taking steps to control costs in the or

Taking Steps to Control Costs in the OR

Janice Hoeksema , RN, BS, MA

Abstract Full Text PDF References

Article Outline Abstract Cost Savings in the OR

o Disposable Versus Reusable Products o Evaluating Implants o Limiting Use of Custom Supplies o Reducing Linen Use

Practice Changes o Talcum Powder o OR Basins o Prep Kits o OR Attire o Towels

Setting Up a Product Evaluation Committee Conclusion Examination. Continuing Education Program

o Taking Steps to Control Costs in the OR Questions

Learner Evaluation. Continuing Education Program o Taking Steps to Control Costs in the OR

Objectives Content

References Biography Copyright

yes platform+medline author author

Abstract Hospitals continue to be challenged by rising expenses in an environment of moderate reimbursements. Health care costs have increasingly come under scrutiny and, with the advent of health care reform, will continue to be scrutinized. Perioperative nurses play a key role in evaluating product safety, effectiveness and efficiency, environmental concerns, and cost and how these factors affect patient care. Cost-saving opportunities that a hospital product evaluation committee can consider include choosing less expensive but equivalent supplies, comparing the expenses associated with disposable versus reusable products, limiting the use of custom supplies, determining ways to reduce linen use, and changing practices to eliminate products that are found to have little clinical value. Adopting effective product evaluation and purchasing practices can lead to reduced costs without affecting the quality of patient care.

Key words: health care cost, health care reform, cost reduction, perioperative cost control

The need to reform health care, provide equal access, and reduce costs is currently a prominent political topic. At a press conference on June 23, 2009, President Obama stated,

When it comes to health care, the status quo is unsustainable and unacceptable. So reform is not a luxury. It's a necessity, and I hope the Congress will continue to make significant progress on this issue in the weeks ahead.1(p2) … if we start from the premise that the status quo is unacceptable, then that means we're going to have to bring about some serious changes … our top priority has to be to control costs.1(p5)

Although there was considerable debate in Congress over various health care reform proposals, there has been no controversy around the president's premise that health care is too expensive and that the continued increase in health care costs is unsustainable under our present system. President Obama has since signed a health care reform bill, and implementation is pending.

Regardless of how health care reform is implemented, RNs have a professional responsibility to consider how cost affects the planning and delivery of patient care. Hospitals will continue to be challenged by rising expenses in an environment of moderate reimbursements. On a daily basis, perioperative nurses can “significantly affect supply management practices by encouraging and implementing strategies that promote a safe and healthy environment. Cost considerations have a fundamental place in our professional performance. The strategies should be cost effective and conserve resources.”2(p535)

Many hospitals have effectively reduced the cost of medications through pharmacy and therapeutic evaluation programs. The actions of these pharmacy programs have resulted in

■standardization of medication purchases to specific vendors through the use of group purchasing organizations (GPOs);

■use of therapeutic equivalents (ie, generic medications);

■management of medication dispensing through the use of unit doses; and

■reduction of costs through practice changes (eg, review of antibiotic usage, standardization of medication protocols).3

Pharmacy practice evaluation groups make their decisions based on research data and published recommendations. In my experience as a consultant, however, purchasing committees have been less successful in reducing costs related to medical-surgical supplies. It is important for nurses on product evaluation committees to exercise the same level of professionalism as their pharmacy colleagues when considering the selection of supplies. The pharmacy evaluation processes can provide an effective model on which to base medical-surgical supply evaluation, selection, and implementation activities.

Back to Article Outline

Cost Savings in the OR Although most hospitals belong to a GPO for the purchase of supplies, ensuring that all departments comply with purchasing from the GPO can be difficult. It is not unusual to see supplies from non-GPO vendors used in a hospital. Most commonly, members of specialty departments in the hospital (eg, radiology, diagnostic radiology, the OR) do their own purchasing because their supplies are not generic to other units in the hospital, and it can be more efficient to allow them to purchase their own supplies. Specialty department members are less likely to adhere to GPO contracts because items purchased for these departments often are nonstock items.

Eliminating the practice of ordering outside the GPO has the potential to create significant cost savings. Pharmacy practice evaluation groups, for example, have been very successful in standardizing medication use to the least expensive medication by using generic medications.3 It is important to evaluate common practices in the OR whenever possible to determine whether there are less expensive alternatives.

Disposable Versus Reusable Products

A good way to look for less expensive equivalents in perioperative supplies is by comparing disposable and reusable products. Personnel in charge of ordering supplies must perform cost analyses periodically because the cost of reusable and disposable products changes when new products are developed, pricing practices change, or the costs of disposal increase.

A specific opportunity for cost savings in the reusable/disposable category, for example, relates to pulse oximetry probes. Disposable pulse oximetry probes can be a significant expense to the hospital. They are applied to the intact skin of patients much like blood pressure cuffs, and like blood pressure cuffs, there are some situations in which using a reusable probe makes sense. An alert, cooperative patient who needs short-term or periodic oxygenation assessment would be a good candidate for a reusable product. When disposables are required, using a disposable finger probe with a reusable cable is one way to save money.

Another opportunity is the use of reusable products in laparoscopic surgery. There are outside vendors who can manage the products to ensure that the reusable trocars are appropriately sharp. There are also combination products that involve reusable cannulas with disposable trocars.

Basin sets are routinely used in the OR. Consideration should be given to whether use of reusable or disposable basins would be most cost-effective.

Consideration also should be given to reprocessing disposable products if the manufacturer supports this process and provides directions to do so and the hospital is able to provide or can contract with a facility to do the recommended reprocessing.4 A systematic review of all disposable products and whether they can be safely reprocessed for use or whether there are reusable products available has the potential to create significant cost savings.

Evaluating Implants

Members of a physician-based technology committee should evaluate all implants before they are ordered for the hospital to determine whether one type or certain types can be used that are more cost-effective. For example, several brands of total joint prostheses may be stocked for use in the OR without any consideration for the cost, function, and level of use. Varying types of catheters in the cardiac catheterization laboratory are often stocked as well when perhaps one or two types would work quite well.

Limiting Use of Custom Supplies

Another perioperative cost-saving opportunity relates to the use of custom packs. Although custom packs have a place, supply evaluation committee members should review and analyze the cost of each custom pack compared with the cost of using enriched standard packs. Enriched standard packs are available that include items required for the procedure such as suction tubing, sharps containers, x-ray sponges, laparotomy sponges, blades, specialty drapes, and specialty gowns. It is possible to find enriched standard packs that include nearly all of the items needed for many frequently performed procedures. There are often several options to choose from for specific procedures as well. Hospital personnel can choose the pack option that most closely matches the supplies they use for a procedure. Examples of these are enriched standard vaginal delivery and arthroscopy packs (Table 1). Other enriched packs are available that have a slightly different product configuration. Table 2 shows one option in which two standard packs can be combined to provide most of the required items for an abdominal laparoscopy. A second option would be to use a standard enriched laparoscopy pack.

Table 1. Examples of Enriched Standard Packs

Quantity Item descriptionObstetrical pack1 Placenta basin1 Receiving blanket1 Umbilical cord clamp

Drapes1 each abdominal cover, back table cover, reinforced under-buttocks drape

Dressings2 perineal pads1 vaginal packing sponge1 Impervious reinforced obstetrical gown with one hand towel10 X-ray detectable sponges1 Impervious, reinforced gowns1 Absorbent towel2 Leggings1 20-oz bulb syringeStandard arthroscopy pack1 6-inch elastic bandage1 each #11 and #15 knife blades2 32-oz bowls2 2-oz medicine cups2 each 7-quart containers and emesis basins1 Specimen container

Drapes1 each half sheet, extremity drape, U-drape1 impervious stockinette, extra large1 reinforced back table cover1 reinforced Mayo stand cover2 large reinforced gowns1 extra large, extra long impervious specialty gown10 X-ray detectable sponges1 Absorbent disposable towel3 Cloth towels1 12-ft nonconductive suction tubing

Table 2. Examples of Laparotomy Packs

Option 1: use of 2 standard packsStandard laparotomy pack Standard basin set

1 Reinforced back table cover 1 Emesis basin4 Reinforced laparotomy drape 2 each 32-oz and 7-quart basins

Option 1: use of 2 standard packsStandard laparotomy pack Standard basin set

1 Reinforced Mayo stand cover 1 Cautery tip cleaner1 Impervious, reinforced gown with towel 2 Medicine cups1 Scrub gown with towel in outer wrap 1 Specimen cup with screw-top lid1 Wrap 1 Needle counter1 Suture bag 1 Graduated 1,000-mL pitcher4 Adhesive drape towels 10 Laparotomy sponges 18 × 18

10 X-ray detectable 4 × 4 sponges1 Bulb syringe1 12-ft suction tubing

Option 2: use of 1 enriched standard major abdominal pack

1 Large scrub gown with cloth towel 1 Fabric reinforced large gown

1 Reinforced Mayo stand cover 1 Laparotomy drape

1 Reinforced back table cover 4 Adhesive drape towels

7 Cloth towels 2 Each #10, #15, #20 knife blades

10 Laparotomy sponges 10 X-ray detectable 4 × 4 sponges

1 Suture bag 1 Mayo tray

1 Needle counter 1 Cautery tip cleaner

1 Yankauer suction tip 1 12-ft nonconductive suction tubing

1 60-mL Asepto syringe 1 Prep tray kit

With these options, hospital personnel should be able to find a configuration that works well for them without resorting to using a custom pack. The few additional items that may be included in a custom pack are often priced higher than the same items when purchased separately. It would be more cost-effective, therefore, to have staff members add these items to the set instead of using a custom pack. Procedures such as vaginal delivery, tonsillectomy, myringotomy, breast biopsy, hernia repair, arthroscopy, and major abdominal procedures should not require a custom pack. Use of custom prep kits instead of standard prep kits results in significant unnecessary expense to the hospital as well.

Reducing Linen Use

Perioperative personnel in the past have used bath blankets and pillows to position patients in the OR when other less expensive, patient-safe alternatives have been available. In the interest of patient safety, perioperative personnel should not substitute bedding or linen for positioning

aides. These substitutions are not cost-effective and cannot guarantee the level of protection from pressure ulcer development that commercially available positioning aids can.

In an effort to reduce costs, it is important to review linen use in the hospital. Figures vary from use as high as 22 lb per adjusted patient day (ie, the number of occupied beds divided by the pounds of linen used per day) to as little as 10 lb per adjusted patient day.5 Geography does affect linen use. Hospitals in hot climates tend to use less linen than hospitals in very cold climates; however, there are still many other opportunities to consider to reduce linen use. For example, to reduce the incidence of clean, unused linen ending up in the dirty linen hamper, linen should not be brought into the OR unless it is needed. For the same reason, linen should not be brought into the room of a patient who is expected to be discharged. Enforcement of a rational linen policy is important for cost reduction. Bed linen standards should be established for the OR patient's bed (ie, what the normal linen requirements are for an OR bed and any exceptions to those requirements). Extra sheets and linen should not be placed on the bed when a therapeutic mattress is in use.

From a patient comfort standpoint and as a cost-reduction strategy, gowns with sufficient front and back coverage should be selected to eliminate the need to use a second gown as a cover robe. Use of gowns with adequate coverage can also reduce, if not eliminate, the use of bath blankets to cover patient chairs in the outpatient postoperative area.

Most hospital's linen vendors can supply, free of charge, a “review of linen use” report. Perioperative personnel should analyze this report to identify where opportunities exist for reduced linen use. This review can be undertaken by RNs who are also able to help the hospital determine reasonable targets for reducing linen use based on the hospital's geography and other variables.


Practice Changes All products used in the hospital should be assessed for the clinical value they provide to patients and whether there is evidence to support their use. If there is no added value or clinical reason to justify their use, they should be eliminated.

Talcum Powder

Talcum powder, for example, has been eliminated from use in the newborn nursery. “In the past, it was common to use talcum powder to protect a baby's skin and absorb excess moisture. Physicians no longer recommend this, however. Inhaled talcum powder can irritate a baby's lungs.”6 Unfortunately, talcum powder is still being used on adult patients, especially those who are elderly, obese, or confined to bed. Talcum powder poses a similar respiratory risk to those patients without providing any clinical benefit. Nurses specializing in skin care can offer individual patient assessment and better solutions to managing the skin concerns of these patients.

OR Basins

Basins that are used during surgical or invasive procedures to organize nonliquids should be considered for elimination. Only basins needed for liquids should be used. This could significantly reduce the number of basins purchased and/or reprocessed.

Prep Kits

The long-standing practice of shaving surgical or invasive procedure sites has been eliminated because of its connection to surgical site infections (SSIs). The Centers for Disease Control and Prevention in its “Guidelines for the prevention of surgical site infection” states,

Preoperative shaving of the surgical site the night before an operation is associated with a significantly higher SSI risk than either the use of depilatory agents or no hair removal … Other studies showed that preoperative hair removal by any means was associated with increased SSI rates and suggested that no hair be removed.7(p257)

Thus, eliminating preoperative shave kits and razors for surgical preps is an excellent cost-saving tactic.

OR Attire

Many items of OR clothing have undergone scrutiny in regard to their use in infection control. For example, AORN states that “the use of cover apparel should be determined by the individual practice setting. The value of cover apparel worn in the institution is unsubstantiated. The use of cover apparel has been found to have little or no affect on reducing contamination.”8(p68) The practice of wearing a cover gown outside the OR should be evaluated and eliminated if this will reduce costs and does not affect patient safety.

Perioperative Product Selection Guidelines1

Evaluating products for use in the perioperative setting requires input from all stakeholders and is best handled by a committee chosen for this purpose. Committee members should be representative of personnel from the surgical services, anesthesia, nursing, and central processing departments. Committee members from outside the perioperative department may include, but are not limited to, personnel from the infection control, administration, pharmacy, biomedical engineering, radiology, laboratory, and risk management departments.

Committee members should evaluate all products proposed for use in the OR for safety, function, and cost-effectiveness. Members of the team may be required to participate in or initiate clinical evaluation of proposed products or devices. When evaluating products or devices, committee members must assess ease of use, processing, and sterilization. It is important to ensure that proposed products are compatible with the ability of facility personnel to comply with product or

device requirements for use or processing. Proposed products should be compatible with existing equipment and supplies, have a positive effect on patient care, and be under regulatory control.

Products selected for use should be evaluated for liability issues. Clinical evaluations of certain products may be needed to ascertain their appropriateness for use in the individual facility. To facilitate this process, management personnel should write appropriate policies and procedures, review them at specified intervals, and make them available to staff members and members of the committee.

Eliminating the traditional skull-type surgeon caps is an effective cost-reduction strategy. These caps usually do not adequately cover the hair or prevent shedding of hair or skin cells,8 the sole reason for wearing a head covering, and they have a higher cost. Standardizing hair covers to bouffant caps, or hoods for staff members with facial hair, provides better hair coverage, is more effective for infection prevention, and reduces cost.

Towels

In the OR, woven cotton towels are commonly used during surgical procedures. This type of towel has a very loose weave; it readily absorbs liquids and wicks moisture. It is not an effective barrier, however, and should not be used for patient draping in surgical or invasive procedures. There are nonwoven, synthetic towels that provide a superior barrier at a lower cost.9, 10, 11 It generally is less expensive to use a nonwoven, heavy-duty back table cover than to use cotton towels for padding on the back table. A nurse practice committee should review the use of these towels and set a goal to eliminate them from the practice setting.


Setting Up a Product Evaluation Committee These are just a few examples of the cost-savings opportunities that are available to hospitals. Nursing practice committees should systematically review practices and the products they use in the same manner as pharmacy practice evaluation groups. Department members who have served in leadership positions on committees that have conducted similar reviews would be good resources to provide information about setting up a product evaluation committee in the OR. They will have addressed political issues specific to a given hospital and can provide guidance on what worked and what did not. AORN's “Recommended practices for product selection in the perioperative practice setting” also provides useful guidance in setting up a committee and directions for its function.12 An initial step for selecting items for study is to obtain a list from the purchasing department or the business office of all the products used in the OR, sorted in descending order of annual cost. These lists can be used to prioritize evaluations of products used in the OR for safety, necessity, and cost-effectiveness.


Conclusion

Significant savings are available to most hospitals when ordering practices and patient care practices are evaluated and amended. It is in the best interest of employees and patients that these reviews be conducted on a regular basis. Depending on the size of the hospital, these savings could reach millions of dollars. When done carefully and with patient care as a driving focus, scarce health care money that is saved can be better spent.


Examination. Continuing Education Program


PURPOSE/GOAL

To educate perioperative nurses about perioperative cost-control measures.

OBJECTIVES

1.Discuss the role of the perioperative nurse in OR cost containment.

2.Identify practices that increase OR costs.

3.Describe methods to reduce OR costs.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.

Questions

1.Perioperative nurses can significantly affect supply management by implementing strategies that1.are cost-effective.

2.are tailored to individual physician requests.

3.provide a safe environment.

4.conserve resources. a. 1 and 2 b. 3 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4

2.Supplies from vendors outside of the group purchasing organization are often used in the hospital because1.members of specialty departments may do their own purchasing.

2.supplies used in specialty departments are not generic to other units in the hospital.

3.ordering supplies outside of the group purchasing organization can result in significant cost savings.

4.some of the items used specialty departments are nonstock items. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4

3.When evaluating the cost of using reusable versus disposable products, personnel in charge of ordering supplies must perform periodic cost analyses because1.the costs of products change as new products are developed.

2.pricing practices change.

3.the cost of disposal increases.

4.personnel compliance with usage decreases. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4

4.Items included in a custom pack are often priced higher than the same items when purchased separately. a. true b. false

5.Using bath blankets and pillows to position patients in the OR is a safe and inexpensive alternative to using commercially available positioning aides. a. true b. false

6.To reduce costs associated with linen use1.only disposable linen should be used.

2.linen should be assigned to each patient.

3.linen should not be brought into the OR unless it is needed.

4.gowns with sufficient front and back coverage should be used to eliminate the use of a second gown as a cover gown.

5.personnel should analyze the review of linen use report available from the hospital's linen vendor. a. 1, 2, and 3 b. 3, 4, and 5 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

7.Eliminating preoperative shave kits and razors for surgical preps is an excellent cost-saving tactic. a. true b. false

8.The wearing of _________________________ is not supported by evidence and should be eliminated if it reduces costs and does not affect care.a.disposable hair covers

b.long-sleeved warm-up jackets

c.shoe covers that ground electricity

d.cover gowns outside the OR

9.Eliminating traditional skull-type surgeon caps is an effective cost-reduction strategy because the caps usually do not cover the hair adequately and have a higher cost than other types of head covers. a. true b. false

10.Members of a product evaluation committee should evaluate products for1.safety.

2.function.

3.cost-effectiveness.

4.ease of use. a. 1 and 2 b. 3 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4

The behavioral objectives and examination for this program were prepared by Helen Starbuck Pashley, MA, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Center for Perioperative Education. Ms Pashley and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.


Learner Evaluation. Continuing Education Program


This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below.

Objectives

To what extent were the following objectives of this continuing education program achieved?

1.Discuss the role of the perioperative nurse in OR cost containment. Low 1. 2. 3. 4. 5. High

2.Identify practices that increase OR costs. Low 1. 2. 3. 4. 5. High

3.Describe methods to reduce OR costs. Low 1. 2. 3. 4. 5. High

Content

4.To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High

5.To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High

6.Will you be able to use the information from this article in your work setting? 1. Yes 2. No

7.Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)

7A.How will you change your practice? (Select all that apply)1.I will provide education to my team regarding why change is needed.

2.I will work with management to change/implement a policy and procedure.

3.I will plan an informational meeting with physicians to seek their input and acceptance of the need for change.

4.I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice.

5.Other: _____________________________

7B.If you will not change your practice as a result of reading this article, why? (Select all that apply)1.The content of the article is not relevant to my practice.

2.I do not have enough time to teach others about the purpose of the needed change.

3.I do not have management support to make a change.

4.Other: _____________________________

8.Our accrediting body requires that we verify the time you needed to complete the 1.6 continuing education contact hour (96-minute) program: ___________

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Event: #10506; Session: #4053 Fee: Members $8, Nonmembers $16

The deadline for this program is December 31, 2013.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.


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2009;http://www.nytimes.com/2009/06/23/us/politics/23text-obama.htm?pagewanted=1&_r=1Accessed June 28, 2010

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2. AORN guidance statement: Environmental responsibility. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 533–540

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3. American Society of Health-System Pharmacists. ASHP guidelines on medication cost management strategies for hospitals and health systems. Am J Health-Syst Pharm. 2008;65(14):1368–1384http://www.ashp.org/DocLibrary/BestPractices/MgmtGdlCostManag.aspxAccessed August 2, 2010

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4. AORN guidance statement: Reuse of single-use devices. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc:649-655.

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5. Phillips GP. Linen use in an era of managed care. Health Facilities Manage. December 1, 1996;http://www.hfmmagazine.com/hfmmagazine_app/jsp/articledisplay.jsp?dcrpath=AHA/NewsStory_Article/data/HFMMAGAZINE356&domain=HFMMAGAZINEAccessed July 28, 2010

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6. Diaper rash: lifestyle and home remedies. MayoClinic.com. June 23, 2009;http://www.mayoclinic.com/health/diaper-rash/DS00069/DSECTION=lifestyle-and-home-remediesAccessed June 29, 2010

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7. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999 (Hospital Infection Control Practices Advisory Committee). Infect Control Hosp Epidemiol. 1999;20(4):250–278http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdfAccessed June 29, 2010

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8. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 67–73

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9. Wubbe E. Disposables on the rise in the medical market. Nonwovens Industry. November 2001;http://www.nonwovens-industry.com/articles/2001/11/disposables-on-the-rise-in-the-medical-marketAccessed June 28, 2010

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10. Belkin NL. The new barrier standard—whose interests does it serve?. AORN J. 2004;80(4):647–651

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11. US Patent 5409761—Breathable non-woven composite barrier fabric and fabrication process. PatentStorm. July 2, 1993;http://www.patentstorm.us/patents/5409761/fulltext.htmlAccessed August 2, 2010

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12. Recommended practices for product selection in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 189–192

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Janice Hoeksema, RN, BS, MA, was the director of the Perioperative Department at Spectrum Bodgett Memorial Medical Center, Grand Rapids, MI, and worked as a sales representative and a senior consultant in cost reduction/supply chain management for Cardinal Health, Dublin, OH, before retiring. Ms Hoeksema has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

1 Recommended practices for product selection in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:189-192.

indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire December 31, 2013.

PII: S0001-2092(10)01056-2

doi:10.1016/j.aorn.2010.04.020

© 2010 AORN, Inc. Published by Elsevier Inc. All rights reserved.

taking steps to control costs in the or

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