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The most common cause of endophthamitis is gram positive bacteria with coagulase negative staph being the majority of cases. The most likely source of this is the eyelids, eyelashes or conjunctiva. Patients at higher risk for this include patients with blepharitis. They should be instructed to apply warm compresses and perform lid scrubs at least twice daily for 2 weeks prior to surgery. When draping, the eyelashes should be completely covered to minimize contamination. Even though there is lack of evidence that the use of perioperative topical antibiotics prevents or decreases the chance of the endophthalmitis, it has become a common performed measure. Antibiotics such as Zymaxid, Vigamox and Moxeza are among those commonly used because of their broad-spectrum coverage. It has become preferred to use self-sealing corneal incision instead of a sutures incision, there is no evidence to support this practice but it has also become widely accepted. Post-op antibiotic injections have become controversial. There are many studies that have proven it both beneficial and not beneficial in the past years. However, in a recent ESCRS study, cefuroxime was injected intracamerally at the end of the case. There was a five to six fold increase in endophthamitis when not used.

Source: Cataract and Refractive Surgery Today

Victor Chang MD and Terry Kim MD

• Right patient
  
• Right medication
  
• Right dose
  
• Right time
  
• Right route
  
• Right indication
  
• Right documentation
  

• Laryngoscope blades in both Miller and Macintosh types and a full range of sizes.
  
• Tracheal tubes and guides. Flexible-tipped tubes, available in multiple sizes. Guides such as stylets.
  
• Laryngeal masks airways, available in sizes to fit pediatric through adult.
  
• Visualization instruments. Fiberoptic bronchoscopes have become a rising trend in ASC’s.
  
• Invasive access. If all else fails a retrograde intubation set or a cricothyrotomy kit can provide ventilation in an emergency situation.
• End tidal CO2 detector- either as a handheld or part of your anesthesia monitoring equipment is required.

Hand Hygiene Pledge Poster: Make a poster highlighting your facilities commitment to hand hygiene. Take pictures of staff performing hand hygiene  and be sure to include MD’s and business office staff then have each person sign their photo. Patient's love to see the staff actively committed to their health and safety.

Idea from Outpatient Surgery Magazine 

• Remind patients several times about them. It's proven the more you tell people about a survey the more likely they are to complete the survey. Maybe mention it in the post op phone call or give information about it in the pre-op packet.
• Include pre-paid envelopes or use a post card with postage already paid.
• Encourage completion before they leave. 

All disinfectant cleaners must be registered with the EPA. If the cleaner/disinfectant is EPA registered you will know because there will be an EPA number on the product label. The label should also list which microorganisms it kills. Some other questions that should be answered on the label:

How should the product be applied to the surface or equipment it is cleaning?

For what length of time must the product have contact with the surface that it is cleaning?

Should the surface be cleaned first to remove debris before disinfecting?

What can the product be used on?

Does it need to be diluted?

What precautions must be taken by healthcare personnel when using this product?

All personnel using your cleaning and disinfectant products should be aware of the manufacturers instructions for use and use them accordingly.

Keep cleaning and disinfectant MSDS sheets on these products.

05-10-2011Outpatient Surgery Magazine  Take the skin prep quiz.....

2. Which surgical skin antisepsis is recommended by the CDC, TJC and AORN?

3. it’s important to allow chlorahexadine to dry before making an incision because_______?

4. If the ophthalmic patient reports and allergy to iodine what is a suitable alternative?

5. Which prepping agent has the longest residual activity?

7. Is chlorahexadine suited for use on open wounds?

Yes, but if a patient comes in contact with the eye dropper it must be discarded. Be sure you have a protocol in place for this. Your staff must also be performing hand hygiene according to nationally recognized guidelines when instilling eye drops.

How long can you use multi dose eye drops?

As with every multiple dose medication it must be dated with an opening date and an expiration date of 28 days after the open date. 

Eye Prep how long and what kind?

You must allow the prep to dry ALWAYS, NO MATTER WHAT. Iodine needs a contact/dry time of at least 2 minutes for it to be effective. Read the instructions on you iodine for proof and create a policy. You will need an alternative to iodine for your skin prep. Work with your medical staff to find one...see previous post, ask colleagues.

Flashing Instruments: What are the Rules?

Flashing must be the exception not the rule. It must be done in a container so that when it is transported to the OR that container is closed. It must be logged every time you flash. CMS has clarified the rules on flashing and short cycle steam sterilization see our infection control page.

05-16-2011   OR Nurse Tips for Hand Hygiene Compliance

Measure, then act- Gather data and then act on it. Anytime you are evaluating something you need to measure and collect the data and then make an action plan (QI Study). 

• Get buy in from the top down- Make sure your administrator and physicians are involved. With them involved it will be easier to get compliance across the board.
• Work on the barriers- If you identify staff members that are repeat offenders, counsel them. There is a good chance there is a reason and you should get to the bottom of it. 
• Put gel where it is needed- Look for places where you may be lacking these. Hand hygiene needs to be made easy for the staff, so make it easier. Put it by the patient beds, doorways, RN station, charting areas, etc.
• Educate patients- Place hand gel in areas where the patient can use them. Educate patients on the importance of cleaning their hands and ask them to do it.

• Prolonged hospital stay,
• Exposure to an ICU,
• Having been on a ventilator,
• Colonization pressure (amount of people colonized around you),
• Exposure to antimicrobial agents,
• Having undergone surgery or an invasive procedure recently.

• Emphasis on hand hygiene,
• Placing patients who are colonized in contact precautions,
• Performing active surveillance,
• Culturing hands of employees,
• Performing strict environmental cleaning according to the CDC standards,
• Holding regular meetings with staff to educate and update them on caring for these type of patients and infection risks. 

05-18-2011 OR Today - Better Together: Team Building

You should pair employees to work together who are like-minded and will complement each other in their strengths and weaknesses. When assigning jobs or tasks to people be sure to take into account their strengths so that they will succeed in their task. This will help them build confidence in themselves and hopefully allow them to excel in their position and as part of the team in your facility. Be sure that your team has a leader who is good at leading. With the right leader you should expect to see your team increase in their functionality and autonomy.

Autonomy fosters creativity! This is only part of what drives success, you must also create and foster a collaborative environment that not only allows but also encourages input from all team members. With input, you must be sure you always give feedback, employees and team members are looking for it and without it you will hinder the very environment you are trying to create. When you have a goal in mind you must remember to make people feel like they are involved and engaged by assuring them they belong and are a vital part of the team. The best way to do this is by positive reinforcement or feedback.

Set a vision and develop a path for your team that can change along the way to accommodate the future circumstances. Team members should be able to cover for each other in a sense that a lot of people in a team can do all the respective jobs in that team. This will create a sense of camaraderie and thus allow for great team outcomes. 

05-24-2011 Outpatient Surgery Magazine - 8 Trocar Safety Tips

• Position patients so important anatomical structures are not in the trocars path.
• Make sure the incision is large enough to accommodate the trocars shield.
• Only the surgeon should arm the trocar.
• Insert trocar slowly and steadily.
• Avoid gripping trocar too tightly.
• Stop pushing and withdraw if unusual resistance is felt.
• Blood pressure loss could be an indication of vascular injury. 
• If operating surgeon is unfamiliar with management of the vascular injuries be sure to have a physician who is nearby. 

Wear Gowns and Gloves: For patients who are suspected or known to have MRSA, AORN recommends placing that patient in standard precautions. It is also recommended that you place the patient in a private room. However, this is not feasible in many facilities and with proper hand hygiene is may not be necessary. Have a policy in place in regards to dealing with this patient population and reasoning on why you are not enacting contact precautions.

Clean Surfaces: MRSA can survive for weeks to months on surfaces that is why it is so important to clean surfaces. You must use an EPA approved disinfectant and follow the directions for use. Take note of the kill/exposure time and what antibacterial coverage it has. As far as disinfection and sterilization of your instruments it should be done the same way. This process should already be one that sterilizes or kills everything.

Tell Patients to take pre-op CHG showers: Consider implementing this policy, especially for open abdominal and ortho cases. It may also be a good idea to instruct all patients to shower the day of surgery this can help cut down on the amount of staph the patient is carrying on them. 

• Begin conversation with “I am confused” or “I have a problem”.
• Stick to the facts and do not let your opinion pollute what you are trying to say.
• Listen and encourage the person to respond by saying “tell me about it”.
• Nodding and repeating what the person said convinces the speaker you were listening.
• Note your body language.  If someone is hesitant to communicate try uncrossing your arms, leaning back in your chair and opening up.
• If the person is not listening to or taking you seriously, sit straight, close arms and lean forward.
• Close conversation in a positive expectation of change.

• Keep natural fingernails short and avoid wearing finger nail polish or artificial nails. (AORN standard is no artificial nails in the OR)
• Remove watches, bracelet and rings before washing hands. These items should NOT be worn in the OR. 
• Use only hand lotion that has been approved for use in the OR environment and facility provided. Your infection preventionist with a team should evaluate and review all hand hygiene products, including lotions.  
• Use a standard procedure for hand washing and have a policy in place for how and when it should be performed. 
• Wash hands between every surgical procedure.
• Follow all DFU's for all hand hygiene products used in your facility.
• Healthcare workers should receive education and competency education on surgical hand hygiene products. Document this.
• When performing surgical scrub use a sponge instead of a brush. 

Implement consumer-driven healthcare plans with Health Savings Accounts: Opinions on these are mixed however these allow you to pay routine healthcare expenses directly, while large medical expenses are protected through a high deductible policy. The employee can contribute to this savings account and funds roll over year to year. These allow employers to reimburse medical expenses by participating employees.
Implement a wellness program with Health Risk Assessment: If implemented correctly this can impact your benefit premiums positively. HRAs help to assess the health status of your employees, estimate the level  of health risk, provide risk calculation's and provide feedback on motivating behavior change.

1. Circulating Nurse-continues to help the surgical team and anesthesiologist.
2. Dantrolene Nurse-takes charge of the dilution of Dantrolene.
3. Medication Nurse-focuses on medication needed to treat the symptoms associated with MH; hyperkalemia, metabolic acidosis, dysrhythmias.
4. Cooling Nurse-monitors pt's temperature and implements the cooling process as needed.

Facilities that use the Steris System 1 table top liquid chemical sterilizer now have an additional 6 months to make the federally mandated transition to an alternative reprocessing method. Steris will continue to support customers who have the SS1 trough Feb. 12, 2012. Steris requested an extension of the date because of the FDA's scrutiny and review of the System 1E biological indicator submission.  System 1E is marked as the successor of the SS1 and has been under review regarding the efficiency of its biological indicators. 

Start with your job description, this should be competency based. This allows you to set the standard of knowledge, skills, and behaviors you expect. This becomes a sort of contract with your employee, detailing your expectations. Also with your annual performance appraisal's you should be verifying their competency in all areas of their job description. Focus on daily, high-risk, high-volume procedures and be sure to include regulatory requirements as well. See the Policy and Procedure page for an example of a job description.  

Second, you need to make sure that your employees are actually performing their competencies effectively. Observe your employees in action. If you note that they are not carrying out there competencies effectively then you must take action. 

• Provide staff with easy to understand and evidenced based examples; for example the AAMI standards. 
• Require return demonstration.
• Document in inservice log.
• Annual competency testing of not frequently performed tasks. 
• Create special competency for new devices/equipment.

The Association for the Advancement of Medical Instrumentation recommends that all personal performing sterile processing activities be certified (The Certified Ambulatory Surgery Sterile Processing Technician) as a condition for employment.

Treating patients effectively with multiple eye drops prior to an ophthalmic procedure can pose several difficulties.

It is a common practice to administer antibiotics, steroids, anesthetics, mydriatics, cycloplegics and anti-inflammatory agents prior to a procedure. However,

“Dilution of the drug by the tears is immediate... and [since] the conjunctival cul-de-sac can hold a temporary maximum of 20 to 30 microliters, up to 50% of the dose is lost on installation. Reflex tearing results from topical instillation and results in increased dilution of the drug. Administration of a second drop before the tear volume returns to normal just dilutes both drops, and decreases the concentration of drug at the site of absorption. Application of single drops at five to ten minute intervals provides for optimal drug absorption.” (Reynolds A, 1993)

For multiple medications, in multiple patients, the proper dosing of these drops can add up to hundreds of drops administered over a long period of time. Of course, time constraints in most practice settings don’t allow this. Often one drop will follow another, flushing and diluting the previous dose, requiring additional doses and delayed effects. Most of the medications simply end up on the patient’s pillow or systemically absorbed through the sinuses. And the potential for missed or inaccurate doses compounds the problem.

Alternatively, some practices have turned to a mixture or “slurry” of all of the medications, so that one drop of the mixture delivers all the drugs. Or does it? While it may deliver all of the drugs desired, during the mixing process, each drug is diluted from 3 to 25 times by the other solutions, resulting in significantly sub-therapeutic dosing. That means it will now take 25 drops of the mixture to deliver the standard dose of one, undiluted antibiotic drop.

To illustrate, if a practitioner were to mix 5ml of a 1% solution with 5ml of a different 1% solution, the resulting mixture would be 10ml total, but each drug is now 1/2 of the original concentration. It will now take two drops to deliver the same dose as one drop did before dilution. Additional drugs and volumes amplify this effect.

In addition, the mixture is made in a fashion that does not meet new United States Pharmacopeia (USP) Chapter <797> standards for compounded sterile medications. At a minimum, the mixture would meet the definition of medium risk compounding, and may be considered high risk. (The United States Pharmacopeial Convention, Inc., 2008). This can pose accreditation and other issues for the facility. Either way, staff time is taxed and opportunities for missed, contaminated, wasted or inaccurate dosing arise.Many clinics have turned to dedicated compounding pharmacies with the equipment and staff to make sterile medications under strict USP standards. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) states, “You either have to upgrade your facilities and procedures for handling high-risk preparations, or you must outsource them to a pharmacy that has the required facilities and personnel.” (International Journal of Pharmaceutical Compounding, January/February 2005). There are several other advantages.

First and most importantly, one drop of a compounded pre-op formula can deliver all medications at their standard therapeutic concentration. In other words, the antibiotic (and other drugs) is full strength, not 1/25th of the therapeutic dose. This can significantly reduce administration time and waste.

Second, the compounded pre-op drop can be prepared with increased viscosity to greatly improve tissue contact time: medications stay in the eye, not on the cheek or in the nasal sinuses where systemic absorption can occur.

Finally, these combination drops are formulated in a sterile environment by trained personnel that adhere to USP and other standards and regulations regarding the preparation of sterile medication. Your assurance of the highest standards is a PCAB-accredited compounding pharmacy. Similar to JCAHO for hospitals, the Pharmacy Compounding Accreditation Board is your promise of the highest quality in compounding pharmacy. PCAB accreditation is supported by the USP, the American Medical Association and every major pharmacy association.

Obviously there are countless combinations in varying concentrations of antibiotics, steroids, anesthetics, mydriatics, cycloplegics and anti-inflammatory agents that can be formulated into a combination drop. O'Brien pharmacy has a formula that includes therapeutic concentrations of ciprofloxacin, cyclopentolate, phenylephrine, tropicamide, ketorolac and lidocaine. While other combinations are available, a standard formula keeps the solution cost-effective and is well- accepted.

Some newer commercial antibiotic drops like Vigamox or Zymar remain under patent and are not available for compounding. While many doctors prefer our formula over other options, Vigamox or Zymar can still be instilled prior to the combination drop.

Thus, one drop delivers all drugs at therapeutic concentrations in a sterile, aqueous, preserved viscous vehicle – addressing most of the issues surrounding pre-treatment for ophthalmic procedures.

Eric Everett, RPh, FIACP O’Brien Pharmacy Mission, Kansas www.obrienrx.com

Bibliography

Reynolds L, C. R. (1993). Extemporaneous Ophthalmic Preparations. Vancouver, WA: Applied Therapeutics. The United States Pharmacopeial Convention, Inc. (2008). United States Pharmacopeia. Rockville, MD: USP.

• Read and React in the OR-Always be one or two steps ahead of the surgeon. If you can read his body language do it and have the supplies available.
• Use colored tape to mark the OR floor where the wheels of the bed and the foot pedals should be placed.
• Wheel the patient into the room on the bed and invest in eye beds. You can spend an extra 2-3 min positioning the pt on a bed in the OR. Have all of this done in pre-op on the eye bed.
• Don't let you Docs stand idle- you never want your surgeon to have to wait for you. With all the new regulations accomplishing this can be difficult. But, while the surgeon is seeing the pt in pre-op and signing the discharge note in PACU, the pre-op RN is positioning the pt and the OR staff is turning the room over. With disinfectant kill times at a low of 3 min. the surgeon should be entering the room around the same time the pt is and the scrub tech should be ready to go.
• Appoint a cataract team with the same people and use the same team throughout the day. This will speed the process up since the staff is familiar and clear on what their role is. 
• Post a procedure list on the wall in the OR as a manual or instructions sheet for the day. Cross out cases as you complete them and use this as a communication tool that can be used by the entire surgical team.

Start with your job description, this should be competency based. This allows you to set the standard of knowledge, skills, and behaviors you expect. This becomes a sort of contract with your employee, detailing your expectations. Also with your annual performance appraisal's you should be verifying their competency in all areas of their job description. Focus on daily, high-risk, high-volume procedures and be sure to include regulatory requirements as well. See the Policy and Procedure page for an example of a job description.  

• Require return demonstration.
• Document in in-service log.
• Annual competency testing of not frequently performed tasks. 
• Create special competency for new devices/equipment.

The Association for the Advancement of Medical Instrumentation recommends that all personal performing sterile processing activities be certified (The Certified Ambulatory Surgery Sterile Processing Technician) as a condition for employment. 

The much anticipated regulations from Medicare which are scheduled to begin operation in January 2012 have been drafted. The health reform law created a Medicare Accountable Care Organization (ACO) program that will allow providers to voluntarily form ACO's to manage the care of Medicare patients and share in any savings that the ACO generates. The ASC association has begun to analyze the 429 pages of regulations and will soon provide more information on the effect these regulations will have on ASCs. 

Copy of the Medicare Regulations

• Make sure you are a member of the Ambulatory Care Association. Then be involved, volunteer. The website can be accessed on the Professional Organization Page-easy to join, easy to volunteer.
  Encourage other ASC's to become members. This is great way to network with facilities that may be near you.
• Join your states ASC association. More info on our home page.
• Sign up to receive the "ASC Championships Newsletter" This newsletter delivers up to date information about state and federal law making. champions@ascassociation.org.
• Complete and return surveys you get from ASCA...when you contribute you give the ASCA the data they need to fight for ASC's on the government level.
• Sponsor the National ASC Open House event. This year it is on August 11. Consider sponsoring an event and inviting your policy makers and local media. (Watch for more to come on this in the future).
• Attend the annual ASCA's conference. It is in Florida, this May.

The New automatic reprocessing systems are better than ever. If you are in the market for one here is what you can expect to see. Fewer manual cleaning steps-The reprocessor can handle all the steps of manual cleaning, high level disinfection and documentation. The automatic reprocessor also check's for leaks. It is very different then what most sterile processing staff are use to.   

Shorter cycles: The automatic process has brought reprocessing time from 50 minutes to 30 minutes and can do 2 at a time! 

Better Documentation: The reprocessor will do all the documentation for you. So it will be standardized and have exactly what you need to prove sterilization. 

Smart Cabinets: Cabinets are no longer just a place where you store your scopes; they can track where they are as well. This is especially helpful for larger facilities. 

1. Trust- Your manager, surgeons and staff are smart people with enough common sense to complete their tasks without you micro-managing. Let your staff do their job and take a step back, this will help save your time and the staff stress.
2. Delegate-You might feel the need to tackle every task yourself so everything gets done right. You will discover that there is not enough time in the day to complete all the tasks and you will fall behind and be overwhelmed.  When you delegate and share responsibility you develop trust with your staff members and encourage teamwork. You will also not burn yourself out. 
3. Socialize- Get out from behind your desk at least twice a day. Interact with your staff. It is also a great way to make sure staff is performing at your expectations. 
4. Bond- Interact with your staff, ask them how they are doing and be involved! This will help you become more approachable.
5. Praise- Compliment more than you criticize. 
6. Help- If you notice that something needs to be done, pitch in. Help the aide with the linen. Help turnover the room so a tech can take a break. These little actions will keep you involved and part of the team. It also lets your staff know that you are not above taking the trash out. 
7. Inform- Keep staff informed on any new system, process, medications, cost of supplies and any new equipment. This helps staff not only be well prepared but involved in cost savings. 
8. Listen- It's a valuable tool. Staff will appreciate your time.
9. Relax- When you go on vacation...go! Do not answer e-mails, return phone calls, etc. 
10. Laugh- Look for the right time to share a laugh. Our jobs are stressed enough, so lighten the mood whenever you can.

• Instrument passing: Develop a neutral zone where hands free passing can be done. You can use brightly colored trays, magnetized pads or hard plastic as your neutral zone. 
• When this is not possible, for example during ophthalmic/spine cases, you should be passing instruments in a way that will prevent sharps injuries. So, when passing instruments make sure MD's hand is finished moving and place instrument in MD's hand so as to not cause a sharps injury.    Tissue manipulation: Keep your hands out of the wound during closing. Use retractors or forceps to hold the tissue.
• Make sure all sharps have been isolated. All sharps should be in the same place so that staff is aware where the sharps are during clean up/turnover.   Use needle holders, never your hand to remove a scalpel blade from its handle.
• Lead by example: If you want your staff to implement your policy you also must actively participate and reinforce it. It must be understood that all staff must comply with your policies 100% of the time.