Letters & E-mails

Scalpel Safety, Not Safety Scalpels
Sharps safety equals a safety device plus a safe work practice.
Re: "Make the Switch to Safety Scalpels" (September, page 69). A safety scalpel is safe only if and when the safety feature (retractable blade) is activated. To make doubly sure, the best sharps safety program would combine a safety device with a safe work practice of using a passing tray or neutral zone. If this practice is accepted, as a manufacturer we will be able to make devices that both better satisfy the surgeon and are safer than the traditional scalpel.

Furthermore, defining safety and trying to apply this definition to a number of products — syringes, suture needles and scalpels — is very restrictive in formulating the design inputs for each device. It would be more accurate to evaluate safety issues for each device type and base safety requirements on this evaluation. As an example, the sliding blade guard is a disincentive to implementing passing trays because it is assumed that the scalpel has a feature that renders it safe when passing. But what if the feature is not activated? When a surgeon makes a stab incision during an arthroscopy and twists the blade when removing it, the blade can break. What about this safety issue?

Panda Kerr
Managing Director
Jai Surgicals Limited
New Delhi, India
[email protected]

Ban Clothing in Surgery Suites
I'm concerned that in the interest of saving time, some surgical centers are taking patients back into a sub-sterile and sterile environment where surgeries are performed in their clothes. The AORN Recommended Practice for Surgical Attire states that "all individuals who enter the semi-restricted and restricted areas of the surgical suite should wear freshly laundered surgical attire for use only within the surgical suite."

Surgical attire is worn to minimize the potential for contamination. It has been my experience that all personnel in surgery, either in a hospital or ASC, wear scrubs and not street clothes into the semi-restricted and restricted areas of the operating room for this purpose.

In a setting where no surgical procedures are done, allowing a patient to come into a room where a procedure is done in their clothes may be acceptable practice. In an environment where surgery is done and patients may also receive implants, it is not acceptable.

We live in a time where patients can have CA-MRSA, be carriers of MRSA because they live or work in an environment with MRSA, VRE and C-difficile and not be aware they are carriers. Also, Medicare may not reimburse for infections acquired in hospitals in 2009. I believe this will carry over into ASCs as well.

I encourage every center to look at its practices. We are here to serve our patients and we should strive to follow best practices for their safety. I question whether it is good practice to allow patients to wear their street clothes into the operating suites.

Dawn Bisceglia, RN
Director
Microsurgical Spine Center
Puyallup, Wash.
[email protected]

For the Record
Re: "Booms Done Right" (September, page 44). The clear height to hang a boom is a minimum of 14 feet from floor-to-deck, not floor-to-ceiling. Floor-to-deck refers to the height from the finished floor (concrete) of the OR to the bottom of the floor or slab (concrete) for the next floor/pan above.

Re: "3 Steps to Right-sizing Your Suture Stock" (Manager's Guide to Surgical Supplies, October, page 4). The suture purchase of 12 boxes mentioned on page 5 refers to an annual purchase, not monthly. Go to www.outpatientsurgery.net/resources/forms for a corrected version of the article.

Re: "Prepping for Success" (Manager's Guide to Surgical Supplies, October, page 10). The author mentions only povidone-iodine, implies that there are no meaningful differences between preps and recommends that readers use the least expensive one. Although there is no research to show that one surgical prep is more successful than another at preventing surgical site infections,[1,2] there are significant differences between active ingredients in preps:

• Alcohol. This is the top performer for immediate efficacy. Alcohol is best known for its ability to destroy bacterial pathogens effectively and quickly. It can't be used on mucous membranes or near the eyes. Alcohol does not continue to actively kill bacteria after it dissipates from the skin. However, bacteria regrow at a slowed pace. It is also flammable.
• Chlorhexidine gluconate. CHG typically takes longer than alcohol to achieve the bacterial kill rate deemed acceptable by FDA. However, CHG is known for its persistence. It binds to the skin and remains active — providing prolonged bacterial kill. Like alcohol, CHG cannot be used on mucous membranes or near the eyes.
• Chloroxylenol. PCMX acts with moderate speed against bacteria and also has some persistent effects. A primary advantage is that it is safe for mucous membranes. It is non-toxic and has a low potential to induce allergic reaction.
• Povidone-iodine. Povidone-iodine can take up to 3 minutes to achieve an acceptable microbial kill level, although manufacturers' test results vary depending on the formulation and other factors. It has moderate persistence. Depending on the concentration, povidone-iodine solutions can be safe for mucous membranes. Allergic reactions are possible and povidone-iodine can be inactivated by blood or serum proteins.

Other considerations include the number of application steps, application time and drying time. Preps can take from 30 seconds to 5 minutes to apply; some need up to 3 minutes to dry on the skin. Cost, staining and removal procedures are also potentially important factors. For detailed information on the characteristics of surgical preps, which may include more than one active ingredient, see the pullout poster in our February 2005 issue.

References
1. Edwards PS, et al. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2004;3:CD003949.
2. Fletcher N, et al. Prevention of perioperative infection. J Bone Joint Surg Am. 2007;89:1605-18.

Standing Up to Cuts
Re: "Can GI Pass its Toughest Test?" (September, page 34). The strategies outlined in the article are important in dealing with the CMS cuts. However, all of those items should have been addressed and managed since inception of a GI center, multispecialty ASC or even a hospital OR. Day-to-day competent management of an ASC requires a daily commitment to managing staff, supplies, vendors, physician schedules and managed care contracts. Only ASCs or GI centers that are either poorly managed or lack volume will possibly suffer from the CMS payment cuts. However, those two problems are able to be fixed. I see the payment cuts as an opportunity to fine-tune a center's ability to function within a shifting market. The three GI centers that I man will not suffer. I admit the bottom line will be hit, but the doors will not close.

Rod Carbonell, RN
Regional Administrator
Nueterra Healthcare
Kansas City, Mo.
[email protected]

Physician-owned Hospital in Harm's Way
The Children's Health and Medicare Protection Act of 2007, which is intended to expand access to health care for low-income children, includes a poorly drafted provision that may result in the elimination of health care for thousands.

Buried in the bill is Section 651, "Limitation on Exception to the Prohibition on Certain Physician Referrals for Hospitals." In non-lawyer language, the bill states that physicians who have an ownership interest in a hospital would be prohibited from referring patients to that hospital. Supporters of Section 651 argue that it's needed because some physician-owned "boutique" hospitals in urban areas are attracting higher-paying patients away from community hospitals, threatening the existence of community hospitals.

Unfortunately, instead of limiting the prohibition to physician-owned specialty hospitals, the bill would apply to any physician-owned hospital, including an acute care facility such as Wenatchee Valley Hospital. The 20-bed hospital in central Washington is 100 percent owned by physicians who make up the Wenatchee Valley Medical Center.

Section 651 would require our hospital to reduce its physician ownership to less than 40 percent. If the target is not met within 18 months, we forfeit our ability to treat Medicare and Medicaid patients. Should we not meet the 40 percent threshold, we would be prohibited from adding beds or surgical suites to meet demands. As Medicare and Medicaid revenues make up 62 percent of our annual budget, we can ill afford to be shut out of either program. More important, the patients who rely on us for quality health care cannot afford to lose this access.

Wenatchee Valley Medical Center is a group practice of 170 physicians providing medical services throughout 12,000 square miles of very rural north central Washington. Last year we served more than 150,000 patients. WVMC physicians account for the vast majority of referrals at regional community hospitals, as well as a majority of admissions at Wenatchee Valley Hospital.

Unless the language is changed, the medical center may be collateral damage in a health industry squabble being waged in other parts of the country. Because of our critical mass, we've been able to recruit specialists and sub-specialists who would have gone elsewhere. Last year we provided $2.4 million in free care to low-income patients. We operate four federally certified rural health clinics.

As a for-profit hospital, last year we paid more than $4 million in taxes to all levels of government.

Unless Section 651 is changed to let Wenatchee Valley Medical Center continue under its current corporate structure, we will, at a minimum, have to undergo a major restructuring. It could result in dozens of physicians deciding to leave the region. We could be forced to close our primary care clinics in the outlying underserved communities.

How ironic it would be that a bill that ostensibly is intended to improve access to health care for low-income children would do so at the expense of thousands of people living in north-central Washington.

The 1,200 employees of the Wenatchee Valley Medical Center are proud of the quality health care they provide. We urge our state's congressional delegation to find a solution that improves healthcare coverage for low-income children, and allows the Wenatchee Valley Hospital to continue to operate and grow as a physician-owned hospital.

David L. Weber, MD
CEO and Board Chairman
Wenatchee Valley Medical Center
Wenatchee, Wash.
[email protected]