the monthly publication - or manager · dard of care, treatment, and ser-vices throughout the...

June 2009 Vol 25, No 6

The monthly publication for OR decision makers

In this issue

INFORMATION SYSTEMS.Automation ends preop paper chase ....................11

MANAGING TODAY’S OR SUITE.Practical tools for building staff loyalty ...............14

GI ENDOSCOPY.Endo reprocessing lapses at the VA....................................19

OR Manager to launch webinar series...........................21

STERILIZATION & INFECTION CONTROL.Are you ready for Joint Commission?...................22

OR BUSINESSMANAGEMENT.GPO purchasing of implants lags.............................24

AMBULATORY SURGERYCENTERS.Economy is taking a toll on ASCs ...........................26

AMBULATORY SURGERYCENTERS.Automation for ASCs picking up speed......................28

AT A GLANCE.........................32

ASC section on page 26.

Ensuring a comparable standardof care for cesarean deliveries

How could ORs benefit from thegovernment’s health IT funds?

Clinical management

Information systems

The federal government is pro-viding $19 billion in grantsand loans for health informa-

tion technology (IT). Will ORs beable to capture some of the fundingto improve their systems?

The funding comes under theAmerican Recovery and Reinvest-ment Act signed by PresidentObama in February 2009.

Financial incentives will beavailable to hospitals and physi-cians to promote health IT, particu-larly the electronic health record(EHR). The ultimate purpose is to

improve health care efficiency andimprove quality. Payments willstart in 2011 and scale down (side-bar, p 9).

There are big catches. To be eli-gible, hospitals must already haveinvested in IT and be “meaningfulusers” of “certified EHR technol-ogy,” terms to be defined by theSecretary of Health and HumanServices later this year. In general, aqualified EHR will need to havepatient information such as demo-graphics, a medical history, and

Your facility is having a babyboom. The number of ce-sarean births is exceeding

the obstetrical unit’s capacity. Ad-ministrators want the OR to per-form the overflow cases. Whatplans do you make for patientsafety and care of both mother andnewborn?

The cesarean birth rate has risenby more than 25% in this decade.Cesareans accounted for 31% ofbirths in 2006, the latest figureavailable from the Centers for Dis-ease Control and Prevention. Thatplaces a strain on many obstetricalunits and creates a need for closer

collaboration with perioperativeservices.

A surgical services director facedthis situation recently. Her hospital,with 460 beds and 11 ORs, has alarge and growing obstetrical vol-ume. In the OB unit, cesarean birthswere staffed with one circulatingnurse. But the director thought 2RNs were needed: one to circulatefor the mother’s surgery and thesecond to care for the newborn.

She asked what nursing practicestandards and guidelines apply, aquestion other OR directors mayalso be asking.

Continued on page 9

Continued on page 5

3OR Manager Vol 25, No 6June 2009

It’s happened again—endoscopereprocessing errors. More than10,500 veterans have been noti-

fied they may have been exposed tocontaminated equipment at 3 Veter-ans Affairs (VA) facilities (see page19).

Several errors were found: Awrong connector was used. Onetube wasn’t being reprocessed be-tween patients. Other parts weren’talways discarded at the end of theday as intended. And flushing of thescope’s water system wasn’t alwaysperformed.

The VA is not alone. The VA’s na-tional patient safety director, JamesBagian, MD, says manufacturers tellhim as many as 9 of 10 facilitiesaren’t processing scopes correctly.

The risk is considered low. The in-cidence of infection from GI en-doscopy procedures is estimated at 1in 1.8 million (Schembre D B, Gas-trointest Endosc Clin N Am. 2000;57:695-711). Still, endoscopes havebeen associated with more outbreaksthan any other type of device.

A different approach?The remedies are familiar—fol-

low manufacturers’ instructions tothe letter, provide more education,check competency.

These steps are deceptively sim-ple. Endoscopes are complex. Re-processing requires dozens of stepsthat vary by type and brand ofscope. Technicians who do the workearn entry-level pay, and there ispressure to turn around casesquickly.

“This whole system is set up tofall apart,” one expert told us.

Are these remedies enough? Or isit time for a different approach?

Should endoscope reprocessingbe thought of in the same way asmedication safety, as a complex sys-tem prone to errors where failsafemeasures need to be built in?

It used to be when a medicationerror occurred, the response was to

search out the person who made themistake and drum in more educa-tion. Then patient safety expertspointed out the system itself was theproblem.

Facilities started doing high-levelassessments of the medication ad-ministration process and building insafeguards like unit doses, barcod-ing, and automated supply stations.

It’s time for the same approach toendoscope reprocessing. That wouldinclude a high-level assessment ofthe risk of errors from underpaidstaff, multiple parts, easy-to-confuseconnections, hard-to-clean devices,and unclear or conflicting instruc-tions.

That kind of assessment and theremedies would take resources. Butthe cost of testing 10,500 veteransisn’t small either, in dollars or themass anxiety created.

In the meantime, experts wespoke with stressed these points:• Organize the reprocessing area

with safety in mind. That in-cludes good lighting and mini-mal distractions.

• Develop a system for storingparts so it’s easy to select the rightones.

• Instruct staff to verify in writinginformal instructions from com-pany representatives.

• Focus on why each step is criti-cal—staff who understand whysteps are needed may be lesslikely to take shortcuts.A comprehensive patient safety

approach is long overdue. �—Pat Patterson

Upcoming

June 2009 Vol 25, No 6OR Manager is a monthly publication forpersonnel in decision-making positions inthe operating room.

Elinor S. Schrader: Publisher

Patricia Patterson: Editor

Judith M. Mathias, RN, MA: Clinical editor

Kathy Shaneberger, RN, MSN, CNOR:Consulting editor

Paula DeJohn: Contributing writer

Karen Y. Gerhardt: Art director

OR Manager (USPS 743-010), (ISSN8756-8047) is published monthly by ORManager, Inc, 1807 Second St, Suite 61,Santa Fe, NM 87505-3499. Periodicalspostage paid at Santa Fe, NM and addi-tional post offices. POSTMASTER: Sendaddress changes to OR Manager, PO Box5303, Santa Fe, NM 87502-5303.

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Editorial


SCIP: What’s the status? Is all of the work on the Surgical

Care Improvement Project makinga difference?

Block schedulingNow may be the perfect time to

fine-tune your block schedule.Read why.

“

“The system is set up to fall apart.


Clinical management

A related and larger question:How can you help ensure a com-parable standard of care through-out the organization? This is agrowing need as invasive proce-dures expand to GI endoscopy, in-terventional radiology, the cath lab,and other departments. Joint Com-mission standard LD.04.03.07 re-quires that “patients with compa-rable needs receive the same stan-dard of care, treatment, and ser-vices throughout the hospital.”

At Yale-New Haven Hospital inNew Haven, Connecticut, a collab-orative task force has developedpolicies and procedures that applyacross departments (sidebar, p 7).

What guidelines apply?Professional associations have

recommendations applicable to ce-sarean births.

AORN’s staffing guidelines,which apply to any surgical proce-dure, specify 1 RN per patient perOR in the role of circulating nurse.Other AORN recommended prac-

tices also apply, such as counts andmaintaining a sterile field. Thecount recommendations specify asponge count before closure of acavity within a cavity, such as theuterus.

The American Academy of Pe-diatrics (AAP) and the AmericanCollege of Obstetrics and Gynecol-ogy (ACOG) Guidelines for PerinatalCare recommendation for circulat-ing for the intrapartum phase is a1:1 RN-to-patient ratio.

“That means the circulator is re-sponsible for only the role of thecirculator until mom and babyreach the recovery area,” saysCatherine Ruhl, CNM, MS, associ-ate director for the Association for

Women’s Health, Obstetric, andNeonatal Nurses (AWHONN). Theassociation does not issue stan-dards on staffing ratios.

“Therefore, the role of your cir-culator can be no different than therole of the circulator in your gen-eral OR,” says Ruhl, referring tothe requirement for a comparablestandard of care. Thus, “One nurse(or scrub tech) must be available toscrub, one nurse must be availableto circulate, and one nurse must beavailable for the infant.”

About 1 in 10 newborns requiresome assistance with breathing atbirth, and about 1% require exten-sive resuscitative measures, ac-cording to the AAP.

Guidelines for neonatal resusci-tation from the American HeartAssociation and the AAP state thatat every birth “there should be atleast 1 person whose primary re-sponsibility is the newborn.”

This person must be capable ofinitiating resuscitation, with some-one else immediately available toperform a complete resuscitation.With careful assessment, mostnewborns who will need resuscita-tion can be identified before birth,the guidelines note.

What experts sayWhen polled, most members of

the OR Manager Advisory Boardsaid that when cesareans are per-formed in the OR, in addition tothe RN circulator, the OB unitsends a nurse and/or a pediatri-cian to care for the infant.

One advisor, Kathleen Miller, RN,MHSA, CNOR, senior clinical con-sultant for Catholic Health Initiatives,Denver, says she has addressed thissituation a number of times as an ORmanager and director.

“In the OR, the circulating nurseas well as the anesthesia provider canonly be responsible for one patient.

Renae Battié, RN, MN, CNORSeattle

Ramon Berguer, MDChief of surgery, Contra Costa Regional Med-ical Center, Martinez, California

Mark E. Bruley, EIT, CCEVice president of accident & forensic investigation, ECRI, Plymouth Meeting, Penn-sylvania

Jayne Byrd, RN, MSNAssociate vice president, surgical services, Rex Healthcare, Raleigh, North Carolina

Robert G. Cline, MDMedical director of surgical services, MunsonMedical Center, Traverse City, Michigan

Franklin Dexter, MD, PhDProfessor, Department of anesthesia and healthmanagement policy, University of Iowa, IowaCity

Dana M. Langness, RN, BSN, MASenior director, surgical services, Regions Hospital, St Paul, Minnesota

Kenneth Larson, MDTrauma surgeon, burn unit director, Mercy St John’s Health Center, Springfield, Missouri

Kathleen F. Miller, RN, MSHA, CNORSenior clinical consultant, Catholic Health Ini-tiatives, Denver

David A. Narance, RN, BSN, CRCSTManager, sterile processing, MedCentralHealth System, Mansfield, Ohio

Shannon Oriola, RN, CIC, COHNLead infection control practitioner, Sharp Metropolitan Medical Campus, San Diego

Cynthia Taylor, RN, BSN, MSA, CGRNNurse manager, Endoscopy & BronchoscopyUnits, Hunter Holmes McGuire VA MedicalCenter, Richmond, Virginia

Dawn L. Tenney, RN, MSNAssociate chief nurse, perioperative services,Massachusetts General Hospital, Boston

Judith A. Townsley, RN, MSN, CPANDirector of clinical operations, perioperative services, Christiana Care Health System, Newark, Delaware

Ena M. Williams, RN, MSM, MBANursing director, perioperative services, Yale-NewHaven Hospital, New Haven, Connecticut

Terry Wooten, Director, business & material re-sources, surgical services & endoscopy, St Joseph Hospital, Orange, California

Advisory Board

Continued on page 6

Continued from page 1

“

“The circulatorrole is not different.

That patient is the mother,” Millersays. “All of the same rules apply to ac-section surgical case that apply toevery surgical case—counts, aseptictechnique, and so forth.

“The baby is handed off to theOB nurse or pediatrician,” shenotes. “The OR nurse must stay fo-cused on the mother and the sterilefield. This is a critical time for thesurgical case because of bleeding,the count, and other issues.” Ex-pecting the OR staff also to be re-sponsible for the baby is outsidetheir scope of practice and exper-tise and would present a risk to thehospital, Miller adds.

She recommends that policiesbe developed to delineate responsi-bilities of both specialties. The poli-cies should address the range of is-sues, from simple ones, such ashow the bassinette is brought tothe OR, to more serious issues,such as what neonatal drugs,emergency equipment, medicalgases, etc, must be available.

An expert in perinatal nursing,Kathleen Rice Simpson, RNC, PhD,FAAN, says the decision aboutwhether nurses from the main ORor the OB unit perform the circulat-ing duties depends on the hospi-tal’s volume and the ability tomaintain competency.

The common practice is to havea labor RN come to attend to thebaby first and if there are problemsto send a respiratory therapist,neonatal nurse, neonatal nursepractitioner, or neonatologist.Simpson, a researcher, educator,and author, is perinatal clinical spe-cialist at St John’s Mercy MedicalCenter in St Louis, which has 8,000births a year.

Being family friendlyThe trend in the OB OR and re-

covery area is toward being morefamily friendly for births.

Fathers have been able to attendcesarean births in the OB unit forsome time, Simpson notes. Themother sometimes requests an-other person as well. A teenagemother may want her mother to bepresent, for example, and such arequest is often granted.

At the same time, there is amore rigorous focus on safety.

“Being mother and baby friendlydoes not preclude safety,” Simpsonsays.

The ACOG statement on surgi-cal patient safety issued in 2006 ad-dresses issues such as preventionof wrong surgery, the need for ade-quate personnel, and the need tominimize distractions during thesurgery.

“We constantly emphasize sur-gical safety, such as no interrup-tions during counts,” Simpsonsays. Time-outs before cesareanbirths are a way of life, as they arefor any invasive procedure. At StJohn’s, counts are conducted asrecommended by AORN, includ-ing calling for an x-ray if a dis-crepant count cannot be resolved.

A director’s solutionIn a follow-up e-mail, the direc-

tor who asked the question aboutstaffing says her concerns are beingaddressed. She had shared her con-cerns with the hospital’s physi-cians and anesthesia group, whodiscussed them with the medicalstaff leadership. She says they havenow adopted the AORN standardsfor counts.

For cesarean births in the OR,the staffing plan will include a perdiem nurse cross-trained for theOB unit from the postanesthesiacare unit (PACU), or the OB unitwill send a nurse to care for thebaby.

Because this second nurse willbe needed for only 30 to 45 min-utes, there will not be a big impacton productivity. The OB unit wasalso considering how to provide asecond staff member routinely.

The hospital’s education depart-ment will provide education forthe OB nurses on counts and othersurgical practices, with assistanceof veteran perioperative nurses.

Concern about retained items

There’s reason to be concernedabout counts during cesareanbirths. The director says she knowsof 2 incidents of retained objectsthat may be associated with cesare-ans performed in the past at otherhospitals.

In one case, 2 sponges were dis-covered in a woman’s uterus aftershe went to another hospital withabdominal pain not long after hercesarean. In the second case, awoman who had a CT scan per-formed after a fall was found tohave 2 size 0-Vicryl suture needlesin her abdomen. Her history in-cluded previous laparoscopicsurgery and 2 cesarean births. Size0-Vicryl suture needles are used forclosing deep layers and could havebeen left during a cesarean.

Vaginal birth is the most com-mon type of procedure with a re-tained foreign object, accountingfor about one-fourth of such cases,in data from Minnesota’s statewideadverse event reporting system.Hospitals in the state are conduct-ing a Safe Count campaign to pre-vent retained objects in vaginal de-liveries. More information is at

6 OR Manager Vol 25, No 6 June 2009

Clinical management


“

“We emphasize

surgical safety.


Clinical management

www.mnhospitals.org/index/tools-app/tool.385?view=detail. �

—Pat Patterson

ReferencesAmerican Academy of Pediatrics,

American College of Obstetri-cians and Gynecologists. Inpa-tient perinatal care services.Chapter 2 in Guidelines for Peri-natal Care. Elk Grove Village, Ill:AAP, 2007.

American College of Obstetriciansand Gynecologists. Patientsafety in the surgical environ-ment. Committee opinion. ObstetGynecol. 2006;107:429-433.

American Heart Association, Amer-ican Academy of Pediatrics. 2005American Heart Association(AHA) guidelines for cardiopul-monary resuscitation (CPR) andemergency cardiovascular care(ECC) of pediatric and neonatalpatients: Neonatal resuscitationguidelines. Pediatrics.2006;117:e1029-e1038. http://pe-diatrics.aappublications.org/cgi/content/full/117/5/e1029

AORN guidance statement: Periop-erative staffing. PerioperativeStandards and Recommended Prac-tices. Denver: AORN, 2009.

AORN recommended practices forsponge, sharp, and instrumentcounts. Perioperative Standardsand Recommended Practices. Den-ver: AORN, 2009.

AORN recommended practices formaintaining a sterile field. Peri-operative Standards and Recom-mended Practices. Denver: AORN,2009.

Minnesota Department of Health.Adverse Health Events in Min-nesota. January 2009.www.health.state.mn.us/pa-tientsafety/ae/09ahereport.pdf

Simpson K R. Emergent cesareanbirth preparedness. MCN.2007;32(4)264.

The collaborative effort at Yale-New Haven Hospital to harmo-nize standards for cesarean birthsbegan when a senior nursing VPasked the OR management to con-sult with the labor & birth (L&B)unit.

“We had collaborated over theyears, but we wanted to put amore formal structure in place,”says Ena Williams, RN, MBA,MSM, nursing director for periop-erative services. Yale-New Haven’smain campus, with 940 beds, has37 ORs; the L&B unit has 3 ORs.

Williams began with a 2- to 3-week assessment of L&B. “Welooked at the patient populationsand recognized they had similarrequirements,” she says. “The pa-tients need similar intraoperativemanagement and postoperativecare. There are regulatory issues incommon, such as the National Pa-tient Safety Goals.”

These are steps the units’ leader-ship teams took to harmonizepractice between the 2 depart-ments. The collaborative modelhas since been applied to other de-partments, including interven-tional radiology, the GI endoscopyunit, and a freestanding ambula-tory care facility that joined thesystem.

Form a leadership teamA multidisciplinary task force

was formed to oversee the project.As much as possible, the leaderstried to match representatives fromboth departments, includingphysicians, nurses, managers, edu-cators, and support services.

The team set a goal: To ensurethat the ORs in L&B maintain simi-lar standards to the ORs in periop-

erative services “to optimize pa-tient safety, quality, and service ex-cellence.”

Identify focus areasThe task force identified 7 focus

areas common to the OR and L&B: • National Patient Safety Goals,

such as eliminating wrongsurgery, improving handoffs,and medication reconciliation

• infection control, including flashsterilization

• environment of care, such asstandardizing cleaning proto-cols, establishing a latex-free en-vironment, and performingdaily checks of emergencyequipment

• policies and procedures, includ-ing surgical counts, malignanthyperthermia management,and sterilization protocols

• central sterile supply, includinga system for equipment refur-bishment and an audit processfor surgical kits

• patient safety, such as bloodavailability and fire safety

• staff development, includingorientation for L&B RNs to theperioperative department; con-sistent staffing for cesareanbirths; and education in high-risk, low-occurrence cases.

Develop a work planA work plan was devised to ad-

dress the focus areas, and an L&Bmanager partnered with Williamsto implement the plan.

“The first goal was to standard-ize practice,” Williams says. Thesecond was to prepare the L&Bstaff so that if a problem occurred,such as a patient having a cesarean

A plan to harmonize practice for OR, labor and birth units

Continued on page 8


Clinical management

who required a hysterectomy, theL&B staff would be prepared.

Staff from L&B spent time in theOR with the perioperative GYNstaff so they could become morefamiliar with surgeons they mightwork with in an emergency. ORstaff also go to the L&B unit tosupport the staff and act as a re-source when an unexpected situa-tion occurs.

The 2 staffs also worked to-gether to standardize cards foremergency cases. The L&B unit’semergency cart was redesigned tosupport situations the unit mayexperience.

Harmonize policies andprocedures

Comparable policies were de-veloped for relevant aspects ofL&B and perioperative services.These included policies such ascounts, management of emer-gency procedures, and postopera-tive care. Documentation formswere standardized as much aspossible.

A staffing model was developedfor cesareans in the OR and L&B.Current practice is to provide anRN circulator plus a nurse for thebaby.

“We now have a model where asecond circulator is available tosupport the baby during a c-sec-tion so the circulating nurse canstay focused on the surgical proce-dure,” Williams says.

A uniform count policy includesa procedure for addressing dis-crepant counts, including x-rays.”When there is a count discrep-ancy, they follow the same exactstandards. Nobody questions itany more,” Williams says.

She explains this is no longer anursing policy but a hospital pol-

icy agreed upon by the medicaland the nursing staff.

“You can’t fight this battle onyour own,” Williams says. Youhave to get buy-in from the med-ical staff.“

Keep up thecollaboration

To maintain the collaboration, aclinical leader from L&B was iden-tified to become the unit’s “periop-erative leader.” She is the go-toperson for perioperative aspects oflabor and delivery and relatedstaff development and is men-tored by the OR’s clinical leaderfor GYN surgery.

Williams says the position rein-forces the bond between OB andthe OR. “For us, it’s no longer howyou do things versus how we dothings. Now there is a standard.The collaborative leadership struc-ture has eliminated lines betweendepartments.”

Stay prepared for surveysBe prepared for questions on a

comparable standard of care fromthe Joint Commission and statesurveyors, Williams advises.

“They will go from unit to unitand location to location. They willask about your policies, so youhad better be practicing the sameway,” she says.

A collaborative team can also bea good resource for managers onstandards and practice. Yale New-Haven’s team continues to meetevery 4 months to address ques-tions, practice issues, and policydevelopment.

“We have come a long way,” shesays. “It no longer feels like we areworking in silos. We are dis-cussing ways to expand this acrossthe health system because many ofour surgeons practice in other fa-cilities.”

Continued from page 7 Nominate OR Manager of Year

The July 1 deadline is fast ap-proaching for nominations forOR Manager of the Year.

Each year at the ManagingToday’s OR Suite conference, a man-ager or director is named OR Man-ager of the Year.

This year’s conference will be Oct7 to 9 in Las Vegas, Nevada.

The OR Manager of the Year willreceive an expense-paid trip to themeeting, including airfare, hotel,meals, and registration.

In recognizing an individual man-ager, the award honors all OR man-agers for their important roles. It is away of celebrating nursing manage-ment in surgical services.

Readers of OR Manager are in-vited to nominate a manager for theaward. Simply write a letter of about300 words describing what makesthe manager deserving of the award.Supporting letters may also be sent.

Send the entry to OR Manager, Inc,OR Manager of the Year Award, POBox 5303, Santa Fe, NM 87502-5303.Submit the entry for your deservingmanager by July 1.

Nominations are judged by theOR Manager advisory board. �

A conference brochure can be down-loaded at www.ormanager.com

Have an idea?Do you have a topic you’d liketo see covered in OR Manager?Have you completed a projectyou think would be of help toothers? We’d be glad to con-

sider your suggestions. Please e-mail

Editor Pat Patterson at [email protected]


Information systems

problem lists plus be able to:• provide clinical decision support • support physician order entry• capture quality information• exchange and integrate health in-

formation from other sources.

Carrot and stickBesides a carrot, there is also a

stick. Hospitals that aren’t “mean-ingful users” by 2015 will be sub-ject to Medicare payment penaltiesunless they show significant hard-ship.

There is a long way to go. Only1.5% of US hospitals have a compre-hensive electronic records system.More than 90% did not even meetthe requirement for a basic system,according to a report in the April 9,2009, New England Journal of Medi-cine (www.nejm.org). Finances werecited as the major barrier.

Positioning the ORHow can OR leaders position

themselves to take advantage ofsome of the funding?

To start with, hospitals are likelyto need 2 functions in place to qual-ify as a meaningful user—baselinedocumentation and robust quality

reporting, says Mikael Ohman, se-nior vice president of strategy andbusiness development for McKes-son Technology Solutions.

“If I were an OR director, I wouldmake sure anything relating to qual-ity reporting was top notch,” hesays. For hospitals that are alreadypretty advanced, “this is a great op-portunity to take some of the finalsteps,” he says, which might includesystems needed to improve ORthroughput, patient charging, andinventory management.

OR automation could use aboost. Though the majority of de-partments have automated ORscheduling, fewer than half have afully developed perioperative sys-tem, according to the HIMSS Ana-lytics Database (charts).

The last frontierOR leaders can make a strong

case for more robust IT systems. TheOR touches on key goals identifiedfor health IT—clinical documenta-tion, quality reporting, and greaterefficiency, says Jason Hess, generalmanager of clinical research forKLAS Enterprises, which conducts

user surveys of health care informa-tion systems.

Integration continues to be a bigneed. To contribute to these goals,ORs need to be more closely tiedwith the hospital’s core IT systems.

ORs are often the “last frontierfor integration,” Hess says. Despitebeing a major cost and revenuecenter, “ORs are nowhere nearwhere the lab, pharmacy, and someother areas are.”

In the most recent KLAS reporton surgery management informa-tion systems in 2007, 64% of usersnamed essential clinical or finan-cial information that is not inter-faced. Leading the list were inven-tory/materials management andclinical information, both critical toOR throughput and quality report-ing.

The preoperative process, withthe need to coordinate patient as-sessments, testing, and consul-tants, could also benefit from au-tomation and integration (relatedarticle, p 11).

Equally as important as soft-ware but often overlooked is thepersonnel needed for clinical and


What is the purpose of the health IT funding?

The purpose is to promote theadoption of health IT, particularlythe electronic health record (EHR) sopatient information can be shared byhospitals, physician offices, andother parts of the health care system.The eventual goal is to boost qualityand efficiency and reduce costs. Thepromise is that every American willhave the benefit of an EHR by 2014.

Which hospitals are eligible?• Acute care hospitals covered by

the Medicare prospective pay-ment system (PPS)

• Critical access hospitals• State funding is provided for hos-

pitals with 10% Medicaid volume• Hospital must be “meaningful

users of certified EHR technol-ogy,” as defined by the Secretaryof Health and Human Services(HHS).

What are the incentives?• Incentives would begin in fiscal

year 2011.• Eligible hospitals would receive

payments for up to 4 years ac-

cording to a formula. Paymentswould phase down over the 4years.

• Unless they show significanthardship, hospitals that are not“meaningful users” by FY 2015will have Medicare payments re-duced.

Who will administer theprogram?

The program will be administeredby the HHS Office of the NationalCoordinator of Health InformationTechnology (ONCHIT).

Continued on page 10

Fast facts on health IT funds

Related articles, pp 11 and 28

Some types of surgical site infec-tions are no longer reimbursed byMedicare. These include medias-tinitis after coronary artery bypassand infections following some or-thopedic procedures and bariatricsurgery.

Software is a major boon to in-fection preventionists, replacingreams of paper. They can spottrends more quickly, including sur-gical site infection outbreaks. Ifthey can’t get electronic reportsfrom the OR easily, that’s a big gap,Hess notes.

Though chief information officerswill have a big to-do list, OR direc-tors can make a strong argumentthat more robust and better inte-grated perioperative informationsystems are instrumental in helpingtheir institutions and the nationachieve health IT objectives. �

—Pat Patterson


Information systems

Not automated with plans (first-time purchasers) 0.5%

Automated without plans (installed without purchase plans) 47.8%

Automated with plans (replacement purchasers) 0.6%

Not automated; without plans (not installed without purchase plans or contracts) 42.5%

Contracted; not yet implemented 5.5%

Installation in process 3.2%

Use of OR information systems

Perioperative system definition: An OR applica-tion that provides clinical documentation/management of real-time surgical procedure,both from OR nurses’ and anesthesiologists’perspective; includes clinical order manage-ment, decision support, anesthesia documen-tation, integration to anesthesia systems,smart cabinets, IVs, PACS images, monitors,potentially smart surgical instruments forimage-guided surgery. Provides for the man-agement of relevant OR supplies/meds duringsurgery.

Not automated with plans (first-time purchasers) 0.5%

Automated without plans (installed without purchase plans) 56.0%

Automated with plans (replacement purchasers) 0.6%

Not automated; without plans (not installed without purchase plans or contracts) 35.2%

Contracted; not yet implemented 5.3%

Installation in process 2.3%

OR scheduling

Source: HIMSS Analytics Data-base, © 2009 HIMSS Analytics.Reprinted with permission.

Perioperative

technical IT systems. For example,if an OR doesn’t have the person-nel and processes to make surenew surgical devices are added tothe charging system quickly, theOR will not be able to account forall of its costs and could leave re-imbursement on the table.

Support isn’t specifically ad-dressed in the health IT funding.But Ohman says OR leadershipshould be able to put together abusiness case to justify the sup-port needed to improve prefer-ence card accuracy, supply avail-ability, and charge capture.

Quality reportingSoftware also figures in quality

reporting, which is playing a big-ger role in performance improve-ment, regulatory compliance, andreimbursement. Hospitals cur-rently must report 30 quality mea-sures to Medicare to get their fullannual payment update. Amongthese are 7 surgical measures.

Quality reporting relies on goodclinical documentation. “It’s criticalto get data out of your OR system,”Hess says.

Watching for infectionsAutomation is also increasingly

necessary for infection surveillance.


Heated debate overvirtual colonoscopy

Whether Medicare should pay forvirtual colonoscopy is the subject ofa heated debate in Washington, DC,the April 18 Los Angeles Times re-ports. Virtual colonoscopy is less ex-pensive and more comfortable thantraditional colonoscopy, but consen-sus is lacking on its effectiveness.

Proponents say virtual colonos-copy will increase the number ofpeople screened. Critics contend itcould inflate health care spendingbecause a traditional colonoscopy isrequired if there is a finding fromvirtual imaging. The decision onMedicare coverage is expected soon.

—www.latimes.com/business/la-na-colonoscopy18-

2009apr18,0,4333525.story


Automation ends preop paper chase

Information systems

Preparing patients for the dayof surgery can mean chasingfaxes and other documents

that are easily misplaced. Missinginformation can lead to surgicaldelays and cancellations, not tomention frustrated physicians andstaff.

If ever a process was ripe for au-tomation, this is it. With the gov-ernment’s funding for electronichealth records (EHR), the preoper-ative process is one area hospitalsand physicians may be looking at.

One option is to harness the In-ternet. Preoperative documenta-tion is submitted through a secureweb portal where physicians,nurses, and other authorized userscan access it easily.

OR Manager spoke with usersand representatives of 3 companiesthat offer web-based systems formanaging preoperative informa-tion.

Presurgical CareManagement System

Advocate Lutheran General Hos-pital in Park Ridge, Illinois, has beenusing an automated preoperativeevaluation system for about 5 years.

“We almost never cancel a caseanymore because a patient hasn’tbeen prepared appropriately pre-operatively,” says Mary Kay Biss-ing, DO, chair of anesthesia andperioperative medicine. “And wedon’t have to get last-minute con-sults, which we were doing almostdaily.” She estimates the softwarehas reduced the cancellation ratefrom missing paperwork on theday of surgery from about 5% tonear zero.

The Presurgical Care ManagementSystem was developed by DavidYoung, MD, Advocate Lutheran Gen-eral’s medical director of presurgical

testing. The software collects patientinformation, processes it into riskscores and treatment plans, and gen-erates reports. The system is nowowned by DocuSys, Inc, Atlanta(www.docusys. net). Dr Young is thecompany’s medical director of presur-gical care.

Web-based questionnairePatients access the automated

questionnaire at home or throughkiosks in surgery centers andphysician offices using an identifi-cation number.

The questionnaire, developed bythe Cleveland Clinic and used bythe Clinic and Advocate LutheranGeneral, focuses mainly on pul-monary, diabetes, and cardiac is-sues.

Patients answer the yes or noquestions phrased in layman’sterms. Yes answers trigger furtherquestions. A nurse always verifiesthe completed questionnaire withthe patient and asks more ques-tions if needed, Dr Young notes.

The software converts the pa-tient’s responses to medical termi-nology. For example, the question-naire asks: “Do you have shortnessof breath at night that requiressleeping on more than 2 pillows?”If the patient enters “yes,” the pro-gram reports that the patient has“nocturnal dyspnea.”

Once the information is enteredand verified, the software com-

pares the findings with the surgerythe patient will have and deter-mines the lab testing and any fur-ther evaluation needed. The sys-tem then creates different reportsfor the patient, surgeon, preopevaluation clinic, primary carephysician, and anesthesiologist .

My Medical Files Automation has helped end the

paper chase at Christiana CareHealth System, Wilmington, Dela-ware, which in September 2008adopted a web-based system fromMy Medical Files (MMF from MMFSystems, Inc, New York City, www.mmf.com)

Before, a blizzard of faxes led to“many delays on the day of surgeryand physician dissatisfaction,” saysAndrea Rodriguez, RN, BSN, CNOR,manager of surgical services for Chris-tiana Care.

MMF indexes, tracks, and noti-fies clinicians of missing informationwithout the involvement of hospitalstaff.

How it worksWith MMF, patient information

is faxed to a central number. Theincoming faxes are received by faxservices, which digitize and storethe documents in a database. Thedocuments are then made avail-able over MMF’s secure webservers in Virginia and California.Users are given a password to theMMF website.

The digitized documents thengo to trained personnel in Indiawho index patient informationaround the clock, making it avail-able on the MMF website minutesafter receiving it, explains Jose Bar-ranco, MMF’s vice president formarket development and compli-ance. He says the company can


“

“The software has reduced

cancellations.

provide an entire patient folderwithin 30 minutes of receiving apatient’s documents.

None of the data actually travelsto India, Barranco notes. Personnelhave read-only access to the docu-ments that remain in the secureweb servers.

Missing information is trackeddown by MMF staff based inPanama (who speak fluent Eng-lish), who phone surgeons’ offices.

Patients’ folders can be accessedby Christiana Care clinicians andoffice staff. Patients do not have ac-cess to the file.

“I can’t tell you how much thetracking service has changed thequality of life at the points of ser-vice,” says Rodriguez.

Eliminating the paper shuffleThe day before surgery, the OR

staff prints out a hard copy of thepatient’s folder.

“We still need a hard copy of thepatient’s chart. But we have elimi-nated 60,000 pieces of paper wewere shuffling each month,” saysRodriguez, noting physician satis-faction with MMF is high.

Anesthesia providers print outthe patient’s information becausethe anesthesia department doesnot have an automated informa-tion system yet. The goal is to gopaperless.

One Medical Passport One Medical Passport (Medical

Web Technologies, Scituate, Massa-chusetts) is a different approach,giving patients a free portable

health record. Individuals can setup a “medical passport” on thecompany’s website (www.onemedicalpassport.com) and keep itfor their records.

“Patients have a tremendous in-terest in creating a personal healthrecord, and One Medical Passportis a great tool for doing this. Thereis no charge to patients,” saysStephen Punzak, MD, an anesthesi-ologist who is the company’sfounder and CEO.

Health care facilities and physi-cian offices pay a fee to access a pa-tient’s One Medical Passport infor-mation, with the patient’s permis-sion.

Geared for first-time usersTypically, patients find out

about One Medical Passport whenthey schedule surgery with a hos-pital or surgeon who uses the sys-tem. The surgeon gives the patienta card with the surgery date, typeof surgery, and how to access thewebsite. The patient logs on athome, creates a user name andpassword, and fills out the onlinequestionnaire. Patients cannot skipquestions and can review the infor-mation before it is submitted.

“The system is geared for peo-ple who have never used it beforeand for those with limited com-puter experience,” says Dan Short,Medical Web Technologies’s vicepresident of sales.

The completed passport data isstored in the company’s securestorage facility and can be down-loaded by any provider a patienthas granted access to. The informa-tion either is displayed in a reportformat that can be printed or in anelectronic format that can be inter-faced.

Power of the passportThe power of the One Medical


Information systems


Presurgical CareManagement SystemDocuSys

The price is based on the hospi-tal’s annual surgical cases. The soft-ware is available as a site license oron a per-case basis. There is a one-time implementation fee and an-nual maintenance fee.

For a hospital with 5,000 cases ayear, the base one-time license feeis about $80,000 plus implementa-tion services and an annual main-tenance fee of $15,000.

For a surgical center with 2,000cases per year, the base one-time li-cense fee is about $25,000 plus im-plementation and an annual main-tenance fee of $5,000.

Alternatively, the system is of-fered for a per-patient fee of $2.50to $6.50, depending on volumesand configuration.

—www.docusys.net

My Medical FileMMF Systems

Fees are based on the number ofprocedures a facility performs.

For indexing 10,000 cases a year,MMF charges $4,000 a month. In-clude in the request for proposalthe number of representatives thecompany will provide for trainingand for how long, advises AndreaRodriguez, RN, BSN, CNOR, ofChristiana Care, Wilmington,Delaware, which uses MMF.

—www.mmf.com

One Medical PassportMedical Web Technologies

Pricing varies based on the con-figuration, modules purchased,and surgical volume.

A community hospital with astandard configuration, for exam-ple, could expect to pay about$1,000 to $2,000 per month.

—www.onemedicalpassport.com


Preop automation costs

ManagingToday’s ORSuiteOct 7 to 9, 2009Caesars Palace Las Vegas

22nd Annual

With the AORN Leadership

Specialty Assembly

For a conference brochure and to register online,

go to www.ormanager.com.

With the recession, it mightbe tempting to put staffrecruitment and reten-

tion on the back burner. Employeesmay be staying in place for now be-cause jobs are scarce. But these ef-forts are more important than ever,says Brian Lee, CSP, an expert onstaff loyalty and leadership.

“The recession has not solved thestaffing crisis,”he says. “Thereis still a short-age of nurses.And there arenot enoughseats in nurs-ing schools tosolve the prob-lem.”

The focusshould not be

on “warm bodies” but assemblingthe best possible team.

“Basically, you succeed or failbased on the quality of staff you

have,” says Lee. That’s increasinglytrue as managers are pressed forhigher productivity, quality, and pa-tient satisfaction.

A popular speaker from last year,Lee will present 2 sessions at theManaging Today’s OR Suite Confer-ence Oct 7 to 9 at Caesars Palace inLas Vegas:• an all-day seminar on Wednes-

day, Oct 7, titled “Magic ofFrontline Leadership: Secrets ofAccountability and Engage-ment”

• a general session on Thursday,Oct 8, titled “Thriving on Multi-ple Priorities: Proven Strategiesfor Work/Life Balance.”In the all-day seminar, Lee will

teach skills and share practical tools,such as 3 “loyalty-smart questions”to discover whether staff are think-ing about leaving and “resignationrecovery,” ways to save a personwho’s already decided to depart.

He’ll also address what to do

about the “whiners and slugs,” em-ployees who have left mentallywithout letting anyone know.

“That can be a danger for somehospitals with low turnover, particu-larly small rural hospitals,” he says.

Finding a balanceIn his general session, Lee will

suggest how managers can find abalance as they manage multiplepriorities.

He’ll describe strategies for iden-tifying and setting priorities, keep-ing others from wasting your time,and identifying problem areas thatblock managers from achievingtheir goals.

Lee is CEO and founder of Cus-tom Learning Systems, Calgary, Al-berta, Canada. He is author of KeepYour Nurses and Health Professionalsfor Life and Satisfaction Guaranteed,both from Mastery Publishing. �

Learn more about Lee at www.customlearning.com


Practical tools for building staff loyalty

Managing Today’s OR Suite

Passport technology is not only inthe data collection but also in whatit does with the data, Dr Punzaksays. Rather than simply printingout the patient’s information, thesystem routes the information tothe clinician who needs it.

An Assessment Checklist mod-ule lists tasks and forms that needto be completed for each patient.As information comes in, the sys-tem automatically takes the task offthe list. An audit trail shows whoindicated the task was completedand when.

A document manager module

automatically scans documents,alerts the facility the documentshave been submitted, and auto-matically alerts the surgeon’s officeif documentation is missing.

More accurate informationA surgery center that has used

One Medical Passport for about ayear finds the system has im-proved the accuracy of patient in-formation.

Patients can fill out the onlinequestionnaire from their homes ina relaxed manner, which helps en-sure the information is correct andcomplete, says Gina Espenschied,RN, BSN, CNOR, administrator ofThe Surgery Center at BrintonLake, Glen Mills, Pennsylvania,

which performs about 500 to 600cases a month.

“In the past, when preoperativenurses called patients, they oftencaught them in the car or at workwith little time to focus on thequestions,” she says. As a result,the information sometimes wasn’tcomplete or differed from what thepatient gave on the day of surgery.

Espenschied says the documentmanager module has decreasedsurgery cancellations caused bymissing paperwork by nearly 15%.Presently, about 70% of patientscomplete the Passport compared to20% when the program was intro-duced. �

— Judith M. Mathias, RN, MA

AutomationContinued from page 12

Brian Lee, CSP

Computed tomographic (CT) colonography for colorectal cancer screening and diagnosis

OR leaders are striving to make evidence-based decisions about new technology. OR Manager, Inc., and ECRI Institute have joined in a collaboration to bring quarterly supplements with summaries of the Institute’s technology assessment reports to OR Manager readers. ECRI Institute is an independent nonprofi t organization that researches best approaches to improving patient care. It does its work by analyzing the research literature and data on clinical procedures, medical devices, and drug therapies.

Technology descriptionComputed tomography (CT) colonography uses 16- or 64-slice CT with software designed to construct a series of cross-sectional images (slices) of the interior surface of the colon into two-dimensional (2-D) or three-dimensional (3-D) images. CT colonography is intended for colorectal cancer (CRC) screening of asymptomatic individuals or as a diagnostic tool for symptomatic individuals who cannot or choose not to undergo conventional colonoscopy. CT colonography avoids some of the disadvantages of colonoscopy (i.e., inva-siveness, increased risk of bowel perforation, need for sedation) and has been promoted as a way to increase patient compliance with CRC screening. Both procedures require the same bowel preparation.

Clinicians performing CT colonography can obtain images of the entire colon in 20 to 30 seconds. When scanning is complete, reconstructed 2-D or 3-D images are displayed on a workstation. Interpretation takes 15 to 60 minutes. If the interpreter recommends polyp removal or investigation of a suspicious lesion, same-day colonoscopy may be possible.

Regulatory statusTh e U.S. Food and Drug Administration (FDA) regulates CT systems, work-stations, and image processing software under the 510(k) process as Class II devices. Numerous manufacturers have received FDA clearances for systems, workstations, and software used to perform CT colonography.

Editor’sNote

SUPPLEMENT TO OR MANAGER Vol 25, No 6, June 2009

JUNE 2009

years

Hospital impactA successful CT colonography service requires pri-mary care physicians, radiologists, and gastroenterologists to collaborate. Because CT colonography is relatively new, patient inquiries and education can be time-consuming. A program coordi-nator may be helpful to coordinate staffi ng and equip-ment purchasing and to monitor clinician and patient education.

Credentialing/trainingCT scanning is typically performed by technologists and interpreted by board-certifi ed radiologists. Disagreement exists within the medical community regarding which clinicians are most appropriate to interpret CT colonography scans. Specialty societies are developing standards on instruction and qualifi cations considered necessary for profi ciency in interpreting CT colonography. Th ere is no consensus on the best training program.

Effect on other technologiesSeveral technologies can be used as an

adjunct to CT colonography, in-cluding fecal “tagging” (including

barium solution), iodine-containing contrast agents, and computer-generated “virtual reality” images to remove fecal matter from CT images.

CT colonography competes with conventional colonosco-py, the gold standard method of screening for polyps and evaluating symptomatic patients. However, because suspicious polyps can only be viewed but not removed dur-ing CT colonography, CT colonography will not replace conventional colonoscopy.

Phase of diffusionCT colonography is widely available throughout the United States in hospitals and freestanding clinics. Th e addition of CT colonography to the American Cancer So-ciety’s 2008 guidelines for CRC screening and surveillance has spurred adoption of this technology.

Device costs/procedure chargesGenerally, CT colonography is performed using 16-slice or 64-slice CT scanners. Th e average list price for a new 16-slice CT scanner base system ranges from $700,000 to $900,000. Th e list price for a 64-slice CT scanner sys-tem ranges from $1.8 to $2.4 million. Th e price typically includes the scanner unit, control console, and acquisition and processing workstation confi gured with appropriate software packages for image review and postprocessing capabilities. As hospitals are upgrading to 32- and 64-slice CT scanners, secondhand 16-slice scanners are becoming available for $500,000 to $600,000.

Typical charges for CT colonography, including practitio-ner and facility fees, range from $567 to $895 per exam.

Reimbursement/coding/paymentTh e U.S. Centers for Medicare & Medicaid Services (CMS) has not issued a national coverage determination (NCD) for CT colonography. However, in February 2009, CMS determined that there is inadequate evidence to classify CT colonography as an appropriate CRC screening test. CMS expects to issue a fi nal NCD in May 2009.

Th e American Medical Association has assigned two category III Current Procedural Terminology codes for CT colonography: one for screening and one for diagnostic.

According to the 2009 Hospital Outpatient Prospective Payment System, the CMS payment rate for diagnostic CT colonography is $191.78. Physician fees are carrier priced and at the discretion of local carriers, which base payment on a per-case basis following documentation review.

SUPPLEMENT TO OR MANAGER Vol 25, No 6, June 2009

Cost considerationsECRI searches identifi ed eight cost-eff ectiveness analyses published in the peer-reviewed literature (Sonnenberg et al., 1999; Heitman et al., 2005; Arnesen et al., 2007; Has-san et al., 2007; Pickhardt et al., 2007; Vijan et al., 2007; Lansdorp-Vogelaar et al., 2008) and a January 2009 Agency for Healthcare Research and Quality evidence report.

An improvement in CT colonography accuracy, a reduction in cost, and/or an increase in compliance rates were identi-fi ed in the eight reviews as factors that could make CT colonography more cost-eff ective.

Key clinical questions/findings Th e clinical questions and fi ndings are Does the rate of development of CRC, patient-survival,

or quality of life diff er between CT colonography and colonoscopy when used for CRC screening or diag-nosis? No suffi cient follow-up data were available to address this question.

What is the sensitivity and specifi city of CT colonog-raphy for detecting clinically important polyps and cancer when used for CRC screening or diagnosis? CT colonography appears most promising for screening average-risk asymptomatic individuals. Our meta-analysis found the sensitivity estimate to be 91% (95% confi dence interval [CI]: 86% to 95%). We could not accurately estimate specifi city due to diff erences among study fi ndings. For screening high-risk asymptomatic individuals, the results of our meta-analysis suggest that large polyps and cancer may be missed in many patients. Th e estimate for sensitivity was only 72% (95% CI: 60% to 80%). For diagnosing symptomatic patients, the sensitivity was 88% (95% CI: 76% to 95%), and the specifi city was 99% (95% CI: 96% to 100%). Th e posttest probability of disease with a posi-tive diagnostic test was 92% (95% CI: 73% to 98%), and the probability of disease with a negative test was 1% (95% CI: 1% to 3%).

Do patients prefer CT colonography or colonoscopy? Data from nine studies indicated that most patients preferred CT colonography, although the proportion of patients favoring CT colonography ranged widely—from 37% to 90%.

What adverse events are associated with CT colonog-raphy? Adverse events were infrequent and generally minor, but longer follow-up is needed to assess those attributed to radiation exposure. Studying greater num-bers of patients may detect rare events.

Does off ering CT colonography for CRC screening increase compliance with screening recommendations? No conclusions can be drawn due to the insuffi cient quantity of evidence.

Excerpted with permission from ECRI Institute’s TARGET database of evidence reports on emerging technologies. Th e complete report can be purchased from ECRI Institute’s Health Technology Assessment Information Service at [email protected].

ECRI Institute is an independent nonprofi t health services research agency designated as an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. Th e Institute maintains the strictest confl ict-of-interest standards in the healthcare industry to protect against bias and ensure the integrity of its information.

SELECTED REFERENCES Arnesen RB, Ginnerup-Pedersen B, Poulsen PB, et al.

Cost-eff ectiveness of computed tomographic colonogra-phy: A prospective comparison with colonoscopy. Acta Radiol 2007 Apr;48(3):259-266.

Cancer Intervention and Surveillance Modeling Net-work (CISNET). Cost-eff ectiveness of CT colonography to screen for colorectal cancer. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2009 Jan 22. 92 p. Also available: http://www.cms.hhs.gov/mcd/viewtechassess.asp?where=index&tid=58.

Cotton PB, Durkalski VL, Pineau BC, et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA 2004 Apr 14;291(14):1713-9.

Hassan C, Zullo A, Laghi A, et al. Colon cancer prevention in Italy: cost-eff ectiveness analysis with CT colonography and endoscopy. Dig Liver Dis 2007 Mar;39(3):242-50.

Vol 25, No 6, June 2009 SUPPLEMENT TO OR MANAGER

State of Evidence Base

VOL 25, NO 6, JUNE 2009 SUPPLEMENT TO OR MANAGER

SELECTED REFERENCES Heitman S J, Manns B J, Hilsden R J, et al. Cost-

eff ectiveness of computerized tomographic colonography versus colonoscopy for colorectal cancer screening. Can Med Assoc J 2005 Oct 11;173(8):877-81.

Johnson CD, Chen MH, Toledano AY, et al. Accuracy of CT colonography for detection of large adenomas and cancers. N Engl J Med 2008 Sep 18;359(12):1207-17.

Lansdorp-Vogelaar I, van Ballegooijen M, Zauber AG, et al. At what costs will screening with CT colonography be competitive? A cost-eff ectiveness approach. Int J Cancer 2009 Mar 1;124(5):1161-8. Epub 2008 Sep 24.

Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the U.S. Multi-Society Task Force on colorectal cancer, and the American College of Radiology. CA Cancer J Clin 2008 Mar 5; e-pub ahead of print. Also available: http://caonline.amcancersoc.org/cgi/content/full/CA.2007.0018v1.

Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 2003 Dec 4;349(23):2191-200.

Pickhardt PJ, Hassan C, Laghi A, et al. Cost-eff ectiveness of colorectal cancer screening with computed tomography colonography: Th e impact of not reporting diminutive lesions. Cancer 2007 Jun 1;109(11):2213-21.

Sonnenberg A, Delco F, Bauerfeind P. Is virtual colo-noscopy a cost-eff ective option to screen for colorectal cancer? Am J Gastroenterol 1999 Aug;94(8):2268-74.

Vijan S, Hwang I, Inadomi J, et al. Th e cost-eff ectiveness of CT colonography in screening for colorectal neoplasia. Am J Gastroenterol 2007 Feb;102(2):380-90.

5200 Butler Pike Plymouth Meeting, PA 19462-1298, USA

Tel +1 (610) 825-6000 Fax +1 (610) 834-1275

Web www.ecri.org

SUPPLEMENT TO OR MANAGERVOL 25, NO 6, JUNE 2009www.ormanager.com

© ECRI Institute 2009

Quantity of Evidence Base (High)Th e evidence base consists of 17 studies that assessed 7,460 patients. Of these studies, 6 assessed 5,857 asymptomatic patients, and 11 evaluated 1,603 symptomatic patients.

Quality of Evidence Base (High)ECRI Institute analysts used an assessment tool to formally examine factors of study design that may have the potential to reduce the validity of conclusions.

Consistency of Evidence Base (Low)When possible, ECRI Institute analysts used statistical tests to determine the consistency of the evidence base. No study compared patient survival or quality of life of patients who under-went computed tomographic colonography to that of patients who underwent colonoscopy for colorectal cancer screening or diagnosis. Sensi-tivity was consistent among studies on asymp-tomatic, average-risk individuals and symptom-atic individuals but was not consistent among studies on asymptomatic, high-risk individuals. Consistency was not evaluated for other out-comes due to a paucity of evidence.

years

ECRI

Low

Mod

High

QUANTITY

ECRI

Low

Mod

High

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ECRI

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Endo reprocessing lapses at the VA

Follow the published manufac-turer’s instructions—that mes-sage is being hammered home

once again following errors in thesetup and reprocessing of endoscopyequipment at 3 Veterans Affairs (VA)facilities. The errors involved use of awrong connector and failure to fol-low reprocessing instructions for tub-ing, according to the VA.

The incidents have messages forall GI labs, says James Bagian, MD,director of the VA’s National Cen-ter for Patient Safety.

“This is not just a problem for theVA,” he told OR Manager. “Manu-facturers tell us as many as 9 out of10 facilities they see are not repro-cessing this equipment correctly.”

Testing offeredThe VA has notified more than

10,500 veterans who may havebeen exposed to cross-contamina-tion during endoscopy at VA facili-ties in Murfreesboro, Tennessee;Augusta, Georgia; and Miami dur-ing periods ranging from April2003 to March 2009.

Dr Bagian says it’s not clearwhen the problems first arose, butthe VA took a conservative ap-proach in offering testing.

As of April 27, 2009, 6,687 veter-ans had received their test results,the Department of Veterans Affairssaid. In all, 8 had tested positive forhepatitis B, 25 for hepatitis C, and 5for HIV. Results do not necessarilyindicate any relationship to the en-doscopy procedures, the VA said.An epidemiologic investigation isbeing conducted to check for anysuch relationship.

The risk of hepatitis transmis-sion through endoscopy is “ex-tremely small,” the VA notes. HIVtransmission through endoscopyhas never been reported.

What happened?The first error reported was use

of a wrong connector to attach theauxiliary water tube to the endo-scope’s irrigation source (illustra-tion).

“Somebody apparently disas-sembled one tube and put the con-nector on another tube,” Dr Bagiansays. He said the action shows “alack of appreciation for the fact thatmedical devices should not bemodified by clinical personnelwithout consultation with the ap-propriate authorities.”

The wrong connector has novalve. The correct connector has a1-way valve that prevents fluidfrom flowing backward and conta-minating the irrigation filter andtubing. Both connectors are green,but the incorrect connector has 1wing, and the correct one has 2wings.

Other errors surfaceAs other VA facilities reviewed

their practices, more lapses sur-faced: • In some facilities, the auxiliary

water tube wasn’t being re-processed between patients, asthe manufacturer recommends.The auxiliary water tube must bereprocessed each time it is used,according to alerts from the VAand Olympus, the endoscopemanufacturer.

• The irrigation tube and its filterweren’t always being discardedat the end of the day, as in-structed by the manufacturer.

• The auxiliary water tube was notalways primed and flushed as di-rected.These errors are described in a

VA Patient Safety Alert (www.pa-tientsafety.gov/alerts.html). The

GI endoscopy

During some endoscopy procedures, one facility used an Olympus Auxiliary Water Tube (MAJ-855) that was modified to have an Olympus Washing Tube (MH-974) connector attached instead

of the connector intended to be used with the tube. Source: Patient Safety Alert, Veterans Administration Warning

System, AL09-07, Dec 22, 2008.


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OR Manager to launch webinar series

OR Manager, Inc, is launch-ing an educational webinarseries to provide the latest

information on OR management to3 key audiences:• OR directors and managers• OR business managers• new OR managers.

“OR Manager is the premierprovider of information and edu-cation relating to management ofthe OR,” said OR Manager Presi-dent Elinor S. Schrader.

“We want to make our informa-tion more accessible. With the eco-nomic downturn, hospitals are re-stricting travel, which makes it dif-ficult for some managers to attendeducational events.

“With webinars, you can partici-pate in an education program

without leaving your office. For asingle fee, others can also partici-pate,” Schrader said.

“Ways of learning and accessinginformation are changing rapidly,and OR Manager is adding thistechnology to our electronic infor-mation, which includes the digitaledition of OR Manager.”

OR directorsStarting in June, V. Gerard Ip-

polito will present 4 webinars onsurgical services business develop-ment and planning. He is presidentof OR Efficiencies, LLC. ChristinaDempsey, RN, MBA, CNOR, seniorvice president of clinical operations,Patient Flow Press Ganey, will offera webinar on improving patientflow.

Business managersIn July, several sessions from the

recent OR Business ManagementConference will be offered. ConnieCurran, RN, EdD, FAAN, whokeynoted the conference inChicago in May, will present a we-binar on how OR leaders can dealwith the key issues of money, qual-ity, and manpower.

New OR ManagersIn the fall, a series of webinars

designed to help new managerslearn basic OR management skillswill be offered. These will be valu-able for OR nurses who want tomove into management positions. �

For more information, go to www.ormanager.com

VA stresses that the alert applies toall flexible endoscopes and acces-sories, regardless of the manufac-turer or model.

Many facilities thought theywere doing the right thing butweren’t, Dr Bagian says. He em-phasized the need to follow manu-facturers’ written instructions ex-plicitly for each component in theendoscopy setup.

Relying on diligence alone “isnot enough,” he says. He advo-cates a quality control approachsimilar to that aviation employs forits mechanics, including detailedstandard operating procedures, fre-quent training, testing, and ac-countability.

“The airlines understand if youdon’t do a process meticulously,accidents happen, and people die,”he says.

His advice for GI labs: • Make sure all procedures are

consistent with manufacturers’instructions. Locate instructionsfor all components and do aside-by-side comparison withyour procedures.

• Develop standard operatingprocedures. Make sure the pro-cedures are posted where theycan be easily seen and are fol-lowed. “No one can accuratelyperform 48 reprocessing stepsfrom memory every time,” hesays.

• Instruct personnel to verify anyadvice given by company salesrepresentatives. If a rep says,“Sure, you can do this,” requirethe rep to show where that in-struction is written in the man-ual or to provide the instructionin writing, Dr Bagian advises.

• Test personnel on standard op-erating procedures.

• Conduct informal observations.Walk in and watch scopes beingreprocessed. If some personnelaren’t capable of following di-rections consistently, “they need

to be in different jobs,” he says.Physicians and nurses share in

the accountability, he adds. Allclinicians should know the equip-ment and how to use it correctly.They should hold one another ac-countable. For example, if one clin-ician observes another is not flush-ing the endoscope when necessarybefore inserting it in the patient,“the clinician is obligated to speakup,” Dr Bagian says. “It’s just liketelling someone to wash theirhands or change gloves.” If theperson doesn’t comply, a supervi-sor should be notified. �

Standards for endoscope reprocessingare posted on the Society of Gastroen-terology Nurses and Associates web-site at www.sgna.org

Refer also to the AORN RecommendedPractices for Cleaning and ProcessingFlexible Endoscopes and EndoscopeAccessories in the AORN Periopera-tive Standards and RecommendedPractices, 2009 edition. www.aorn.org

EndoscopyContinued from page 19

What is needed to be readyfor a Joint Commissionsurvey with regard to

sterilization practices, both now andin the future? Experiences with re-cent surveys were shared by 20 op-erating room managers with re-sponsibility for the OR and sterileprocessing department (SPD) at anall-day session on sterilization at theAORN Congress in March in Chi-cago. The managers identified is-sues the surveyors were concernedabout, departments they visited,and questions they asked.

In the past,though survey-ors often askedto see docu-mentation ofOR and SPDservices, theydid not alwaysdon scrubs andwalk throughthe operating

room or the sterile processing depart-ment. It appears this has changed.Participants reported that surveyorswalked through both departments,visiting the decontamination, prepand pack, and storage areas in SPDand the instrument processing andsterilization areas in the operatingroom.

None of the issues surveyorslooked for were surprises. Theywere issues that should be in-cluded in routine quality assuranceaudits, such as flash sterilization,pack integrity, sterilization processmonitoring, and whether practiceis consistent with policies and pro-cedures.

Interestingly, except for check-ing to see that documentation offlash sterilized items identified thepatient involved, none of the par-ticipants said the surveyors in-

cluded instrument processing in pa-tient tracers. In the tracer process, asurveyor selects a patient and, usingthe patient’s record, retraces the“specific care processes that an indi-vidual experienced.” The purpose ofa tracer is to assess an organization’ssystems of providing care and ser-vices.

It may be only a matter of timebefore the tracer process is ex-panded to include the ability totrace instrument sets to specific pa-tients. The tracer methodology andinstrument traceability seem to gotogether. Although SPD does notprovide patient care, it does pro-vide services that affect the qualityand safety of care. In fact, one sur-veyor specifically asked if the de-partment could track instrumentsto patients but did not pursue thisfurther.

Flash sterilizationRegarding flash sterilization,

managers said surveyors wanted toknow the flash sterilization rate,what was being flash sterilized, andhow often. Eye instruments were ofparticular concern. Several man-agers reported having to purchaseeye instruments as a result of thesurvey as well as concern about re-ports of TASS (toxic anterior seg-ment syndrome). TASS, an acute,noninfectious inflammation of theeye’s anterior segment, is a compli-cation of surgery on the anterior seg-

ment, such as cataract extraction. Surveyors asked to see the pol-

icy for flash sterilization to deter-mine if practice reflected the policy.They also inspected flash steriliza-tion documentation records forcompleteness and traceability tothe patient.

Documenting flashsterilization

Managers need to monitor howwell flash sterilization documenta-tion is being maintained. TheAORN recommended practices forsterilization state that flash steril-ization documentation should in-clude:• item being processed• patient receiving the item• cycle parameters used (eg, tem-

perature, duration of cycle, andthe date and time the cycle is run)

• operator information• reason for flash sterilization.

Flash sterilization records shouldbe neat, well organized, and legible;anything else suggests carelessness.One suggestion is to use a 3-ringbinder with one page for one flashsterilization cycle, with a preprinteddesignated space on each page forthe sterilizer printout (or printout in-formation entry). The printoutshould fit into the space and notoverlap the page. Any excess paperon the printout should be removed.Tethering a pair of scissors and a sta-pler to a site next to the log book canhelp accomplish this.

Documentation should be pro-tected from water splashes. A flashsterilization log kept next to a ster-ilizer located near a sink is a primetarget for splashes and stains,which can result in a messy andcrinkled log that suggests sloppypractice. Plastic page covers maybe used to protect the documenta-


Are you ready for Joint Commission?

Sterilization & Infection Control

“

“What did surveyors look

for?


tion and convey a sense of order.Periodic review of the condition andcompleteness of the flash steriliza-tion log should be an ongoing partof OR and SPD quality process au-dits.

A separate log should be main-tained listing what was flashed,why it was flashed, and whatcould have been done to preventflashing. Although keeping this logadds an extra 30 seconds to thedocumentation process, it helps intrending what is being flashed andwhy flashing is necessary. Fromthis data, an implementation strat-egy can be developed to reduceflash sterilization. This data is es-pecially important in supplying therationale for a request for addi-tional instrumentation, a change inscheduling, or other strategies toreduce flash sterilization.

Other survey issuesIn addition to checking flash steril-

ization logs, surveyors examined ex-piration dates of disinfectant teststrips and chemical indicators. In onefacility, the surveyor checked the lotnumbers of biological indicators (BI):Did they match the BI control? Onesurveyor checked wrapped packagesfor tears and loose tape on wrappedsets. The surveyor also inspected peelpacks to see if a complete chemicalindicator was inside each one.

Several surveyors requested tosee documentation of tempera-ture and humidity in the SPD de-contamination, prep and pack,and storage sections; documenta-tion of SPD staff training and con-tinuing education; and documen-tation of quality improvement ac-tivities.

One surveyor asked how often aBI was run and why, that is, forsterilizer efficacy or for load releasewith and without implants. Moni-toring with a BI is optional forloads that do not contain implants.

But BI monitoring is not optionalfor loads containing implants.

Considering the mix of mostloads in high-volume facilities,monitoring every load with a BImakes sense. Monitoring everyload ensures that any set contain-ing an implant (screw, wire, plate,etc) will not inadvertently be re-leased without a BI having beenrun with the load. It makes it easyto answer the Joint Commissionsurveyor wanting to know whenand why a BI is run.

Tracers in the future? Joint Commission surveyors

may not include instrument sets intracers right away. But managersshould be aware that is a possibil-ity for the future.

Traceability is addressed in thesteam sterilization standard fromthe Association for the Advance-ment of Medical Instrumentation(AAMI ST:79), which states, “Ide-ally, cleaned medical devices shouldbe traceable to the patients onwhom they are used. . . . Ideally,every processed device, especiallyan implant, should be fully traceableto the patient on whom it is used orin whom it is implanted.” The word“ideally” is used because the AAMIcommittee responsible for writingthis guideline recognizes that manyfacilities do not yet have automatedtracking systems that allow trace-ability. In addition, most trackingsystems permit traceability to a par-ticular instrument set but not to in-dividual instruments.

Is it only a matter of time beforesurveyors ask to see documentsthat can identify the instrumentsused on a particular patient? Facili-ties with low surgical volumesmay be able to track instrumentsmanually, but for large-volume fa-cilities, a computerized instrumenttracking system would be neededto meet the AAMI recommenda-tion for instrument traceability. Ifin the future, the Joint Commissionincorporates instrument processinginto the tracer methodology, an au-tomated tracking system wouldserve the facility well. �

—Cynthia Spry, RN, MA, MSN, CNOR

Independent Clinical Consultant

ReferencesAssociation of periOperative Regis-

tered Nurses. Recommendedpractices for sterilization in theperioperative practice setting.Perioperative Standards and Rec-ommended Practices. Denver:AORN, 2009. www.aorn.org

Association for the Advancement ofMedical Instrumentation. Com-prehensive guide to steam steriliza-tion and sterility assurance inhealth care facilities. ANSI/ AAMIST79:2008. Arlington, Va: AAMI,2008. www.aami.org

Joint Commission. AccreditationProcesses: Facts about the tracermethodology. www.jointcommis-sion.org/AccreditationPrograms/Hospitals/AccreditationProcess/Tracer_Methodology.htm

Sterilization & Infection Control

“

“Monitor flashsterilization

documentation.

Do you have a questionon sterilization andinfection control?

Send questions to Pat Patterson, editor, at

[email protected]’ll consider them

for the column.

On average, hospitals pur-chase 73% of their materi-als through group purchas-

ing organizations (GPOs), with awide range from 30% to 90%. Butfewer—19% —purchase expensiveorthopedic implants through GPOcontracts, a new survey finds.

Eugene S. Schneller, PhD, a busi-ness professor at Arizona State Uni-versity, Tempe, and a supply chainconsultant, surveyed 28 systemsrepresenting 429 hospitals abouttheir commitment to group purchas-ing, including savings, satisfaction,and perceived value. The study wasfinanced by the Health IndustryGroup Purchasing Association(HIGPA), a GPO trade group.

GPOs are organizations that buyon a large scale and negotiate dis-counts from vendors. They also pro-vide services like consulting andperformance improvement efforts.

Survey highlights:• Overall average savings attrib-

uted to GPO contracts: 18.7%. • Percent of general med-surg sup-

plies purchased through GPO:82%.

• Average hospital supply expenseas percent of net revenue: 18.5%.On the labor impact of group

purchasing, findings indicated theaverage hospital would have tohire 9 FTEs to replace servicesGPOs provide.

The average hospital in thestudy had 380 beds, 20,000 annualinpatient admissions, and $62 mil-lion in supply spending.

From the findings, Schnellerprojected that GPOs save the USover $36 billion in direct healthcare costs annually. More savingswould be possible if GPOs weremore widely used, he added.

He and others speaking at anApril 29 news conference called

GPOs “key players in health carereform” and said greater use ofgroup purchasing could aid hospi-tals, which have been heavily hitby the recession.

Implant purchasing lagsFor items such as total joint

prostheses, pacemakers, and car-diac stents, group purchasing hasnot penetrated far (table, p 25).

These items, driven heavily byphysician preference, are more dif-ficult to consolidate for group buy-ing than bulk supplies.

They are also a big cost chal-lenge, accounting for about 60% ofa hospital’s total materials spend,according to a 2007 report bySchneller and his coauthor Kath-leen Montgomery.

For hospitals that do purchasethese items through GPO contracts,estimated average savings are:• 15% for orthopedic implants• 17% for cardiac devices.

It’s hard to compare these sav-ings with savings hospitals can geton their own because of thenondisclosure clauses in their con-tracts, Schneller notes.

The most common way hospi-tals use GPOs for physician prefer-ence items, employed by 50%, is asa starting point for negotiations,the survey found.

Over a third (37.5%) say theyhave a strategy to use GPOs for im-plant purchasing, even though

only 19% buy their hip, knee, andspine implants mainly throughGPO contracts.

The findings suggest many hos-pitals indicated they would like togo further, with over half (56%)saying they want to improve theirGPO contract participation forthese items.

Why the gap?Why the gap between intentions

and behavior on physician prefer-ence items? Schneller suggestedseveral reasons: Some may believethere is an advantage in doing theirown contracting, using GPO pric-ing as a benchmark, or they maybe working with their GPO on cus-tom contracting.

Schneller told OR Manager hesees collaboration increasingamong orthopedic makers, hospi-tals, and GPOs, though that wasnot part of the survey.

“As some orthopedic suppliershave had issues with the Depart-ment of Justice and are less able toreach physicians, they have tendedto collaborate more with hospi-tals,” he says.

He was referring to the JusticeDepartment’s 2007 agreement withmajor implant manufacturers. Inthe deal, the companies avoidedcriminal prosecution and paidmore than $300 million to settleclaims over charges they had paidphysicians kickbacks for use oftheir brand of implants. As part ofthe deal, companies were requiredto post on their web sites lists ofconsulting arrangements withphysicians.

There have also been calls forstricter conflict of interest policiesfor physicians and industry, mostrecently by the Institute of Medi-cine.


GPO purchasing of implants lagsOR business management

“

“Many would like to go further.


Schneller says he has been“fairly vocal” about the need fortransparency in implant pricing aswell as a national registry to trackimplant use and outcomes. Theoutcomes data could be used tocompare the effectiveness of vari-ous types of implants. Attempts toset up a registry have been slowedby questions about funding, how toencourage participation, data pri-vacy, and who would manage andown the data.

Supply expense perdischarge

In the overall findings, hospitalswith lower use of GPO contractsare likely to have higher expensesper adjusted discharge than hospi-tals with high GPO contract use, es-pecially for general medical prod-ucts, housekeeping, and other clini-cal products.

All of the reasons for this differ-ence aren’t known, but Schnellersays hospitals that aren’t makinghigh use of their contracts “wouldbe wise to review their currentstrategies.”

For every 1,000 admissions, a hos-pital underperforming in this areacould save as much as $400,000, anda system could save almost $900,000,he noted.

In addition, he notes, hospitalsgive a high value to other services

GPOs provide besides pricing, suchas monitoring the market for drugshortages, identifying safety prod-ucts, and managing suppliers’ fail-ure to adhere to terms and condi-tions. �

ReferenceMontgomery K, Schneller E. Hospi-

tals’ strategies for orchestratingselection of physician preferenceitems. Milbank Quarterly.2007;85:307-335.

Schneller E S. Value of Group Pur-chasing—2009: Meeting the Needsfor Strategic Savings. Scottsville,Az: Health Care Sector Ad-vances, 2009. Download atwww.gpossavemoney.org

Wilson N A, Schneller E S, Mont-gomery K, et al. Hip and kneeimplants: Current trends and pol-icy considerations. H Affairs.2008;27:1587-1598.

GPOs’ role in physician preference items% % % %

principally have GPO use GPO for use GPOuse GPO assist in local “reference price data ascontracts negotiation pricing” benchmark

Cardiology (pacemakers) 16.7 16.7 8.3 20.8

Cardiology (stents) 29.2 8.3 8.3 20.8

Orthopedics (hips) 19.2 15.4 15.4 23.1

Orthopedics (knees) 19.2 15.4 15.4 23.1

Spine 19.2 11.5 11.5 15.4

New report advisesstronger policies onconflict of interest

The Institute of Medicine (IOM)recommends voluntary measuresto curb conflicts of interest betweenphysicians and industry.

The report, released April 28,2009, calls on Congress to requirecompanies to report on a publicwebsite payments to physicians,researchers, and others.

Recommendations address dis-closure of financial ties, limits tocompany payments and gifts, andremoving industry influence frommedical education and practiceguideline development.

The report advised medical cen-ters, professional societies, and oth-ers to establish or strengthen theirconflict of interest policies.

The IOM committee said itfound a great deal of variation inconflict of interest policies and ad-herence with them. �

ReferenceLo B, Field M J, eds. Conflict of Inter-

est in Medical Research, Education,and Practice. Washington, DC:National Academies Press, 2009.www.nap.edu/catalog.php?record_id=12598

Source: Schneller E S. Value of Group Purchasing—2009. Health Care Advances, Inc, 2009. Reprinted with permission.

“

“Collaborationwith implant

vendors is increasing.


Economy is taking a toll on ASCs

The economy is taking its tollon ambulatory surgery cen-ters (ASCs) and other outpa-

tient facilities. In all, 60% of ambulatory care

organizations in a new surveyhave seen demand for their ser-vices fall over the past 12 months.For 11%, the decline was 20% ormore. About one-fourth (27%)have seen no change.

Most of the survey participants(76%) were ASCs, 9% were office-based surgical centers, and the restwere other outpatient organiza-tions. The majority (64%) arephysician owned.

“A number of ASCs are hurtingfrom the economy, though it reallyvaries. If they have not been im-pacted, they are getting ready. Al-most everyone is in some form ofwatchful waiting,” says NaomiKuznets, PhD, of the AccreditationAssociation for Ambulatory HealthCare Institute for Quality Improve-ment (AAAHC Institute). The in-stitute invited 4,000 AAAHC-ac-credited organizations to partici-pate in the online survey in March,

with 985 responding (25%). Declines in volume were highest

in the Midwest, the Southeast, andthe Southwest.

For 57% of organizations, elec-tive procedures were decliningfaster than nonelective procedures.And for just over half (51%), self-pay procedures were droppingfaster than procedures reimbursedby third-party payers.

Basic services affectedThe recession’s effect is being

felt not only on self-pay and elec-tive services like cosmetic surgerybut also on basic services such asgeneral surgery, ENT, and painmanagement, Kuznets says (side-bar, p 27).

Three-fourths (76%) of respon-dents reported a negative impacton patients’ ability to pay their co-pays and deductibles.

Some facilities said they had seenan increase in patients who are de-laying, canceling, or not showing upfor procedures. Among reasonswere the higher copays and de-ductibles or fear of losing work be-cause of illness or taking time off.

In response, facilities are tight-ening their belts. Even those thathave not had a decline in volumeare taking steps to conserve re-sources. Two-thirds (67%) reportedthe economic downturn had hadnegative effects including:• making capital purchases (44%)• purchasing supplies (31%)• hiring or retaining staff (29%)• purchasing services (12%)• floating payroll expenses (9%).

In addition, 2% said the econ-omy had affected decisions to giveraises or bonuses, and 2% said ithad affected staffing hours orwages (1%).

Staffing changes“Most didn’t say they are reduc-

Lee Anne Blackwell, RN, BSN, EMBA,CNORDirector, clinical resources and educa-tion, Surgical Care Affiliates,Birmingham, Alabama

Nancy Burden, RN, MS, CAPA, CPANDirector, Ambulatory Surgery, BayCareHealth System, Clearwater, Florida

Lisa Cooper, RN, BSN, BA, CNORExecutive director, El Camino SurgeryCenter, Mountain View, California

Rebecca Craig, RN, BA, CNOR, CASCCEO, Harmony Surgery Center, FortCollins, Colorado and MCR Surgery Cen-ter, Loveland, Colorado

Stephanie Ellis, RN, CPCEllis Medical Consulting, IncBrentwood, Tennessee

Rosemary Lambie, RN, MEd, CNORNurse administrator, SurgiCenter of Balti-more, Owings Mills, Maryland

LeeAnn PuckettMaterials manager, Evansville SurgeryCenter, Evansville, Indiana

Donna DeFazio Quinn, RN, BSN, MBA,CPAN, CAPADirector, Orthopaedic Surgery CenterConcord, New Hampshire

Ambulatory Surgery Advisory Board

“

“Effect felt on basic services.


ing the number of staff,” saysKuznets. “It’s more that they areredistributing hours and keepingsalaries where they are.”

Reports on changes in the num-ber of RN staff over the past 12months varied widely, from -14 to+ 35, with a median of 0.

A number of centers com-mented that they were reducingstaff hours and freezing hiring andpay.

Some said their benefit costs arerising, perhaps because staff mem-bers are adding spouses who havelost their jobs or insurance.

Some add staffNot everyone was tightening up.

One ASC had added 30 RNs overthe past year. The facility was fo-cused mostly in orthopedics, podia-try, and pain management, which

are paid for by Medicare and work-ers’ compensation, Kuznets notes.

Several other centers that re-ported they were hiring more nurs-ing staff were also performing po-diatry, pain management, and or-thopedic cases.

She says most centers are likelyto follow similar strategies by shift-ing their mix of cases to specialtieswhere more patients are coveredby government payers such asMedicare and workers’ comp.

How are ASCs adjusting?Some centers are going after

more volume, with 28% reportingthey have stepped up their market-ing efforts in the past year. But al-most none (91%) said they havelowered their prices in response tothe economy.

Perhaps because of the greaternumbers of patients who must payfor more of their care out of pocket,40% of centers said they have in-creased their collection practices,while only 12% have reduced theseefforts.

Kuznets says the institute plansto repeat the survey in 6 months. �

Referencehttp.www.aaahc.org/web/dynam-

icpage.aspx?webcode=aaahc_iqi

AmbulatorySurgery Centers

Hardest hitspecialties

Percentage of facilities report-ing declines:

• Cosmetic surgery (76%)

• General plastic surgery (73%)

• General surgery (72%)

• Vascular surgery (71%)

• Podiatry (68%)

• ENT (67%)

• Pain management (66%)

• Gastroenterology (66%)

• Pediatrics (65%)

• Urology (65%)

• Orthopedics (64%)

• Obstetrics/gynecology (63%)

• Ophthalmology (62%)

Source: AAAHC Institute.

Change in volume inpast 12 months


Minus 30%or more

5%Minus

20%-30% 6%

Minus0-20%

50%

Nochange

27%

Increase12%“

“Some are going after

more volume.

Are elective proceduresdecreasing faster thannonelective procedures?


Don’tknow14%

No29%

Yes57%

Test-drive the new digital OR Manager atwww.ormanager.com.

It’s included with the SuperSubscriber subscription. You canupgrade to a Super Subscription

by calling 800-442-9918.



Electronic commerce, slow tocome to hospitals, has beeneven slower to reach ambula-

tory surgery centers (ASCs). Part ofthe reason is that large, distributor-hosted ordering systems were im-practical for small clients such asASCs. Even most Internet-basedsystems, now in common use,were designed for high-volumetransactions.

That is changing. In January, Cardinal Health,

Dublin, Ohio, joined a growingnumber of distributors supportinga software package called Source-Plus Purchase Connection (PCX),which provides order managementand supply chain forecastingthrough an electronic data inter-change (EDI) connection using aweb portal. Three other distribu-tors currently link to PCX: MedlineIndustries, Mundelein, Illinois;McKesson Corporation, San Fran-cisco; and Blue Medical, Jack-sonville, Florida.

SourcePlus was designed specif-ically for ASCs by SourceMedical,Wallingford, Connecticut.

The system allows users to sub-mit supply orders to participatingvendors and to have a single com-puter-based record of their order-ing, receiving, and spending. Ven-dors do not need to make anymodifications in their own systemsto work with it.

Using SourceMedical’s softwareand a distributor’s ordering sys-tem, SourcePlus also gives surgerycenter customers rapid order con-firmations and price updates. Cus-tomers pay a monthly subscriptionfee for access to the web portal.

The company recently intro-duced an advanced version thatcoordinates just-in-time (JIT) distri-bution and another that posts pay-ments electronically to other busi-ness systems.

Choice expands Purchasing is only one ASC

function for which automationtechnology is becoming available.

Since the beginning of 2009, thechoice of ASC-dedicated systemshas expanded, often as a result ofjoint ventures between SourceMed-ical and smaller companies seekingaccess to its customer base of about2,250 ASCs and 65 surgical hospi-tals. According to president andchief operating officer Scott Palmer,“Because we have by far the great-est market share, we get to pick thebest companies to partner with.”

New products include OneMedical Passport, an online patientregistration system developed byMedical Web Technologies (relatedarticle, p 11); AutoPost, the pay-ment system, from ZirMed; Busi-ness Intelligence, a reporting sys-tem used by multi-facility ASCs,created by MediBis; Edge Survey, aphysician satisfaction measurefrom CTQ Solutions; and Source-Plus Elite, the JIT version, devel-

oped with IOS Corporation.

Core productsOn its own, SourceMedical mar-

kets 3 “core” products: billing,scheduling, and registration sys-tems. All were developed by com-panies SourceMedical acquired.Now, Palmer says, the company isoverhauling those systems andmaking them compatible with ad-vanced technology and changingregulations.

For example, the company’selectronic health record (EHR) is anoption that can be plugged into ex-isting core systems. The next ver-sion, he says, will be embedded inthose systems and automaticallyupdated with financial and clinicalinformation.

SourceMedical is one of many au-tomation vendors an ASC may con-sider. The large software companiessuch as Lawson, PeopleSoft, andMcKesson have hospital systemswith multiple components, such asmaterials management, financial,and clinical, that a large ASC mightbe able to afford and use.

Some distributors provide hard-ware to set up direct e-commerceordering and payment but only forproducts that distributor sells.

At the other end of the scale,smaller companies offer systemsdesigned for physician practices.

The catch, say experts, is thatthose systems are not designed tomeet the specific needs of ASCswith their focus on high surgicalvolumes, small staff, and cost con-tainment.

Software “timeshare”? Mike Cummins, senior vice

Automation for ASCs picking up speed

“

“E-commerce is expanding

for ASCs.


president and chief information of-ficer of the hospital alliance VHA,Irving, Texas, who has watched theevolution of e-commerce and elec-tronic data processing at hospitalsfor the past decade, believes ASCsmay be better off with the big com-panies but under agreements thatallow them to avoid major invest-ments.

“They run on a much thinnershoestring in terms of profit,” hesays of ASCs. “If you’re small, youcan’t afford Lawson. However, youdon’t have to buy a whole system.You can go to software suppliersand in effect lease time on a server.Lawson or PeopleSoft [among oth-ers] do that.”

In fact, Cummins says, thatmodel may be the trend for ASCautomation.

Trends“There are 2 things I think will

happen,” he says. “First, I see anevolving group of small companiesthat will try to service [ASCs].Most will be software ASP (appli-cation service providers, or soft-ware accessed online) services.

“Second, we will see ASCs andeven hospitals using a model thatwas discarded in the past. Theywill go back to software services,integration, and fewer data centerswithin the organization to avoidthe cost of maintenance and staff.”

The rapid pace of technologyadvancement will only make the“rent” option more attractive,Cummins notes.

Most hospitals buy equipmentand software, which they mustmaintain, upgrade, and integratewith other systems. Cummins pre-dicts many hospitals will return tothe days when they let a vendor

provide and maintain the system inreturn for a monthly lease payment.

“What I’m seeing is, hospitalsare not interested in owning a sys-tem,” he says. “That allows themnot to use capital. They pay for ac-cess to the system owned by some-one else, the big software company,like a time share.” Reliability andsecurity are the vendor’s responsi-bility, he adds.

“It depends on your philoso-phy: Do you buy and own or payas you go?”

He believes they will even pre-fer this model to new web-basedsystems. “A web system can be ashard to talk to as an owned system.They must conform to standards,but not all do.”

A different pathThe “time-share” model would

seem ideal for ASCs. But the recentexpansion of products custom-made for ASCs may set some on adifferent path.

Stephen Punzak, MD, CEO ofMedical Web Technologies, Scituate,Massachusetts, notes about 45% ofthe ASC market has already in-vested in SourceMedical products.

The new systems will include allof the financial, communication,and clinical functions, he says, butwill be built around the EHR. “Anelectronic health record system willbe the key to bringing together

technology and workflow toachieve these results.”

For SourceMedical clients, theASC-specific product will be theVision series of upgraded systemsthat will automatically transfernew data to an embedded EHR.

Palmer maintains ASCs needdedicated products because oftheir purpose and structure.

“By its very mission,” he says,“an ASC is a lean facility, focusedon quality, convenience, and lowcost. If you look at that model, canyou put in a hospital system? No,because it doesn’t support beinglean.”

Unlike hospitals, with manyfunctional departments, ASCsneed a unified system, he explains.“There are no modules. You buythe whole system, and you don’tneed an IT department; it is run bya nurse administrator, typically.”

The cost of such an integratedsystem is about $40,000, Palmersays, and adding an EHR compo-nent currently adds $40,000 to thecost.

Virtual procedure traysOne of SourceMedical’s new

products aids sterilization record-keeping. Currently, sterilizers printout data tapes that must be re-viewed and stored. The new In-strument eManager system, part ofthe company’s AdvantX series, fol-lows the process from receivingused instruments from the OR, intothe sterilizer, through preparingnew trays for the next procedure. Itconnects with the sterilizer and cre-ates an electronic report of steril-ization results. It shows a “virtualtray” on the screen, so the technol-ogist can see which instruments



“

“Do you buy or pay as you go?


are needed in assembling the ac-tual tray.

“It’s harder for the tech to makea mistake,” Palmer notes. “Havinga picture is a big benefit. There’s atraining effect and no more track-ing of sterilizer tapes.”

Conditions convergingConditions are converging to

make automation almost inevitable.The American Recovery and Rein-vestment Act of 2009 (the so-calledstimulus package) makes technol-ogy use, especially EHRs, a priorityin the effort to improve health carequality (related article, p 1).

Even without the new rules, DrPunzak says there are good eco-nomic reasons to choose electronicprocessing.

“The economy is going to causesurgical facilities to review more

closely how they can maximize theirinvestment dollars and take advan-tage of technologies that willstreamline efficiencies and reducecosts,” he notes.

Besides, Palmer adds, physiciansappreciate the convenience as wellas cost-effectiveness of automation.“There is going to be increasingpressure on margins. How do youcombat that? With good informationand technology.” �

ElectronicContinued from page 29

Share yoursuccess!

Has your ambulatory surgerycenter made major strides?Have you improved care or

found ways to be moreefficient? Share your success

with your colleagues.Contact Pat Patterson, editor,

for a possible interview [email protected]

Consumer groupcites progress onsurgical infections

Hospitals have made progress inpreventing surgical infections, buttoo many patients fail to get the rightcare, according to a new ConsumersUnion report.

Analyzing data from the govern-ment’s Hospital Compare website,the group estimated that for 2007-2008: • 90.8% of patients received an an-

tibiotic within 1 hour beforesurgery

• 95.4% received the appropriate an-tibiotic

• 87.1% had antibiotics stoppedwithin 24 hours after surgery.The report shows how hospitals

are performing by state. �—www.stophospitalinfections.org/

infection_prevention/

REVIEWpeer Competency for Safe Patient

Care During Operative and Invasive Procedures

A New Perioperative Textbook Published by CCI

How do you feel this textbook will assist institutions with their perioperativeeducation goals?“This book is ideal to be incorporated into any safety, standards or quality class, especially at the graduate level. It can also be easily incorporated into any surgical services department. The organizational focus of the book lends itself to looking at the patient from a systems ap-proach as they proceed through the Perioperative milieu. This should allow the Perioper-ative Educator to tailor a plan for individuals and meet both the nurse and the organization’s needs. As a reference book the Perioperative community will be able to support educational offerings with evidence and rationales that will give validity to surgical nursing interventions.”

How can this textbook benefit perioperative professionals preparing for the CNOR® certification?“This book would be an ideal companion book to be used with AORN Standards and Recom-mended Practices to provide a comprehensive data base to prepare for the CNOR® certification. The Perioperative nurse with two years of experience will be able to take the knowledge in this book and synthesize it into practice type situations. This will allow the nurse to prepare for ap-plication-based questions that are important in assessing not only knowledge but competency.”

How does this textbook compare to similar textbooks already in the market?“The safety focus of this textbook is definitely what separates it from its comparative counterparts. The Perioperative systems based approach starts by taking an upper-level view of the surgi-cal environment. The bird’s-eye view allows us to examine the system and breaks the situation down into Microsystems all the while keeping patient safety in the forefront. Then the book leads us into specialty scenarios that are similar to the organization of other texts. I especially like the combination of graphics and photos to support the information that is provided in text format.”

Who would you recommend this book to and why?“I would and have recommended this book to be utilized at many different levels of Perioperative education. Novice nurses that are gaining Perioperative knowledge will be able to utilize this text-book to provide them with a strong foundation of Perioperative skills. Nurses that have spent at least two years refining their skills will be able to take this text and utilize it to gain surgical knowledge and synthesize it to allow them to be suc-cessful with knowledge in application-based assessment techniques that are incorporated in both the CNOR® and CRNFA® assessments.”

Theodore J. Walker, RN, BSN, MSN, CNOR®, ACNS, BC Major, USAF, NC is a Perioperative Clinical Nurse Specialist with the Mike O’Callaghan Federal Hospital in Las Vegas, Nevada. He has been a perioperative nurse for 15 years.

QAQAQAQA

For information on how to purchase Competency for Safe Patient Care During Operative and Invasive Procedures, visit the CCI website at www.cc-institute.org/land_patientCare_ORM.aspx. Or call 888.257.2667.

Reviewed by: Theodore J. Walker, RN, BSN, MSN, CNOR®, ACNS, BC Major, USAF, NC

A D V E R T I S E M E N T


P O Box 5303Santa Fe, NM 87502-5303


The monthly publication for OR decision makers Periodicals

At a Glance

Economic crisis takes tollon patients, hospitals

Nearly half of 1,078 hospitals re-sponding to a survey by the Amer-ican Hospital Association releasedApril 27, 2009, have cut staff, and 9in 10 have made cutbacks to ad-dress economic challenges. High-lights:• 59% have seen a decline in elec-

tive procedures, with 18% see-ing a significant decline.

• 65% have seen a decrease intotal margins in 2009 over 2008,with 39% reporting a significantdecrease.

• Hospital employment is nolonger growing.

• The number of mass layoffs forhospitals in February, at 23, wasdouble the 12 in February 2008.More than 40% expected losses in

the first quarter, up from 26% for thefirst quarter of 2008. Some 80% re-ported cutting capital spending forfacilities upgrades and technology.

—www.aha.org/aha/content/2009/pdf/090427econcrisisreport.pdf

Meta-analysis:Supplemental oxygenlowers SSI rate

Perioperative supplementaloxygen has a significant effect onthe prevention of surgical site in-

fections (SSIs), finds a meta-analy-sis in the April Archives of Surgery.The analysis included 5 random-ized, controlled studies involving3,001 patients.

The data showed a 12% infec-tion rate in the control group and a9% infection rate in the supple-mental oxygen group, for a relativerisk reduction of 25% and an ab-solute risk reduction of 3%. Thebenefit was greater in colorectalprocedures.

—Qadan M, Akca O, Mahad S S,et al. Arch Surg. 2009;144:359-366.

http://archsurg.ama-assn.org

Bariatric surgery outcomesno better for centers ofexcellence

Designation as a bariatricsurgery center of excellence doesnot ensure better patient outcomesnor does annual procedure vol-ume, according to a report in theApril Archives of Surgery.

Researchers compared out-comes of 19,363 patients who hadbariatric surgery in 253 hospitals.About 28% had the procedures atcenters of excellence. Outcomeswere equivalent at centers of excel-lence and hospitals without thisdesignation. The average cost atcenters of excellence was $11,527,

compared with $10,984 at otherhospitals.

Since 2006, Medicare has paidfor bariatric surgery only at centersof excellence.

—Livingston E H. Arch Surg2009;144:319-325.

http://archsurg.ama-assn.org

Study backselectrophysiologistsimplanting cardioverterdefibrillators

Patients who have cardioverterdefibrillators implanted by cardiol-ogists trained in electrophysiologyhave fewer serious complicationsthan patients who have the devicesimplanted by other cardiologists,thoracic surgeons, or other special-ists, according to a study in theApril 22/29 JAMA.

A review of more than 110,000patients who received defibrillatorsfound the rate of heart attacks andinternal bleeding during implantwas lowest (1.3%) when the proce-dure was performed by an electro-physiologist. The highest rate of se-rious complications (2.5%) oc-curred when the implant was per-formed by thoracic surgeons. �

—Curtis J P, Luebbert J J, Wang Y,et al. JAMA. 2009;30:1661-1670.

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