Emollients leave hands feeling soft and silky

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For a FREE Sterillium Rub

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STERILLIUM

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1. Topical Antimicrobial Drug Products for Over-the-Counter Human Use;Tentative Final Monograph for Health Care Antiseptic Drug Products,59 FR 31042 (1994) (to be codified at 21 CFR 333)

2. Data on file

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Sterillium Rub is the only waterless, brushless

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antisepsis. Sterillium Rub provides a rapid and

comprehensive kill of transient and resident skin

flora, with a 6 log reduction within two minutes.2


8/124

8 The OR Connection

Three Important National Initiativesfor Improving Patient Care

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

projects and policies that are driving changes in care.

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

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

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

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

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

The IHI Improvement Map covers the entire landscape of outstanding hospital care to help hospitals make sense of countless requirements

and focus on high-leverage changes to transform care. There are 70 processes grouped into three domains: leadership and management,patient care and processes to support care.

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

(formerly the Sentinel Event Advisory Group)

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

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

guidance to help organizations meet goal requirements.

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

no new NPSGs will be developed for 2011; however, revisions to the NPSGs will be effective in 2011.

Origin: Initiated in 2003 as a national partnership. Steering committee includes the followingorganizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the

Joint Commission

Purpose: To improve patient safety by reducing postoperative complications

Goal: To reduce nationally by 25 percent the incidence of surgical complications by 2010

SCIP aims to reduce surgical complications in three target areas. Participating hospitals collect data on specific process and

outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgical

complications annually (just in Medicare patients) by getting performance up to benchmark levels.

IHI Improvement Map1

Joint Commission 2011 National Patient Safety Goals2

Surgical Care Improvement Project (SCIP)3


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IHI Improvement Map: 73 Processes to Transform Hospital Care

Surgical Care Improvement Project (SCIP): Target Areas

Joint Commission 2011 National Patient Safety Goals

Aligning practice with policy to improve patient care

Patient Safety

Effective January 1, 2011:

Improve the accuracy of patient identification.

Improve the effectiveness of communication

among caregivers.

Improve the safety of using medications.

Reduce the risk of healthcare-associated

infections.

Accurately and completely reconcile medications

across the continuum of care.

The organization identifies safety risks inherent in

its patient population.

Universal Protocol for Preventing Wrong Site,

Wrong Procedure, and Wrong Person Surgery.

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

The IHI Improvement Map is an online tool that distills the best knowledge available on the key process

improvements that lead to exceptional patient care.

To learn more about the IHI Improvement Map and the 73 processes to transform hospital care, go to www.ihi.org/imap/tool

1. Surgical infections

Antibiotics, blood sugar control, hair removal, perioperative

temperature management

Remove urinary catheter on Post Operative Day (POD) 1 or 2

2. Perioperative cardiac events Use of perioperative beta-blockers

3. Venous thromboembolism Use of appropriate prophylaxis

3 New Key Processes as of June 2010

1. Anticoagulation Management

2. Essential Care for Frail Older Patients

3. Glycemic Control in Non-Critically Ill Patients

Top 5 Key Processes Shared by Improvement Map Users

1. Central Line Bundle

2. CA-UTI

3. Anti-Biotic Stewardship

4. Falls Prevention

5. Heart Failure Core Processes

Visit www.qualitynet.org

By the numbers:

3,740 hospitals are submitting

data on SCIP measure #9, representing

75 percent of all U.S. hospitals

Currently, SCIP has more than 36

association and business partners


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10 The OR Connection

The Department of Health and Human Services recently

released its findings that about 134,000 Medicare patients

experienced adverse events in hospitals during a single

month in 2008. About 44 percent of the events were con-

sidered to be preventable. The cost to treat the affected

patients was estimated at $324 million.

The Centers for Medicare and Medicaid Services (CMS)

responded that it will aggressively pursue efforts to expand

adverse event reporting and the types of events that are

considered reportable. Only six states currently require

public reporting of medical errors.

New suggestions for blood glucose

management during outpatient surgery

The Society for Ambulatory Anesthesia (SAMBA) issued a

consensus statement at the end of 2010 outlining glucose

management suggestions for anesthesia providers. The

significant practice changes include:2

Preoperative advice to the patient regarding the use

of their anti-diabetic drug on the day of surgery

The use of rapid-acting insulin rather than regular

insulin during surgery

Use of the 1500/1800 formula for determining the

dose of insulin

Avoiding the temptation to normalize blood glucose

levels in patients with inadequately controlled levels

References1. Hospitals hurt 134,000 Medicare patients a month. Outpatient Surgery

Magazine. November 30, 2010.2. SAMBA issues suggestions for blood glucose management in diabetic

patients. Outpatient Surgery Magazine. December 2010.

National Patient Safety Foundation

launches new membership organization

for healthcare professionals

The American Society of Professionals in Patient Safety

(ASPPS) is a new membership organization launched by the

National Patient Safety Foundation (NPSF). It is seeking mem-

bers from across the spectrum of healthcare disciplines to

help extend the groups agenda of accelerating the delivery of

safe patient care and establishing consistency in safety prac-

tices and tools. The organization plans to implement a certi-

fication program to validate competencies and practices that

are proven to reduce medical errors. Information on mem-

bership and the May 2011 Patient Safety Congress can befound at www.npsf.org/hp/ASPPS.php.

PATIENT SAFETY NEWSPATIENT SAFETY NEWS

134,000 Medicare patients per month hurt at hospitals1


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Aligning practice with policy to improve patient care 1

Since the summer of 2008, the Centers for Medicare and

Medicaid Services (CMS) has encouraged states to model theirMedicaid payment rules after the federal Medicare program.

Now, the Affordable Care Act (ACA) has mandated that the

Medicare rules for withholding payment for never events now

be extended to state-run Medicaid programs. The Affordable

Care Act (ACA) requires the new rules extension be effective

July 1, 2011.

The eleven CMS-recognized preventable conditions are:

Retained items after surgery

Air embolism

ABO blood incompatibility

Catheter-associated urinary tract infection (CAUTI)

Pressure ulcers

Central line-associated bloodstream infection (CLABSI)

Surgical site infection (SSI)/mediastinitis

Falls and certain other traumas

SSI after certain elective procedures

Poor glycemic control manifestations

Deep vein thrombosis (DVT)/pulmonary embolism (PE)

This list is exhaustive for Medicare, but for Medicaid CMS has

intentionally granted states the flexibility for including other con-

ditions beyond the eleven that CMS has already identified.

The different nature of Medicaid and the services it pays for has

created a new set of terminology to learn. HAC, hospital-

acquired condition is now pass, as is HCAC, the more generic

healthcare-acquired condition. The preferred new term is

provider preventable condition, or PPC. The definition of a PPC

is a condition that could have reasonably been prevented

ProviderPreventableConditions:

ExpandingNever Event/No-Pay

Regulations

Patient Safety


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through the application of evidence-based guidelines. PPCs

would encompass the same healthcare-acquired conditions as

defined for Medicare purposes, plus other PPCs defined by

states and approved by CMS.

Perhaps more significant than the what of a PPC is the

where it may occur. CMS proposes using PPC as an umbrella

term for both hospital and non-hospital conditions identified by

a state for nonpayment. PPCs would encompass hospital-acquired conditions, as defined for Medicare purposes, and

other PPCs applicable to service settings beyond the inpatient

hospital setting. CMS notes that preventable conditions can

occur in an outpatient hospital, nursing facility and ambulatory

care settings. The denial of claims for PPCs happening in any

of these environments is a significant expansion of the existing

regulations.

What does all this mean?Like any significant policy change such as this one, there will be

both expected results and unexpected consequences. The

original Medicare claims denials for HACs are running at

approximately $20 million per year. Over the next five years, the

Medicaid claims denials for PPCs are expected to total $35 mil-

lion, or an average of an additional $7 million per year. The Med-

icaid savings are divided approximately 60/40 between Federal

and state savings.

There will be costs associated with this new rule, too. CMS

estimates that both states and providers regulatory and

reporting compliance will be relatively small. Providers, however,

will incur additional costs to reduce PPCs. These costs may be

from hiring more nurses and infection control professionals aswell as training staff on best practices for PPC prevention.

Equipping staff with evidence-based products and programs

that help deliver better outcomes may be seen as an additional,

but very necessary cost as well. Most hospitals have taken

these PPC prevention steps to comply with Medicare rules.

However, most non-hospital health care settings will now find it

necessary to make expenditures to address the PPCs that

occur in their environment.

While the explicit purpose of the regulation is cost containment

through administrative action, the implicit purpose is the public

benefit of an overall reduction in PPCs and a correspondingincrease in healthy years of life. CMS is quick to point out, how-

ever, that the regulation itself is not responsible for the better

health of the population, but rather the responses made to it by

hospitals and other care providers.

For more information, visit: https://www.federaregister.gov/

artices/2011/02/17/2011-3548/medicaid-program-pament-

adjstment-for-provider-preventabe-conditions-incding-heath

CMS no pay for never events policy used to

be Medicare only. In July its set to be part ofall 50 state Medicaid plans.


13/124

Promote Correct-Site Surgery

Our Surgical Time Out Procedure (S.T.O.P.)

safety products alert the surgical team to

perform a time-out verification and help reduce

the risk of wrong-site surgery.

Support Sharps Safety Practices

Transfer trays, scalpel holders and needle

counters with blade guards promote sharps

safety and help make you OSHA compliant.1

Improve Fluid Disposal Safety

The Safety-Splash fluid management system

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minimizing the risk of exposure.

2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.Safety-Splash and S.T.O.P are trademarks of Medline Industries, Inc.

References:

1. Occupational Safety and Health Standards, Toxic and Hazardous Substances,

Bloodborne pathogens. Regulations (Standards - 29 CFR). Available at: http://

www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_

id=10051#1910.1030(d)(2)(i). Accessed October 13, 2010.

Medlines Gold Standard safety products stand out against thesea of blue in the OR to alert the surgical team to focus on safety.

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MEDLINE GOLD STANDARD SAFETY COMPONENTS

SAFETYDESERVES

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14/124

Avoiding Surgical Complicationswith Adequate Patient Warming


CE Article


15/124

SCIP-Inf-101Measure: Surgical patients should be actively warmed during surgery or have at least

one recorded body temperature equal to or greater than 96.8 degrees Fahrenheit

within 30 minutes prior to the end of anesthesia to 15 minutes after anesthesia ends.

(Patients with intentional hypothermia are excluded from this measure.)

In 2003, the Joint Commission and the Centers for Medicare and

Medicaid Services (CMS) teamed up to align their common meas-

ures. In the process, they decided to add a set of measures for Sur-

gical Infection Prevention (SIP), which was quickly added as a core

measure set.2 In July, 2006, SIP was renamed the Surgical Care

Improvement Project (SCIP).

Members of the SCIP Steering Committee include the Association

of periOperative Nurses (AORN), the Joint Commission, the Centers

for Medicare and Medicaid Services (CMS), Agency for Healthcare

Research and Quality (AHRQ), American College of Surgeons

(ACS), American Hospital Association (AHA), American Society of

Anesthesiologists (ASA), Centers for Disease Control and Prevention

(CDC), Department of Veterans Affairs, and the Institute for Health-

care Improvement (IHI).3This national partnership of organizations

works together to improve the quality of surgical care.

To date, SCIP has introduced 10 measures, plus three others

specifically addressing cardiac patients and venous thromboem-

bolism. All measures are to be followed in order to reduce surgical-

site infections and other complications of surgery. (For the complete

list of all SCIP Measures, turn to the back of this article.)

SCIP-Infection (Inf.)-10, also known as SCIP Measure 10 Surgery

Patients with Perioperative Temperature Management, went intoeffect October 1, 2009.4 When the measure was first adopted, the

best available temperature management evidence was on patients

having colectomies while under general anesthesia. Consequently,

the measure initially focused on this population.

Currently, SCIP-Inf.10 applies to patients of any age undergoing

surgical or therapeutic procedures while under general or neurax-

ial anesthesia for one hour or more. It does not include patients

undergoing cardiopulmonary bypass.5

Contined on Page 17


16/124

For protection from unintentional hypothermia in patients

undergoing surgery, PerfecTemp is an excellent alternative

to forced-air warming systems.

While other systems use disposable blankets to force

warm air on top of patients, PerfecTemps unique

surgical table pads offer.

Efficient underbody warming as effective asforced-air systems for preventing unintentionalhypothermia.1

More accurate patient monitoring

Complete patient access

Silent operation

Reduced staff time

No blowing air Energy conservation

PerfecTempOR Patient Warming System

Innovation in Patient Warming

2011 Medline Industries, Inc. Medline and PerfecTemp are registered trademarks of Medline Industries, Inc.

Flexible and durable carbon heating

element for uniform heating.

Underbody Warming for All

Patients and Procedures

References

1. Egan C, Bernstein E, Reddy D, et al. A Randomized Comparison of Intraoperative Warming With the LMA PerfecTemp

and Forced Air During Open Abdominal Surgery.


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Intraoperative core temperatures

about two degrees Celsius below

normal increase the incidence

of wound infection threefold and

prolong hospitalization by about

20 percent.5

Under SCIP-Inf-10 clinicians must either actively warm patients

during surgery or record a body temperature of 36 degrees C (96.8

degrees Fahrenheit) or higher within 30 minutes before or 15 minutesimmediately after the end of anesthesia. Clinicians must provide clear

documentation of the temperature during active warming or in rela-

tion to the end of anesthesia.

What causes perioperative hypothermia?As warm-blooded creatures, human beings organ systems are

designed to operate within a narrow temperature range. Hypother-

mia occurs when a persons body loses more heat than it can pro-

duce, leading to a core body temperature drop. In nature, we know

what makes us cold and we can respond. Exposure to cold air

encourages us to get out of the cold or bundle up. Being dampcauses us to seek drier conditions. We put on jackets or seek shel-

ter to get out of the wind. In the OR, perioperative hypothermia is

common, resulting from the effects of anesthesia on the bodys ther-

moregulatory control system.6

Many factors can contribute to unplanned perioperative hypother-

mia, including cool air temperature in the OR, length of surgery (the

longer the surgery, the greater the likelihood of hypothermia occur-

ring), blood and fluid loss, and effects from anesthesia, which alters

the patients ability to regulate body temperature. A patients body

type can also affect heat loss. Very thin, malnourished patients aswell as those who are very young or elderly are more susceptible to

perioperative hypothermia.7

Elderly patients are more susceptible to hypothermia for a number

of reasons. The body's ability to regulate temperature and to sense

cold may lessen with age. Comorbidities that affect temperature reg-

ulation are more likely in older adults, including conditions such as

hypothyroidism, stroke, severe arthritis, Parkinsons disease, and

neuropathies including diabetic neuropathy. They are also frequently

more dehydrated and malnourished than the general population.

Finally, medications including some antipsychotics and sedatives

(both of which are used more frequently in long-term care settings)

can impair the bodys ability to regulate its temperature.

Core body temperature changes occur in three stages, beginning

with the onset of general anesthesia. During the first hour, redistrib-

ution is the main cause of potential perioperative hypothermia.

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After indcing anesthesia, a patients

core bod temperatre drops rapid.9

Complications associated with perioperative hypothermiaHypothermia, which is defined as having a core body temperature

of less than or equal to 36 degrees Celsius or 96.8 degrees

Fahrenheit, is associated with several complications and an in-

creased risk of death. Perioperative hypothermia can result in: 11

three times the incidence of surgical site infection

increased bleeding and increased need for blood transfusions

three times the risk for cardiac complications

a higher risk for developing pressure ulcers

prolonged recovery after surgery

Surgical site infection. Hypothermia causes the blood vessels

to constrict, decreases blood flow to tissues and decreases oxy-

genation of surgical wounds, allowing a more favorable environ-

ment for bacterial growth. In 1996 Andrea Kurz, MD, andcolleagues published a study involving 200 colorectal surgery

patients; 100 were randomly assigned to undergo surgery with

warming and the other 100 without warming. For those who did

not receive warming, the final mean intraoperative core temper-

ature was 34.7 degrees Celsius. The final mean temperature for

those who were warmed was 36.6 degrees Celsius. Surgical

wound infections were found in 19 percent of the hypothermic

group and in six percent of the normothermic group. The

authors concluded that intraoperative core temperatures about

two degrees Celsius below normal increase the incidence of

wound infection threefold and prolong hospitalization by about20 percent.12

Melling et al. also conducted a study of wound infection rates

following surgery. The random controlled trial included 421

patients and resulted in a four percent infection rate among

patients who received local warming and 15 percent among

those who were not warmed.8

During this stage, warmer blood from the core is allowed to mix

with cooler blood from the rest of the body. The blood cools as

it circulates, and the cooled blood that returns to the heart cancause a decrease in body temperature8 of up to one degree

Celsius.7

Redistribution is followed by the second phase, which occurs

during the second and third hours of anesthesia, during which

heat loss exceeds the bodys ability to produce heat. During this

phase, warming the patient can effectively limit further heat loss.

Finally, after about three to five hours of anesthesia, the patients

temperature reaches a plateau, which usually remains constant

for the remainder of the surgery, regardless of how long the rest

of the procedure takes.

Did you know?

Some patients report that shivering and being

cold are worse than surgical pain. Hypothermia

can cause a vigorous shivering response, which

increases carbon dioxide production and increases

oxygen consumption 400 to 500 percent.10

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Contined on Page 20


19/124

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20/124


Cardiac complications.A 1993 study by Johns Hopkins anes-

thesiologist S.M. Frank, MD, and colleagues revealed that a

greater number of hypothermic patients (36 percent) experi-

enced myocardial ischemia compared with normothermic

patients (13 percent). The incidence of angina postoperatively

was also greater among the hypothermic group (18 percent)

compared with the normothermic group (1.5 percent).15All 100

subjects in the study underwent a vascular reconstruction

procedure.

It is important to recognize the difference between unintended

hypothermia that leads to cardiac conditions, and the growing

practice of therapeutic, induced hypothermia in cardiac patients.

Unintentional hypothermia (perioperatively or otherwise) can lead

to an unusually slow or irregular heart rate, which manifests as

a weak or slow pulse or other arrythmias.16 Therapeutic hy-

pothermia is an evidence-based intervention that attempts to

lower core temperatures to around 33 degrees Celsius

for 24 hours after a cardiac event for the purpose of improving

neurological outcomes.

Perioperative pressure ulcers. Because of circulatory and

metabolic changes that occur during surgery, the etiology of

perioperative pressure ulcers is more complex than those that

One suspected cause of surgical site infections has been

understood to be a lack of oxygen, in particular bactericidal

oxide radicals. As a drop in core temperature leads to vaso-

constriction to preserve heat in the body, less oxygenated blood

flows to a wound site on the skin. That reduction in available

oxygen at the wound site makes it more conducive to bacterial

growth. One study found that dissolved oxygen (pO2) is a

strong predictor of infection. Measuring levels of subcutaneous

oxygen in post-surgical patients, he found that none with an

oxygen tension greater than 90 mmHg developed a SSI

whereas 43 percent of patients with an oxygen tension between

40 and 50 mmHg did develop a SSI.

Increased blood loss.A meta-analysis published in 2008 by

Daniel Sessler, MD, professor and chair of the Department of

Outcomes Research at Cleveland Clinic, and colleagues found

that less than one degree of hypothermia is enough to increaseblood loss by about 16 percent and increase the need for in-

traoperative transfusion by about 22 percent. Normothermia,

however, was associated with a reduced chance of blood loss

and a reduced need for transfusion.13 Similarly, an earlier study

by Schmied and colleagues in 1996 also found that mild hy-

pothermia can increase blood loss and the need for transfusion

during surgery.14

Published evidence shows

high rates of complications

among hypothermic surgical

patients, making it important

for perioperative professionals

to keep patients warm.


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occur in medical patients.17 In a 2001 study researchers

hypothesized that patients capacity to withstand mattress pres-

sures during surgery would increase if hypothermia were

prevented. They performed a randomized control trial to explore

the relationship between tissue viability and patient coretemperatures during surgery and to test the hypothesis that

patient warming would reduce the incidence of pressure ulcers.

Their trial involving 324 surgical patients resulted in an eight

percent pressure ulcer incidence among patients who were

warmed with a forced air over-blanket, versus a 65.4 percent

incidence among patients who were not warmed.18

Prolonged recovery. Rainer Lenhardt, MD, clinical director of

the Neuroscience-Anesthesia Intensive Care at the University of

Louisville School of Medicine, and colleagues hypothesized that

intraoperative hypothermia may prolong immediate surgicalrecovery by increasing the potency of the anesthetic, delaying

drug metabolism or depressing cognitive function. They followed

150 patients undergoing elective major abdominal surgery and

discovered that hypothermic patients required about 40 minutes

longer than normothermic patients to reach fitness for discharge.19

Length of stay in the post-anesthesia care unit (PACU) is an

important issue for health care managers. PACU nurses care for

a small number of patients because of the high level of attention

and care needed by a person recovering from anesthesia. Some

have calculated that the personnel cost for two-hours in thePACU stay is similar to the personnel cost for a full day on a general

care unit in a hospital.20 In an era of cost control, decreasing

recovery time is economically desirable for the institution.

Warming methodsAs summarized above, published evidence shows high rates of

complications among hypothermic surgical patients, making it

important to maintain normothermia. There are several kinds of

surgical warming devices available.

Types of warming devices include forced air over or under the

body; circulating warm-water devices; or conductive, active

warming devices, which include under-the-body warming

mattresses or over-the-body warming blankets. In addition to

requiring perioperative professionals to maintain normothermia

in patients, SCIP-Inf.-10 also requires clear documentation

regarding the use of active warming devices.11

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Pulmonary artery.The most accurate measurement

of the core body temperature is through the pulmonary

artery, which is bathed in blood from the core. This

invasive form of monitoring, however, is not justified

solely for temperature assessment.

Recommendation IVThe core temperature of patients at risk for unplanned

hypothermia should be monitored pre-operatively,

intraoperatively and postoperatively.

Recommendation V

Interventions should be implemented to prevent

unplanned hypothermia.

Recommendation VI

Warming devices should be used in a manner that

minimizes the potential for patient injuries.

Recommendation VII

Competency

Personnel should receive initial education and competency

validation and updates on the prevention of unplanned

hypothermia and the use of warming equipment.

Recommendation VIII

Documentation

Patient assessments, the plan of care, interventions

implemented, and evaluation of care to prevent unplanned

perioperative hypothermia should be documented.

Recommendation IX

Policies and Procedures

Policies and procedures for prevention of unplanned

hypothermia should be developed in collaboration with

anesthesia care providers, reviewed periodically, revised as

necessary, and readily available in the practice setting.

Recommendation XQuality

A quality improvement/management program should

be in place to evaluate the structure, process, and

outcomes of interventions used to protect patients from

unplanned perioperative hypothermia.

How to prevent perioperative hypothermiaAlthough SCIP recommends keeping patients warm during

surgery, it does not recommend how to keep them warm.21

Nursing organizations, including the Association of

periOperative Registered Nurses (AORN) and the American

Society of Perianesthesia Nursing have developed standards

for preventing hypothermia during surgery. The followingare highlights from AORNs Recommended Practices for

Prevention of Unplanned Perioperative Hypothermia.22

Recommendation I

The perioperative registered nurse should assess the

patient for risk of unplanned perioperative hypothermia.

Recommendation II

The perioperative registered nurse should develop

a plan of care to minimize the risk of unplanned

perioperative hypothermia in patients identified at risk.

Recommendation III

Equipment to monitor core temperature should be

selected based upon reliability and access to the route.

III.a.1

There are four reliable sites for measurement of core

temperature:

Tympanic membrane.The tympanic membrane

temperature, measured by a thermocouple, is the

preferred method in many perioperative and postoperative

areas. This method is noninvasive, and the monitoring

site receives blood supply from the carotid artery, which

supplies the thermoregulatory center of the hypothalamus.

Distal esophagus.The distal esophagus is considered

a desirable site to measure temperature, particularly in

the operating room, and is less prone to artifact than most

others. It is an alternative to the pulmonary artery and is

widely used intraoperatively. Placement of the probe in the

lower fourth of the esophagus prevents artifactual cooling

of the probe by respiratory gases. Nasopharynx.The nasopharynx is another reliable

monitoring site for intraoperative measurement because it

approximates core temperature. A thermistor probe is

inserted through the nares to the nasopharynx.

Measurements may be influenced by the temperature

of inspired gases and often are 0.5 degrees Celsius

lower than pulmonary artery temperatures.


23/124


near the patients skin to continuously monitor and control the

heat generation of the pad. Warming can begin as soon as the

patient is positioned on the OR table. The anesthesiologist can

select one of five preset temperatures of 37, 38, 39, 40, or 40.5

degrees Celsius. The heating element is placed below one inch

of viscoelastic memory foam to provide pressure redistribution

for the patient. The entire pad is encased in a fluid proof cover

and all seams are sealed to prevent penetration by spilled fluids,

meaning the mattress can be cleaned and reused, eliminating

unnecessary environmental waste. In addition, because the

patient is warming from underneath, blankets need not be

placed on top of the patient, allowing for greater surgical access.

The device also operates with no noise.

Warming blankets. Warming blankets are one option that is

portable, easy-to-use and effective. The downside, however, is

that nurses must make multiple trips to and from the blanket

warming cabinet to ensure the patient always has a warm blanket.

This can reduce efficiency and increase laundry costs.23

Also,adding too many layers of warmed cotton blankets is ineffective

in raising the patients body temperature. The first blanket can

reduce heat loss by 33 percent, however, adding another blanket

only adds another 18 percent reduction in heat loss. Adding

three or more blankets adds no further warming.8

Forced air warming.Another widely used option is forced air

warming. The system consists of a warming unit and a remov-

In an interview with OR Manager, perioperative hypothermia

expert Dr. Sessler stated that it doesnt matter which warming

method is used as long as the patients temperature is approx-

imately normal at the end of the surgery.21 Dr. Sessler is a lead-

ing researcher in surgical warming and has co-written many

studies on how hypothermia affects surgical patients and the

effectiveness of warming devices.

Warm IV fluids. Warming IV fluids is another way to increase

body temperature, but only under certain circumstances.

AORNs Recommended Practices for Prevention of Unplanned

Perioperative Hypothermia states:22

Warming intravenous (IV) fluids should be considered only if

large volumes (i.e., more than two liters/hour for adults) are

being administered. Warming IV fluids to near 37 degrees Cel-

sius (98.6 degrees Fahrenheit) prevents heat loss from the

administration of cold IV fluids and should be considered as an

adjunct to skin surface warming. When less than two liters ofvolume is given, fluid warming is of limited value because fluid-

induced cooling is minimal.

Conductive warming devices. One type of patient warming

pad on the market is an electrical resistive/conductive device

that warms underneath the patients body. It takes the place of

an existing OR table mattress pad. The device incorporates dual

fiber optic interface temperature sensors under the pad cover

Methods of Patient Warming

Warm IV Fluids

Conductive Warming Devices

Warming Blankets

Forced Air

Circulating Water Garments

Increased Operating Room Temperature


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Differences in perioperative patient warming sstems rest

arge from what tisses are in contact with what heating ee-

ment and the avaiabe srface area. Heat transfer aso depends

on phsica characteristics of the heater-skin interface. For

exampe, the srface area of the ng is enormos, bt airwa

heaters and hmidifiers transfer trivia amonts of heat becase

the therma capacit of air is sma.

With an ctaneos warming sstem, heat transfer into the ther-

ma core depends on skin temperatre, tisse insation, and

circator convection of heat within the bod. Device efficac

ths depends on which srface area is heated becase the core

is reative isoated from dista skin srfaces. Bt most impor-

tant, ctaneos heat transfer depends on skin temperatre.

Near a commercia avaiabe patient-warming sstems are

eectrica powered; there is, therefore, no intrinsic phsica imit

to the caories that can be provided. Instead, the imitation is a-

was the skin temperatre that can be toerated withot nde

risk of brns.

Despite the high heat capacit and therma condctivit of water,

the efficac of conventiona circating-water mattresses is mod-

est. Poor efficac rests becase 1) the posterior srface is a

reative sma fraction of the bod srface area, 2) this area is

poor perfsed becase the weight of the bod compresses

ctaneos capiaries, and, 3) most heat is ost via radiation and

convection from the anterior srfaces rather than condction

able disposable blanket. The warming unit, which resembles an

industrial vacuum cleaner, draws in air from the room and

warms it to a specified temperature. The warm air is then

pumped through a hose into a disposable blanket that covers

the patient. According to Dr. Sessler, operating rooms tend to

use forced-air warming covers because they are effective, safe

and inexpensive. The blowers are often provided, and the blan-

kets are inexpensive.21

One difficulty with forced air warming is that it cannot always

sufficiently warm a large enough surface to maintain normoth-

ermia during very large procedures when the patient is not in

the supine position. For example, it can be difficult to maintain

normothermia in a patient undergoing a colectomy in the litho-

tomy position. So much skin is exposed that there is not enough

surface area to warm. In cases like this, a combination of patient

warming devices and an ambient operating room may be thesolution for maintaining normothermia.21

Some surgical staff reject the use of forced air warming because

it can contribute to field contamination and the unit itself can be

a source of pathogens. Another criticism of forced-air warming

is that it can create too warm an environment for the surgeon.8

The blowing can also create a considerable amount of noise in

the OR.

Circulating water garments.These devices circulate water

through a segmented garment that is wrapped around theanterior and posterior sides of the patient. This is in contrast to

circulating water mattresses, which the patient lies on in a

supine position, thereby warming the posterior side of the body.

Research conducted by Dr. Sessler has shown that circulating

water garments and energy transfer pads warm patients about

50 percent better than forced air because they warm both over

and under the body. These systems tend to be more costly,

however, experts argue the cost is justified by better patient out-

comes when compared with other warming methods.

The following is an excerpt from a study by Taguchi et al., which

compares the efficacy of circulating water garments versus

forced air to maintain perioperative normothermia.6To read the

study in its entirety, go to www.ncbi.nlm.nih.gov/pmc/arti-

cles/PMC1409744/?tool=pubmed. Akiko Taguchi, MD, is an in-

structor in the Department of Anesthesiology at Washington

University in St. Louis, MO.

Despite the high heatcapacity and thermalconductivity of water, the

efficacy of conventionalcirculating-watermattresses is modest.


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tner et a. who fond that periphera tisses isoate the core from

heat appied to the skin srface in the post-anesthetic period.

Simiar, Szmk et a. fond that core rewarming was sowed b

postoperative vasoconstriction. In contrast, periphera-to-core

heat transfer is nimpeded dring anesthesia, whether sbjects

are vasodiated or vasoconstricted. The critica distinction

amongst these stdies is that vonteers were f anesthetized

in the ater protocos whereas the were nanesthetized in the

former ones. Athogh or vonteers remained intbated, the

were ver ight anesthetized and f vasoconstricted. It is ths

nike that the were given sfficient anesthesia to case di-

rect arterioar vasodiation that seems to be critica for rapid pe-riphera-to-core heat transfer.

Athogh core temperatres were virta identica at onset of

warming, periphera tisse temperatre was sight cooer on the

circating-water da. This ower initia skin temperatre and greater

initia core-to-periphera tisse-temperatre gradient increases the

apparent efficac of circating water. However, the tisse tem-

peratre difference was on a few tenths of one degree Cesis

and ths nike to have sbstantia atered the rests.

Traditiona circating-water mattresses are associated with pres-sre-heat necrosis (i.e., brn) that rests when tisse com-

pressed b the weight of the patient is simtaneos warmed.

Gai et a. recent reported the case of a 67-ear-od woman who

deveoped brns on her back after 6.5 hors of srger whie

being warmed with the same circating-water garment we sed.

Ths, when sing this sstem, cinicians shod consider an risk

factors sch as age, ength of srger, and ntritiona stats,

which ma predispose a patient to skin injr.

In smmar, the circating-water garment transferred more heat

than forced air, especia dring the first hor of warming, with

the difference resting arge from posterior heating. Excessive

heating of periphera therma compartment indicates that pe-

riphera tisses insated the core, ths sowing heat transfer.

Increasing operating room temperature. When active skin

warming is not feasible or skin warming by itself is inadequate for

maintaining normothermia, increasing the room temperature is

into the operating-tabe mattress. As might ths be expected,

the circating-water garment transferred on 21 kca/h across

the posterior skin srface. This is more than reported previos

with a conventiona circating-water mattress, possib be-

case of a better interface materia. However, it is rogh the

same change in ctaneos heat transfer that is provided b a

singe cotton banket in a normothermic sbject.

Anterior srface heat transfer was comparabe with each warm-

ing sstem, and the change in anterior srface heat gain from 0

to 0.5 eapsed hors averaged 65 kca/h with each treatment.

Heat transfer per anterior nit area was ths simiar with eachsstem. A coroar of this observation is that virta the entire

difference between the two tested warming sstems rested

from heat transfer into posterior srfaces, that is from the portion

of the circating-water garment that acts as mattress. Core

temperatre increased 0.4 degrees Cesis/h faster with circ-

ating water than forced air, a rest that is consistent with Jan-

icki et a. Athogh not tested in this std, or rests sggest

that heat transfer and core rewarming with the circating-water

garment wod be simiar to that provided b combining a

forced-air cover and a conventiona circating-water mattress.

The core and periphera therma compartments were of simiar

size (e.g., weight). However, active warming increased periph-

era tisse heat content rogh three times as mch as the core

over the corse of the std. The differences were even more

prononced dring the initia warming phase. For exampe,

periphera heat content after one hor of circating water

increased 114 kca whereas core content increased on

34 kca. The anaogos vaes for forced air were 71 and 9 kca.

Periphera compartment heat content ths increased 60-80 kca

more than the core compartment with each device. These data

indicate that tisse insation restricted rapid flow of heat from

the peripher to the core. In other words, appied heat was

constrained b the insating properties of periphera tisses,

ths significant imiting the rate at which core temperatre

increased.

That periphera tisses insated the core and sowed heat

transfer in or vonteers is consistent with observations of Pat-

For most patients, raising the room

temperature to more than 73.4 F may

reduce the severity of hypothermia.

CE Article


26/124


6 Taguchi A, Ratnaraj J, Kabon B, Sharma N, Lenhardt R, Sessler DI, et al. Effects

of a circulating-water garment and forced air warming on body heat content and

core temperature. Anesthesiology. 2004; 100(5):1058-1064.

7 Lynch S, Dixon J, Leary D. Reducing the risk of unplanned perioperative

hypothermia. AORN Journal. 2010; 92(5):553-562.

8 Weirich TL. Hypothermia/warming protocols: why are they not widely used in the

OR? AORN Journal. 2008;87(2):333-344.

9 Sessler D & Todd M. Perioperative heat balance. J Amer Soc Anesth. 2000;

92(2):578.

10 Paulikas CA. Prevention of unplanned perioperative hypothermia. AORN Journal.

2008; 88(3):358-364.

11 Wagner VD. Patient safety chiller: unplanned perioperative hypothermia. AORN

Journal. 2010; 92(5):567-571.

12 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the inci-

dence of surgical-wound infection and shorten hospitalization. The New England

Journal of Medicine. 1996;334(19):1209-1215.

13 Rajagopaian S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hy-

pothermia on blood loss and transfusion requirement. Anesthesiology.

2008;108(1):71-77.

14 Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases

blood loss and transfusion requirements during total hip arthroplasty. The Lancet.1996; 347(8997):289-292.

15 Frank SM, Beattie C, Christopherson R, Norris EJ, Perler BA, Williams GM et al.

Unintentional hypothermia is associated with postoperative myocardial ischemia.

Anesthesiology. 1993; 78(3):468-476.

16 Mayo Clinic Researchers Confirm Value of Therapeutic Hypothermia. February 18,

2011. Available at: http://www.mayoclinic.org/news2011-rst/6184.html. Accessed

March 4, 2011.

17 Rogan J. Pressure ulcer risk during the perioperative period focusing on surgery

duration and hypothermia. Wounds. 2007; 3(4):66-74.

18 Scott EM, Leaper DJ, Clark M, Kelly PJ. Effects of warming therapy on pressure

ulcersa randomized trial. AORN Journal. 2001; 73(5):921-938.

19 Lenhardt R, Marker E, Goll V, Tschernich H, Kurz A, Sessler DI, et al. Anesthesiol-

ogy. 1997;87(6):1318-1323.

20 Waddle JP, Evers AS, Piccirillo JF. Postanesthesia care unit length of stay: quanti-

fying and assessing dependent factors. Anesthesia and Analgesia 87. 1998;

87(3):628-633.

21 Mathias JM. Taking steps to keep OR patients warm. OR Manager.

2006;22(12):14-16.

22 Recommended Practices for Prevention of Unplanned Perioperative Hypothermia.

In: 2010 Perioperative Standards and Recommended Practices. Denver, CO: As-

sociation of PeriOperative Register Nurses; 2010.

23 Cantrell S. New normothermia measure heats up patient-temperature manage-

ment. Healthcare Purchasing News. March 1, 2010. Available at: http://www.hp-

nonline.com/inside/2010-03/1003-IC.html. Accessed February 25, 2011.

an option. For most patients, raising the room temperature to

more than 23 degrees Celsius (73.4 degrees Fahrenheit) may

reduce the severity of hypothermia.22

Combining warming techniques

Some have suggested the need for a holistic approach incor-porating several different warming techniques to adequately

warm a patient. Overall, depending on the surgeon, the surgi-

cal team, and patient and the circumstances, the best method

of active warming may vary.23

ConclusionLooking to the future, as surgical team awareness and further

research into normothermia continues to develop, even more

effective patient-temperature management devices are sure to

follow. Warming device experts predict the development of more

sustainable technologies that can be cleaned and re-used,unlike forced air warming which creates environmental waste

with its disposable blankets. In addition, developing effective

equipment that covers less of the body surface than forced-air

warming or circulating water devices can offer greater conven-

ience and access for anesthesiologists and surgical teams.23

References

1 Measure Information Form. SCIP-Inf-10. Available at:

http://www.hsag.com/App_Resources/Documents/SCIP_LS3_Inf10_MIF.pdf.

Accessed February 25, 2011.

2 Surgical Care Improvement Project. The Joint Commission Web site. Available at:

http://www.jointcommission.org/surgical_care_improvement_project/. AccessedMarch 4, 2011.

3 National SCIP Partnership Developing to Reduce Surgical Complications. The

Leapfrog Group website. Available at:

http://www.leapfroggroup.org/news/leapfrog_news/144968. Accessed February

27, 2011.

4 Gunn M. SCIP expanded normothermia measure to go into effect for all surgical

patients in October. AORN Management Connections. July 2009. Available at:

http://www.aorn.org/News/Managers/July2009Issue/Normothermia. Accessed

February 25, 2011.

5 Wagner VD. Patient safety chiller: unplanned perioperative hypothermia. AORN

Journal. 2010; 92(5):567-571.


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Patient Safety Quality Measures for theSurgical Care Improvement Project

Measure Rationale Strategy

SCIP-Inf-1

Prophylactic antibiotics areadministered one hour prior toincision.

Studies find that the lowest incidence of post-operative infection is associated withantibiotic administration during the one hourprior to surgery. The risk of infectionincreases progressively with greater timeintervals between administration of theantibiotic and the skin incision.

Include administration and documentation ofthe antibiotic in the surgical time out. For one-hour antibiotics, the antibiotic is hung

in pre-op, a surgical team member administersand documents the antibiotic infusion.

SCIP-Inf-2

Prophylactic antibiotics areconsistent with currentguidelines (specific to each typeof surgical procedure).

Use an agent that is safe, cost-effective, andhas a spectrum of action that covers most ofthe probable intraoperative contaminants forthe operation. First- or second-generationcephalosporins satisfy these criteria for mostoperations, although anaerobic coverage is

needed for colon surgery.

The use of pre-printed orders that include therecommended antibiotic will assist surgeonswith choosing appropriate antibiotics.

Vancomycin is appropriate if there is a risk ofMRSA.

SCIP-Inf-3

Prophylactic antibiotics are to bediscontinued within 24 hoursafter anesthesia end time.The discontinuation timeextends to 48 hours for cardiacsurgery patients.

Administration of antibiotics for more than afew hours after the incision is closed offers noadditional benefit to the surgical patient.Prolonged administration increases the risk ofClostridium difficile infection and thedevelopment of antimicrobial resistantpathogens.

Begin antibiotics in the PACU. Administer cephalosporins every 6 hours

rather than every 8 hours.

Antibiotics are not provided for more than 24hours after surgery without appropriatedocumentation.

SCIP-Inf-4

Cardiac surgery patients withcontrolled 6 a.m. blood glucose(0 mg/dL) for the first two

postoperative days.

Hyperglycemia in the immediatepostoperative phase increases the risk ofinfection in both diabetic and non-diabeticpatients; the higher the level of

hyperglycemia, the higher the potential forinfection in both patient populations.

Blood glucose levels are monitored from pre-op through 48 hours post operative.

The use of an insulin protocol for treatinghyperglycemia with an insulin drip is stronglyrecommended.

SCIP-Inf-6

Surgery patients withappropriate surgical site hairremoval. No hair removal, hairremoval with clippers, ordepilatory is appropriate.

There is no strong evidence to contraindicatepreoperative hair removal; however, there isstrong evidence against hair removal with arazor. Shaving is considered inappropriate.

Take ALL razors out of the peri-operative area Instruct patients not to shave the surgical site.

SCIP-Inf-9

Surgical patients with urinarycatheter removed onPostoperative Day 1 orPostoperative Day 2 with day of

surgery being day zero. (Thismeasure does not apply tocertain urological, gynecologicalor perineal procedures.)

It is well-established that the risk of catheter-associated urinary tract infection (UTI)increases with increasing duration ofindwelling urinary catheterization.

Create a system of alerts or reminders toidentify all patients with urinary catheters andassess the need for continued catheterization

Develop guidelines and protocols for nurse-directed removal of unnecessary urinarycatheters and management of postoperativeurinary retention.

Consider the use of external catheters forcooperative males


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Measure Rationale Strategy

SCIP-Inf-

10

Surgical patients should beactively warmed during surgeryor have at least one recordedbody temperature equal to orgreater than 96.8 F within 30minutes prior to the end ofanesthesia to 15 minutes afteranesthesia end time. (Patientswith intentional hypothermia areexcluded from this measure.)

Research has correlated impaired woundhealing, adverse cardiac events, altered drugmetabolism, and coagulopathies withunplanned perioperative hypothermia. A studyby Kurtz, et al. (1996), found that incidence ofculture-positive surgical site infections amongthose with mild perioperative hypothermiawas three times higher than the normothermicperioperative patients.

Use aggressive warming measures duringsurgery.

Ensure accurate documentation of post-operative temperature.

SCIP-

CARD-2

Surgery patients on beta-blockers prior to admissionshould continue beta-blockertherapy during the perioperativeperiod.

The American College of Cardiology and theAmerican Heart Association recommend

continuation of beta-blocker therapy in theperioperative period as a class I indication,and accumulating evidence suggests thattitration to maintain tight heart rate controlshould be the goal.

Instruct patients to take their beta blockers tday of surgery.

Educate in-house clinicians about theimportance of patients receiving their betablockers the day of surgery, even while thepatients are otherwise NPO.

Meet with physician office staff to ensureconsistent instructions to the patients.

SCIP-VTE-

1

Surgery patients withrecommended venousthromboembolism (VTE)

prophylaxis ordered anytimefrom hospital arrival to 48 hoursafterAnesthesia End Time.

Despite the evidence that VTE is one of themost common postoperative complicationsand prophylaxis is the most effective strategyto reduce morbidity and mortality, it is oftenunderused.The frequency of venous thromboembolism

(VTE), which includes deep vein thrombosisand pulmonary embolism, is related to thetype and duration of surgery, patient riskfactors, duration and extent of postoperativeimmobilization, and use or nonuse ofprophylaxis.

Use pre-printed orders that include nationalrecommended guidelines for VTE prophylax

A hard stop would be not to allow patientsleave the recovery area until VTE orders arecompleted by the surgeon.

Ensure that surgeon preference cards mirnational guidelines. Pharmacists should assist surgeons with

understanding the risk of bleeding withpharmacological interventions.

SCIP-VTE-2

Surgery patients who receivedappropriate venousthromboembolism (VTE)

prophylaxis within 24 hours priortoAnesthesia Start Time to 24hours afterAnesthesia EndTime.

Timing of prophylaxis is based on the type ofprocedure, prophylaxis selection, and clinicaljudgment regarding the impact of patient riskfactors. The optimal start of pharmacologicprophylaxis in surgical patients varies andmust be balanced with the efficacy-versus-

bleeding potential. Due to the inherentvariability related to the initiation ofprophylaxis for surgical procedures, 24 hoursprior to surgery to 24 hours post surgery wasrecommended by consensus of the SCIPTechnical Expert Panel in order to establish atimeframe that would encompass mostprocedures.

(Please note that rates for SCIP-VTE- 2 mabe lower than those for SCIP-VTE-1 as a reof more stringent criteria. SCIP-VTE-2 requdocumentation that prophylaxis was orderedand actually started, whereas SCIP-VTE-1requires only documentation of an order. )

Organizations with decreased VTE 2 ratesshould assess their processes to determinewhy physician orders are not beingimplemented.

This material was prepared by Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Arizona, under contract withe Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented donot necessarily reflect CMS policy. Publication No. AZ-9SOW-6.2.3-110609-01



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True/False

1. Extremely thin and malnourished patients are more

susceptible to perioperative hypothermiaT F

2. SCIP Inf.-10 went into effect April 1, 2007. T F

3. Forced air warming is a widely used option for patient

warming. T F

4. Cool air temperature in the operating room can

contribute to unplanned perioperative hypothermia. T F

5. Perioperative hypothermia can cause a drastic drop in

blood pressure.T F

6. Some surgical professionals reject the use offorced air warming because it can contribute to

field contamination. T F

Multiple Choice

7. A 2008 study by Sessler and colleagues found that less

than one degree of hypothermia during surgery is

enough to increase blood loss by about ___ percent.

a. 25

b. 46

c. 16

d. None of the above

8. In the Scott study, what was the incidence of

pressure ulcers among patients who were not

warmed during surgery?

a. 72.5 percentb. 15.3 percent

c. 65.4 percent

d. 22.8 percent

9. Which of the following is NOT a known complica-

tion of perioperative hypothermia?

a. Surgical site infection

b. Prolonged recovery

c. Myocardial ischemia

d. Pneumonia

10. During anesthesia, core body temperature

changes occur in ____ stages.

a. Three

b. Five

c. Two

d. Seven

Visit www.medlineuniversity.com

and login or create an account.

Choose your course to take

the test and receive

1 FREE CE credit.

CE Test

Turn Up the HeatAvoiding Surgical Complicationswith Adequate Patient Warming

Corses approved for contining edcation b the Forida Board

of Nrsing and the Caifornia Board of Registered Nrsing.



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The foowing is a tre stor shared b nrses Kath Magee andEmi Sndee from Hnt Regiona Hospita, Greenvie, TX.

Imagine this scenarioA patient arrives at the hospital for a scheduled abdominal sur-

gery. Everything is running on time. The patient is placed on the

operating room table, a Time Out is called, and anesthesia is

administered. The patient is intubated and placed on a

mechanical ventilator. The sponges are counted by the circulator

nurse and the scrub nurse. The surgery begins. The procedure

is going well; however, the surgery extends through a shift

change for the scrub nurses. Upon arrival of the second shift,

the patient experiences a large amount of blood loss and packs

of sponges are counted and quickly used. As the surgeon

focuses on recognizing the reasons for blood loss, the nurses

are instructed to order a back up blood supply for the patient.

The surgeon controls the bleeding and begins to close the

patients incision. The staff realizes there is an unreconciled

sponge count. The staff attempts to recover the missing sponge.

Many questions and concerns arise such as: Could it be in the patients cavity?

Was it thrown away in the linens?

Did we miscount?

Is it possible the previous shift made the error?

The surgeon quickly decides to use the SmartWand-DTX and is

able to locate and retrieve the missing sponge. The patient has

a good outcome.

Exploring technologyHunt Regional is community-based hospital with 192 beds

located in Greenville, Texas. The organization takes pride in a

culture of innovation and transparency. If any staff member says

this is a safety issue its viewed as very important and the lead-

ership team is committed to following up and resolving the con-

cern. Hunt Regional is dedicated to patient safety and quality

outcomes. That is one of the reasons they were the first hospi-

tal in the state of Texas to begin using ClearCount. Hunt Regional

realizes that retained objects is a standard problem for hospitals

nationwide.

ClearCount Clearly Makes a Difference

in Patient Safety at Hunt Regional HospitalBy Rebecca McPherson, MSN, RN

Contined on Page 32

Patient Safety


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Retained Surgical ItemsAORNs latest confidence-based learning (CBL) module.AORNs Confidence Based Learning (CBL) is a

unique educational program that is designed to

help you achieve mastery in both knowledge and

confidence of that knowledge when providing care

that meets AORN Standards and Recommended

Practices. CBL is used to train, teach and retainperioperative professionals. CBL supports the

learner in reducing time to master knowledge and

increasing retention of critical information.

I N T R O D U C I N G

Visit Medline booth # 3408 or Clear Count booth # 53at AORN Congress for a FREE DEMO of the Retained

Surgical Items module.2011 Medline Industries, Inc.


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The retention of a foreign object is considered a serious and pre-

ventable event by the National Quality Forum.1The Centers for

Medicare & Medicaid Services (CMS) includes the retention of

foreign objects in its list of hospital-acquired conditions for which

reimbursement will not be provided.2The Joint Commission cat-

egorizes the unintended retention of a foreign object as a sentinel

event.3The Joint Commissions sentinel event statistics reported

360 instances of unintentional retention of a foreign body during

the period of 2005 through March 2010.4

National adverse event data demonstrates that retained surgical

items are the most frequent and costly surgical Never Events,

with surgical sponges representing the bulk of these incidents.

According to CMS, the cost of a retained foreign object (RFO)

after surgery is $62,631 per hospital stay.5 In addition to hospi-

tal costs, RFOs can produce major litigation expenses. The total

cost of an RFO, including legal defense, indemnity payments,

and surgical costs unreimbursed by CMS, would be approxi-

mately $166,135. At the previously quoted incidence of 1 in

5,500 operations, the cost of an RFO amortizes to approximately$30 per operation.

The concern of retaining sponges or foreign objects can occur

even when the staff follows procedures. The risk elevates with

emergency procedures, deviation from planned procedures, type

of procedure, patients with a higher mean body-mass index

(obesity), and failure to count or inaccurate counts during the

procedure.7The longer the patient spends on the operating

table, the greater the chance of developing pressure ulcers.

The incidence of postoperative pressure ulcers may be as high

as 66 percent.8The Institute for Healthcare Improvement (IHI)

estimates nearly one million people develop pressure ulcers eachyear, with some 60,000 deaths related to complications. The

cost of treatment ranges up to $11 billion annually.9

Hunt Regional made the commitment to reducing or eradicating

the incidence of retained surgical sponges by recognizing that

even one such event is one too many.

ClearCount benefits the patient and the organization by:

reinforcing safe, efficient, quality care

creating reassurance for the physician and staff that there

is another system they can rely on to account for all sponges

increasing staff productivity, avoiding time spent to

relocate sponges

Using ClearCount does not take the place of manually counting

sponges; however, it serves as reinforcement that the sponges

have all been accounted for. Practitioners should continually

check for RFOs before closing body cavities and develop safety

practices to minimize errors. Hunt Regional is committed to end-

ing retained lab sponges; they created a policy to use ClearCount

for all open abdominal cases in addition to the nurse counting.

Human error is a reality; however, Hunt Regional Hospital

accepted responsibility, and their objective is to address retained

surgical sponges head-on. They could not accept just any solu-

tion. Efficiency is important to them as well, particularly in the

healthcare reform climate.

The nursing team was highly focused on patient safety. After fur-

ther research, they discovered publications from AORN that

made them aware of new technology for the prevention of

retained sponges.

Surgeons also prefer using ClearCount and SmartWand.

According to Joshua K. Trussell, MD, board certified general sur-

geon, Primary Care Associates Affiliated and medical director of

the Trauma Program at Hunt Regional Medical Center in

Greenville, Texas, Using the lap sponge and raytec (X-ray gauze)

have not changed practice or the way I operate, in fact, they are

very user friendly and increase the level of confidence of the

physician.

About the author

Rebecca McPherson, MSN, RN, is vice president of clinical serv-

ices for Medline Industries, Inc. Prior to joining Medline, Rebecca

worked at Sherman Healthcare Systems as the director of opera-

tions for the immediate care centers. Her background also includes

emergency nursing.

1. Centers for Medicare & Medicaid Services. Hospital-acquired conditions

(present on admission indicator)[online]. 2009 Feb 19 [cited 2009 March11].

2. National Quality Forum. Serious reportable events in health-care 2006 update:

a consensus report. Washington (DC): National Quality Forum; 2007.

3. Joint Commission. Facts about the sentinel event policy [online]. 2008 Mar 20[cited 2009 Mar 11].

4. The Joint Commission. Sentinel event statistics: updated through March 31, 2010.

5. Centers for Medicare & Medicaid Services. C