The Safety of Multi-Dose Vials

November 7, 2014 Leave a comment

It has long been embraced in the healthcare industry that using multi-dose vials is cost-effective and saves the organization lots of money. Some healthcare providers will argue that they are safe. ..that safeguards in place in the organization deem the possibility of an infection contacted from the use of multi-dose vials to be remote. The argument is presented over and over and over in many institutions. However, evidence refuses to support these arguments.\

It is true that multi-dose vials do, in fact, contain common preservatives that are effective against most bacteria. However, these same preservatives are NOT ant-viral. Furthermore, the true hazard lies in the potential for contamination with multiple penetrations of the protective seal/lid/stopper. According to a paper published by Barbara DeBaun, RN, MSN, CIC contaminating pathogens can live for longer than two hours in the container before the preservative “kicks in”. It is possible, according to Ms. DeBaun, that endotoxins survive even after the preservative inactivates the organism.

Faulty aseptic technique is the leading cause for contamination in MDVs. It has been reported that 25% of practitioners reentered a vial with a needle that had been introduced into a patient. At the least, it is common to see the provider use a needle to administer the medication into an IV line, then stick the needle and syring back into the vial awaiting the next dose. Nursing staff report numerous incidents of contamination of MVDs especially by the anesthesia providers in the OR or Procedure Room. Some studies show the incident of contaminated vials to be as high as 27%. In the face of this totally unacceptable statistics, anesthesia providers, especially,continue to refuse to follow protocal It is the responsibility of the nurse circulator in the room to monitor the use of the MVDs and to report on an incident report breaks in technique in using these containers.

When discussing infections and the use of MVDs, HCWs tend to look only at stopper penetration. Stopper penetration is, of course, crucial to maintaining the sterility of the contents of the container. No MVDs should be used without a transfer device to minimize the number of stopper penetrations. Everytime the stopper is penetrated there is an increased risk of contamination. Surveyors have reported seeing stoppers with so many penetrations as to look like the stopper is mesh. Again, a transfer device MUST be used for MVDs.

Other considerations for the safe use of MVDs has to do with storage. This author noted in one center that in the medication room, half of the inventory of a specifice MVD medication was stored in a cupboard while the remainder was divided between the drug refrigerator and the anesthesia cart. Care must be taken to identify the correct storage requirements for all medication and to follow those carefully.

Labeling MVDs becomes crucial, and yet, surveyors continue to find containers where there is no label, or where the outdated medication is still in circulation. Arguments may be that it is just the preservative and not the medication. Say what?????

Some of the pathogens identified in contaminated MVDs include:

  • HIV, hepatitis B and C, staph aureus, klebsiella pneumonia, streptococcus A, serratia marcescens, pseudomonas aeruginosa and candida albicans.

Lipoid medications such as propofal are more likely to be associated with outbreaks than others followed by preservative free medications. One contaminated vial can lead to widespread outbreaks. Protection of our patients is the primary responsibility of the staff in any healthcare setting. This is not the place to note that the anesthesia provider stuck the syring and needle back into the MVD and left it there after administering the drug into the IV line. This “one little time” could be deadly—and we all know there is no such thing as “this one little time”

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IMPORTING EBOLA

October 8, 2014 Leave a comment

In 2005 CDC and WHO put us on alert for the Avian Flu. We were told we were at threat for a widespread pandemic imported from Asia and other countries. Indeed, we read about the spread of this disease. The TV news stations stirred the “fear” pot daily reporting the number of cases abroad and the danger we were all in. Discussions regarding the use of rebreathing masks, especially fitted, were all over the news. Some people went to army surplus stores and stockpiled these. When news of the vaccine broke, those same people spent hours searching for a source, and, once found, stocked enough for their entire family.

Fortunately, this disease did not spread, as forcasted, in this country, and we lazy, complacent Americans leaned back and put our feet upon our desks scoffing at dire predictions regarding various diseases and potential epidemics. Regardless of CDC’s efforts to get everyone vaccinated against the flu, the % of Americans paying attention to these efforts and complying with the CDC’s recommendations remains low…perhaps, to some, alarmingly so.

We have become “non-believers” when it comes to protective vaccines. Perhaps if we had experienced the epidemics in other countries, we would be less so.

Recently, in exploring and researching information regarding childhood immunizations, I found a statement coming out of a healthcare committee studying the influenza vaccine and childhood immunization vaccinations of healthcare workers. In this article, the committee members asserted that the United States, for the most part, imports its diseases from other countries. Our immunization rates for these diseases are significantly higher than other nations, however, there are “pockets” of Americans, such as the Amish communities and reservations, where immunization is not practiced, thus putting these populations “at risk” should they be exposed to someone with the disease. Indeed, the measles epidemic in the Amish community in Ohio was traced to a person who had come in from Europe where he had contacted the disease.

Having just researched the above, it was with alarming recognition that I viewed the television reports of the gentleman from Liberia coming into this country sick with Ebola. Other admissions across the country are patients who have been flown here after becoming ill. One hospital in DC reports a possible case. It appears that we are importing this deadly disease.

What can surgery centers do to protect their patients and staff?

  • Screen the patient during the preop call. Ask them, “Have you or a member of your immediate family traveled outside the US in the last 30 days”? If yes, inquire as to where the travel occurred.
  • Query the patient about a fever or flu-like symptoms. Ask them if they have been around someone who is sick with flu-like symptoms in the last 30 days?

Ask who and the extent/type of contact.

  • Query the patient, specifically, about his having a fever, or someone with whom he has contact having a fever.
  • If your center doesn’t make those preop calls, meet with your admitting office and set up a process by which these become questions that are asked at the time of admission.
  • Teach the people performing the admitting process how to take a temperature with your skin or ear probe. If un-educated persons in Liberia can learn to do this, surely your admitting staff can learn how to perform this task.
  • Where the answers to the above questions, are a “yes”, develop a protocal for safely dispensing of the patient. If the person is febrile, or is experiencing other symptoms, remove him, to the extent possible from other patients and staff. Alert his physician advising him of the questions and responses. Follow his orders to either discharge the patient with instructions to go to the hospital for follow-up or call an ambulance for immediate transfer.

Recently, while working with a particular surgery center, I was advised the admitting office was not qualified, nor were they staffed to perform the above task. This particular center wanted to bypass those questions, and especially, never take a temperature citing lack of training, experience and time. Ergatz! In the face of a potential exposure to Ebola, I assert we cannot afford NOT to train the staff and NOT to take the time! This group suggested that the preop nurses should be managing this process. So….risk the exposure of the admitting staff and add the potential exposure of the preop nurse(s)??? Really? Again, as a group, meet. Discuss the risks. Review the disease, symptoms and risks. Discuss the logistics. Take on that this is something that has to be done, and is best done on the initial patient contact, which is at the admitting desk. Taking that on, then explore methods and avenues to make it happen. Perhaps, posting a nurse at admitting, or having a nurse assigned on a daily basis, to go to admitting when a patient is being admitted to ask the questions and take the temperature. For many centers this would mean bringing on additional preop staff. Is there a CMA or LPN who could perform these duties and who would call for the RN only if a positive result or answer is found?

In the face of the Ebola pandemic it is crucial that the ASC staff and leaders stay alert to the seriousness of this crises. We cannot afford to keep our heads buried in the sand thinking “it doesn’t apply to us”. IT APPLIES TO ALL OF US! We need to do our part to prevent the spread of and to control this disease.

Begin a QA/PI study identifying the number of your patients who HAVE traveled outside the US in the last 30 days. This will illustrate to you the degree of mobility present among your patient population and will emphasize the importance of tracking such travel. Some surgery centers ask this question as a matter of course during their initial preoperative contact.

In closing, you cannot be too vigilant—-always!

Categories: Uncategorized

NO SUCH THING!

September 12, 2014 Leave a comment

As we wait to hear more news as to how the comedienne, Joan Rivers, is doing following her “minor” throat surgery and subsequent respiratory/cardiac arrest, I am reminded of the phrase I used to preach to my staff early on in this ambulatory movement.

I remember working in the hospital recovery room managing 13 recovering outpatients a day mixed in with the inpatients. On this particular day one of the outpatients scrunched into the preop “holding” room was an 18 year old female coming in for a local D & C. I recall hearing the OR staff refer to her as “just a local”. At that time the hairs on the back of my neck stood straight up, as subconsciously I registered that there couldn’t possibly be “no such thing” as “just a local”. Sure enough a few hours later, the doors from the OR corridor burst open and anesthesia propelled a bed on which lay this same young woman being bagged with an ambu bag. During the hand-off communication, the anesthesia resident advised me that she had experienced an apparent allergy to the local—lidocaine. It was touch and go for a while, but ultimately the allergic reaction abated. When interviewing this patient in preparation for her discharge, I queried her regarding any previous such reactions. She confided in me that she had undergone some recent dental work during which she had experienced problems with her mouth swelling, etc. She allowed as how she had not told the physician or the anesthesia provider because she didn’t think it was important—–BUT, neither had they ASKED!!! We clearly could have lost this patient just from the lack of a detailed preoperative history.

The collecting of a thorough preoperative history as part of the preop assessment is a challenge always, whether the patient is an inpatient OR an outpatient. However, it becomes even more crucial in the outpatient setting where the amount of time allocated for the collection of data can be minimal in the face of busy, busy schedules, short staff, and the effort, and time, required to reach patients over the phone vs. visiting them in their hospital room. Nevertheless, such information is crucial in assuring patient safety and a safe outcome.

We do not know what the issue was with Joan Rivers. Was it a drug reaction?…a drug overdose?…some underlying, previously undetected condition? I recall the incident of a few years ago regarding an 8 year old patient in one of the surgery centers. The child came in for pe tubes and an adenoidectomy.The patient had a history of Transposition of the Great Vessels which had been repaired during infancy. He was under the care of a cardiology, was active in school playing flag football, was symptom free of any lingering health problems. A medical clearance was obtained from his cardiologist. The decision was made to do the tubes first followed by the adenoids using an LMA device to protect the airway. Bottom line, once the surgeon inserted the electrosurgery pencil ( he made no incision),the patient bled out in a bit over 1 and ½ minutes. Even the post did not reveal what happened. The point is that we, who work in ambulatory surgery, must NEVER be complacent. We must NEVER assume that the procedure being performed is “just another pe tube, etc.” We must NEVER assume that anything is routine. We must NEVER assume nothing will ever happen. We must, rather be ever vigilant through all established processes. We must never assume that a detailed patient history/assessment isn’t required. I hear so often that certain practices reserved for general anesthesia patients are not implemented for “just a local”. At one time in the ambulatory industry, local patients did not have a comprehensive H&P performed. Rather, a “procedure specific H&P” was considered adequate. CMS put the kebash on that practice with the new regulations of 2009. Too often “just a local” can turn into a major disaster!

What can be done to decrease the possibility of a catastrophe occurring in the surgery center? I would suggest:

  • Perform a comprehensive preoperative assessment on ALL patients. Demand that the patient’s H&P have been performed within the last 30 days and that it adequately documents the patients health status. I recently had an EGD performed at a corporate/physician owned “chain” center. No member of the ASC staff contacted me preoperatively to conduct a preop assessment, and during my preop visit with my physician (whom I adore and respect immensely.), he spent most of the time at the desk across the room with his back to me filling out forms on the EMR. As a knowledgeable HCP I KNOW my health status, but I should have screamed, “Hey, LOOK AT ME! This visit was followed by my annual healthy patient visit. The same thing happened. This physician, who has been my FP for many years, listened to my heart in one spot on my chest, did not auscultate my lungs any further than what he might have heard while listening to my heart, did not palpate my ankles, my glands, my belly, didn’t look in my ears,…but he sure did get that EMR filled out, and the lab requisitions! Is this happening to your patients?

As nurses, it is our responsibility to make sure that our patients are safe. It is our job to read that H&P. It is our job to collect a thorough patient assessment and to alert the physician/anesthesia provider to special conditions, or conditions not heretofore disclosed. Talk to the patient about previous medication issues from anesthesia to pain medications, to locals….all of it.

CMS says that the physician must update the H&P on the day of the procedure. Initiate a policy whereby the patient is not taken back to the OR unless the physician has been at the patient’s bedside as required by CMS.

  • Be alert regarding the drugs patients are being given. The nurse in the operating room is ultimately responsible for patient safety.       Confirm with the anesthesia provider the drug and dosage. Observe the patient. Watch the monitors. We are getting reports that not only is the anesthesia provider playing on the Notepad, but the circulating nurses are also joining in this fun Who is watching the patient?

Nurses complain about anesthesia not being vigilant during procedures. They complain about those games, the stockbroker calls, but what do they do about it?

Complete an incident report and forward it to your manager EVERYTIME you see inattention being given to the patient.

  • Use those alarms! The Joint Commission and CMS continue to beat us over the head for failure to use the alarms in the centers. Use an alarm log. Walk through with your staff and identify every alarm in the center.       Activate it such that all persons working in the center will recognize what the alarm sounding is …and where it is. Check those alarms to make sure they work. In the ORs, and PACU, make sure they are never turned down or off….and they continue to be turned off throughout the country. Perhaps the status of the alarms needs to be added to the Surgery Flow Sheet? Perhaps it is going to take a requirement for such documentation for it to be taken seriously.
  • Check the equipment.

Are you familiar with the equipment, its state of readiness for patient procedures, and its maintenance history? ADA receives numerous incident reports on an ongoing basis regarding malfunctioning equipment during a surgical procedure. Who in your organization is responsible for determining the equipment is in good working order PRIOR to its being used on a patient—-PRIOR to the start of the case? Does your organization demand that an Equipment Assessment be performed on any and all pieces of equipment that either could cause injury to a patient during a procedure, or whose absence due to a breakdown, could cause harm to a patient? If so, how often is this information updated? Who reviews it?

Is it shared with staff members? Too often, we see it done just to meet a standard prior to a survey.

Finally, beware of ROTE! Beware of performing while on auto-pilot. ThisCondition occurs where staff perform the same type of procedure over and over  and over. The advantage is that they become experts in that procedure. The danger is that they can do the procedure “in their sleep”….kinda like driving home, pulling into your driveway and wondering how you got there ‘cause you ave no recollection of the drive home. This goes with being alert, but even more so.

In conclusion, remember nothing more than this: The patient is someone’s child, mother, father, husband, wife, brother, sister, etc. His life is in your hands. You  are his advocate, his Patient Safety Officer.

Categories: Uncategorized

WHAT? MORE SHOTS?

September 12, 2014 Leave a comment

Measle cases have hit a 20-year high in the United States. CDC believes that the number of reported cases may be more elevated due to unvaccinated international travelers.

Between Jan1, 2014 and May 23 of this year, 288 measles cases were reported to CDC, the highest since 1994.

According to CDC homegrown measles was, essentially, eliminated in 2000,.but cases imported from those unvaccinated travelers and patients traveling abroad continue to infect unvaccinated Americans.

A large outbreak in the Phillipines was connected to 138 cases this year involving the Ohio Amish community, as well as that in Pennsylvania.

Unvaccinated residents of the US provide a “welcome wagon” for measles imported from abroad. Measles is still common in Europe, Asia and Africa. The Phillipines has reported more than 32,000 measles cases and 41 deaths from January to April 20, 2014.

CDC recommends not only children receive the vaccination, but adults who were not previously immunized or are unsure of their immunity status.

The Advisory Committee on Immunization Practices and the Healthcare Infection Control Practices Advisory Committee (HICPAC) for vaccinating healthcare personnel in the United States has made recommendations for vaccination of HCP to include HCP in long-term care centers, nursing homes, skilled nursing facilities, physician’s offices, hospitals, rehabilitation centers, urgent care centers, outpatient clinics, home health care and emergency medical services. Ambulatory Surgery Centers fall under outpatient clinics.

According to this report (discussed in this article), many HCP are at risk for exposure to, and possible transmission of, vaccine-preventable diseases because of their contact with patients or infective material from patients. Employers and HCP have a shared responsibility to initiate reasonable precautions to prevent transmission of vaccine-preventable diseases. Vaccinations are an integral part of the organization’s Infection Prevention Program. .Inclusion of this process into the active IPP could substantially reduce the number of susceptible HCP as well as the potential risks of transmitting vaccine-preventable diseases to their patients and other persons with whom they come in contact.

In so far as the Hepatitis-B vaccination is so widely acceptable among HCP, we will not be discussing this vaccination in this article. Rather, we shall be discussing the efficacy of the influenza and rubeola vaccines, specifically..Additional information regarding other childhood diseases will also be included.

Influenza:

According to the Advisory Committee report influenza causes an estimated average of >200,000 hospitalizations and 3,000-4,900 deaths annually in the United States. The majority of influenza-related severe illnesses and deaths occur among persons with chronic medical conditions, infants, young children, seniors and pregnant women. Reducing the risk for influenza among higher risk patients is a focus of influenza prevention strategies.

HCP are especially susceptible to exposure in their workplace, and are, thus, at risk for transmission of influenza to their patients and other HCP. A study conducted among hospital staff reported 37% were experiencing flu-like symptoms during the active “flu” season. The average staff member lost 7 days of work. Of concern, however, are those HCPs who continue to work while experiencing flu symptoms, thus infecting all in their environment. While few expansive studies have been conducted, one study did report that HCP receiving the vaccination had fewer respiratory infections associated with influenza.

Influenza outbreaks of severe respiratory illness among HCPs have been associated with low HCP vaccination rates. Vaccination of HCPs can provide additional protection for those patients who are at risk for influenza, but who cannot receive the vaccination;e.g., infants, the elderly, pregnant women, those with sever allergic reactions, and the immuno-suppressed, among others.

Barriers to HCP acceptance of the influenza vaccination include:

  • Fear of vaccine side-effects (especially influenza-like symptoms0
  • Insufficient time or inconvenience
  • Perceived ineffectiveness of the vaccine,
  • Perceived low likelihood of contracting the flu
  • Avoidance of medication
  • Fear of needles

CMS has mandated that the flu vaccine be offered to all staff to include physicians and allied health staff. In addition, the organization is to calculate its percentage of staff compliance annually and develop strategies for improving compliance. Such strategies might include:

  • Encouraging the staff person’s desire for self-protection,
  • Identifying previous acceptance of the vaccine,
  • Capitalizing on the desire to protect patients and their family
  • Stressing the effectiveness of the vaccine
  • Developing a campaign to include posters and educational material identifying the benefits of vaccination
  • Vaccination of leaders
  • Making the vaccination process easy and stress-free
  • Providing intranasal vaccine for those staff who dislike needles

Those staff who refuse the vaccine should sign the Declination Form themselves stating the reason for the declination. The Employee Health Nurse/Infection Preventionist should calculate total compliance and shall identify annual compliance goals to reach the CMS goal of 90% by 2020.

Effectiveness of the vaccine varies from year to year and is specific to the individual and to the strain in circulation.Vaccine strains are selected for inclusion based on international studies identifying those in circulation.

Measles

Measles is a highly contagious illness that is transmitted by droplets and is airborne spread. Prior to the national immunization program being implemented in 1963 an estimated 3-4 million persons in the US acquired measles annually. Approximately 500 persons a year died, and 1000 had permanent brain damage from encephalitis. Measles remains widespread in countries outside the Western Hemisphere with an estimated 20 million cases reported each year. The United States continues to experience international importation leading to transmission to unvaccinated residents with resultant outbreaks.

Of reported cases, over half of the patients had never been vaccinated.

Vaccine coverage in the US is high with 90.5% of adolescents having received the vaccination.

Medical settings played a prominent role in perpetuating outbreaks of measles. Because of the severity of the disease, infected persons are most likely to seek medical care in primary-care settings. Because of the greater risk of exposure, HCPs are at a higher risk for contracting the illness. Some studies show this risk as high as 19% greater than the general population. Studies show that immunity among those having received the vaccination in infancy remain at 93-95% through the ages of 6-49 years.

The recommendation from the Advisory panel is that all HCP should have demonstrated evidence of immunity to measles. This information should be documented and readily available in the employee’s health file.

New York, Oklahoma, Rhode Island and New Jersey have laws regarding the proof of measles immunity and do not allow for religious or philosophic exemptions.

The measles vaccine is given in conjunction with rubella and mumps thus protecting the patient from all three infections.

Mumps

Adults experiencing either measles or mumps may react severely requiring intensive care in the hospital setting.

There is a concern that the reporting of mumps infections may be under-reported, as in some patients, the symptoms are minimal. The highest rates occur among dentists and Health Care Persons. Mumps outbreaks have occurred in the US as late as 2010 in the northeastern region of the U.S.with 3,400 cases reported. Of these only 7 were healthcare workers. Most likely, the HCPs were infected by the patients.

It is estimated that as high as 13-14% of healthcare workers lack antibodies to the mumps virus This author knows, personally, of two HCPs who contacted the disease at work and ended up in the intensive care unit fighting for their lives.

The Advisory Committee recommends all persons who work in health-care facilities should have presumptive evidence of immunity to mumps.

Rubella

Rubella (German measles) is a viral disease characterized by a rash, low-grade fever and malaise. Prior to the vaccine being licensed in the US, reported rubella diseases were at 57,686 annually. This disease could lead to encephalitis, fetal deaths, miscarriages, stillbirths, various other birth defects to include blindness, deafness, mental retardation and congenital heart defects. From 2005-2009 54 cases were reported. 23 of these were import-related. Rubella importation is expected to continue.

Only three states (as of 2011) have laws mandating proof of rubella vaccination among HCPs with no exceptions. The Advisory Committee recommends vaccination, or proof of immunity among all HCPs.

Whooping Cough

Pertussis is a highly contagious bacterial infection that was once prevalent in the US. Like the other infections discussed above contact is through respiratory secretions. Symptoms in the early stage are indistinguishable from other upper respiratory infections.

Vaccinated adolescents and adults whose immunity wanes (5-10 years from the most recent dose of the vaccine, are an important source of pertussis. Outbreaks across the US occur frequently. Some are misdiagnosed and result in continued transmission in the population. One report included a young mother who unknowingly had pertussis and passed it to her infant who had not, as of yet, been vaccinated, and who subsequently died.

In healthcare settings transmission can occur from patients, visitors or HCPs. Exposure

is difficult to define in the healthcare environment. The exposure is highest in those facilities catering to pediatric patients; however, even in ambulatory settings not catering to pediatric patients, children may abound in the waiting room.

Summary:

Care of the patient exhibiting any of the above infectious processes, must include the masking of the patient. Part of the patient’s preoperative assessment should include the status of his childhood immunizations and the presence of any symptoms that might be indicative of the infections discussed above.

The Employee Health Program should include the status of the employee’s childhood immunizations, and, if the employee has no knowledge of his status, titers should be drawn with results placed in his employee health file. If no antibodies are present, re-immunization or a booster shot should be indicated.

It is time for Ambulatory Surgery Centers managers to fully embrace the hazards that failure to become knowledgeable about their staff’s health status regarding childhood immunizations and to incorporate this information into their basic employee health program.

Categories: Uncategorized

Is Your Surgery Center Safe?

January 15, 2013 Leave a comment

safetyfirstThe patient is in the pre-operative area lying comfortably on the stretcher bed when the physician approaches him to do the H&P update.  After greeting one another, the patient reaches into the top sheet and pulls out a gun.  “You better do a good job, Doc,” says he.  The doctor reaches down and takes the gun away from the patient without incident telling him that weapons are not allowed in the center.

A similar incident occurs at another center when the patient, a police officer, does the same thing.  That surgeon reaches for the gun and tells the patient, “John, you are not a police officer at this time, but a patient.  Give me the gun.” They laugh about it, but later the staff share their alarm with the OR Supervisor and Administrator.

In another occurrence the patient, who has become quite argumentative and irascible, is being escorted to his car.  Upon being told, again, that he cannot drive, he opens the driver’s side door and reaches under the seat.  He retrieves a gun which he carries around to the passenger side and puts the gun in the glove compartment.  In this instance, the OR Supervisor drove this patient home!

In one other center a former employee is found dead outside of town in a desolate spot.  The victim of multiple complaints of domestic violence involving her former husband during her time at work, this person is dead and the former husband is still free.

Most adults spend more of their waking hours in their work place during the week than they do in their homes.   This familiarity breeds a feeling of comfort and safety.  This is their “home away from home.”  Their guard is as down as it is at home—maybe more so based upon the “safety in numbers” thought processes most humans have had in the past. We can no longer afford to think along those lines, but must, rather, consider not only our safety at work, but that of our patients, visitors and other staff members.

The safety of your work environment from a security aspect has to be evaluated.  Gather the staff and work with your Safety and Security officer to conduct an intensive security assessment.  Begin in the parking lot.

parking-lotIs your parking lot well lit?  Is it close to the building?  Are there large bins/dumpsters and shrubs behind which someone could hide?  Do staff members arrive at nearly the same time thus forming a “buddy” system for leaving their cars and crossing the lot to enter the building?  Would such a system be possible for all those entering (or leaving), especially during those times when it is dark?

Is the staff entry door well lit or is it an alcove that enhances the darkness and isolation? Is the door easy to enter such as a keyless system, or does it require a key that can be dropped or fumbled thus increasing entry time?  Is the staff entry door kept locked?

Is there a back or side delivery door for supplies?  Is this door kept locked or is it propped open for vendors or visitors—especially those bringing food?  Do external doors include windows, a side window panel, or, at the very least, a peep hole? Even though staff can see the person ringing that bell, is identity confirmed before they can gain entry?

Vendors should always check in at the front desk prior to going to the back or side door to deliver supplies.  At the very least, a known vendor should call the center to advise them that he is about to deliver supplies, etc.  A doorbell should be installed at the delivery door.  Human beings have a Pavlovian response to someone knocking on a door or ringing a doorbell; i.e., the response is to automatically open the door.  But…is this the safest action to take?  With a pre-arranged phone call, once the doorbell rings, the staff member can look through the window or peep hole and verify the delivery person.  However, if this person is not familiar to the staff, some form of identification needs to be presented, before that person gains entry.  Have them show picture ID as well as a company ID.  Vendors going to the front desk would have already presented identification and had it verified.

peepingLeaving back doors propped open or unlocked is a common practice not only for vendor access, but for smokers who want to just pop out for a quick smoke.  This is not a safe practice and should be stopped in your center immediately.

Another issue with the service, staff or emergency doors is that they are frequently all glass in a metal frame.  While this may be more attractive from the outside, and certainly lets in light, consideration should be given to replacing these doors with the solid core variety.  One rule of thumb in any hostile situation is to reduce the visualization of staff, patients and visitors.  A glass door lacks the safety of invisibility.

In one very active OR, a gun wielding man came flying through the double doors of the operating room suite waving the gun in the air and making wild threats.  The man was clearly not of “sound mind,” but his gun was definitely based in reality.  Following that incident, the administration had a lock system installed to separate the patient care areas from the reception/waiting room.

Conduct a complete safety assessment of the waiting/reception/admitting area.  Who unlocks the front door?  When?  Who else is in the building when this happens?  Is it usually dark outside when the doors are unlocked?  If the center is located in an office building, are other offices open already or is the center the only “sitting duck”? Several centers have reported vagrants sleeping either on the benches outside the entrance or in the entry alcove.  Other centers have reported vagrants sleeping in rooms such as that containing the vacuum pump that were left unlocked.  Two centers reported that vagrants had been sleeping IN THE CENTER overnight.  Access was gained by the vagrant slipping into a lobby bathroom while the reception desk was unattended and after the waiting room was empty.  They merely, in both instances, had to wait until everyone left.  With no motion detectors as part of the security system, they were free to raid the refrigerators, shower in the locker rooms, don clean scrubs, and watch television until bedtime.

In two other instances, recovery nurses walked in on strangers in their recovery rooms on “no surgery” days.  Both strangers took off running when the nurses entered.  Only one was caught.  He had been looking for drugs and money.  In both cases, the vagrants were able to enter past the unattended reception desk after the waiting room emptied—as clearly visible, by the way, through the floor to ceiling windows and glass doors in the lobby and waiting room.  While nothing except stark terror occurred in these instances, it could have been otherwise.  When the last person leaves that waiting room, the door needs to be locked regardless of the inconvenience.  Either a thumb lock or crash bar system is acceptable.  A word of caution about the thumb lock is warranted.  If this lock is visible through a glass window, it is worthless…and we are back to the problems with glass doors or doors with large windows!

As mentioned before, all the areas off the waiting/reception area need to have keyless entry locks i.e., into the patient care areas and administration.  There was a time this seemed like overkill in the ambulatory surgery world. Those days are long past.  These locks help prevent, or at least will slow down, easy access to these vulnerable places.

There needs to be a panic button that is knee or foot controlled at the front desk.  This panic alarm should be silent and should go straight to the Central Service/police as recommended by your local authorities.  A good idea would be to have it light up in administration and at the nurses’ stations alerting all in those areas of a violent situation at hand.  The administrator would follow up the silent alarm with a 911 call.

panic buttonCheck this alarm on a regular basis.  Shortly after the Joint Commission introduced its patient safety goals concerning alarms, many centers reported theirs were present but either non-working, or, in one instance, had never been connected to the alarm system. Make sure all staff know where it is, when it is to be used, how it is to be used and their jobs should it be used.

Develop a policy for Aggressor in the Workplace.  Inservice the staff thoroughly and conduct an annual drill.  We have learned much, unfortunately, regarding aggressors from the Columbine, Chardon, Sandy Hook events.  Secure your area.  Shut doors, blinds and curtains.  Lock as many doors as possible.  Stay out of restrooms.  Get as far away from doors as possible.  Evacuate only if safe to do so.  Stay quiet and, if unable to evacuate to a safe place, wait for the authorities.

What would you do if an aggressive attack happened during surgery?  In one center, a patient’s husband in the waiting room, jumped up and screamed that he had a bomb attached to him.  Imagine the terror!  This center had no means to control the bomber’s access to any areas.  He was free to roam while keeping staff, patients and visitors as hostages until the police arrived!  This could have happened in the Pre-op or PACU areas just as easily…and in those centers with the “open” floor plan this is just a door away from the room where surgery is being performed!

In one ambulatory center a staff member’s husband arrived at the front desk and asked for her.  The receptionist called her to the front, where the husband pulled a gun and shot her dead right there in the waiting room.  It can happen anywhere…a hairdresser’s salon, a McDonald’s…a surgery center.  Later it was discovered that this staff person had asked her husband for a divorce the night before.  Urge your staff to communicate problems/issues with you as a leader.  As a leader, you should look for and watch for signs of abuse in your staff members…physical and emotional.  Be alert.  Talk to that person.  Ask them if they believe the safety of the surgery center is at risk.

gunmanRecently, a national poll advised that Americans no longer feel safe.  This is an unfortunate state of affairs, but has us join our sister nations in this aspect.  You need to stay alert. Be observant. Review your policies. Conduct your drills.  Include the physicians in your Safety Plan and Drills. Take your Safety and Environmental Hazard Assessments really seriously. Implement sound safety practices, and most of all, be safe!

Where Was The Detour? Turning ORs in 7 to 10 Minutes

November 12, 2012 Leave a comment

An article was recently published regarding the possibility of turning operating rooms in ambulatory surgery centers in 7-10 minutes.  In this article the author talked about the fact that turning the rooms inside this time frame is still a possibility.

I was left struck with, yet again, that we in the ambulatory surgery business took another detour somewhere.  I recently responded to a previous article calling for surgery centers to consider moving toward a patient-centered environment.

As someone who has been involved in the development of ambulatory surgery centers since 1979, I simply had to respond because back in the ‘old days’ this was what ASCs were all about.  In reviewing the article about room turnover times, I was, once again, stuck with the fact that back in the early days of ambulatory surgery, we pledged to turn all our operating rooms over in 7-10 minutes—-patient to patient.  Should the turnover time exceed 10 minutes, a QI study was immediately conducted to identify the problem/area for improvement.  And yet, over the last twenty years, I have begun observing that these times are being extended.

Some of the reasons put forth by ASC leaders for this extended time include the fact that more complex surgeries are being performed in the ASCs.  Another issue presented during QA/PI studies is that our patients are more challenging.  More and more centers are admitting ASA class III and more patients who require a great deal more attention.  Care of the morbidly obese has become a big issue.

The question arises, however, if these are valid reasons for longer turnover times, or is it just that we need to better plan for those challenges?  The second question that arises is that if the condition of those patients validate the longer room turnover times, then what is going on that room turnover times, in general, are increasing?  One could make an assertion that the industry, in its proliferation, has lost track of its roots—its initial commitments.  Is it that more and more centers popping up means more and more hospital trained nurses being put in leadership roles with no distinctions from the freestanding ambulatory surgery center culture.

As long ago as the early 1990s a study was done documenting room turnover times in hospitals.  Understanding that the turnover times were being measured from patient out to next patient in, these times ranged from 45 minutes to 1 ½ hours.  During this same study, it was observed that the average freestanding ASC was able to turn their rooms within the 7-10 minute time frame.  Outlier times were identified for procedures where there were excessive irrigation fluids used, or in shoulder joint replacement surgeries.  It was further documented that turnover times in hospital owned ASCs were primarily in line with hospital turnover times.

In reviewing practices within 36 different ASCs, it has been noted that turnover times have been increasing exponentially with the exception of, universally, cataract surgery.  However, even in this surgery, in multi-specialty centers, turnover times of 15 minutes has become acceptable.  It was cataract surgery centers that perfected the ability to turn rooms in seven minutes with patients commenting that they knew they were on a conveyor belt kind of schedule, but that the personalization of their care was such that had they not observed this, they would not have known.  It was further observed that turnover times for GU and GI procedures generally were far shorter than in other specialties, but still exceeded the 10 minute goal.

So, what happened? 

We have to first look at the commitments of the staff and physicians.  Are they aware that with the turnover times being inside the declared goal of 7-10 minutes,  more procedures/cases could be performed and that this results in happier surgeons who are more likely to utilize their center more and more?   Are they aware that greater utilization increases profitability and, thus, increases their chances of getting a raise or a bonus at year’s end?  Are they aware that faster turnover times, means that patients get out of the center faster and aren’t left with long waiting room times?  This makes for happier patients reporting back to their physicians.  It is a ‘win-win’ all the way around.  The staff has to be gotten on board with the possibility of faster room turnover times.  You need to enroll them 100%! And this includes those physicians who like to hit the staff lounge to gossip, make calls, etc. Or who like to go to their office next door between patients.  Educate them into what is possible in coming right back to the OR after they have seen their patient in recovery and the care person in attendance.

It is impossible to experience rapid room turnovers without assessing the layout of your ORs and procedure rooms.  Hospital operating rooms are typically equipped with large banks of storage cupboards which are usually stuffed full of supplies.  In the ambulatory surgery industry it was quickly recognized that if the procedures were to be reimbursed on a ‘flat fee’ basis, rather than for every widget used, then it was imperative that supplies be strongly controlled.  The basis materials management premise that supplies sitting on shelves have a powerful intrinsic cost become paramount in cost containment practices.  Supplies were moved out of the ORs and were centrally located such that turning them and reducing PAR levels could be easily controlled.  All supplies for the center were treated in this manner with the exception of those supplies only used in certain areas such as peel packs for the sterile processing area.  Thus, all inventories were conducted out of the bulk and sterile storage areas excepting those specialized items stored in those specialized areas.  This kept supply costs down significantly and reduced manpower hours in conducting weekly inventory and re-ordering of supplies.

Operating rooms were equipped with one supply cupboard and one “case cupboard.”  The inventory for the supply cupboards was limited to only those items that were essential as back up for items already pulled for the cases to be conducted in that room.  These included two each of the various sized, most commonly used gloves, one package of sterile 2x2s, 4x4s, etc.  Again, thought was put into what kind of cases were being performed in the center, what would be pulled from the two different storerooms to perform the procedure and what else might be needed because a glove was punctured or ripped, a gown sleeve contaminated, or additional sponges might be needed.

However, staff considered what eventualities would drive them to tap into the back-up supplies.  They considered the most common eventualities, rather than those that might be rare.  Consideration was given that emergency supplies would most likely be found in anesthesia carts, but also considered what surgical supplies like drains, hemmorrhagic sponges, etc. should be stored in limited numbers in the room. The supply cupboard was never considered to provide everything needed to perform a case.  Limits to the number of items stored there relied heavily on the concept that these were only ‘back-up’ supplies.  The inventory stored in this cupboard was listed on an inventory sheet kept in the cupboard.  The cupboard was restocked at the end of each operating day from the bulk or sterile storage areas.  The restocking of this cupboard was identified on the duty list for each or staff to complete each day.  This list required a date, a ‘completion’ check mark and the initials of the staff.

A second cupboard was dedicated as a case cupboard.  In cataract surgery, GI and GU rooms, two case cupboards were installed to allow for the increased volume.  Each cupboard contained 6-7 shelves representing one shelf for each case scheduled for that room for that day.

In looking at what it would take to get turnover times to that magical 7-10 minutes, staff met in one of the ORs and looked at every task performed in turning a room from the circulating nurse going with the anesthesia provider to take the patient to PACU, to delivering the soiled instruments to the soiled receiving area for processing, to mopping the room, cleaning the or bed…the whole gamut.

AORN recommended practices and the center’s policies were reviewed and implemented for housekeeping and cleaning between cases.

Job functions were reviewed and assigned.  Who was to do what to turn the rooms was not only identified but embraced.  Who was to grab the mop?  Thrown out the window was any conversation about ‘not my job’.  The OR Supervisor and the Executive Director both pitched in with the mop when needed, as did the physician.  All kept the agreed upon goal clearly in mind.  Mopping was not done during non-invasive procedures.  Surgical team areas were identified for mopping between invasive procedures.

It was agreed upon that at the end of the case the RN would take the patient to the PACU with anesthesia, give the hand off communication, visit the next patient scheduled for that room then return to the or to assist in the turnover.

The organization employed a sterile processing technician to wash and process instruments.  Any surgical technician not working a room was assigned to assist in the sterile processing and soiled receiving areas.

At the end of the procedure the surgical technician removed the soiled instrumentation from the room to the soiled receiving area for processing and returned to the room to begin the turnover process.

When the page for turnover was heard, any available staff reported to that room.  The staff lounge was reserved for assigned breaks and lunches.  The organization also employed an orderly, receiving, housekeeping, maintenance person who helped as available turn rooms in this seven-OR facility.  However, whoever was available either grabbed a mop or begin wiping off the flat surfaces and or bed with the germicidal solution.

The OR was equipped with a soiled linen hamper, a biohazardous waste hamper, a general waste hamper and two kick buckets—one for anesthesia and one for sponges.  At the end of the case, these were emptied and disposed according to recommended practices and standards.

In identifying all the elements involved in turning a room the staff noted the hamper liners, kick bucket liners and the linen needed for the or bed as routine.

Physician procedure cards were scrutinized and updated as necessary. Staff met and agreed to follow these rigorously in pulling cases.

It was decided that all cases would be pulled the afternoon prior to the procedure.  All supplies would be put on the shelves in the close cupboard designated as the case cupboard.  Each shelf would be labeled; e.g., #1, #2, etc.  The cupboard shelves were equipped with a lip around the entire shelf and pulled out of the cupboard allowing it to be used as a transporting tray.

The organization approached the local grocery store and were able to get, free of charge, grocery carts with those irritating wobbly wheels.  These carts were cleaned up and the wheels were changed out transfiguring them from grocery carts to supply carts.  Staff used these to transport supplies from the bulk and sterile storage areas and to pick their cases.

Staff, following their procedure cards, pulled every item needed for each case and placed those on the assigned shelf in the case cupboard.

As part of the process for rapid room turnovers, the staff developed a system for “room turnover packs.”  These consisted of the OR table/bed sheet, the draw sheet, the kick bucket liners, and the various hamper liners.  Staff were assigned daily to make these packs by gathering all the items and making rolls that were held in place with a strip of masking tape.  These were kept at the OR control desk.  When pulling cases the staff person would pull however many of these rolls needed based on the number of cases scheduled for that room for the next day.  One of the rolls was placed on each shelf with the supplies for the case.

Once the room was cleaned, the RN or other staff person, as agreed in their assignment meeting, would pull the roll, make the table/bed and place the liners in the appropriate spot.  The surgical technician would pull the pack and place it on the back table and begin draping the instrument table and mayo stand . The RN Circulator began assisting in the opening of sterile supplies and dropping them onto the sterile field while the surgical technician scrubbed.  The RN then would set up the prep table, then leave the room to collect the patient with the anesthesia, provider.  Upon re-entering the room, the RN finishes gowning the tech and physician and turns to assist anesthesia in sedating the patient as needed.

Many larger organizations are turning to developing and/or hiring an anesthesia technician.  Certification for this person is available on the internet, but in-house training on the part of the anesthesia providers is acceptable.  This person can be quite valuable in assisting in room turnovers, too.  In the absence of an anesthesia technician the anesthesia providers have to assume an “assistive” position in turning rooms.  Include them in your training.  In the absence of an AT, the medication management nurse should be assigned the job of keeping the anesthesia carts fully stocked.

The system/process described above will absolutely allow you to turn rooms within the identified national standard of 7-10 minutes.  However, it is crucial to this process, that each staff person remember that every time someone leaves a room to go fetch something, it is manpower hours that translate to increased room turnover times.  Plan to review your turnover times at least twice a year.  Develop an electronic log and assign a data entry person the task of documenting times patients enter and leave rooms to facilitate your study.

Housekeeping…The Backbone Of The ASC

November 7, 2012 Leave a comment

The patient’s car pulls into the parking lot of the ASC.  He is here for his pre-anesthesia/surgery assessment and education visit.  He can’t help but notice that there is trash here and there around the lot.  A nagging little thought enters his mind about the apparent disregard for tidiness.  He approaches the front door of the Center and, again, notices some pieces of napkins and a styrofoam coffee cup lodge in the corner by the entrance.  There is a sand-filled ashtray near a bench, but the ashtray is overflowing.  That nagging little thought is getting bigger.  When he enters the reception area he notices the wilting—almost dead—plant on the corner of the reception desk.  The carpet shows a clearly defined dark/dirty traffic path.  The upholstery on one of the chairs is badly stained while another is clearly frayed along the front seam.

Does the above scenario sound implausible?  It shouldn’t, for it is a scene CMS surveyors are reporting across the country.  That patient’s nagging thought becomes a roaring symphony to CMS surveyors entering a Center.

Infection Control Surveys

When CMS began the unannounced infection control surveys in the summer of 2009, it became evident that housekeeping practices in ASCs were an urgent issue in the rising rates of infections being reported in the ambulatory surgery Centers.  Surveyors came out of these surveys certain that housekeeping, the training of housekeepers, and the follow-up of the housekeeping practices was not a high priority among the leaders in the ASCs.  Indeed, some surveyors were heard making statements like “it is clear that the leaders of this organization hire incompetent, unskilled and unqualified persons to perform housekeeping (and sterilization) services in this organization.”

In assessing the housekeeping practices in some 36 surgery Centers across the US what was discovered was that the ASC leaders largely hired housekeeping contractors who had “experience” cleaning healthcare facilities.  However, some of this experience was in cleaning doctor’s offices.  Some did list other ASCs.  On occasion, some owners of the housekeeping service had worked, themselves, in the housekeeping department of the hospital.  Several Centers interviewed performed all the housekeeping inservices internally using their RN staff.  In none of the Centers did the organization meet with the housekeeping staff themselves to perform training or to observe their cleaning practices.  And yet, virtually all of the Centers had quite a litany of complaints regarding the services that were being delivered.

In performing inspections of the various ASCs, CMS has reported;

  • Water stained ceiling tiles throughout many Centers.  These stains harbor bacteria.
  • Rust on stretchers, or tables, IV poles, the legs of instrument tables, anesthesia and emergency carts, endoscopic cleaners, in and on sterilizers, medical gas connectors, oxygen tanks and connectors…the list becomes extensive.  Rust harbors bacteria.
  • Dust—everywhere!  Windowsills, blinds, tops of suction canisters, the top of emergency and anesthesia carts, microscope arms, behind equipment on counters, inside drawers in medication rooms and in the OR and sterile processing.  Dust is a large contributor to post-op infections!
  • Chipped and peeling formica throughout the Center on doors, counters, cupboards.  This leaves a surface that is far from ‘seam-free’ and harbors bacteria.
  • Peeling and torn wallpaper—again, not smooth and seam free for washing w/o harboring bacteria.
  • Chipped paint on walls and door frames—same story as above as far as preventing adequate cleaning.
  • Nasty, dirty areas behind sterilizers and open drains that are full of what looks like mold.
  • Mold in air vents—dirty and dusty air vents.
  • Blackened separated floor seams.
  • Separated coving on floors in sensitive areas like the OR
  • Separated back splashes leaving gaping spaces between the back splash and the wall in sterilization and soiled cleaning rooms.
  • Housekeeping closets that either have no or too long black hoses that are touching the bottom of the sink pan.
  • Housekeeping closets that are dirty, cluttered and un-kept.
  • Corners of floors, especially behind doors, that are dirty and appear to have been ‘waxed over’.

In one Center, CMS instructed the ORs/Administrator to demand the housekeepers come in during the day shift in order for CMS to observe their cleaning the ORs.  It was disastrous!  The cleaning crew mopped the OR walls with dripping mops starting at the bottom and working their way up.  In addition, the same mop head was taken into the second OR to use, but, then, so was the same bucket of water!

While observing housekeepers in another Center, the observation was made that the housekeeper pushed the bucket full of solution out of the one OR, mopped the OR corridor and proceeded into the Pre-op/Recovery area.  When the observer questioned the housekeeper as to when she would change the water/solution in the bucket, the housekeeper replied that she changed it when it got dirty!

In another Center where the RN staff performed all housekeeping duties, it was discovered that counters were never being cleaned, nor was deep cleaning behind equipment, or corners being done.  It appeared that the old ‘a lick and a promise’ was the rule of thumb, as this service was being done at the end of the day’s schedule, and staff were eager to ‘get out of here’.

One cannot assume that these are isolated occurrences.   In the face of increasing numbers of infections in ASCs, we in this industry must cast a disparaging eye toward housekeeping practices in our own ASCs.  ]

We have to carve out the time to address this very serious issue.

  1. Comprehensive Housekeeping Policies.  Surgery Centers should have comprehensive housekeeping policies.  Housekeeping guidelines for hospitals and healthcare facilities can provide the stepping stone for your policies and protocols.  Look at every area beginning with the entry into your Center.  What does it tell the patient about what he can expect from a safety/infection-free environment for him?  What does it tell him about your commitment to cleanliness?  Patients know about sterility.  They strongly suspect that the place where they are having their surgery should be above and beyond clean, if their outcome is to be good.  They all have friends or family, or they know someone who got a post-operative infection.  The condition of your Center also has a huge impact on your marketing.  What does it say to your patient community if you have not maintained your Center either physically or through housekeeping?
  2. Orientation.  Develop a housekeeping orientation program and tools.  Include all areas and essential tasks.  Look at your own expectations in each area.  Meet with your key staff members to discuss and explore their expectations, issues and complaints.  Incorporate clear instructions based upon this analysis as part of the housekeeping orientation.
  3. Tools and Recommended Practices. Develop housekeeping checklists for each area.  Look at recommended practices from the AORN.  These checklists should include terminal cleaning of the ORs, the expected schedules for the cleaning of all areas and the contents of all the different rooms.  What pieces of equipment are they to clean, if any.  Also, develop checklists to document what the nurses are expected to clean and how often.
  4. In developing checklists identify those things that are outside of the daily or weekly routine; e.g., carpets, tile, windows, upholstered furniture, stripping and waxing floors, woodwork, doors, inside cupboards, etc.
  5. Housekeeper’s checklists should hang in their closet.  Get in the habit of checking these several times a month.
  6. Put together a housekeeping training packet and meet, not only with the supervisor, but with the housekeepers who are going to be cleaning your Center.
  7. Determine whether or not the housekeepers have had training in both blood-borne pathogens and toxic/hazardous substances, but also HIPAA.  If not, provide them with those policies and demand that the contractor provide further, documented training.
  8. Provide the housekeepers copies of your housekeeping policies and complete the orientation tool.  Observe their cleaning practices.
  9. During the orientation and training period there should be a conversation regarding the ability of the housekeeping staff to read and speak English.  If the staff is unable to do so, you are expected to provide instructions, checksheets, MSDS in their language!  There are sources for this available on the internet, or contract with an interpreter to make these changes.  You can also have the interpreter provide all the instructions verbally.  Document this in the contract workbook with their contract.
  10. Orient the ASC staff to housekeeping practices.  This should include not only what can be expected from the housekeepers, but what is expected of them.  It is unfortunate that we still see RNs who drop some piece of paper on the floor and leave it stating that it is not in their job description to clean, or they call the MA to pick it up.  The RN’s job is to provide a safe environment for their patient.  This includes a clean environment.  During a recent survey, the surveyor did the white glove test on the bottom of a drawer in the medication room.  She held up a finger laden with dust and showed the RN who was the medication management nurse.  The RN said, ‘housekeeping doesn’t clean inside drawers.’  The surveyor remarked, ‘and clearly, neither do you, nurse!”…..not a good impression…and this is a room where medications are prepared!
  11. CMS expects that the leaders are periodically observing the housekeeping staff at work.  Schedule a midnight visit at least several times a year to ensure that best practices are being followed.
  12. Lastly, CMS also expects that the leaders of the organization are conducting housekeeping inspection tours.  It makes sense that the infection control coordinator be responsible for monitoring the housekeeping practices in the Center.  However, the leaders should hold this person accountable by reviewing the logs on a regular basis and demanding that the housekeeping practices and results of the weekly housekeeping inspection tours be included in her quarterly infection control report to the QA/PI meeting.

In closing, housekeeping practices are the backbone of the Surgery Center.  Without good, sound and solid housekeeping services, low infection rates are in jeopardy, and, eventually, word is going to get out that your Center is less than an ideal place for patients to have their surgery.  Remember, they do have a choice.

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