Evaluating Microorganism Levels On X-Ray Aprons And Lead Wearables: The Science Of ATP Testing

How Have Microorganisms and Bioburden Been Measured?

In the previous blog post regarding X-Ray lead aprons, we explored the history of healthcare associated infections or HAIs, and how transmission risks are posed to patients and staff via contaminated “high touch, non-critical surfaces,” including X-Ray aprons and protective lead wearables.  In laying out the content of this blog, I was reminded of the phrases, “things aren’t always as they appear” and “don’t judge a book by its cover.” Is it possible that newer (clean looking) X-Ray aprons can carry a higher level of biological contamination when tested in comparison to older X-Ray aprons (which are dirty looking & smelling)? It is completely possible and plausible due to the concept of bioburden.

What is Bioburden?

Bioburden is defined in numerous medical dictionaries as the number of microorganisms contaminating an object.  So how does one assess for bioburden?  The gold standard for assessing for bacterial/fungal contamination has been to assess for colony forming units or CFUs.  A CFU equals one viable bacterium that has the ability to spread and replicate.

3 Main Ways to Measure CFUs: 

  1. A scientist could dilute the sample and count the bacteria by microscopic examination or through the use of a cell counter.  However, if bacteria are too small or clump together, then this method is problematic.  This method will yield total bacteria counts, both living and dead.
  2. A scientist could use Optical Density (OD) to estimate the number of viable bacteria in a sample.  This is where the scientist measures how cloudy a liquid culture of bacteria is.  While the bacteria are actively growing the liquid culture should continually become more and more cloudy.  Again, this method will yield total bacteria counts, both living and dead.
  3. A scientist could make serial dilutions of a liquid culture and plate out the bacteria in known dilutions until they can count single colonies and extrapolate back to figure out total CFU in a sample. This method only yields viable bacteria totals.

4 Challenges Associated with Bioburden Assessment

Assessing for bioburden (microorganisms) by calculating CFUs is not as easy or straight forward as one might imagine.

  1. The first challenge posed is that one needs to have a lab in which to grow bacteria, and depending on the bacteria one is dealing with there are different governmental regulations to follow.
  2. The second challenge presented is that of time, one needs to have the time and equipment to properly grow the bacteria/fungus.  Different species of bacteria or fungus grow at different rates, for example, culturing of bacteria on plates can take anywhere from overnight to multiple days.
  3. A third and very important challenge is posed by the bacteria and fungus themselves.  They are similar to people in the fact that not all of them grow and thrive under the same conditions.  In lab work, if only one kind of food source is used, one will only be able to assess for bacteria that grow on that particular food source.
  4. Finally, one needs to have a trained technician who knows how to assess which bacteria to grow under the correct conditions and then also how to properly count the bacteria.

While assessing for CFUs has traditionally been viewed as the gold standard for assessing bioburden, and it is vitally important for various microbial studies, it is not a good way to assess bioburden in real time.  It can be complicated.

What is ATP and How is it Evaluated?

What if there was an easier way to determine surface levels of biological contamination?

What if there was an easier way to assess for a molecule that is found only in living cells, both bacterial and human living cells?

There IS an easier way to evaluate for this molecule in real time (by using a simple swab and handheld reader), and it can be used by any hospital staff member as a surrogate for such complicated CFU work.  Let me introduce you to the molecule known as the “molecular workhorse,” called adenosine triphosphate (ATP).

Adenosine Triphosphate (ATP)

ATP is an energy molecule utilized by cells. It is present in humans, animals, plants and microbial cells.  ATP levels rise as a cell is undergoing apoptosis (programed cell death), but is generally consider to be completely degraded within 30 minutes of cell death (1).  This makes ATP a useful marker for the presence of unwanted biological contamination, including organisms that can cause infection and disease.

Okay – Get to the Point!

An increase in biological cells on a surface results in an increase in the amount of ATP present on that surface, thus making ATP an effective marker for the assessment of the hygienic status of an environmental surface. Simply stated, the amount of ATP present on a testing swab is a quantitative measurement of the cleanliness of the surface tested! In fact, ATP cell viability assays were determined to be the fastest, most sensitive, and least prone to artifacts, partially due to a lack of an incubation period (2).  The sensitivity of laboratory cell based ATP cell viability assays can detect fewer than 10 cells per well (2).  This technology has been modified to create a portable, ATP bioluminescence test, using a swab instead of plated cells.  This now allows for a real time assessment of bioburden on site.  These tests have been used to assess bioburden in many healthcare settings, including the ICU (3).  ATP measuring units, called luminometers, are handheld, user friendly, and display the results in seconds. (It doesn’t take a scientist to use an ATP luminometer!) The read out of an ATP bioluminescence test is not in CFUs, but is in relative light units or RLUs.  In the past, some scientists have questioned the validity of using a bioluminescence test instead of assaying for CFU.

Is There a Correlation Between CFUs & RLUs? 

Like most assessments, ATP bioluminescence assays also have limitations, but they are an excellent surrogate that allows the everyday staff member to assess bioburden in real time.  Those new to ATP bioluminescence testing often inquire about a correlation between CFUs and RLUs.  (Most laboratory microbiologists have the capability to perform CFU testing, and are not confined to real time assessment of bioburden.)  The most controlled way to achieve this is to look at different known amounts of CFUs and assess whether or not the RLUs increase accordingly.  That is exactly what Dr. Sciortino’s group did when they assessed three different portable ATP bioluminescence kits for their ability to detect various CFUs of two different HAI relevant bacteria (Staphylococcus aureus and Acinetobacter baumannii) and one strain of fungus (Candida albicans).

What they discovered was there was a linear relationship between bacterial CFUs and RLUs for all three luminescence kits, and for two of the three kits between fungal CFUs and RLUs (1).  Such research validates that the use of ATP luminometers can be used to assess for bioburden on surfaces in real time.  This research, plus Dr. Jaber’s study, in which 25 lead aprons were cultured for CFUs and showed that 21 were colonized with Tinea species (the family of fungus that causes ringworm) and 21 were colonized with Staphylococcus aureus, of which 3 aprons were colonized with MRSA (4), validates the ATP bioluminescence results for X-ray aprons and protective lead wearables.

In fact, these X-ray aprons and protective lead wearables, which are worn throughout many different areas within a healthcare system, including the operating rooms, cath labs, radiology/imaging areas, emergency rooms and beyond are regularly testing with RLU readings in the THOUSANDS to HUNDREDS OF THOUSANDS (5), which is scary. The bottom line is regardless if you are a classically trained microbiologist used to looking at CFUs or a hospital staffer looking at luminometer readouts in RLUs, when surfaces inside an OR or Cath Lab are testing in the hundreds of thousands range, it is a problem!

Is ATP Testing Growing in Use?

Through utilization of ATP luminometer testing systems, companies like Radiological Care Services (Indianapolis) are able to enter a facility’s Cath Lab, OR or Radiology Department and test lead apron inventories on site, providing real time numbers (bioburden levels) in a matter of seconds. An advocate for ATP luminometer testing, Dr. Sciortino even states, “ATP system monitoring may uncover the need for new disinfectant designs that adequately remove hospital surface biofilms, rendering used hospital equipment to its native state whereby a zero reading by ATP monitoring can be achieved” (1).  If you look back at the first blog post, “Contaminated X-Ray Aprons and The Risk of HAIs”, I positioned that “using wipes alone” was insufficient and through the use of ATP testing, Dr. Sciortino could be inferring a similar position.

Looking Ahead…

In the next blog post, we’ll specifically look at the science/methodology behind the use of sanitizing wipes and we’ll further explore the differences between true “cleaning” and “sanitization.” We’ll later examine what the governing bodies, such as AORN, CDC, HFAP and JCAHO state regarding their expectations of such surfaces within healthcare facilities. Understanding the science behind HAIs, testing for biological contaminants on surfaces, biofilms, and the difference between “cleaning” and “sanitization” will help us understand that current healthcare protocols in regards “non-critical, high touch surfaces” need to be changed in order to better protect hospital patients and staff.

About The Author:

Kathleen R. Jones received her BS from Purdue University (West Lafayette) in Biology specializing in Genetics and Microbiology.   After working for five years in Quality Control she then completed her MS at Purdue University in Indianapolis.  Her growing interest in Infectious Diseases lead her to the Uniformed Services University of the Health Sciences where she obtained a Doctorate in Emerging Infectious Diseases.  Kathleen has a passion for progressive sciences and initiatives, and employs her keen understanding of the biofilm formation and elimination processes into her research and work.

Sources:

  1. Sciortino, C. V. and R. A. Giles.  2012. Validation and comparison of three adenosine triphosphate luminometers for monitoring hospital surface sanitization: A Rosetta Stone for adenosine triphosphate testing.  AJIC.  40 (e233-9)
  2. Riss T.L., R.A. Moravec, A. L. Niles, H.A. Benink, T.J. Worzella, L. Minor. Minor, L, editor.  2013,  Cell Vialblity Assays. In: Sittampalam G.S., N.P. Coussens, H. Nelson, et al., editors. Assay Guidance Manual [Internet]. Bethesda (MD): Eli Lilly & Company and the National Center for Advancing Translational Sciences; 2004-. Available from: http://www.ncbi.nlm.nih.gov/books/NBK144065/
  3. Moore, G., D. Smyth, J. Singleton, P. Wilson. 2010. The use of adenosine triphosphate bioluminescence to assess the efficacy of a modified cleaning program implemented within an intensive care setting.  AJIC. 38(8):617-622 DOI: http://dx.doi.org/10.1016/j.ajic.2010.02.011
  4. Jaber, M., M. Harvill, E. Qiao.  2014.  Lead aprons worn by interventional radiologists contain pathogenic organisms including MRSA and tinea species.  Journal of Vascular and Interventional Radiology.  25:3:S99-S100.  DOI: http://dx.doi.org/10.1016/j.jvir.2013.12.279
  5. “Outcomes: What do your numbers look like?” Radiological Care Services. Nov 20, 2014. http://www.radcareservices.com/radiolgical-care-services-outcomes.html

Contaminated X-Ray Aprons And The Risk Of HAIs

Contaminated, Dangerous, and Unacceptable: The Impact of Contaminated X-Ray Aprons and the Risk of Health Care-Associated Infections (HAIs)

Infection Prevention checklists today include many new areas of concern such as contamination in lab coats, neckties, telephones, remote controls, privacy curtains and more. X-ray aprons and protective lead wearables are worn throughout many different areas within a healthcare system, including the operating rooms, cath labs, radiology/imaging areas, emergency rooms and beyond. Clinical studies have proven that X-ray aprons silently carry a number of microorganisms – Dr. Jaber (Wayne State) cultured 25 lead aprons to discover 21 were colonized with Tinea species (the family of fungus that causes ringworm) and 21 were colonized with Staphylococcus aureus, of which 3 aprons were colonized with MRSA (1).  

The Association of periOperative Registered Nurses (AORN) makes cleaning recommendations for items such as kick buckets, stools, patient restraints, keyboards, surgical lights and more; however, lead aprons which are routinely engulfed in sweat, blood, bodily discharge and surgical debris/residue have been consistently overlooked. Healthcare systems can no longer compromise both patient and staff safety through such perilous practices.  (Note – upcoming posts will further explore “current cleaning practices,” as well as cleaning recommendations and guidelines from National Governing Bodies such as the CDC/JCAHO/HFAP and AORN.)

Health Care-Associated Infections

HAIs are the 4th largest killer in the United States, claiming 100,000 American lives each year – more deaths than AIDS, breast cancer and auto accidents combined (2).

Hospitals are meant to be safe havens.  They are meant to be a place of refuge against disease, a place to heal and a place to recover from surgery or injury.  If that is the dream, then the nightmare would be a place in which you end up more ill than you were when you were first admitted!  Unfortunately, that nightmare becomes a reality for many unsuspecting patients and staff members today. One reason for this nightmare is the acquisition of a Health Care Associated-Infection or Hospital Acquired Infection (“nosocomial infection”).

The World Health Organization (WHO) uses a 1995 definition for a Hospital Acquired Infection (HAI):

An infection occurring in a patient in a hospital or other health facility in whom the infection was not present or incubating at the time of admission.  This includes infections acquired in the hospitals but appearing after discharge, and also occupational infections among staff of the facility (3).

HAIs in our Healthcare System

Think about it – it only makes sense that hospital acquired infections would be prevalent in our healthcare systems today.  Hospitals & medical facilities are places that people congregate when they are immunocompromised and/or are sick and in need of some type of care or treatment.

World Health Organization Study

In fact, a WHO study of various hospitals in 14 countries across Europe, Eastern Mediterranean, Southeast Asia and Western Pacific regions in the late 1980s concluded that 8.7% of patients had at least one Hospital Acquired Infection equaling 1.4 million afflicted people at any one time (4-5).

Centers for Disease Control and Prevention Estimate

In the United States alone, the CDC estimates roughly 1.7 million annual hospital-associated infections, from all types of microorganisms including bacteria combined, cause or contribute to 100,000 deaths each year (6). In fact, approximately 1 in 25 hospital patients has a hospital acquired infection at any one time (7). While these statistics are startling and horrifying, sadly they do not paint the complete picture. These statistics are patient specific and do not include the number of healthcare workers and hospital staff who have also acquired Hospital Acquired Infections.

Economic Impact of HAIs

Such infections lead to additional stress, longer hospital stays, lost wages for healthcare providers and higher morbidity and mortality rates overall.  HAIs also have a HUGE economic impact.  In addition to being the 4th largest killer in America, it is estimated Hospital Acquired Infections will cost the healthcare system an additional $30 Billion (2).

Why do HAIs Occur? 

We live in a medically advanced society, so why do Health Care Associated-Infections still run rampant, and what are we doing about them?  That is a good question, but the answer is multifaceted.  The first point to consider is that patients are usually immunocompromised when in need of healthcare services. They are either already ill or they have had a procedure that puts immense stress on their bodies, e.g., a joint replacement, major illness or other surgical procedure or treatment. 

As wonderful as modern medicine is, it is not without risks.  In fact, many diagnostic and/or therapeutic procedures involve the use of a medical device, e.g, catheters, intubation tubing, scopes, etc. These devices and even many “non-critical” surfaces and “high touch objects” such as X-ray aprons and lead wearables can become contaminated when not properly cleaned and sanitized.

Healthcare facilities are a place where sick and immunocompromised patients regularly navigate and patients are often transferred between units/floors.  This allows infectious agents to travel to different areas in a hospital and expose multiple people, including patients, family and staff members.

Infectious Agents

Infectious agents (bacteria, viruses, parasites, and fungi) present their own issues.  There are species that form spores that are resistant to most mechanisms of eradication. Kramer’s group recently performed a meta-analysis of the literature and summarized that most clinically relevant species of viruses could easily survive on dry, inanimate surfaces for between a few HOURS to DAYS and clinically relevant bacterial and fungal species could survive for DAYS to MONTHS (8).  The longer the infectious agent can be found in the environment the greater the chance that it can be passed to a new host.

The Need for New Policies/Protocols

Unfortunately, Health Care-Associated Infections (HAIs) are still a substantial source of morbidity and mortality throughout the healthcare continuum today.  While recent initiatives such as improved hand washing policies have helped that burden, there are additional new policies/protocols with regards to cleaning that need to be implemented in order to address other critical “high touch objects” such as X-ray aprons and lead wearables.

Education and Awareness

Through education and open-mindedness, we can bring awareness to the importance of following the cleaning recommendations of the governing bodies, such as the CDC/JCAHO/AORN and HFAP.  In knowing that infectious agents can still adapt to become drug resistant, antiseptic resistant, and increase their ability to survive in the environment, so, we too must adapt and be open minded to new concepts in our vigilant fight against hospital acquired infections.

Oft-Overlooked: X-Ray Aprons and Lead Wearables

X-ray aprons and lead wearables can no longer be overlooked, and they will need a renewed commitment to servicing. They need to be properly cleaned prior to sanitization efforts, in accordance with the guidelines of the CDC & JCAHO.  In my next blog entry, we’ll dive into the science behind testing X-ray aprons for the presence of microorganisms and examine how these surfaces are measured and evaluated.

SPOILER ALERT – If you think you have an idea of how contaminated such surfaces are inside of our healthcare systems, you will be in for a SURPRISE!

About The Author:

Kathleen R. Jones received her BS from Purdue University (West Lafayette) in Biology specializing in Genetics and Microbiology.   After working for five years in Quality Control she then completed her MS at Purdue University in Indianapolis.  Her growing interest in Infectious Diseases lead her to the Uniformed Services University of the Health Sciences where she obtained a Doctorate in Emerging Infectious Diseases.  Kathleen has a passion for progressive sciences and initiatives, and employs her keen understanding of the biofilm formation and elimination processes into her research and work.

Sources:

  1. Jaber, M., M. Harvill, E. Qiao.  2014.  Lead aprons worn by interventional radiologists contain pathogenic organisms including MRSA and tinea species.  Journal of Vascular and Interventional Radiology.  25:3:S99-S100.  DOI: http://dx.doi.org/10.1016/j.jvir.2013.12.279
  2. “What is RID?” Committee to Reduce Infection Deaths.  n.p.  d.p.  Web.  Nov 7, 2014.  http://www.hospitalinfection.org/objective.shtml
  3. Benenson, AS.  1995.  Control of communicable diseases manual.  16th edition.  Washington, American Public Health Association.
  4. Tikomirov, E.  1987. WHO Programme for the Control of Hospital Infections.  Chemiotherapia. 3:148-151.
  5. Mayon-White, RT, G.  Ducel, T. Kereselidze, E. Tikomirov.  1988.  An internal survey of the prevalence of hospital-acquired infection.  J. Hosp. Infect.  11 (SupplementA): 43-48
  6. Klevens, RM, JR Edwards, CL Richards, TC Horan, RP Gaynes, DA Pollock, DM Cardo.  2007.  Estimating health care-associated infections and deaths in U.S. hospitals, 2002.  Public Health Rep 122:160-166
  7. Magill, SS, JR Edwards, W Bamber, ZG Beldavs, G Dumyati, MA Kainer, R Lynfield, M Maloney, L McAllister-Hollod, J Nadle, SM Ray, DL Thompson, LE Wilson, SK Fridkin.  2014.  Multistate Point-Prevalence Survey of Health Care-Associated Infections.  N Engl J Med 370:1198-1208
  8. Kramer, A., I. Schwebke, and G. Kampf.  2006.  How long do nosocomial pathogens persist on inanimate surfaces? A Systemic Review. BMC Infectious Diseases.  6:130  Doi: 10.1186/1471-2334-6-130

Laser Safety Glasses: The Ugly Truth About Laser Radiation Exposure

Avoiding Eye Damage

In the time that it takes to blink an eye, laser radiation damage to the eye may have already occurred. Unprotected exposure to lasers can result in the development of cataracts or even a corneal burn, which can result in vision loss. If you are working with or around lasers, it is very important to understand the consequences of laser radiation exposure. We have decided to dedicate this post to educating you about laser beams and the safety precautions you should take when working around them.

Laser Beam Exposure

In addition to direct laser beam exposure, there are several other types of dangerous indirect laser beam exposures. Intra beam exposure occurs when the eye or skin is directly exposed to all or a part of the laser beam. It is also important to be careful of specular reflections. This is when the laser beam is reflected off mirror like surfaces. Reflections from flat mirror surfaces can be as harmful as exposure to a direct laser beam. Curved mirror surfaces decrease the intensity of the beam, but there is a larger area for possible laser radiation exposure. Diffuse reflections happen with surfaces that reflect the beam in many directions. Because the beam is reflected in so many directions, this exposure does not have the same power and energy of a direct beam. It is important to keep in mind that diffuse reflections are still harmful.

Protecting Your Eyes

The biggest risk with working around lasers is having any of these types of exposures enter the eye unprotected. In the human body, the eye is the most sensitive to light. When the eye is exposed to a laser beam, the lens in the eye focuses the beam into a tiny spot. This can actually burn the retina of the eye. At different wavelengths, lasers cause several types of eye injuries. Exposure to laser radiation with wavelengths that are less than 400 nanometers and greater than 1400 nanometers result in cataracts and burn injuries. This is because the eye absorbs this level of exposure through the cornea and lens. The most damaging wavelengths are between 400 and 1,400 nanometers, which results in the heating of the retina and can cause retinal burns. The image below shows which parts of the eye absorb the laser rays at different wavelengths.

Determine The Appropriate Protection

Fortunately, wearing laser safety glasses or goggles can protect the eyes from the risks that lasers pose. The U.S Occupational Safety and Health Administration require staff to wear laser safety glasses or goggles when operating or around lasers that are Class 3b and Class 4. Class 3b lasers are lasers that powered from 5 to 500 milliwatts and Class 4 lasers have output powers of more than 500 milliwatts. These laser safety glasses and goggles provide protection from reflected laser light and direct beam exposure. Laser safety eyewear is available for different wavelength ranges and for specific types of lasers. It is recommended that you find out the class of the laser you are working with as well as the appropriate wavelength range to ensure the best possible protection.

We can’t emphasize enough how important it is to protect your eyes and yourself from the harmful effects of laser radiation. Remember, the damage done to the eyes from laser radiation exposure can be permanent!

Avoiding Retained Surgical Items In The OR

Avoiding Serious Reportable Events (“Never Events”) In The OR

Retained Surgical Items (RSI) are included in the National Quality Forum’s list of Serious Reportable Events (commonly referred to as “Never Events”) as a, “foreign object unintentionally retained after surgery.” The Centers for Medicare & Medicaid Services (CMS) will no longer pay the extra cost of treating the following categories of conditions that occur while the patient is in the hospital. (Section 5001(c) of the Deficit Reduction Act (DRA) of 2005).

  • pressure ulcer stages III and IV;
  • falls and trauma;
  • surgical site infection after bariatric surgery for obesity, certain orthopedic procedures, and bypass surgery (mediastinitis)
  • vascular-catheter associated infection;
  • administration of incompatible blood;
  • air embolism; and
  • foreign object unintentionally retained after surgery 

The National Quality Forum (NQF) defines Never Events as errors in medical care that are of concern to both the public and health care professionals and providers, clearly identifiable and measurable (and thus feasible to include in a reporting system), and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures if the health care organization.

Nothing Left Behind: A National Surgical Patient-Safety Project To Prevent Retained Surgical Items

The site www.nothingleftbehind.org is an educational resource that was started in October 2004 to work with multiple healthcare stakeholder to make sure Retained Surgical Items (RSI) become a true “never” event. The categorical classification of “foreign object unintentionally retained after surgery” may include swallowed pennies, pins, shrapnel, bullets and other objects while surgical items are the tools and materials that we use in procedures to heal not to harm¹.

Patient Safety Problem 

“More than a dozen times a day, doctors sew up patients with sponges and other supplies mistakenly left inside. The mistake can cost some victims their lives².” Although there is no federal reporting requirement, research studies and government data suggests that there are between 4,500 and 6,000 retained surgical items left in patients every year in the United States. “That’s up to twice government estimates, which run closer to 3,000 cases, and sponges account for more than two-thirds of all incidents².”

Simple Solution? 

According to Atul Gawande, a Harvard public health professor and surgeon at Boston’s Brigham and Women’s Hospital, “It’s a recurrent, persistent and nearly totally avoidable problem…There are technologies that reduce the risk, that actually reduce the overall cost (to hospitals and insurer), and yet they are not the standard. That, to me, is the shocking thing.”

Sponge-Tracking Technology

Research shows that sponges account for 67% of all surgical items mistakenly left in patients². Data complied by Medicare estimates the cost of hospitalizations involving a lost sponge or instrument at more than $60,000 per case, according to USA Today.

Why have so few hospitals adopted systems to prevent lost sponge incidences?

A USA Today survey of companies that manufacture the sponge-tracking technology found that fewer than 15% of U.S. hospitals use sponges equipped with tracking devices, which reduce the risk of leaving a sponge in a patient, that add an additional cost $8 to $12 per surgery.

Barcodes and X-Rays at U-M

Surgeons at the University of Michigan Health System created a system to prevent retained surgical items. “In its effort to be the safest hospital in the country, the U-M uses new technology to insure no objects are left behind in surgery³.” According to Ella Kazerooni, M.D., M.S., professor of radiology at the U-M and associate chair of clinical affairs at the U-M Health System, “Having a foreign object left behind during surgery is something we consider a ‘never event’. It’s something that should never happen³.”

Methods Put Into Practice

  • Bar-coded sponges – sponges have been bar-coded so that they can be scanned when they are used and again when they are taken out of the body. Computers assist the medical staff in counting and if there is a count discrepancy they will know to search the surgical field. (Bar-coded sponges also contain a radiopaque tag)
  • Electronic radiology orders – X-rays are used to find retained items while the patient is still in the OR.

“RSIs can be discovered hours to years after the initial operation and a second operation may be required for removal¹.” According to Dr.Gibbs, author of the Nothing Left Behind site (educational resource), “New ways of thinking about human error and OR practices and understanding systemic changes in OR culture are required to prevent this event. System fixes require knowledge and information, a winning strategy, consistent multi-stakeholder engagement and leadership¹.”

Preventing Future Problems

According to the Institute of Medicine, “the problem is not bad people; the problem is that the system needs to be made safer.” Some hospitals have required four counts of sponges and instruments to improve the system and reduce the number or accidents; while careful counting could prevent some mistakes, counting carries its own risks. Human error can play a major role in RSI incidences, as a majority of the cases of RSI occur under a reported correct count.

Takeaways

  • Bar coding technology can be used to improve counting and tracking sponges in the OR
  • Bar coded sponge management systems are cost-effective
  • Sponge tracking systems are part of a growing trend in which bar coding is utilized to improve the management of medical supplies, equipment and tools throughout the hospital

 

Resources: 

1. Nothing Left Behind: A National Surgical Patient Safety Project To Prevent Retained Surgical Items

http://www.nothingleftbehind.org/

2. Eisler, Peter. “What Surgeons Leave behind Costs Some Patients Dearly.”USA Today. Gannett, 08 Mar. 2013. Web. 10 Sept. 2014.

http://www.usatoday.com/story/news/nation/2013/03/08/surgery-sponges-lost-supplies-patients-fatal-risk/1969603/

3. “University of Michigan Health System Creates System to Prevent Retained Surgical Items.” Web log post. University of Michigan. N.p., 06 Feb. 2012. Web. 10 Sept. 2014.

http://www.uofmhealth.org/news/retained-surgical-items-0206

Using Gel Positioners To Prevent Pressure Ulcers

Preventing Pressure Ulcers In The Operating Room

Pressure sore, decubitus ulcer, and pressure ulcer are all terms used interchangeably to describe localized injuries to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction.

What Is A Pressure Ulcer?

The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as an area of unrelieved pressure over a defined area, usually over a bony prominence, resulting in ischemia, cell death, and tissue necrosis.

According to a 2009 article, Prevention of Pressure Ulcers in the Surgical Patient, in the AORN Journal; “pressure ulcers (PUs) are a serious health care problem, and it is crucial to assess how patients acquire pressure ulcers after admission to a health care facility. In the OR, factors related to positioning, anesthesia, and the duration of the surgery, in addition to patient-related factors, all can affect PU development¹. . . All surgical patients should be considered at-risk for pressure ulcer development; therefore, preoperative departments should develop and implement strategic plans for pressure ulcer prevention.”

Quick Facts

Did you know?

Number of patients affected by pressure ulcers: 2.5 million per year

Cost

  • Pressure ulcers cost $9.1-$11.6 billion per year in the U.S.
  • Cost of individual patient care ranges from $20,900 to $151,700 per pressure ulcer.
  • Medicare estimated in 2007 that each pressure ulcer added $43,180 in costs to a hospital stay.

Pressure Ulcer Management

In 2008, The Centers for Medicare & Medicaid Services (CMS) included hospital acquired pressure ulcers (HAPU’s) as a “Never Event” which marked a turning point for most facilities. “Pressure ulcer management has become a standard part of every modern hospital’s protocol¹.”

Four Major Factors Contributing To Pressure Ulcers¹

  1. Uneven weight distribution
  2. Pressure
  3. Shear
  4. Heat and humidity build up

“Pressure ulcers are a costly, debilitating, and avoidable complication of surgery².”

The National Pressure Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) created the Pressure Ulcer Prevention: Quick Reference Guide outlining risk factors for patients in the operating room.

1. The following factors increase the risk the patient developing a pressure ulcer during a surgical procedure include:

a)Length of the operation
b)Increased hypotensive episodes intraoperatively
c)Low core temperature during surgery
d)Reduced mobility on day one of postoperatively
2. Use a pressure-redistributing mattress on the O.R. table for all individuals identified as being at risk of pressure ulcer development.

Action Products manufactures O.R. overlays that are cited by AORN best practices for Pressure Ulcer Prevention. The O.R. overlays, available in standard and custom sizes, provide pressure redistribution and reduce shear effects across the entire table surface. The low profile, simple design of the 1/2 inch Akton poymer O.R. overlay maximizes effectiveness and minimizes patient movement.

3. Position the patient in such a way as to reduce the risk of pressure ulcer development during surgery.

4. Elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting all the pressure on the Achilles tendon.

The heel support gel positioner by Action is designed to secure and protect the heel area as well as cradle the patient’s Achilles tendon area.

5. Pay attention to pressure redistribution prior to and after surgery.

a) Place patient on pressure-distributing mattress prior to and after surgery.
b) Position the patient in a different posture preoperatively and postoperatively than the posture adopted during surgery.

Types of Gel Positioners

Head & Neck Gel Positioners help protect and cradle the patient’s head and neck by stabilizing the head movement and assists in the prevention of neck overextension.

  • Lateral Head Pad with Center Dish
  • Donut Head Pads
  • Prone Headrests
  • Horseshoe Head Pads
  • Contoured Head Pad
  • Ophthalmic Headrests
  • Ophthalmic Cradle Headrests

Extremity Gel Positioners protect the patient’s arms and legs during procedures.

  • Contoured Armboard Pads
  • Armboard Pads
  • Hand/Wrist Support
  • Foot Pad
  • Heel Support
  • Stirrup Pad Set

Torso & Hip Gel Positioners provide support for the torso and upper body by providing increased stability.

  • Flat-Bottomed Chest Rolls
  • Contoured Chest Rolls
  • Chest Gel Positioners
  • Trapezoid Gel Positioner
  • Dome-Shaped Gel Positioner

Proper patient positioning and cushioning of all pressure points is a priority and using the correct padding can protect the patient from pressure ulcers.

“Procedures longer than 2 1/2 hours to 3 hours significantly the risk of pressure ulcer formation. Positioning problems can result in significant injuries and successful lawsuits.” ~Patient Positioning In The Operating Room

AORN recommends “Classifying all surgical patients as “at risk” for PU development is an appropriate preoperative intervention to successfully reduce the incidence of possible PU development.” The uncontrollable length of surgeries and effects of anesthesia are two of the main contributing factors leading to the development of pressure ulcers. Although it is impossible to eliminate the risk of patients developing pressure ulcers during surgical procedures – some patients will develop pressure ulcers from skin breakdown regardless of preventative measures. It is important to be aware of the causes of pressure ulcers and what steps you can take to minimize the risk.

Additional Information:

References:

 

Whiteboard Wednesday: Surgeon Cooling Systems

How Do Surgeons Stay Cool In The Operating Room?

Today on Whiteboard Wednesday we talk about how surgeons stay cool in the operating room. A major concern for medical staff working in the OR is fatigue caused by overheating.  Overheating is caused by the multiple layers surgeons and staff must wear for protection. During certain procedures the surgeon’s body heat is intensified, the CoolVest can help keep the surgeon more comfortable and alert.

What Is A Surgeon Cooling System?

The CoolVest System is a unique and innovative personal cooling system that is designed to keep surgeons cool and focused while performing surgery. The Single-Surgeon CoolVest System allows you to regulate your personal comfort so that you won’t perspire, suffer fatigue or lose concentration. The surgeon cooling system includes a lightweight vest that is constructed of hospital-grade ventilated nylon for maximum cooling, a variable flow control with quick-dry disconnect, wheeled cart with handle for convenient portability, and a UL listed cooler with variable flow 110V pump.

How Does The Surgeon Cooling System Work?  

The CoolVest is worn over scrubs and under surgical gowns. The tubing connection is located at the lower back of the garment to help keep the water supply tubing from interfering with the sterile field. Cooling tubes are located in the front and back of the garment for maximum cooling. The patented, thin-walled, non-kink tubing has been specifically designed for use under lead aprons.

Setup

  1. To begin, the cooling unit is filled with a mixture of approximately one gallon of water and ice (preferably block ice) or cube ice to the top of the unit.
  2. After the unit has been properly filled, you will want to attach the 8 foot insulated supply hose (quick disconnect) to the CoolVest.
  3. Apply the protective hose cover and then attach the other end of the insulated supply hose to the cooling unit.
  4. Listen for an audible click from both quick disconnect hose connections to ensure that they are properly connected.

Operation

  1. Once the supply hose has been properly protected and connected, you will want to plug the cooling unit’s electrical adapter into a grounded 110V outlet.
  2. Turn the unit on using the green On/Off power switch.
  3. Allow the unit to cycle until L.E.D indicator on Speed Control is activated (30 second pump start delay).
  4. Press “Ice Cube” on the Speed Control display on the lid of the system to start unit at desired level. L.E.D. on display will light from left to right for increased water flow. (e.g. 20-40-60-80-100% levels)
  5. To increase flow rate, press the “Ice Cube” button again, as needed, to adjust to the desired flow rate.
  6. To reset Speed Control setting: press “Ice Cube” until the surgeon cooling system stops; restart by pressing “Ice Cube” again until correct setting is indicated.

Relief From Heat While Performing Surgery

Surgeons have been impacted by excessive heat surrounding their bodies due to stress and other environmental factors. For example, neurosurgeons are required to wear appropriate radiation protective shielding (lead aprons, thyroid collars, lead glasses) while using imaging technology to protect them from the harmful effects of ionizing radiation. The use of these protective garments in addition to scrubs and surgical gowns can significantly increase the surgeon’s body temperature during surgical procedures. The increase in temperature can result in the surgeon becoming fatigued and perspiring during long surgeries which can reduce their focus and attention, resulting in a decrease in their ability to perform their tasks at the desired level.

Share Your Experiences

Have you experienced an increase in your body temperature while performing complicated surgeries? Interested in learning more? Make sure to check out our post on the Active Cooling Vest System For Surgeons In The OR!

Active Cooling Vest System For Surgeons In The OR

What is an active cooling vest? 

A cooling vest is a piece of equipment designed to cool a person down. Cooling vests are used by doctors, athletes, industrial workers, working dogs, individuals with Multiple Sclerosis or hypohidrotic ectodermal dysplasia, race care drivers, and military personnel.

Active cooling vests and systems require some form of power, electricity or battery, to operate. This type of cooling technology provides continuous cooling to lower the body’s core temperature by circulating cold water via a cooler through a tube to the vest.

CoolVest System 

Although cooling vests are used by a variety of people for a variety of uses, the CoolVest System has been designed specifically for surgeons working in the OR. Staying cool in the OR is an important consideration for surgeons, especially when performing pediatric surgeries, burn or trauma cases. The CoolVest System will keep you cool and focused – even when the OR has been warmed to AORN (recommended OR temperature 68-73 Fahrenheit) and Joint Commission Standards. When performing surgical procedures where the surgeon is exerting a great deal of physical effort, body temperatures can easily rise while covered with sterile gowns and lead aprons, not to mention the heat emitted from the OR lights.

CoolVest System Features

  • Lightweight vest made with hospital-grade ventilated nylon for maximum comfort.
  • Variable flow control and quick-dry disconnects for ease-of-use.
  • Choice of styles & sizes from small – XXXL
  • Variable hose lengths for freedom of motion.
  • Up to 70 feet of patented, thin wall, no-kink tubing for use under lead aprons.
  • Low-profile cooling unit for easy storage.
  • Wheeled cart with handle for convenient portability.
  • Single and dual vest capacity.
  • Heavy duty pump system.
  • Limited Lifetime Warranty with Free Loaner Program
  • UL Listing guarantees the highest quality standards for use in the OR.

Single-Surgeon System Includes

  • One premium CoolVest (Small-XXXL)
  • 8 foot insulated supply hose with quick disconnects
  • Protective hose cover
  • T-Drain kit
  • Maintenance additive (16 ounce bottle)
  • Stainless steel cart with hospital grade wheels
  • UL Listed cooler with variable flow 110V pump

A Dual-Surgeon System is also available and comes with two premium CoolVests. 

Remain Alert And Focused

The CoolVest System offers variable flow control, which allows you to regulate the fluid flow to your personal comfort level so that you won’t perspire, suffer fatigue or lose concentration. No matter how long or complex the surgery, you’ll remain alert an focused.

Stay Cool And Comfortable

The lightweight vest is made with hospital-grade ventilated nylon for maximum comfort. Available in sizes ranging from small to XXXL the CoolVest is lightweight, comfortable, and durable for OR conditions. Comfort is essential when working under intense pressure and performing hundreds of high-risk procedures each year. The CoolVest will help surgeons and medical staff stay cool and focused while working in the OR. Make sure to visit our Surgeon Cooling section on our main site for more CoolVest products.

Why Medical Training Models Are Essential For Medical Students

Medical training models are common for teaching medical students certain medical applications and procedures. Anatomical models and simulators will help guide students in learning the process of a procedure, while increasing their comfort level with the application. Medical training models not only provide the student with hands-on practice, it gives the student a visual to apply real life situations instead of reading about it via books and slides.

We have a variety of models and simulators to choose from, such as CPR simulators, medical patient simulators, IV training models, real baby care dolls, and more! Our I.V. Injection Arm Model is unique in that it allows a realistic training to teach competence to medical staff. This model is also great for group instructors because of its high quality, stain resistance and easy to clean material. Many instructors use this model for the following training:

  • Intravenous injections
  • Correct puncture of peripheral veins for blood sampling. The following veins can be punctured: basilic vein, cephalic vein, median cubital vein, dorsal venous rete of hand
  • Positioning of a venous catheter

Another popular medical training model is our Basic Billy Basic Life Support Simulator. This simulator is used to teach students CPR techniques focusing on the depth and force of compression during cardiopulmonary resuscitation. Cardiac failure is one of the leading causes of death and with this medical training model, it shows how easy it is to provide help and save lives through correct CPR techniques.

Are you currently using any medical training models in your facility?

Why Are Head & Neck Positioners Important In The OR?

Why are neck and head positioners important for patients to use while in the operating room? The number one reason for positioning a patients head with a positioner in this situation is safety purposes. Many patients need support of their head and neck  to relieve pressure while going in to surgery.

Below are a few examples of a few different kinds of head and neck positioners we offer.

  1. Head & Neck Support is an ideal positioner for general skull work. Dimensions are 6.5″ high x 10″ wide x 12″ long
  2. 5.5″ D Ring is a reusable foam positioner that provides a safe area for minimizing pressure points and nerve damage during surgery. Dimensions are 5.5″ diameter x 1.5″ thick with a 2″ hole in the center.
  3. Slotted Adult Head Positioner has a soft flexible coating to provide comfort to patients, with 1″ deep slots for tubing. Dimensions are 8.5″ x 8″ x 4″ thick at the highest point, 3″thick at center.
  4. Waters Positioner was especially designed for laminographs of the orbits and facial bones. Dimensions are 7.4″ high x 12.4″ wide x 8″ long.
  5. Concave Disc are ideal for general skull work in general positioning, CT scan, MRI, nuclear medicine, and ultrasounds. Dimensions are 7″ in diameter and available in  1.5″ high, 2.5″ high and 3″ high discs.

Making sure patients are comfortable, safe and don’t develop pressure sores or pain. With our large selection of head and neck patient positioners, you’ll be able to find the support needed for your medical setting. Have any questions on this post? Let us know in the comment box below!

Featured Product: TruLife Oasis Elite Closed Head Ring

Our featured product for today is the TruLife Oasis Elite Closed Head Ring, an excellent gel positioner to provide pressure relief for your patients. This head positioner is designed with lightweight foam with silicone Trugel, the foam and gel work together to conform to the patient’s body shake and helps distribute weight evenly.

Product Features:

  • Unique gel & foam combination conforms comfortably to the patient’s head
  • Suitable for use in many surgical procedures
  • Dimensions:
  • Adolescent: 5.5″ Diameter x 1.3″ Thick
  • Adult: 7.8″ Diameter x 1.9″ Thick
  • MRI Safe
  • Latex Free
  • Non-Hazardous