the monthly publication for or decision makers · 4patients at memorial medical center in new...

September 2006 Vol 22, No 9

The monthly publication for OR decision makers

In this issueReforms to revamp Medicare payments . . . . . . . .5

A musical odyssey about the mysterious human mind . . . . . . . . . . . . . .7

FDA seeks input on device IDs . . . . . . . . . . . . . . .12

SALARY/CAREER SURVEY.Fewer vacancies, lower turnover for ASCs . . . . . . . .15

Bariatric complications rise after discharge . . . . . . . .19

SURGICAL CAREIMPROVEMENT.Aiming for tighter glucose control . . . . . . . . . . .21

More data on surgical quality . . . . . . . . . . .25

AMBULATORY SURGERYCENTERS.ASCs dismayed over new payment plan . . . . . . . .27

Share successes at 2007 meetings . . . . . . . . . . . . . . . .29

AMBULATORY SURGERYCENTERS.Inexpensive ideas to keep staff happy . . . . . . . . . .30

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

ASC section on page 27.

OR nursing leaders continue tograpple with the nursing short-age. Only one-third report they

do not have a shortage of OR nurses, achange from 2 years ago, when nearlyhalf did not. The effects are felt in theincreased use of overtime and agencyand traveler nurses.

Despite the shortage, the averagenumber of open positions, staff turnoverrate, and the number of weeks positionsremain open are roughly the same as lastyear.

Today, two-thirds of OR leaders saythey hire new graduate nurses, and 92%hire RNs without OR experience, prac-tices that were much less common 15years ago.

These are results of the staffing por-tion of the 2006 annual OR ManagerSalary/Career Survey. This is the sixth

year that staffing questions have beenasked. The survey was mailed in May toa random sample of 1,200 OR Managersubscribers with 266 returned for a rateof 22%. A separate survey was sent toambulatory surgery centers. Resultsfrom the remainder of the survey,including salaries and benefits, will bereported in the October issue.

Slight rise in openings The average vacancy rate is 7% for

perioperative RNs and 6% for surgicaltechnologists (STs), compared to 6% forboth groups in 2005. Nationally, thevacancy rate for RNs in general is 8.5%.

The 2006 figures are an improvementover 5 years ago when vacancy rateswere 9% and 12% for RNs and STsrespectively.

OR leaders grapple with shortage;two-thirds are hiring new grads

Best practices for retaining your‘sages’—nursing staff over age 50

To prevent baby boomer nursesfrom taking their collective wis-dom with them when they retire,

health care institutions are finding waysto keep these mature and experiencedworkers from leaving en masse.Hospitals also are trying to dam a floodthat will exacerbate the nursing shortageas this largest age group of nursesretires.

According to a new report by theRobert Wood Johnson Foundation(RWJF), Wisdom at Work: The Importanceof the Older and Experienced Nurse in theWorkplace, approximately 40% of the USnurse workforce will be over age 50 by

2010. A 2003 online survey by theAmerican Nurses Association showsmore than 82% of nurses age 40 or olderplan to retire in the next 20 years.

“Our older nurses are so sharp—theypick up on everything going on aroundthem,” Mary Ann Crisci, RN, CNOR,manager of surgical services at ScrippsGreen Hospital in La Jolla, Calif, told ORManager. “Some of them have workedwith our surgeons for over 30 years.Their opinions are valued, and they’veearned the respect to express them.”

The Robert Wood Johnson Founda-tion report defined 12 best practices of

Recruitment & retention

Continued on page 16

Salary/Career Survey

Continued on page 9

2

Please see the ad for MEGADYNEin the OR Manager print version.

What would you do? A doctorand 2 nurses have beenaccused of intentionally killing

4 patients at Memorial Medical Center inNew Orleans in the aftermath of Hurri-cane Katrina. Their recent arrests have dis-turbed many health care workers andraised ethical issues about end-of-life care.

Put yourself in this place. You are caring for patients in an 82-bed

long-term, acute-care unit in a hospitalsurrounded by floodwater. The generatorshave failed. The heat is debilitating—over100 degrees with high humidity. There isno running water or sewerage. There areno telephones. Food is in short supply.Essential supplies are dwindling.

You don’t know when help will arrive.You don’t believe that your severely illpatients will survive.

What happened at MemorialIt is the third day that the hospital has

been isolated by the floodwaters.Katrina had arrived with all its fury on

Monday morning, Aug 29. On Mondaynight, the levees failed, flooding large seg-ments of the city with as much as 15 to 20ft of water.

Here is what happened at Memorial. On Tuesday, at the 317-bed hospital,

owned by Tenet Healthcare, Inc, personnelcleared an abandoned helicopter pad onthe roof of the hospital’s parking garage.To get to the pad, patients had to bepassed through a 3 ft by 3 ft hole in a sec-ond-floor maintenance room, then trans-ported by vehicle up a ramp, then carriedup 3 flights of steps to the landing pad.

The first helicopter to arrive intendedto deliver evacuees to the hospital. Somepilots only wanted to take pregnantwomen or babies. Boats were used toevacuate patients and the 1,500 residentswho had taken shelter at the hospital.

On Wednesday, the generators failed.By evening 115 patients were still waitingevacuation, but the boats had stoppedcoming. Patients were brought back in,fed, given fluids, and put on cots. Noboats or helicopters arrived that night.

On Thursday, 6 helicopters charteredby Tenet arrived, and the remaining livingpatients were all evacuated.

But 45 patients, more than at other hos-pitals, died (11 reportedly before thestorm); 25 were patients of the 82-bedlong-term acute-care LifeCare Holdings

unit. The Louisiana attorney general andNew Orleans district attorney movedquickly to launch a criminal investigation.

In July, Anna M. Pou, MD, and 2 nurs-es, Lori L. Budo and Cheri A. Landry, werearrested and charged with second-degreemurder of 4 residents in the long-term carecenter. According to the affidavit, theyadministered “lethal doses of morphinesulphate and/or midazolam (Versed).”This allegedly occurred on Thursdaymorning. One patient was a 380-poundparalyzed 61-year-old man. Another wasan 89-year-old patient with dementia andgangrene. A third was 90 years old andapparently recuperating well.

A respected medical school professor,Dr Pou had chosen to stay at the long-term care unit to help. The case will nowgo to the grand jury, which will determineif Dr Pou and the nurses will be charged.

Lessons for hospitalsWhat hospitals in New Orleans faced is

described in a compelling report by theUrban Institute, After Katrina: Hospitals inHurricane Katrina. It describes the “terribleconditions” that caregivers faced. You’llfind the report on the OR Manager web-site, www.ormanager.com. It includeslessons that may help hospitals face futuredisasters. The Urban Institute report con-cludes that “the way hospitals dealt withadversity is a part of the Katrina experi-ence that must be remembered for thefuture.”

The arrests of Dr Pou and the 2 nurseshave created a backlash in the health carecommunity. Said a doctor who stayedthrough the flood at Lindy Boggs MedicalCenter, “We had no help—no help was insight. And we felt abandoned. We didn’tknow what we were dealing with.” v

—Elinor S. Schrader

3September 2006

Upcoming

OR Manager Vol 22, No 9

September 2006 Vol 22, No 9OR Manager is a monthly publication forpersonnel in decision-making positions inthe operating room.

Elinor S. Schrader: PublisherPatricia Patterson: EditorJudith M. Mathias, RN, MA:

Clinical editorBillie Fernsebner, RN, MSN:

Consulting editorKathy Shaneberger, RN, MSN, CNOR:

Consulting editorLeslie Flowers: WriterKaren Y. Gerhardt: Art directorOR Manager (USPS 743-010), (ISSN 8756-8047)

is published monthly by OR Manager, Inc,1807 Second St, Suite 61, Santa Fe, NM87505-3499. Periodicals postage paid atSanta Fe, NM and additional post offices.POSTMASTER: Send address changes toOR Manager, PO Box 5303, Santa Fe, NM87502-5303.

OR Manager is indexed in the CumulativeIndex to Nursing and Allied HealthLiterature and MEDLINE/PubMed.

Copyright © 2006 OR Manager, Inc. All rightsreserved. No part of this publication may bereproduced without written permission.

Subscription rates: $86 per year. Super sub-scriptions (electronic) $129 per year.Canadian, $98. Foreign, $115. Single issues$10. Address subscription requests to POBox 5303, Santa Fe, NM 87502-5303. Tele:800/442-9918 or 505/982-0510. Web site: www.ormanager.com E-mail: [email protected]

Editorial Office: PO Box 5303, Santa Fe, NM87502-5303. Tel: 800/442-9918. Fax: 505/983-0790. E-mail: [email protected]

Advertising Manager: Anthony J. Jannetti,Inc, East Holly Ave/Box 56, Pitman, NJ08071. Telephone: 856/256-2300; Fax: 856/589-7463. John R. Schmus, national adver-tising manager. E-mail: [email protected]


What are your peers earning?Read results on salaries, benefits, sup-

ply management, and other issues in theannual OR Manager Salary/CareerSurvey.

Restoring civility What’s needed to stop disruptive

behavior among staff and physicians?Organizations share their policies.

Publisher’s Note

“

““We had nohelp—no helpwas in sight.”

4

Please see the ad for ADVANCED STERILIZATION PRODUCTSin the OR Manager print version.

The Centers for Medicare andMedicaid Services (CMS) inAugust announced a package of

rules and reforms it says will improvethe accuracy of payment and the qualityof Medicare services.

Among the reforms: A final inpatientpayment rule, a proposed outpatientpayment rule for hospitals that includesa plan to revise ambulatory surgery cen-ter (ASC) payments, and a report on spe-cialty hospitals.

The government is particularly con-cerned about rising hospital and physi-cian outpatient costs, which grew by 12%in the past year. CMS administratorMark McClellan, MD, PhD, called thegrowth “unsustainable.”

Inpatient ruleIssued Aug 1, the rule adopts some

changes CMS proposed but is lesssweeping than hospitals and the deviceindustry had feared. The rule takes effectOct 1, 2006, the start of the 2007 fiscalyear.

Still, the rule includes reforms CMSsays will reduce incentives to invest inprofitable specialties, such as cardiac ser-vices, which some in Congress say arefueling development of specialty hospi-tals.

Among modifications in the final rule:

• phase-in of DRG system changes over3 years rather than full implementa-tion in 2007

• adjustments for a limited number ofDRGs rather than all DRGs

• a refined method for estimating costs. CMS is moving to base DRG weights

on costs rather than charges because ofconcerns that variation in markups haveintroduced bias. For example, markupsfor cardiac services are higher than aver-age, so these procedures end up withhigher DRG weights.

On average, hospital per-case pay-ments will increase by 3.5%. But cardiacspecialty hospitals will see a 5% declinefor fiscal 2006 and 2007. No DRG will seea decline in payment of more than 5.4%under the rule, Dr McClellan said.

A Wall Street analyst called the final

rule “a win for cardiac and orthopedicdevice companies, specialty hospitals,and general acute care hospitals,”according to the Aug 3 New York Times.The paper cited “intense pressure” fromlobbyists and lawmakers.

The American Hospital Associationexpressed relief, saying CMS “listened tothe hospital field’s views and madeimportant changes from its proposal.”

The Wall Street Journal said the pro-posed rule “provoked an outcry fromhospitals and medical device companies,which argued it would stifle medicalinnovation and compromise patientcare.” More than 200 lawmakers signedletters to Medicare asking for a delay inthe ruling.

New technologyAs part of the inpatient rule, new

add-on payments were approved for onedevice, intended for minimally invasivetreatment of back pain. The X STOPInterspinous Process DecompressionSystem from St Francis Medical Tech-nologies is an alternative to conservativetreatment and major back surgery. Thecompany estimates that in 2007 about2,000 patients will be eligible for thedevice, which will be paid under DRG499 and 500.

CMS will continue add-on paymentsin 2007 for 2 technologies approved forpayment in 2006: • Restore Rechargeable Implantable

Neurostimulator • GORE TAG, an endoprosthesis for the

thoracic aorta.The final rule was scheduled to be in

the Aug 18 Federal Register.

Outpatient proposalFor the first time, CMS wants to tie

hospital outpatient payments to qualityreporting, beginning in 2007.

“Our current payment systems foroutpatient services must be improved,and we are seeking public input on themost effective way to address this chal-lenge,” Dr McClellan said in a press con-ference.

The quality reporting is an expansionof a program already in effect for inpa-tient services. CMS notes many of theinpatient measures, such as surgicalinfection prevention, involve the sameactivities as outpatient care. CMS is ask-ing for input on quality measures specifi-

Reforms to revamp Medicare payments

5OR Manager Vol 22, No 9September 2006

William R. Anton, RRTBusiness director, surgical services;Director, value analysis, University ofWashington Medical Center, Seattle

Amy Bethel, RN, MPA, CNAExecutive director, surgical services, IowaHealth, Des Moines

Mark E. Bruley, EITVice president of accident & forensicinvestigation, ECRI, Plymouth Meeting, Pa

Ramon Berguer, MDChief of surgery, Contra Costa RegionalMedical Center, Martinez, Calif

Helen K. Crouch, RN, MPH, CICDirector, infection control & epidemio-logy services; Infection control consul-tant for Army Great Plains RegionalCommand, Brooke Army MedicalCenter, San Antonio, Tex

Christy Dempsey, RN, BSN, MBA, CNORVice president, St John’s Regional HealthCenter, Springfield, Mo

Franklin Dexter, MD, PhDAssociate professor, Department of anesthesia, University of Iowa, Iowa City

Mary Diamond, RN, MBA, CNORDirector of surgical services, SharpHealthcare, San Diego

Marion L. Freehan, RN, MPA/HA, CNORNurse manager, main operating rooms,Massachusetts General Hospital, Boston

Jo Harbaugh, RN, BS, CGRNEndoSite advisor, Olympus America IncNormal, Ill

William J. Mazzei, MDMedical director, perioperative services,University of California, San Diego

Mary M. Murphy, RN, BSN, CNORDirector, surgical services, MunsonMedical Center, Traverse City, Mich

Susan Nielsen, RN, MSA, CNORDirector, central processing department,William Beaumont Hospital, Royal Oak,Mich

Barbara Pankratz, RN, MSNDirector, surgical services, University ofWisconsin Hospital & Clinics, Madison

Ena M. Williams, RN, BSNursing director, perioperative services, Yale-New Haven Hospital, New Haven, Conn

Advisory Board

“

“Growth of outpatient costs are

‘unsustainable.’

Continued on page 7

6

Please see the ad for SKYTRON INC.in the OR Manager print version.

David Harp has 2 passions—cogni-tive psychology and playing theharmonica.

At the Managing Today’s OR Suiteconference, he will present a special lec-ture, “Usable Smarts: Beyond Fear, Anger,and Other Engrossing but UselessPastimes.” The conference is Nov 8 to 10 inOrlando.

The special lecture, at 4:30 pmThursday, Nov 9, is sponsored byCardinal Health, Medical Products andServices. David Harp replaces StuartAltman, PhD, who is unable to speakbecause a scheduling conflict.

An author, cognitive scientist, andcorporate speaker, Harp combines hispassions in a hilarious and joyful butcontent-driven event.

Cognitive psychology is the study ofhow the brain processes informationincluding thoughts, emotions, beliefs, andthe way they affect our words and actions.

Harp believes the most importantkind of leadership comes from within. Itis the ability to master or manage yourown thoughts and emotions.

He will lead you on a musical odysseythrough that mysterious—and often muti-nous—entity known as the human mind. The Three-Minute HarmonicaChallenge

You will receive a souvenir harmonicaand experience how learning a newskill—playing on the harmonica—affectsthe chains or “paths” of neurons thatunderlie every aspect of our existence.Harp’s Three-Minute Harmonica Chal-lenge guarantees you’ll play your firstsong in 3 minutes.

With Harp, you will learn how neuralpath therapy™ (NPT) can help youchange traditional habits and attitudesthat may affect your work and home life.

Harp is author of several books,including Neural Path Therapy: How toChange Your Brain’s Response to Anger,Fear, Pain, and Desire (with MatthewMcKay) and The Three-Minute Meditator,as well as books on music and on playingthe harmonica. He has presented hisunique harmonica-cognitive psychologyevents for clients ranging from Ben &Jerry’s Ice Cream to the FBI. v

To learn more about this speaker, visitDavidHarp.com.


A musical odyssey about the mysterious human mindcally for outpatient services. The quality

data is available to consumers on theHospital Compare web site at www.HospitalCompare.hhs.gov.

The outpatient proposal includes a3.4% inflation update, which CMS esti-mates will result in an average increase of3% in Medicare payments for outpatients.

The rule was scheduled to appear in theAug 23 Federal Register with commentsaccepted until Oct 10. (The deadline isextended to Nov 6 for the ASC proposal.)

Ambulatory surgery centersIn a move long awaited by the ASC

community, CMS proposes expandingthe list of surgical procedures approvedfor payment in ASCs. The only proce-dures excluded would be those that pose“a significant safety risk” or generallyrequire an overnight stay.

The proposal is part of an extensiveplan mandated by Congress to revampthe ASC payment system, which is slatedto take effect Jan 1, 2008 (see p 27).

Specialty hospitalsThe moratorium and suspension on

Medicare payments to specialty hospitalsexpired Aug 8.

In a new report mandated by Con-gress, CMS discusses its plans for over-sight of specialty hospitals, includingrequiring more financial disclosure ofphysician investments.

“Specialty hospitals often achieve highlevels of service, but there have been ques-tions about them picking the most prof-itable services,” Dr McClellan said.

Specialty hospitals will have to disclosephysician compensation and investmentto CMS. Those that delay may face fines of$10,000 a day. Specialty hospitals also willhave to tell patients that their staff physi-cians are investors in the hospital.

CMS says financial disclosure will help itwatch for physician payouts that are out ofproportion to investments. CMS takes theposition that out-of-proportion returns vio-late the physician self-referral statute andare suspect under the anti-kickback statute.

For example, if a physician has a 1% to2% investment in a specialty hospital butreceives a 5% to 6% payout, the extraamount could be considered questionable.

A CMS survey of specialty hospitals,“found no concerning patterns of invest-ment, but many hospitals did notrespond,” Dr McClellan said. There willbe followup with possible fines for thosethat do not respond, he said. v

Continued from page 5

Old Floridatheme forreception

Enjoy the Old Florida experience atthe gala reception, sponsored by IMS,from 5:30 to 7:30 pm Thursday, Nov 9,at the Managing Today’s OR Suite con-ference in Orlando.

“Throw off those winter clothesand experience the Florida of old andtoday in this tropical setting of fun.”

That’s the theme for the reception,which will follow the David Harp pre-sentation. Don your best resort wear—your fancy dress or Tommy Bahamashirt—and join the fun. Old Floridapostcards, pink flamingos, and palmtrees will set the scene.

There will be entertainment, ele-gant hors d’oeuvres, passed cham-pagne, and other beverages.

Join your colleagues for this funevent for good food, a cool beverage,and an opportunity to network anddiscuss the day’s events.

David Harp with harmonica.

8

Please see the ad for KARL STORZ ENDOSCOPY-AMERICAin the OR Manager print version.



OR managers report the averagenumber of open RN positions is 1.9, thesame as in 2005. Hospital ORs in Centralstates report an average of 1 open posi-tion, compared to 2.6 in the South, 2.5 inthe East, and 2.1 in the West.

Teaching hospitals have an average of3.5 positions open, compared to 1.3 atcommunity hospitals.

Hospitals with more than 10 ORshave an average of 3.2 openings, com-pared to 1.0 at hospitals with 6 to 9 ORs,and 0.6 at hospitals with 1 to 5 ORs. Thenumber of openings is similar for STs.

The West reported the highest rate ofopen positions for both RNs (13%) andSTs (12%). Hospitals in the Centralregion report the lowest rate. A majorityof respondents in the Central region(54%) report no open perioperative nursepositions, while 62% have no open STpositions.

Recruiting and staffing are more diffi-cult for rural hospitals because they havesmaller staffs and fewer resources forrecruitment. Rural hospitals have anaverage of 1 open position for RNs, butthis is a larger percentage (9%) of their

Hospital respondents to survey

Region Distribution Response

East 219 18%South 369 31%Central 372 31%West 240 20%


RNs 40%STs 50%

ORs with no open positions

Is recruiting experienced OR nurses difficult?

East Central South WestVery 51% 46% 48% 46%Somewhat 44% 39% 41% 44%Not at all 5% 15% 11% 11%

Numbers may total more than 100% due to rounding.

Notat all11%

Somewhat42%

Very47%

Community 56%Teaching 69%

Yes, by type of facility

Do you routinely useovertime to staffyour ORs?

No41% Yes

59%

Does your OR hire RNs without ORexperience?

No8%

Often31%

Occasionally61%

What effect has the OR nursing shortage had on your OR?

2004 2005 2006

Do not have a shortage 49% 44% 37%

Longer patient waits for elective surgery 11% 15% 5%

Extended hours for scheduled cases 33% 34% 26%

Increased use of overtime to complete schedule 47% 44% 53%

Increased use of agency/traveler nurses 16% 17% 25%

Extended hours for PACU 31% 31% 28%

Patients discharged home or to surgical floor later in day 23% 24% 16%


10 OR Manager Vol 22, No 9 September 2006


ORs that hire new graduate nurses

Type of facility

Overall Community Teaching

67% 65% 79%

East Central South West

70% 57% 74% 73%

Region

Number of ORs

1-5 ORs 6-9 ORs 10+ ORs

47% 64% 83%

No66%

Yes34%

Hospitals1991

No33%

Yes67%

2006

ASCs

No73%

Yes27%

budgeted FTE positions than in largerhospitals.

Staff turnover rate The average staff turnover rate is 7%

for RNs and STs, the same as in 2005.That is a drop from 2001, when turnoverrates were 13% for RNs and 10% for STs.

The turnover rate in the West (14%) isdouble the rate in the South and East (7%each) and more than triple that in theCentral region (4%).

Teaching hospitals report a 9% staffturnover rate, compared to 6% at com-munity hospitals.

Challenges in the WestOpen RN positions are taking an

average of 13 weeks to fill, while ST posi-tions take 9 weeks. Positions at rural hos-pitals stay open longer than in suburbanor urban facilities—11 weeks versus 6and 9 weeks, respectively.

The West has the most staffing chal-lenges, taking an average of 21 weeks tofill open RN positions, compared to theEast (13 weeks), South (10 weeks), andCentral region (7 weeks).

Positions at hospitals with 1 to 5 ORsalso stay open longer, averaging 18 weeksto fill, compared to hospitals with 6 to 9

In some ways, staffing has improved in the past 5 years.Since 2001, the number of open RN positions has decreased slightly. Open sur-

gical technologist (ST) positions decreased, then leveled off. Open positions represent a smaller percentage of budgeted FTEs in 2006 than

in 2001. This may be because ORs are tightening their staffing or relying on over-time and temporary nurses to stretch their staffing.

The staff turnover rate also has improved, both for RNs and STs.

Trends in staffing

2001 2002 2003 2004 2005 2006

Average number of open positions in the OR

RNs 2.2 2.2 1.7 1.8 1.9 1.9STs 1.8 1.6 1.1 1.1 1.1 1.1

Open positions as a percentage of budgeted FTEs

RNs 9% 10% 5% 9% 6% 7%STs 12% 9% 7% 6% 6% 7%

Average number of weeks positions have been open

RNs 14 16 12 12 13 13STs 14 14 11 10 10 9

Average staff turnover rate

RNs 13% 11% 7% 7% 7% 7%STs 10% 8% 7% 7% 7% 7%

Routinely use agency/travelers

19% 27% 25% 23% 23% 25%






Type of facility Region


RNs 7% 6% 9%STs 7% 7% 7%


7% 4% 7% 14%7% 5% 7% 12%

Note: Turnover was defined as the percent of staff who have left and been replaced in the past year.

Average number of open positions in ORs


What percent of budgeted FTE positions are open?


Average number of weeks positions have been open


ORs that routinely use agency/travelers to fill budgeted positions



25% 23% 31%


27% 17% 19% 46%


RNs 1.9 1.3 3.5STs 1.1 0.9 1.8


2.5 1.0 2.6 2.11.2 0.7 1.5 1.0


RNs 7% 6% 7%STs 6% 7% 7%


6% 4% 6% 13%7% 5% 4% 12%


RNs 13 12 13STs 9 9 9


13 7 10 2110 7 7 12



ORs (13 weeks) or more than 10 ORs (11weeks). Results are similar for STs.

Filling staffing gaps To fill the gaps, OR leaders are mak-

ing the most of existing staff by increas-ing overtime to complete the staff sched-ule; 53% say they are doing so—a jumpover last year’s average of 44%. They arealso extending hours for scheduled cases(26%) and the PACU (28%). In a fewfacilities (5%), patients wait longer forelective procedures.

One-fourth of hospitals use agencyand traveler nurses, similar to the 23% in2005. Use of temps is up from 19% in2001.

Use of contract staff is most commonin the West (46%)—where use has dou-bled from 25% in 2001—and East (27%).

Community hospitals (42%) and hos-

pitals with more than 10 ORs (32%) aremore likely to use temps than teachinghospitals (22%) or hospitals with 5 orfewer ORs (15%). Only 15% of rural hos-pitals use agency or travelers versus thesurvey average of 25%.

More hiring new grads Nearly 9 in 10 managers—89%—find

it difficult to recruit experienced nurses. Overall, 67% use new graduates to fill

positions, a reverse from 15 years ago,when only 34% did. New grads are morelikely to be hired in teaching hospitals(79%) than in community hospitals(65%). The more ORs a hospital has, themore likely it will take on new gradu-ates.

To compensate for the shortage ofexperienced OR nurses, 92% of respon-dents say they prepare nurses withoutOR experience. That’s also a change fromthe early 1990s, when 64% said they

would hire an RN without OR experi-ence within their own institution, butonly 41% would hire an RN withoutexperience from another facility.

In contrast to hospitals, only 27% ofambulatory surgery centers hire newnursing graduates, and 58% hire nurseswithout OR experience. v

—Billie Fernsebner, RN, MSN, and Leslie Flowers

The majority of managers (51%)say they don’t have enoughresources for orientation and contin-uing education—an increase from46% in 2004 when the question wasfirst asked.

Education is particularly impor-tant at a time when 67% of ORs arehiring new graduates, and 92% aretaking RNs without OR experience.Only 13% say their number of edu-cators has increased in the past 2years.

Educational resources areadequate

Teaching Community50% 48%

1-5 ORs 6-9 ORs 10+ ORs39% 41% 57%

How many educators/staffdevelopment staff do youhave in the OR?

1-5 ORs 6-9 ORs 10+ ORs0.5 0.5 1.3

Education resources lackingDo you consider your educa-tional resources adequate?

In the past 2 years, the number of educators has…

No51%

Yes49%

Stayed the same80%

Decreased7%Increased

13%

Salary/CareerSurvey director

Billie Fernsebner, RN, MSN, edu-cation specialist for OR Manager,Inc, has coordinated the OR ManagerSalary/Career Survey for the past 9years.

Thank youOR Manager thanks its subscribers

who generously took time to com-plete this year’s survey. We appreci-ate your part in gathering this infor-mation, which will be useful to yourcolleagues around the country.


FDA seeks inputon device IDs

The Food and Drug Administration(FDA) is asking for comments to help itunderstand how unique identifiers formedical devices might improve patientsafety. The agency is also inviting inputon use of technologies such as bar codingand radiofrequency identification foridentifying devices. The FDA also seekscomments on whether such a systemshould be voluntary or mandatory.

The FDA says it plans to assesswhether unique IDs would help identifydevices for adverse event reporting andrecalls. IDs might also enable users tosearch databases for information such ashow to sterilize a device or device com-patibility, such as which devices can beused safely with MRI systems.

The notice was published in the Aug11 Federal Register, with comments accept-ed until Nov 9. v

—www.fda.gov



The ratio of RNs to surgical technol-ogists in hospital ORs remains steadyat 63% to 37% in this year’s ORManager Salary/Career Survey.

Federal regulations say STs may cir-culate with an RN in the room orimmediately available.

The percentage of hospital respon-dents who have STs circulating hasdeclined in the past 5 years, from 14%in 2001 to 8% this year. None reportthat STs circulate on their own.

Of the 20 hospitals that said STs circu-late, either with an RN supervisor in thesame room or immediately available:• 13 are community hospitals• 9 are large departments with 10+

ORs, and 7 are small with 1 to 5ORs

• 10 are in the Central region.A small number of hospitals, 6%

(n=16), have staffs that are 90% ormore RNs. Nine of these are smallORs.

Ambulatory surgery centersAmbulatory surgery centers (ASCs)

report an average skill mix of 62% RNsand 38% STs.

A higher percentage of ASCs thanhospitals report that STs are circulat-ing. Nearly 1 in 5, 18% (n=20), of ASCssaid STs circulate either with an RN inthe room or immediately available.That compares with 11% in 2005.

Of ASCs with STs circulating, 16have fewer than 5 ORs; 10 are physi-cian owned, and 10 are joint ventures.No ASCs reported having STs circulat-ing on their own.

Though ASC respondents indicatethey staff both ORs and procedurerooms, the survey did not ask whetherthey staff differently for those settings.

Do surgical techs circulate?Hospitals

2006

2001

Ambulatory surgery centers

Ratio of RNs to surgical techs

2006 63:37

2005 64:36

2000 61:34

1995 69:31

Skill mix in the OR

Yes, RNavailable

2%

Yes, RNin room

6%

No92%

Yes, RNavailable

2%

Yes, RNin room

12%

No86%

No82%

Yes, RNavailable

11%

Yes, RNin room

7%

Big picture of thenursing shortageNational vacancy rateRNs: 8.5%Nursing assistants: 7.6%LPNs: 7.3%

Vacant RN positionsAn estimated 118,000 RN positions arevacant in US hospitals.

Recruiting more difficult49% of hospitals report more difficultyrecruiting RNs in 2005 than in 2004.

Effects of workforce shortageImpact reported by hospital CEOs fromshortages of all types of personnel:Decreased staff satisfaction: 52%ED overcrowding: 40%Decreased patient satisfaction: 38%Reduced number of staffed beds: 21%Surgery cancelled: 11%

—American Hospital Association, 2006.www.ahapolicyforum.org/

RN demandMore than 1.2 million new andreplacement nurses will be needed by2014. By that year, RN positions willaccount for 2 out of 5 new jobs inhealth care.

—US Bureau of Labor Statistics,November 2005

Age is risingThe average age of RNs in 2004 was46.8, up from 45.2 in 2000.

—National Sample Survey of RegisteredNurses. Preliminary results, December

2005

Enrollments up but not enoughEnrollment in entry-level RN pro-grams increased by 9.6% in 2005, butthe increase is not enough to meet theprojected demand.

—Buerhaus P, Health Affairs, 2003

Applicants turned awayUS nursing schools turned awayabout 42,000 applicants in 2005-2006because of a lack of faculty and otherresources.

—American Association of Colleges ofNursing

14

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Open FTE positions in ASC ORs

Average number No open positions of open positions

RNs 67% (n=108) 0.6 (n=108)

STs 79% (n=97) 0.3 (n=97)

What percentage of budgeted FTEpositions are open?

RNs 6% (n=29)

STs 5% (n=18)


RNs 6% (n=94)

STs 3% (n=81)

Has recruiting becomemore difficult in thepast year?

RNs

STs

Does your ASC hireRNs without ORexperience?

Do you offer ORtraining for nurses?

Do you routinely use overtime to staffyour ORs?

No42%

Often16%

Occasionally42%

No49% Yes

51%

No56%

Yes36%

Yes,elsewhere

34% Yes,at the ASC

66%

Yes23%

No77%

Fewer vacancies, lower turnover for ASCs

Ambulatory surgery centers(ASCs) continue to have low staffvacancies and turnover.

The 2006 annual OR Manager Salary/Career Survey for ambulatory surgerycenters was mailed in May to managersat 600 ASCs, with 112 surveys returned, arate of 19%. Results of the survey relatingto management, including salaries andbenefits, will be in the October issue.

In all, 67% of the ASCs report theyhave no vacant RN positions, and 79%have no vacant surgical technologist (ST)positions. The average number of posi-tions open is 0.6 for RNs and 0.3 for STs.Vacancy rates are 6% for RNs, and 5% forSTs.

ASCs have lower staff turnover ratesthan hospitals. The average RN staffturnover rate is 6.4 %, compared to 7.3%for hospitals. The ST turnover was 3.5%compared to 6.9%.

Although ASCs have fewer vacanciesand less turnover, ASC managers facedifficulties in recruiting.

About half, 51%, say recruiting staffhas become more difficult in the pastyear, and 77% report it is at least some-what difficult to recruit experienced ORnurses.

While two-thirds of hospitals are hir-ing new graduate nurses to fill vacantpositions, only 27% of ASCs report theyhire new graduates. Hospitals are alsomore willing to hire RNs without ORexperience (92%), compared to 58% ofthe ASCs.

A few changes between the 2005 and2006 ASC survey data:• 66% of ASCs offer OR training for

nurses, compared to 62% in 2005. • RN positions stay open an average of

9 weeks compared to 7 weeks in 2005,and ST positions are open an averageof 6 weeks compared to 5 weeks lastyear. v


hospitals around the country to recruitand retain baby boomer nurses, bornbetween 1946 and 1964. These hospitalsare on the American Association ofRetired Persons’ (AARP) 2005 list of BestEmployers for Workers over 50.

Here’s how hospitals are incorporat-ing the best practices to retain maturenurses:

Boost 401(k) participation andredefine pensions

Some hospitals automatically enrollemployees intheir 401(k)plan to encour-age employeesto save for re-tirement. Car-ondelet HealthNetwork inTucson, Ariz,switched froman employer-

controlled pension plan to a 401(k).“With the hospital’s matching funds,

the 401(k) outdid our pension plan,” saysCarol Martin, RN, MBA, director of peri-operative services. “Our associates (staff)like it much better because they can putin more money as they get older, andthey feel like they control their invest-ments.”

Scripps Health offers structured pen-sion plans as defined contributions withemployee after-tax contributions, whichallows employees to straddle retirementand employment. Scripps recently addedretiree health insurance to its benefitsand created a tax-free health account forretirees to save toward additional med-ical expenses.

Provide caregiving and griefresources

Workers age 45 and over may be car-ing for both children and parents.Offering support helps these caregiversto stay on the job, the RWJF report states.

Scripps Health provides a free servicethat researches elder care options foremployees’ parents, even if they areacross the country, Crisci says. Scrippsalso has a program to assist workers inplanning for personal needs at everystage of life, from increasing family timeand putting children through college tocaring for parents and protecting assets.

Bon Secours Richmond HealthSystem in Richmond, Va, subsidizes 50%of elder- and sick-child care. Employeescan receive home health care assistancefor dependents up to 10 days a year andsubsidized child care for grandchildren.

Carondelet Health Network offersgroup counseling support for employeeswho are widowed or divorced.

Create cultures that value themature worker

Hospitals that retain older workersview mature employees as resources tobe cherished, rather than liabilities to beminimized, the report states.

“Most of our corporate executives areseniors, so they value the mature work-er,” says Martin, who has worked forCarondelet for 35 years. She believesCarondelet is attuned to the experiencesolder employees can bring. “I frequentlyget called to give a history lesson aboutthe hospital.”

Bon Secours Richmond Health Systemincludes its director of senior services onthe diversity team, specifically to addresssenior employee issues.

Scripps Health has a program called“Crossing the Generation Chasm” to sen-sitize managers to working with variousage groups, including mature workers.

Crisci says her older nurses valuepublic recognition with awards andbirthday and work anniversary celebra-tions.

Flexible work optionsFlexible scheduling is a primary

incentive to delay retirement, managerssay.

“I schedule almost anything our olderworkers want,” Martin says. She offers 8-, 10-, and 12-hour shifts; full-time orpart-time employment; and job-sharearrangements where partners can splitthe day or week. Staff is paid a percent-

age of benefits based on hours worked.Carondelet also has a seasonal workerprogram that allows nurses to sign short-term contracts and work when they’re inArizona.

Employees who have worked atBeaumont Hospitals outside Detroit for15 or more years do not have to rotate tooff shifts. If they have worked there 20 ormore years they do not have to workweekends, holidays, or take call.

Knowledge transfer pairedwith phased retirement

Pinnacle West Capital Corporation inPhoenix has a knowledge-transfer pro-gram in which soon-to-retire employeestrain their replacements within a certaintime period. The retiring employees aregiven considerable flexibility in arrang-ing their work schedules.

In Carondelet’s ORs, retiring nursesserve as preceptors to new hires for 6months prior to retirement, particularlyin manager and clinical coordinator posi-tions, Martin says.

Magnet statusStudies show RNs working in hospi-

tals that have earned the AmericanNurses Credentialing Center’s magnetrecognition have higher rates of job satis-faction.

Baptist Health South Florida, whoseSouth Miami Hospital received magnetstatus in 2005, offers benefits attractive tothe older worker, such as elder-careresources and cash-outs on an elective oremergency basis for medical expenses,imminent loss of home, catastrophes(fires, floods, hurricanes), and vehiclepurchase or repairs. Employees also cancash out paid time off to purchase ahome or pay tuition for themselves orfamily members.

MentoringAt St Joseph’s Hospital in the Caron-

delet Health Network, preceptors men-tor new OR employees for 6 months,working the same schedules. After 6months, mentees are paired with a sea-soned associate for another 3 to 4months.

“I have the best retention in our sys-tem because of this preceptorship,”Martin says. “Our new nurses never feellike they’re going to be stranded. It maybe a little expensive, but it’s not nearly as



“

“View matureemployees as

resources to becherished.


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expensive as replacing personnel.” Scripps Health has a clinical mentor-

ship program in which mature nursesserve as resources for experienced andinexperienced staff. In exchange, the clin-ical mentors can schedule shorter, moreflexible shifts, which are less demandingphysically—a benefit for older nurseswith superior clinical skills.

Phased retirementOrganizations are developing ways

for older workers to leave the workforcegradually, such as reducing the numberof hours worked before full retirementwhile continuing to accrue benefits,rehiring retirees without affecting theirretirement benefits, or allowing tenuredemployees to collect full retirement bene-fits while continuing to work part-timeor at reduced hours.

St Mary’s Medical Center in Hunting-ton, WVa, allows workers in their finalyears of employment to reduce hourswithout decreasing their pension benefits.

Scripps Health allows employees age55 or older who have worked in the sys-tem at least 10 years to reduce work to asfew as 16 hours per pay period whilemaintaining full-time benefits. The costhas been offset by decreased turnover.Scripps also allows employees to draw ontheir pension fund while still working.

“Some nurses just aren’t ready toretire but want or need to cut back,”Crisci says. “Working keeps them men-tally and physically active, and theyenjoy the connections and camaraderiein the OR.”

Several managers say retirees provideOR lunch relief, cover breaks, or come inas needed when managers are in astaffing bind.

“We had a 69-year-old nurse whocouldn’t quite leave, so she would pre-pare specialty trays,” Martin says. “Thenshe taught nonmedical personnel how todo it, saving us money.”

Retirement planningThis best practice helps nurses with

retirement planning. Carondelet offers afree 12-week series on retirement andfinancial planning to help associates pre-pare for their future.

Talent managementThis best practice is an employer’s

assessment of the impact of projectedchanges in the workforce, according tothe RWJF report. For example, InovaHealth System in Fairfax, Va, attracts andretains top employees with help from aWeb-based talent management systemthat includes tools for applicant tracking,employee referral, career development,succession planning, performanceappraisal, and learning management.

Lifelong learning, professionaldevelopment

Employee development opportunitiesare one of the top ways to attract andretain older workers.

Ohio State University Medical Centeroffers Program 60+, which allows any-one over 60 to audit classes free ofcharge, and the Bridge Program, whichhelps older workers transition into col-lege.

Louden Healthcare Inc in Leesburg,Va, partners with George MasonUniversity to hold classes for a master’sin nursing at Louden’s facilities. BonSecours Richmond Health Systememployees can enroll in 50 differentclasses and development programs heldat varying times and locations to accom-modate individual schedules.

Workplace redesign andergonomics

Physical working conditions con-tribute to turnover and burnout, particu-larly in older nurses, The RWJF reportstates.

At Carondelet, booms suspendedfrom OR ceilings have been installed sonurses do not have to move as muchequipment. Two technical personnel intheir 20s move, clean, and placeendoscopy equipment. Patient transferdevices such as inflatable mattresses areused to move obese patients.

The University of Pittsburgh Medical

Center-Shadyside gives nurses noncellu-lar phones. Nurses receive the shiftreport by dialing a password-protectedvoice messaging system, saving everynurse 20 minutes per shift and returning$420,000 to bedside care, according to theRWJF report.

Scripps increased the type size in thenursing assessment record. The physio-therapy department offers in-servicetraining in the OR on proper lifting, bodymechanics, and foot care.

Some hospitals have installed betterlighting to decrease eye strain andimprove reading conditions for oldereyes. v

—Leslie Flowers

ReferenceWisdom at Work: Importance of the Older and

Experienced Nurse in the Workplace.Princeton, NJ: Robert Wood JohnsonFoundation, 2006. www.rwjf.org/files/publications/other/wisdomat-work.pdf



“

“Retiring nursesare preceptors to new hires.

Bariatric complicationsrise after discharge

Four of every 10 bariatric surgerypatients develop a complication such as ahernia within 6 months of leaving thehospital, according to the August issue ofthe journal Medical Care. Researchersfound the complication rate amongnonelderly bariatric surgery patientswith private insurance increased by 81%following hospital discharge—from 22%while they were still hospitalized to 40%after 6 months.

Many of the complications were soserious that patients were readmitted tohospitals or visited emergency roomswithin 6 months. Six-month medicalspending for patients who required read-mission averaged $65,031 compared to$27,125 for patients without readmission.The authors conclude that “a clear way toreduce the costs and improve outcomesof bariatric surgery is to address the highrate of postoperative complications.” v

—Encinosa W E, et al. Medical Care.2006;44:706-712. www.lww-medicalcare.com

Check our web site for the latest news, meetingannouncements, and other

practical help. www.ormanager.com

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Part of a series on the Surgical CareImprovement Project.

Physicians and nurses used to betaught not to worry about a glu-cose level of 200 mg/dL. “Now we

know what we were taught is probablywrong. We need blood sugars at muchless than that—less than 150 mg/dL andprobably less than 120 mg/dL,” saysYale University researcher Ronnie A.Rosenthal, MD, MS.

Patients with glucose levels above 200mg/dL have a high risk of postoperativeinfection, as reported in landmark studiesby Furnary and Van den Berghe.

Moreover, 20% of patients—1 in 5—coming in for surgery have diabetes butdon’t know it.

The Surgical Care ImprovementProject (SCIP) chose glu-

cose control as 1of 7 infection

control mea-sures, setting200 mg/dLor below as

the postopera-tive target level

for 6 am blood glucosein cardiac surgery patients (sidebar).

A positive step St Joseph Hospital in Lexington, Ky,

seized the opportunity to help other hos-pitals achieve better glucose control whenit joined SCIP’s pilot project in 2003.

Karen McKnight, RD, LD, director ofSt Joseph’s Diabetes Treatment Center,notes that the SCIP target of 200 mg/dLis much higher than what St. Josephstrives for but believes many hospitalsaren’t ready for tight control.

“The target of 200 mg/dl is a positivestep,” she says.

St Joseph’s goal matches recommen-dations of the American College ofEndocrinology (sidebar, p 25).

St Joseph worked on improving glu-cose control for 6 years before joining theSCIP pilot. McKnight, also chair of theInpatient Management Specialty PracticeGroup of the American Association ofDiabetes Educators, led a team thatdeveloped a basic inpatient surgery pro-tocol requiring anesthesiologists to checkblood glucose levels at least every 2

hours intraoperatively, whether thepatient has a diabetes diagnosis or not.Before, each anesthesiologist had proto-cols that varied with each patient basedon the anesthesia assessment.

“It seems almost radical to some ofthe physicians that we want to controlblood sugar so tightly. They learned intheir training to focus on hypoglycemiaprevention before we had this great bodyof evidence about the dangers of evenmild perioperative hyperglycemia,” saysMcKnight. “Our task is to share thenewer evidence and change our practicesto be evidence based.”

All patients known to have diabeteshave a fingerstick immediately beforesurgery, and almost all surgical patientshave a basic metabolic panel or othertesting that provides a glucose level pre-operatively. The anesthesiologist adjustsinsulin doses to regulate blood glucosebased on those results plus resultsobtained every 2 hours during surgery.

Even before SCIP, St Joseph empha-sized glycemic management for cardiacsurgery patients and implemented aninsulin drip protocol in the critical careunit. This protocol brings blood glucoselevels into the desired range of 80mg/dL to 110 mg/dL within 6 to 9 hourspostoperatively with less than 0.5%severe hypoglycemia.

Diabetes educators monitor hospital-wide blood glucose results. Whenpatients have 2 or more results over 180mg/dL or less than 70 mg/dL in 1 day,the educator reviews the care plan andmakes recommendations or calls thepatient’s physician for a change in thera-py. The educators also provide instruc-tions to nurses and physicians.

St Joseph has been able to justify thecost of the extra staffing because of the

reduced length of stay for diabeticpatients—from 6.6 days to 5.5 days.McKnight uses the hospital’s nondiabeticlength of stay as a benchmark becausenational measures are not yet defined.The targeted gap between diabetes and

Aiming for tighter glucose control Surgical Care Improvement

“

“Fear of hypoglycemia is the biggest

barrier.

SCIPSCIP

Landmarkstudies onglucose controlRisk of hyperglycemia

In a prospective study of 2,467 diabet-ic patients who had open heart surgicalprocedures between 1987 and 1997,researchers from the Providence HealthSystem, Portland, Ore, were the first toshow that hyperglycemia was the signif-icant risk factor for death, infection, andlength of stay in diabetic patients. Theywere also the first to show that eliminat-ing hyperglycemia with perioperativecontinuous IV insulin infusion preventsthese complications.

—Furnary A P, Zer K J, GrunkemeierG L, et al. Ann Thorac Surg.

1999;67:352-362

Benefits of insulin therapyA prospective controlled study by

researchers from Belgium randomized1,548 adults (diabetic and nondiabetic)admitted to a surgical intensive careunit to receive: • intensive insulin therapy (main-

taining blood glucose between 80mg/dL and 110 mg/dL) or

• conventional treatment (insulinonly if blood glucose level exceed-ed 215 mg/dL and maintainingglucose between 180 mg/dL and200 mg/dL).

Findings showed intensive insulintherapy:• cut mortality almost in half—from

8.0% to 4.6%• reduced bloodstream infections by

46%, acute renal failure by 41%,and blood transfusions by 50%.

—Van den Berghe G, Wouters P,Weekers F, et al. N Engl J Med.

2001;345:1359-1367


22

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nondiabetes length of stay is one-halfday or less. St Joseph has achieved a gapof 0.38 days.

Fear of hypoglycemiaPhysicians’ fear of hypoglycemia is

the biggest barrier to improved bloodsugar control. Rose Garcia, RN, BSN, car-diovascular ICU nurse at St Luke’sHealth System, Kansas City, Mo, advisesstarting slow, with 200 mg/dL as the tar-get, as SCIP recommends, to get physi-cians used to titrating insulin drips with-out worrying about hypoglycemia.

“The worry for physicians comeswhen you start narrowing it down below100 mg/dL because that is when you geta higher risk of hypoglycemia,” she says.

She recommends these targets fortightening glucose control:• 200 mg/dL or below for 5 months• 80 mg/dL to 150 mg/dL for 6 months• 80 mg/dL to 120 mg/dL as the opti-

mal target range.

“Buy-in is so crucial,” says Garcia.“When you start asking anesthesiologistsand nurses to do more work with hourlyor half-hour blood sugar draws, you hadbetter have the data to prove the benefitsof blood sugar control.”

Once the OR data started comingback, buy-in was easier, Garcia notes.Surgical site infections fell from 4.29 per100 patients in 2001 to 2.7 in the secondquarter of 2004, lower than the NationalNosocomial Infections SurveillanceSystem’s figure of 3.45.

Potassium shiftsAnother fear is hypokalemia. “You need an incredibly large buy-in

from the anesthesiologists because treat-ment with insulin causes hypokalemia,which puts patients at a significant riskfor developing arrhythmias that are diffi-cult to treat,” advises Dr Rosenthal, asso-ciate professor of surgery at YaleUniversity School of Medicine and chiefof surgery at VA Connecticut HealthcareSystem, West Haven, Conn.

“You have to get the anesthesiologistsover the hurdle of potassium shifts,” shesays. “You have to get them to understandthat giving insulin is not only safe but ben-eficial. This is why it is wise to start offwith protocols that allow higher bloodsugars and lower amounts of insulin.”

Perioperative protocolsBefore developing its glucose control

protocols, St Luke’s gathered a task force,including the cardiac surgery pharmacist,medical director, a cardiac surgeon, a dieti-cian, the infection control specialist, thequality and practice chairmen, an endocri-nologist, and the clinical nurse manager.

The task force recommended basingthe glucose control protocols on thePortland Protocol developed by AnthonyFurnary, MD, lead author of one of thelandmark studies. The protocol is a finely

tuned set of orders for IV insulin infusionfor use in the ICU and patient care units(www.providence.org/Oregon/Programs_and_Services/Heart/portlandproto-col/default.htm).

St Luke’s protocol requires an insulindrip to be started in the preoperativeholding area for:• diabetics with a blood glucose of 150

mg/dL or more• nondiabetics with a blood glucose of

more than 200 mg/dL. The anesthesi-ologist checks blood glucose forpatients on an insulin drip every 30minutes during surgery.Before the new protocol was imple-

mented, physicians did not treat patientswith insulin unless their blood glucosewas more than 250 mg/dL.

Cardiac surgery protocolFor cardiac patients, glucose levels are

checked hourly as well as before, during,and after cardiopulmonary bypass.

Cardiac patients are especially proneto hyperglycemia, Garcia notes, becauseof:• the stress of the surgery • mechanical ventilation• vasopressor therapy• corticosteroid therapy for chronic

obstructive pulmonary disease (COPD)• decreased physical activity• glucose in the cardioplegia fluid.

When the new protocol was imple-mented, anesthesiologists discoveredglucose spikes of up to 500 mg/dL whenthe cardioplegia solution was injectedinto the heart.

They asked the surgeons to take theglucose out of the cardioplegia solution.All surgeons did but one, who didn’tbelieve it had any effect. He was con-vinced when he was shown that hispatients were the only ones with spikesin glucose levels. He finally agreed totake the glucose out also.

The cardiovascular program’s qualitychairperson monitors infection rate data aswell as blood sugars on postoperative days1 through 3, sending a report to physiciansand nurses every 6 months.

Discovering undiagnoseddiabetics

Through its testing, St Luke’s hasfound at least 20% of surgery patients areundiagnosed diabetics.

Surgical Care Improvement

“

“You had betterhave the data to prove the

benefits.


SCIP targetsglucose control

This article is the fourth in a seriesfocusing on the Surgical CareImprovement Project (SCIP). SCIP tar-gets 4 broad areas:• surgical site infections• adverse cardiac events in patients

having noncardiac surgery• venous thromboembolism• perioperative ventilator-related

pneumonia.

SCIP process measureGlucose control is one of the mea-

sures for preventing infections. Themeasure is:• Cardiac surgery patients with con-

trolled 6 am postoperative serumglucose.

Previous articles discussed antibiot-ic prophylaxis (April 2006), venousthromboembolism prevention (May2006), and using computerized data toguide OR QI (June 2006).

More information on SCIP is atwww.medqic.org/scip.


24

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When St Luke’s began its new proto-col, the task force recommended havinga hemoglobin A1c (HbA1c) drawn pre-operatively on all surgical patients. Thistells them not only if a diabetic’s glucoselevel is controlled but also if a patient isan undiagnosed diabetic. Results in the7% to 8% range trigger an automaticendocrinology consult.

In a new report published in April2006, Dr Rosenthal, Melissa Perkal, MD,and colleagues found a strong associa-tion between a patient’s preoperativeHbA1c level and postoperative infectionsin diabetic noncardiac surgery patients.

An HbA1c level <7% was significantlyassociated with decreased postoperativeinfectious complications.

“We now draw an HbA1c on allpatients preoperatively,” says Dr Perkal,assistant clinical professor at YaleUniversity and assistant chief of surgeryat VA Connecticut.

“If the preoperative clinic coordinatorsees that an elective surgery patient has ahigh HbA1c of 9% or 10%, the patient issent back to the primary care physician,and surgery is delayed until the patient’sblood glucose is corrected.”

Though anesthesiologists check everydiabetic’s glucose frequently duringsurgery, this hasn’t been the case for non-diabetics, says Dr Perkal, though it isknown that about 30% of hypergly-cemics are not identified as diabetics.

All patients are routinely tested forglucose in the holding area after theyhave their IV placed so they don’t needan additional needle stick. If the HbA1cis at a certain level, the anesthesiologistsgive them insulin during the case andcheck their glucose levels.

Who will follow up?A sticking point for anesthesiologists

is who will follow up on the insulin theygive during surgery.

“This is not just a situation for a fewhours in the perioperative services—ithas to be followed up or the patientcould suffer,” says Dr Perkal.

In June 2005, she and her colleaguesjoined the Institute for HealthcareImprovement’s reducing surgical siteinfection initiative, which includes pre-operative glucose control (www.ihi.org).

“We’re almost there, but our formalresponse to an elevated glucose is notprotocol driven yet,” says Dr Rosenthal,noting that an anesthesia champion isneeded to help achieve that. v

—Judith M. Mathias RN, MA

ReferencesFurnary A P, Zer K J, Grunkemeier G L, et

al. Continuous intravenous insulin infu-sion reduces the incidence of deep ster-nal wound infection in diabetic patientsafter cardiac surgical procedures. AnnThorac Surg. 1999;67:352-362.

Van den Berghe G, Wouters P, Weekers F,et al. Intensive insulin therapy in thecritically ill patient. N Engl J Med.2001;345:1359-1367.

Dronge A S, Perkal M F, Rosenthal R A, etal. Long-term glycemic control andpostoperative infectious complications.Arch Surg. April 2006;141:373-380.

Najarian J, Swavely D, Wilson E, et al.Improving outcomes for diabeticpatients undergoing vascular surgery.Diabetes Spectrum. 2005;18:53-60.

Surgical Care Improvement

“

“Who will follow up

on the insulin?

Glucose controlrecommendations American College ofEndocrinology

Recommendations for upper limitsfor glycemic targets:• maximum of 110 mg/dL for critical

care patients• maximum of 110 mg/dL before

meals and never more than 180mg/dL for noncritical carepatients.—American College of Endocrinology

Position Statement on Inpatient Diabetesand Metabolic Control. Endocrine

Practice. Jan/Feb 2004;10:77-82.www.aace.com/pub/positionstatements/

Consensus conference The American Association of

Clinical Endocrinologists, AmericanCollege of Endocrinology, andAmerican Diabetes Association met ata consensus conference in January2006 to develop strategies for manage-ment of hospitalized adults with highblood glucose. Facts from the confer-ence include:• Blood glucose readings need to be

reduced to less than 110 mg/dL.• 1 of 3 people with diabetes are

unaware of their condition.• 30% to 40% of heart surgery

patients have diabetes.• Fear of hypoglycemia is a major bar-

rier to improving glycemic control.—www.aace.com/meetings/consensus/

IIDC/IDGC0201.pdf


More data onsurgical quality

Starting in 2007, hospitals will beasked to provide data on more qualitymeasures for surgery and other aspects ofcare to the Hospital Compare web site.

On surgery, hospitals will be asked toreport steps taken to prevent venousthromboembolism, surgical-site infec-tions, and postoperative heart attacksand pneumonia. Also being added aremeasures for patient experience such ascaregiver responsiveness and hospitalcleanliness, mortality rates, pediatricasthma, and intensive care.

Hospital Compare, which providesinformation for consumers, is a project ofthe Hospital Quality Alliance, a public-private partnership of 19 organizations,including hospitals, the federal govern-ment, and other groups.

Hospitals are required to report onquality measures to receive a full updatein their inpatient payments. CMS is alsoproposing to introduce quality measuresfor hospital outpatient services. v

—www.HospitalCompare.hhs.gov

Have an idea?Do you have a topic you’d like to see

covered in OR Manager? Have you completed a project you think wouldbe of help to others? We’d be glad to

consider your suggestions. Please e-mail Editor Pat Patterson at

[email protected]

26

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The government on Aug 8 issued aproposal for revamping ambulatorysurgery center (ASC) payments. The

new system, to start in 2008, would pegASC payments to hospital outpatient ratesand expand the list of procedures approvedfor Medicare payment in ASCs. Thereforms are designed to make paymentsmore accurate without costing Medicaremore, according to the Centers forMedicare and Medicaid Services (CMS).Updates were also proposed for 2007.

“The goal is to help Medicare benefi-ciaries get care in the most appropriatesetting by addressing payment differencesthat may favor one setting over another,”CMS Administrator Mark McClellan,MD, PhD, said at a press conference.

But ASC leaders are dismayed thatMedicare is proposing to pay ASCs only62% of what hospitals would get for thesame procedures.

The Federated Ambulatory SurgeryAssociation (FASA) said the proposedreimbursement rate “will put a damperon ASC services,” causing Medicare bene-ficiaries to “lose access to the patient-cen-tered care ASCs provide.”

FASA said it is particularly concernedabout single-specialty ASCs that special-ize in GI and pain management proce-dures. Such procedures are now paid atabout 89% of the hospital rate.

“Dropping that to 62% would be ahuge cut,” and a single-specialty centercouldn’t make up for it with other proce-dures, says Kathy Bryant, FASA’s presi-dent. She said it also would be a signifi-cant issue for patients because these arehigh-volume procedures, and pushingthem back into the hospital could causecapacity problems.

The American Association of Ambu-latory Surgery Centers (AAASC) said theproposal “would have a chilling effect” onASCs that focus on Medicare patients. Itsays the reimbursement rate is set too low,and the plan “falls far short” of givingMedicare patients the choices commer-cially insured patients have.

Highlights of the proposals:

Expanded list of ASC proceduresIn a move long-awaited by the ASC

community, Medicare would greatlyexpand the procedures approved for ASCpayment.

• For 2007, 14 procedures would beadded to the current list (see list, p 30).Among these are transcatheter place-ment of intravascular stents (exceptcoronary, carotid, and vertebral vessel)and some vertebroplasties.

• For 2008 and beyond, CMS would takea new approach, excluding from ASCpayment only surgical procedures thatpose a significant safety risk or requirean overnight stay. Procedures exclud-ed would include those involvingmajor blood vessels, major or pro-longed invasion of body cavities, sig-nificant blood loss, or proceduresdefined as inpatient only in the hospi-tal outpatient prospective paymentsystem. That would mean about 750 more pro-

cedures would be eligible for ASC pay-ment. But two-thirds, or about 500, areperformed mostly in physicians’ offices,CMS notes. To make sure Medicare isn’tpaying ASCs more for procedures thatcould be done safely in physicians’ offices,CMS would limit ASC payments for thoseprocedures to the physicians’ office rate.

“We definitely think this [approach] isa step in the right direction,” Bryant says,noting FASA was still analyzing the crite-ria CMS proposes for exclusions and not-ing that the safety of procedures canchange over time. ”We don’t know ifthese are good criteria. We would ratherhave a more flexible approach.”

Lee Anne Blackwell, RN, BSN, EMBA, CNORNational director, clinical education,ambulatory surgery division, HealthSouthCorporation, Birmingham, Ala

Nancy Burden, RN, MS, CAPA, CPANDirector, health services, Morton PlantMease Health Care, Clearwater, Fla

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

Rebecca Craig, RN, BA, CNOR, CASCAdministrator, Harmony AmbulatorySurgery Center, LLC, Fort Collins, Colo

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

Ann Geier, RN, MS, CNOR, CASCVice president of operationsAmbulatory Surgery Centers of AmericaNorwell, Mass

Rosemary Lambie, RN, MEd, CNORNurse administrator, SurgiCenter ofBaltimore, Owings Mills, Md

LeeAnn PuckettMaterials manager, Evansville SurgeryCenter, Evansville, Ind

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

Ambulatory Surgery Advisory Board

ASCs dismayed over new payment plan

See ASC staffing survey results, p 15.“

“The plan will put a

damper on ASCservices.


28

Please see the ad for GETINGE/CASTLE INCin the OR Manager print version.


AmbulatorySurgery Centers

Revised ASC payment systemThe new ASC payment system would

be launched Jan 1, 2008, as required in the2003 Medicare Modernization Act, proba-bly with a 2-year transition. CMS propos-es basing ASC rates on the hospital outpa-tient prospective payment system, usingweights. The ASC weights would be mul-tiplied by a conversion factor to come upwith the payment rate.

The new ASC system, like the hospitaloutpatient system, would use ambulatorypayment classifications (APCs). But ASCpayments would be lower than hospitaloutpatient payments for the same proce-dures, “recognizing the lower costs associ-ated with performing procedures in theASC setting,” CMS says. CMS says ASCshave lower costs because they don’t haveto maintain emergency departments, meetfederal regulations for emergency care,and operate 24 hours a day 7 days a week.

For 2008, the revised ASC rates wouldwork out to be 62% of the hospital outpa-tient rates, CMS estimates.

FASA says this is not enough for someASCs to stay in business, and that willcost Medicare because more patients willneed to have their procedures in the hos-pital, which is a more costly setting.

FASA favors a plan introduced by SenMike Crapo (R-Idaho) and Rep WallyHerger (R-Calif) that recommends ASCrates be 75% of hospital outpatient rates,among other changes.

FASA plans to work with CMS andCongress over the next year “to makesure we get the new payment systemright,” Bryant says.

More specifics of the proposed changes:• ASC payment groups would expand

from the current 9 groups to the same221 APC groups used for hospital out-patient payments.

• ASC payment rates under the expand-ed list would range from $3.68 to$16,146, compared with the range of$333 to $1,339 under the current pay-ment structure.

• For 2008, CMS proposes phasing in thenew ASC payment rates as a 50-50blend of the 2007 and 2008 payment

rates. The new ASC payment systemwould be fully implemented in 2009.Starting in 2010, the ASC conversionfactor would be updated using theConsumer Price Index.

• Medicare patients would continue tohave a 20% copay for ASC facility ser-vices.

Other proposed changes for 2007

The proposed rule would also:• carry out a requirement of the Deficit

Reduction Act of 2005 to cap 2007 ASCpayment rates for procedures at thehospital outpatient rate for the sameprocedure. (A study found ASCs werepaid more for some procedures thanhospitals.)

• continue the current $50 add-on pay-ment for approved new technologyintraocular lenses (NTIOLs) over 5years after the effective date for anactive NTIOL class. CMS also propos-es changes in the process for establish-ing new classes of NTIOLs furnishedwith cataract surgery in an ASC,including incorporating the processinto the annual update for outpatientpayments. v

The proposed rule was scheduled to appear inthe Aug 23 Federal Register. Comments onthe ASC payment plan are due by Nov 6.

Continued from page 27Procedures proposed foraddition to ASC list for 2007

ASC pay CPT Short descriptor group

13102 Repair wound/lesion add-on 113122 Repair wound/lesion add-on 113133 Repair wound/lesion add-on 119297 Place breast cath for rad 921356 Treat cheek bone fracture 322520 Percut vertebroplasty, thor 922521 Percut vertebroplasty, lumb 922522 Percut vertebroplasty, addl 135476 Repair venous blockage 936818 AV fuse, upper arm, cephalic 337205 Transcath IV stent, percut 937206 Transcath IV stent,

percut, addl 143761 Reposition gastrostomy tube 146946 Ligation of hemorrhoids 1

Share your successes at the con-ferences of OR Manager, Inc. Sendproposals of about 500 wordsdescribing the session you wish topresent. Sessions are approximately11⁄4 hours long.

Managing Today’s OR Suite Oct 4 to 6, 2007San Diego

Managing Today’s OR Suitefocuses on practical topics relatedto management of surgical services,such as achieving greater efficiency,management of information, lead-ing and developing staff, and keep-ing costs under control.

The keynote address and generalsessions feature nationally knownspeakers who have important mes-sages for surgical services directors.If you wish to suggest a general ses-sion speaker, please obtain as muchinformation about the person asyou can, such as the speaker’s title,organization, address, and phonenumber.

OR Business ManagementConferenceMay 9 to 11, 2007Savannah, Ga

The OR Business ManagementConference emphasizes financialmanagement, materials manage-ment, OR technology/equipmentmanagement, and OR design andconstruction.

The deadline for proposals andsuggestions for both conferences isNov 1.

Fax or e-mail proposals to BillieFernsebner, RN, MSN, educationdirector, OR Manager, Inc, at303/442-5960 or [email protected]. (Please do not sendPowerPoint presentations.)

If you have questions, please call303/442-1661. v

Sharesuccesses at2007 meetings


AmbulatorySurgery Centers

Retaining staff and building a happyteam doesn’t have to break thebank. There are many inexpensive

ways to recognize and reward staff inambulatory surgery centers (ASCs) forjobs well done. The key is to know yourstaff and what motivates them, says JudyGrimaldi, MBA, administrator of GoldenTriangle SurgiCenter in Murrieta, Calif.

Grimaldi recommends asking staff towrite down 6 ways they would like to berewarded. The only stipulation is that halfthe ideas need to be low or no cost.

“Our relationships with staff are justlike any other relationship—they takeeffort and attention,” Grimaldi says.“Dollar for dollar, ambulatory surgerycenters save more money by rewardingand recognizing good employees than byreplacing them.”

Grimaldi led a session on inexpensivereward and recognition ideas at the 2006Federated Ambulatory SurgeryAssociation annual meeting in May inOrlando, Fla. These are her ideas andthose offered by session participants:

Free rewards and recognition• Offer a balanced work-family environ-

ment with flexible scheduling options.• Facilitate and support career goals.• Post positive comments from patient

satisfaction surveys/comments.• Say thank you, often.• Recognize exemplary staff members as

the employee of the month.• Be a good listener—be open to staff

ideas and validate their concerns.• Devote a board or area for staff to share

hobbies, recipes, and pictures of kidsand pets.

• Post newspaper clippings aboutemployees’ or their family members’accomplishments, such as Little Leaguegames or high school graduations.

• Hold regular staff meetings to commu-nicate company news and listen to con-cerns.

• Offer a casual or theme dress day—allow staff to wear the local team’s col-ors and jerseys.

• Ask employees for the name of some-one in the company they’d like to meetand arrange the introduction.

• Allow employees to choose from a listof potential projects, assignments, andtasks they believe will enrich theirwork.

• Provide a WOW (What OutstandingWork) box near the time clock for staffto nominate each other for recognition.

• Pay for ASC purchases on a credit cardthat offers airline miles and give freetickets to deserving employees.

Low-cost rewards• Give away movie, manicure or pedi-

cure, lunch, coffee shop, grocery, andhome improvement store gift certifi-cates.

• Celebrate birthdays with a monthlycake and signed card for each recipient.

• Recognize national observance dates.• Give flowers—Sam’s Club and Costco

sell bouquets for less than $20.• Bring in continental breakfast.• Supply sundry items in locker rooms—

deodorant, hair spray, shampoo, mois-turizer, cotton balls, and Q-tips.

• Provide snacks and soft drinks.• Make extra gifts bags that you give to

referring surgeons’ and physicians’offices and give them to staff.

• Create a year-in-review album that dis-plays staff achievements at the ASCover the year.

• Give plaques, certificates, pins, or pen-dants at staff meetings or annual staffgatherings.

• Provide company shirts, hats, or otherlogo apparel or accessories.

Moderately priced recognition• Offer in-house wellness and self-care

seminars.• Send staff to outside seminars they

want to attend.• Pay for staff gatherings, such as sport-

ing events, picnics, or happy hours.• Provide personal trainer sessions at

work.• Offer at-work massages.• Provide a catered lunch.• Give event tickets (concerts, theater,

sports, amusement park, and fairs).• Provide a computer in the break room

for personal use during breaks.• Give get-out-of-work free cards, which

can be redeemed to leave work early.• Give coupons for yoga, Tai-Chi classes,

or other wellness-related activities.

Higher priced rewards• Offer a company day at the races,

amusement park, ball game, or winetasting.

• Give away a spa day.• Provide lunch for staff regularly.• Throw a company party.• Offer the company-owned sports box

seating.• Collect the WOWs (see free ideas

above) and periodically draw a winnerwho gets dinner for 2, movie tickets,and an overnight hotel stay.

• Rent a movie theater or game hall forstaff and their families. v

—Leslie Flowers

Resources Staffing.org. This independent nonprofit pro-

vides information and tools to helpimprove the performance of people andwork. www.staffing.org

Inexpensive ideas to keep staff happy

“

“Our relationships

take effort andattention.

31

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in the OR Manager print version.


P O Box 5303Santa Fe, NM 87502-5303


The monthly publication for OR decision makers Periodicals

Hospitals band together onwristband colors

Eleven hospitals in Pennsylvaniahave developed a model for safe practicein the use of colored wristbands. Thetask force formed last year after a patientnearly was not resuscitated after a nurseincorrectly gave the patient a coloredwristband that meant “do not resusci-tate.” The nurse worked at several facili-ties and was confused about the color.

The task force established these wrist-band colors:• red = allergy• yellow = fall risk• green = latex allergy• blue = do not resuscitate• pink = restricted extremity.

Safe practices the task force adoptedare:• limiting the spectrum of color-coded

wristbands and standardizing themeanings associated with each color

• purchasing wristbands with preprint-ed embossed text rather than relyingsolely on color to communicate themeaning

• avoiding handwriting on the bandexcept in emergency situations

• allowing only nurses to apply orremove wristbands

• agreeing that labels or stickers used inthe medical record to communicatethe same risk factors as the wrist-bands will use corresponding colorsand text

• prohibiting non-health care wrist-bands in the health care settings, with

nurses removing them (or coveringthem when patients do not consent toremoval) on admission.An implementation manual, The Color

of Safety, and other tools are on the website of the Pennsylvania Patient SafetyReporting System.

—www.psa.state.pa.us. Look under Advisories.

Adverse anesthesia effectsmore likely late in the day

Cases that start in the late afternoonand early evening have a higher proba-bility of adverse effects from anesthesiathan cases that start in the morning andearly afternoon, in a new study fromDuke University. The most frequentadverse events are pain and postopera-tive nausea and vomiting. Delays alsowere more common in the afternoon.The effects may result from patient-relat-ed factors as well as caseload, fatigue,and care transitions, say the authors. Thestudy involved analysis of more than90,000 records from Duke’s perioperativedatabase.

—Wright M C, et al. Qual Saf HealthCare. 2006;15:258-263. www.qshc.com

Debate over physician trainingfor new devices

Different training protocols, such asthose offered for implantable defibrilla-tors, are “at the center of a growing andcontentious debate,” according to theAug 1 New York Times. The HeartRhythm Society has set voluntary guide-

lines for training for implantation of thedevices. Device makers also offer freetraining, which may or may not meet theguidelines, prompting “concerns aboutpossible conflicts of interest,” becausephysicians may then decide to use thecompany’s product. The issue is impor-tant for hospital credentialing commit-tees, which decide what training torequire. The federal government hasbegun collecting data to determine if thecomplication rate differs for electrophysi-ologists and other physicians whoimplant the devices.

—www.nytimes.com

Associated Press saysreprocessing story was incorrect

The Associated Press (AP) on Aug 11said its July 30 story about reprocessingof single-use devices used incorrect dataon harm caused by reprocessing.

The AP says it relied on “erroneousinformation” from the Food and DrugAdministration (FDA) in reporting thatsince early 2004, the FDA had received13 reports of patient deaths and 421 trou-ble reports, including 130 involving seri-ous patient harm.

In its correction, the AP said it wasinformed by the FDA that “contrary toits initial report, no patient deaths werecaused by reprocessing of single-usedevices, and fewer than 10 seriousinjuries and fewer than 10 device mal-functions were attributable to reprocess-ing single-use devices during that peri-od.” v

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