Education Sessions Give Attendees Valuable Tools for Practice

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Education Sessions Give Attendees Valuable Tools for Practice SATURDAY, MARCH 14, TO THURSDAY, MARCH 19, 2009

T

he educational offerings at the 56th AORN Congress began Saturday morning with the brand-new Intensive Education Workshops and continued through Thursday afternoon. Presentations during the week included self-improvement seminars on mastering communication skills, manager’s sessions to boost team efficacy, and clinical and technical sessions focused on improving best practices. On the pages that follow are overviews of a few of these sessions.

ADVANCED PRACTICE NURSING “Health promotion and disease prevention are major responsibilities of advance practice nurses,” said Thomas W. Barkley, Jr, DSN, ACNP-BC, as he began the 1.5-day Intensive Education Workshop “Advanced Practice Nursing Seminar.” Promoting health and preventing disease begins with performing a thorough health assessment and identifying relevant risk factors of the major causes of mortality in each age group that is served, Dr Barkley explained. After describing specific issues regarding each physiological system, he discussed cultural issues related to patient assessments and then instructed attendees to close every patient interview with a very important question: “Is there anything more that you want me to know?” This vital question can help practitioners correctly diagnose problems, accurately determine treatment options, and avoid missing key information. Dr Barkley used his knowledge of human anatomy, physiology, and pathophysiology to help make complex disease processes understandable for attendees, and he applied this information to perioperative practice in an understandable, memorable, and humorous manner. He discussed different system assessments and used real-case scenarios and personal stories to make the information easier to understand and remember. Dr Barkley also addressed several issues © AORN, Inc, 2009

Education session attendees learn tips for improving clinical practice during Congress 2009.

that affect advanced practice nurses (APNs), including entry into practice; professional roles (eg, consultant, educator, researcher); and the APN’s scope of practice. He then covered credentialing, licensure, certification, and reimbursement, as well as prescriptive authority, which he said is based on legal allowances in each state and can vary widely depending on whether physician supervision (eg, cosignature, practice arrangements, protocols, formularies, collaboration) is required. When discussing ethical issues relevant to APNs, Dr Barkley explained the difference between nonmaleficence (eg, the duty to do no harm) and beneficence (eg, the duty to prevent harm and promote good). Although a fine line separates them, he said, there is a difference that is paramount when dealing with informed consent and using advanced directives when a patient undergoes surgery. Dr Barkley emphasized the importance of patient advocacy; perioperative APNs can be of vital help to patients regarding their right to self-determination when undergoing anesthesia. Dr Barkley continued with a detailed discussion of both hospital-associated methicillinresistant Staphylococcus aureus (MRSA) and community-associated MRSA infections. After JUNE 2009, VOL 89, NO 6 • AORN JOURNAL •

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quickly reviewing the history of antibiotic development, he discussed the causes of antibiotic resistance. He described the consequences of evolution and bacterial mutation, which allows bacteria to survive, continue to reproduce, and pass on resistance traits to offspring that will produce a fully resistant generation. Dr Barkley elaborated on other compounding factors in antibiotic resistance such as patient noncompliance and use of antibiotics as livestock food additives for growth promotion. He concluded by presenting strategies to improve and prevent further antimicrobial resistance. His key takeaway was prevention, because it is always easier to prevent the spread of microorganisms than it is to treat an infection.

THE GLOBAL PERIOPERATIVE NURSING VOICE Jane Helen Reid, RGN, MSc, DPNS, PGCEA, and Mary Jo Steiert, RN, BSN, CNOR, began their presentation, “The Power of the Global Perioperative Nursing Voice,” by stating that 230 million major surgeries are performed each year in industrialized countries around the world; this does not include minor or intermediate procedures. Of these major surgeries, 3% to 16% will result in harm. Reid spoke of the World Health Organization’s (WHO’s) Safe Surgery Saves Lives campaign

Mary Jo Steiert explains the benefits of the World Health Organization’s Surgical Safety Checklist.

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and the WHO’s goal of global sharing and improved connectivity. The WHO held a summit in January during which perioperative nurses helped shape discussions to benefit patient care. In February, members of the WHO summit developed a Surgical Safety Checklist. Their intention is for a June launch with a universal message to reduce harm to patients. “We must make surgical safety our highest priority,” Reid said. According to Steiert, hospitals do most of the right things, on most patients, most of the time. “But, if you or a loved one were the exception,” she said, “this wouldn’t be enough.” She went on to describe the basic tenets of the WHO’s 10 objectives for safe surgery and described the WHO checklist, which can be accessed online at http://www.who.int/patientsafety /safesurgery/tools_resources/SSSL_Checklist_final Jun08.pdf. The checklist is customizable and supported by evidence, was evaluated in diverse settings around the world, promotes adherence to established safety practices, and requires minimal resources to implement. The checklist has three components: before induction of anesthesia (ie, sign in); before the skin incision (ie, time out); and before the patient leaves the OR (ie, sign out). In global pilot tests, Steiert said, compliance with standards increased from 36% to 68% and in some hospitals to almost 100%. The goal of the Safe Surgery Saves Lives Campaign was to enroll 250 hospitals by January 1, 2009, and is to enroll 2,500 by 2010. “This kind of international collaboration will empower the perioperative voice to bring about change,” Steiert added. Steiert concluded the session by displaying a sign that is being posted in many ORs. It explains that performing the time out is as “Easy as APPLE PIEs”: • Antibiotics • Patient name • Procedure (agreement on procedure and informed consent) • Laterality • Equipment (including implants) • Positioning • Images • Everyone participates • Safety and precautions.

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AUTOMATING OR DOCUMENTATION During their session on “Surviving Waves of OR Automation,” Myra Jo Beach, RN, BSN, MBA, NE-BC, and Jacqueline A. Sions, RN, MSN, CNOR, NE-BC, discussed their experiences and recommendations for purchasing and implementing a perioperative electronic documentation system. Beach explained that the first step in implementing an electronic documentation system is to assess the OR’s current status in terms of what equipment it currently contains and which departments will be affected (eg, information technology, pharmacy, preoperative area, postanesthesia care unit, scheduling). In purchasing a new system, Beach emphasized the importance of developing a budget and submitting a request for purchase. To ensure success, she advised assembling a committee of stakeholders (eg, surgeons, anesthesia care providers, perioperative staff members, managers, ancillary department representatives) who have a vested interest in the project’s success. She also recommended soliciting bids from numerous vendors to ensure the best fit for the facility. Beach recommended asking appropriate individuals to define and illustrate patient flow— from scheduling through discharge—to ensure that all of the pieces of the patient record are included. Work flow processes also should be illustrated in every department, from developing preference cards to tracking patients as they move through the perioperative area. She showed a slide of the electronic communication board used in her facility, explaining how patients are depicted with the three-and-three method (eg, the first three letters of the patient’s last name and first three letters of the first name), which ensures confidentiality and is compliant with HIPAA regulations. The inventory supply chain needs to interface with the OR information system, Beach explained. This process involves scanning items (eg, radio-frequency identification), and usually is implemented incrementally starting with medication administration. Sions continued, saying that after her facility purchased an automated record system, the system was validated at several points before going live. With regard to hardware, Sions said that the

Myra Jo Beach details the process for implementing an electronic documentation system.

departments within perioperative services at her facility had different computer station setup requirements. For example, fixed stations in the ORs, workstation on wheels in the preoperative area, and hand-held units for managers who need to do rounds. She recommended that department personnel determine what computer system traits are desirable (eg, ergonomic stand, long battery life, internal cooling fan). She reminded attendees of the need for antimicrobial keyboards that are completely sealed so they can be cleaned properly in the OR. Preplanning is essential, according to Sions, and requires staff member education. Two weeks before the go-live date at Sions’ facility, a dress rehearsal was held to check staff security access codes; assess staff member computer competencies; validate workflow processes; stress computer network systems (ie, have many people working on the system at once to see where it might break down or overload); check device connectivity; and test printer mapping. After “flipping the switch,” Sions recommended using index cards to record problems and to identify a keeper of the “issue” list. It is very important that people are given specific feedback, such as when a problem will be resolved, and to create forums to share discoveries. Sions and the staff members at her facility AORN JOURNAL •

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learned many lessons during their technology changes. She recommended that attendees consider monitoring project finances weekly; consider how the system will be maintained; and evaluate the current state of affairs and forms (eg, determine what forms exist and whether they are still needed). In conclusion, Sions summarized the challenges that were encountered at her facility: • It is human nature to focus on new computer technology instead of the patient. Preoperative assessments are more thorough but require more time. • Tackling physicians’ orders—particularly medications—in the OR was not a small feat and pharmacy practice changes are real and expensive. • Generation Y staff members eagerly embraced the new technology and were quick to develop enhancement lists that might not be practical or financially feasible but should be given serious consideration.

THE FUTURE

OF

PERIOPERATIVE SAFETY

Mark A. Warner, MD, professor of anesthesiology at Mayo Clinic, Rochester, Minnesota, described the future of perioperative practice

Dr Mark Warner predicts that a simple finger-stick test may one day be able to help physicians tailor treatment to individual patients.

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and explained how the coming changes will affect the safety of health care in his session, “Future Directions in Perioperative Safety.” Although the technology is not yet available, Dr Warner believes that in years to come, a simple finger-stick test may be able to provide patientspecific genetic analysis so that medications can be tailored to each patient’s genome (ie, all of the DNA that a person possesses). Dr Warner described studies that are being performed on different populations (eg, ages, cultures) to predict perioperative pharmacogenomics, the study of how variations in the human genome affect the patient’s response to medications. This will allow patient-tailored interventions, Dr Warner explained. For instance, health care providers can use pharmacogenomics to gain information about how a patient metabolizes codeine. Patients who metabolize the medication poorly do not convert the codeine into morphine as they should, so codeine has no effect on the patient’s pain. Conversely, a patient who metabolizes codeine rapidly converts an unexpectedly large amount of codeine into morphine very quickly. For these patients, a very small amount of codeine can put the patient into respiratory depression. Dr Warner went on to describe technologies of the future. Nanocrystals, nanotubes, and microrobots may dramatically affect perioperative practice. NANOCRYSTALS. Nanocrystals have outer shells that are immunologically inert and have an internal capacity to perform specific tasks (eg, carry medications, deliver heat or cold) when signaled to do so by marker recognition (eg, tumor-specific markers, temperature fluctuations, externally applied signals such as ultrasound). In one example, a patient is injected intravenously with a solution that contains nanocrystals. The patient is then put into a magnetic resonance scanner, where the magnet is directed to pull the nanocrystals to the desired site (eg, a liver tumor). Then the patient is taken out of the scanner and an ultrasound wand is used to break open the nanocrystals. This releases the oncology medication and allows it to work directly on the tumor, minimizing collateral damage. NANOTUBES. Another interesting technology

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being developed is physical application of carbon nanotubes, which can be spun into thread and subsequently made into fabric. The nanotube fabric can conduct both electricity and heat and can change form rapidly and repeatedly. Perioperative applications for this nanotube fabric include using it in perioperative garments for patient thermoregulation. MICROROBOTS. Dr Warner showed an animated video of microrobots performing surgery. The microrobots are introduced using a scope via the esophagus through the stomach wall. The microrobots find the appendix, apply two clips, and use argon beam technology to amputate the appendix. The microrobots then carry the appendix back to the scope and attach themselves and the appendix to the scope for removal from the abdomen. The puncture hole in the stomach does not even have to be sutured or clipped closed because the anterior stomach wall fibers overlap and self-close. Many future procedural improvements and patient-tailored therapies will have a direct effect on patient safety and will reduce opportunities for complications, Dr Warner said. These new patient-tailored therapies will result in less tissue trauma, reduce the patient’s analgesia requirements, and improve the selection of medications for their potential effectiveness. In conclusion, Dr Warner emphasized that perioperative educators need to adapt or change the process regarding educating health care team members to fully recognize the potential of minimally and noninvasive surgery and to dramatically change the perioperative experience for many patients, and thus, improve their outcomes. Implementation strategies will require perioperative, multidisciplinary teams.

REDUCING ERRORS AND IMPROVING PATIENT SAFETY IN THE OR “Regardless of our efforts, serious and often tragic events continue to occur,” said Anthony Dawson, RN, MSN, vice president of operations of New York Presbyterian Hospital, New York City, as he began his session, “Critical Success Factors Improving Patient Safety in My OR.” When serious complications occur, expensive resources are overused and effective care is underused. According to Dawson, the changing

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Anthony Dawson discusses the critical factors for reducing errors in the perioperative setting.

landscape of perioperative services (eg, new medications, devices, equipment, and procedures; difficulty finding experienced staff members) is part of the cause of the quality misalignment. “The bottom line is that 80% of medical errors are system derived,” he said. Systems errors can result from highly technical equipment and products, variable patient volume, and patient flow issues. Other factors that lead to errors include • cultural issues (eg, complex human factors, multigenerational staff, loose team structure, lack of a standardized approach to surgery); • human limitations (eg, distractions, rapidly made decisions, time constraints, heavy workloads, inconsistent staffing); and • communication issues (ie, 30% of procedurerelated communication is ineffective). One source of communication errors in the perioperative area is preference cards, which may be inaccurate as a result of inconsistent instructions, use of unacceptable abbreviations, delayed updates, use of high-risk medications, and not using a zero to the left of a decimal point. These are fixable problems, Dawson said. Dawson reviewed the National Patient Safety Goals (NPSGs) as they apply to the perioperative setting, emphasizing that the NPSGs come from the Sentinel Event Advisory Group that highlights problematic areas. One of his key AORN JOURNAL •

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points was a reminder to use checklists. During a discussion of health care-associated infections, Dawson emphasized that no one should assume that hand hygiene is engrained in perioperative culture. At his facility, a Clean Hands Save Lives campaign was instituted to emphasize cleaning hands the right way at the right time. Patients are being involved in the process and are given a list and asked to document whether caregivers wash their hands before having contact with them. Dawson reminded attendees to ensure that the patient is involved throughout the process and that previous medical records and documentation are reviewed to ensure consistency in patient, procedure, and site. Surgical site marking considers laterality; the affected surface (eg, medial, lateral, palmar); and the level. At Dawson’s facility, the attending surgeon is required to mark the surgical site but this can cause complications for some facilities where the attending surgeon is closing in one room while his or her next patient is being taken into another room. Final confirmation must occur during the surgical time out, and Dawson emphasized that the marking must be visible after the prep has been performed and the patient has been draped. He described having a policy in place for individuals who cannot be marked or who do not want to be marked. In his facility, a separate identification is used in these situations. During a discussion of high reliability organizations, Dawson described three components of reliability that should be implemented: • Prevent the failure from occurring. This can be accomplished by implementing basic standardization; using memory aids (eg, checklists); implementing feedback mechanisms regarding compliance with standards; and raising awareness via education. • Identify and mitigate failure. This involves use of reminders; differentiation (eg, color coding, sizing differences); and constraints (eg, computers that alarm when two medications that should be not be taken together are prescribed for the same person). • Redesign the process. This can be accomplished by evaluating failure • modes (ie, what could go wrong);

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causes (ie, why would the failure happen); and • results (ie, what happens if the failure occurs). Dawson ended the presentation by emphasizing his three most important takeaway points: • simplification—make it as simple as possible; • standardization—everyone must do it the same every time; and • communication—you cannot overcommunicate. He reiterated that the “Time Out Day” theme— time out for every patient every time—will go a long way in making strides in error prevention.

NOTES: A NEW APPROACH PERITONEAL PROCEDURES

TO

Annette Wasielewski, BSN, RN, CNOR, and Beth Waterman-Hukari, BSN, RN, CNOR, opened their session, “NOTES: The Next Generation of Minimally Invasive Surgery,” by defining NOTES® (ie, natural orifice transluminal endoscopic surgery). Wasielewski explained that this new approach to peritoneal surgery is being developed because of the benefits of less invasive surgery: reduced recovery times, less physical discomfort for the patient than is associated with traditional procedures, and virtually no visible scarring. During the NOTES procedure, an endoscope is passed through an orifice (eg, mouth, vagina, urethra, rectum) and a small incision is made in the stomach or digestive tract to gain access to the desired body cavity (eg, abdomen, thorax). Wasielewski explained that a range of procedures might be performed with this approach: cholecystectomy, appendectomy, gastric bypass, fallopian tubal ligation, oophorectomy, bladder procedures, and other diagnostic work. There are some disadvantages to NOTES. Specifically, Wasielewski mentioned poor instrumentation, vision challenges, unproven concepts, and the physician’s position relative to the patient (ie, the surgeon is essentially facing backwards). Challenges with this new technology include intraperitoneal navigation and orientation (eg, left is right, up is down). Also, surgeons struggle with loss of insufflation, space restriction, limited

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range of motion, and triangulation of the instruments so they do not bump into one another. Other challenges include gastric puncture, tissue dissection, and specimen extraction. Wasielewski briefly discussed the available approaches, including • transgastric—provides direct access to the abdomen via the stomach; • transrectal—approaches the abdomen via the rectum, which needs to be cleaned or “sterilized”; • transesophageal—may provide access to the thorax; and • transvaginal—provides access to the abdomen but obviously excludes 50% of the population. Wasielewski explained that the NOTES procedure is so new that generally research has been confined to animals. Recently, however, human studies have been conducted, the results of which have shown procedures to be highly successful. Further studies involving a variety of procedures under close supervision by medical experts and review boards are being performed. Some of the current clinical trials include • transgastric appendectomy, • transgastric cholecystectomy, • transvaginal cholecystectomy, • transgastric peritoneoscopy/biopsy at the time of Whipple, • percutaneous endoscopic gastrostomy tube rescue, • transgastric or transduodenal drainage of pancreatic cyst, and • placement of diaphragm pacing wires. Waterman-Hukari addressed several questions about NOTES, beginning with who would be best suited to perform these procedures. She suggested a gastroenterologist, laparoscopic general surgeon, or interventionalist. In jest, she proposed several possible future names for the individuals who perform these procedures, such as laparoendoventionalist or endoscopic surgical interventionalist. Another question about NOTES is how surgeons would be trained. Would they need one to two years of a gastroenterology residency or a general surgery residency, Waterman-Hukari asked. Or, is a residency or fellowship in laparoscopic procedures (ie, minimally invasive surgery [MIS]/minimum access surgery

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Beth Waterman-Hukari asks attendees to consider the increased costs of new technology and whether the benefits justify those costs.

[MAS]) for an additional one to two years the best approach? Younger surgeons are already video trained, she noted, so their learning curve is markedly reduced. Where NOTES procedures should be performed is another question about the new technology. For instance, should they be performed in a traditional OR suite, an integrated OR suite, an endoscopy unit, an interventional suite, or an ambulatory surgery center? And based on where the procedures will be performed, Waterman-Hukari reminded attendees that OR team members might need additional education and orientation in areas such as the endoscopy unit, cardiovascular laboratory, or radiological intervention procedure unit. Furthermore, team members may need additional intensive training in MIS/MAS procedures. During a discussion on patient advocacy issues, Waterman-Hukari asked attendees to consider the increased cost of this new technology and whether the benefits of performing the surgery in this minimally invasive manner justify the increased costs. As the patient’s advocate, is the nurse responsible for informing the patient that he or she has the right to choose a less expensive procedure? If so, how does the nurse find out accurate details about AORN JOURNAL •

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the cost of each procedure? Initially, the learning curve is steep for surgeons and team members (eg, hand/eye coordination, navigation, orientation). The patient’s risk is increased until surgeons and team members are proficient with the new techniques. Furthermore, the procedure takes longer to perform initially than the traditional open procedure, so it exposes the patient to more anesthesia. Waterman-Hukari asked attendees whether the patient should be informed of these risks. And, what is the nurse’s responsibility as the patient advocate if surgeons or anesthesia care providers do not want the patient informed of these issues? There also are psychological considerations or adjustments to a method that uses natural orifices. Some patients may not welcome the idea of having an abdominal surgery performed through their rectum, mouth, or vagina, WatermanHukari said. She recalled a patient saying, “It’s one thing to push a baby out of there, but birthing my appendix is a whole other issue!” Wasielewski explained that technology is being developed today that will facilitate endoluminal and single-port laparoscopic procedures. These include • SPA—single port access, • SILS™—single incision laparoscopic surgery, • OPUS—one port umbilical surgery, • NOTUS—natural orifice transumbilical surgery, and • SITS—single incision telerobotic surgery. Wasielewski explained that not all patients are candidates for these types of surgery. For instance, patients who have undergone multiple abdominal surgeries may not be good candidates. Currently, patients who are obese are not good candidates because of restrictions with instrumentation and difficulty achieving traction, but eventually they may be candidates as instrumentation is improved. Editor’s note: SILS is a trademark of Covidien, Norwalk, Connecticut. NOTES is a registered trademark of the Natural Orifice Surgery Consortium for Assessment and Research. REBECCA HOLM RN, MSN, CNOR CLINICAL EDITOR

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MANAGING SUPPLY COSTS

IN THE

OR

The three keys to lowering supply costs are data analysis, communication, and teamwork, according to Peggy Camp, RN, BSN, MSN, who presented “Perioperative Services: Supply Cost Management.” The trick is to look for opportunities. There are many reasons why supply costs are increasing in surgical facilities—and the OR already accounts for about 60% to 70% of a facility’s supply costs, Camp said. One challenge for nurse managers with regard to new technology is the high number of vendors and products that are available. That will never change, she said, so it is important for nurses to weigh the options when they are looking at purchasing. Physician preferences also can contribute to increasing supply costs because of a lack of standardization. Implants are the most expensive product line, Camp said. For implant purchasing, she recommended that nurses ask vendors about supplemental costs because some vendors will charge a facility for individual components of a single product. “For too many years, we’ve paid whatever the vendor charged us,” she said, telling attendees that there are opportunities for cost savings out there if the right questions are asked. For general supplies (eg, gowns, dressings, masks, surgical blades, drapes) and specialty supplies (eg, trocars), Camp suggested considering generic products instead of demanding name brands, and looking for opportunities to standardize. A big way to tackle waste is to evaluate physician preference cards and case pull tickets, which, Camp said, she knows “is one of the last things people want to do” because it is time-consuming. “But it’s well worth the effort,” she added. Another opportunity for change is implementing a protocol for new products. For example, hospitals should have a protocol that requires the use of only US Food and Drug Administration-approved products, that they are not used off-label, and that the coding is documented so the facility can be paid. She used the example of a $1,500 implant that was missed because it was not coded properly on the front end. “Product entry is critical for

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controlling costs,” she said. In addition to the big things like implants, Camp said, the little things can add up, like paying $0.29 versus $0.89 for a pouch. Using the lower cost item can help save money, as long as it does not affect quality or performance. One way to cut down on escalating supply costs is to look at custom packs. Although customizing packs can assist nurses by reducing turnover times, they also tend to increase supply costs because of items that are discarded without being used. In fact, Camp said, 13% of OR supplies are “wasted” each year. She suggested another good rule of thumb is to review all custom packs at least twice a year because of how fast practices and preferences can change. Also, she recommended keeping anything too specific out of the pack and trying to focus custom packs on more general supplies. Using consignment inventory may appear to be a good idea, and it can be, Camp said. It should be continually monitored, however, because if a consignment item is broken or lost, the facility will be charged for it. Using remanufactured supplies may be an option to reduce costs, as well as to reduce waste. A group of 10 facilities that Camp worked with diverted three tons of waste last year by remanufacturing supplies. She also suggested nurse managers take their staff members on an OR tour every few months to show them how many supplies are thrown away and to take them “grocery shopping” periodically to discuss how much supplies cost. Changing practice requires education, Camp stressed, and making sure all perioperative team members understand the costs involved is a good way to begin making changes. Communicating with physicians about cost is also important, particularly because their relationships with vendors can influence purchasing decisions. Knowledge is power, Camp said, recommending that attendees make sure to do their research before going to any supervisors to discuss purchasing changes. She recommended that nurses research supply costs (eg, this year versus last year, year to date versus budget). She also suggested looking at vendor fees

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Peggy Camp explains how to lower a facility’s costs by streamlining and standardizing supply management.

(eg, delivery fees, upcharges), which may be negotiated away, and instrument acquisition and repair expenses. The savvy nurse manager will “dare to compare,” Camp said, and will negotiate reduced pricing. “Every one of you has the power to negotiate,” she added. “If you’re not, you’re missing the boat.”

PERIOPERATIVE NURSING

IN

BALAD, IRAQ

Perioperative nursing at the 332nd Expeditionary Medical Group Air Force Theater Hospital in Balad, Iraq, is like perioperative nursing in the United States in that patient care is the primary focus; however, it is much more different than it is similar. In addition to ensuring patient safety and providing the best care possible, perioperative nurses in Balad treat much more severe trauma than is typically seen in the United States, and they have to worry about dust storms, Iraqi insurgents, and near-daily mortar attacks. Three US Air Force perioperative nurses presented their experiences in Balad during a first and second deployment in “Balad, Iraq: Return to the Sandbox.” FACILITIES. Maj Tara Constantine, RN, MSN, CNOR, USAF, NC, spoke about the changes that occurred between 2004 and 2008. On September 16, 2004, the Air Force took over the hospital from the Army. Between that date and AORN JOURNAL •

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Maj Tara Constantine discusses the changes at the Balad, Iraq, hospital after the US Air Force took over operations from the Army.

October 24, 2008, more than 22,000 surgeries were performed at the hospital in Balad. When the Air Force personnel first came in, they worked inside of tents that were strung together with vestibules that allowed personnel to walk between departments without having to go outside. The tent hospital did not have modern equipment. The hospitals had primitive wiring and plumbing that ran on the ground outside of the tents, unprotected from the elements. The sinks were small and sparse (ie, one sink per area); there were no indoor restrooms, and the temperature control did not always work—particularly on days when the outdoor temperature was as high as 130° F (54.4° C), Maj Constantine said. In addition to creating daily work challenges, the tent hospital was unsafe during mortar attacks. When “Alarm Red” was sounded, staff members who were not directly involved in patient care evacuated to nearby cement bunkers. Personnel who were directly involved in patient care would stay by their patients’ bedsides and work during the attacks. To prepare for these situations, some hospital staff members would wear their protective gear and helmets during procedures. The tent hospital had three ORs, which were

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essentially iso-shelters connected to the tents. Iso-shelters, Maj Constantine explained, are something like square-shaped shipping containers, which were made into bare-bones ORs. The supply cabinets in each room were organized similarly to help staff members find what they needed quickly no matter which room they were working in. Oftentimes, the ORs had to accommodate two patients and dedicated surgical teams at the same time. One circulating nurse often would be responsible for both procedures. In August 2007, Air Force personnel moved out of the tent hospital and into a brand-new facility that had a blast-resistant roof, functional temperature control, numerous large sinks, brand-new steam sterilizers, and indoor restrooms. The new hospital had three ORs that could accommodate six procedures simultaneously, with the possibility of adapting to four ORs and eight procedures. The new hospital allowed Air Force personnel to maintain higher nursing standards, Maj Constantine said. In 2006, she noted, the number of surgeries and the severity of the procedures made it nearly impossible to count sponges and syringes. Also, they were unable to take x-rays at the end of each procedure, and although some postoperative reporting was done, circulating nurses did not record intraoperative nursing documentation. In 2008, however, mandatory counts, documentation, and a modified time-out procedure were implemented at the hospital. SURGERIES. The types of surgeries that were performed at both the tent hospital and the new facility were varied and numerous, according to Capt Jade Anthony R. Alota, RN, BSN, USAF, NC. The categories of surgeries included neurosurgery; orthopedic surgery; gastroenterology; general surgery; and specialty surgery (eg, ear nose and throat, oral and maxillofacial, ophthalmology, urology). There were similarities and differences in the types of procedures that were performed during the first and second deployments, Capt Alota said. During both, trauma procedures were performed to save “life, limb, and eyesight,” and stents and retranspositions were the most common types of vascular procedures. During the

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second deployment, laparoscopic procedures increased and the casualty rate decreased. Also during the second deployment, the surgical team was able to perform more humanitarian procedures than during the first deployment. One example of a humanitarian procedure was the case of a young boy who suffered severe facial electrical burns in his home because he had put a live wire in his mouth, according to Capt Mary Schroeder, RN, BSN, CNOR, USAF, NC. The boy had to undergo numerous debridement procedures, skin grafts, and other procedures to repair the damage. POST-TRAUMATIC STRESS DISORDER (PTSD). For members of the US Air Force, a post-deployment health assessment is conducted three to six months after they return home, and resources are available to those who need help with PTSD. The emotional impact of deployments includes fear, anxiety, feeling alone, and sleep deprivation, according to Capt Alota, who said he also felt a mix of pride and prejudice—pride in the soldiers and prejudice against the Iraqis—during his first deployment. During his second deployment, Capt Alota said, he was able to focus more on the mission of being in Balad and became more adept at balancing work and play, making sure to take time for fun activities like playing ball games with the other soldiers. Care packages sent from home and from anonymous Americans helped boost morale, he said. Capt Schroeder said that after her first deployment she found it difficult to be in crowds, and she felt angry when she saw everyday people being happy because she wondered if they knew or cared what was happening in Iraq. She said that after her second deployment, she felt better, but that she still thinks of those who have died in Iraq during the war. DEATH AND DYING IN THE OR. There are two rules of war, Maj Constantine, said: 1) young men and women die, and 2) health care providers cannot change the first rule. Maj Constantine told a story about a young US soldier who was brought into the 332nd for care. He was in critical condition upon arrival to the facility, and his arrival seemed to heighten hospital staff members’ senses because of how much they wanted to make sure that he lived. The physicians took on roles they normally would not—the neuro-

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surgeon held traction and the orthopedic surgeon helped with packing—but despite everyone’s efforts, the soldier could not be saved. “That’s when rule number two really hit home,” Maj Constantine said. At the end of the session, a woman stood up and thanked the presenters for sharing their stories, and personally thanked them for saving her son’s life—he had been treated at the 332nd in Balad. KIMBERLY RETZLAFF ASSOCIATE EDITOR

ARE YOU

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GRAY GORILLA?

AORN past Presidents Carol Applegeet, RN, MSN, CNOR, NEA-BC, FAAN, (19891990) and Mark Phippen, RN, MN, CNOR, (1990-1991) shared the stage to discuss mentoring in perioperative nursing during their session “Gray Gorillas Revisited.” The topic, one that they presented years ago, has just as much relevance today as it did when it was first discussed. According to Applegeet and Phippen, mentors are no less significant today than yesterday. Literally, a gray gorilla is a silver-back primate that serves as a leader, teacher, protector, and role model in the wild. A Gray Gorilla Mentor also has these characteristics (Figure 1). Mentors facilitate personal and professional growth by sharing insights they have learned over the years. The relationship, often voluntary

Figure 1 • Characteristics that define the Gray Gorilla mentor. Reprinted with permission from Carol Applegeet and Mark Phippen.

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for both parties, is normally focused on a common goal. There are four stages in mentoring: • Preparing—The mentor begins laying the groundwork in preparation for the mentoring relationship. Roles are then established. Applegeet posed, “In your job, every day there is someone looking for a way to advance themselves; how do you set people up?” • Negotiating—After the mentor and mentee agree on their new relationship, they begin to establish a framework for defining benchmarks for success, creating protocols to work through pitfalls, and meeting goals. • Enabling—At this stage, mentors continue to manage the relationship while actively supporting the mentee’s education. They foster the mentee’s continued growth by encouraging reflection. Phippen said, “Hopefully you can take that reflection and move to where you want to go.” • Closure—This can be one of the most difficult stages, because it often generates feelings of separation and loss and is an inevitable part of the mentoring process. This usually occurs when someone retires. There must be honesty for a positive mentoring relationship to work. Even if a mentor and mentee disagree, the relationship is not compromised because it has been built on trust and compatibility. An effective mentor is one who will take time to listen first and then provide feedback. They also will share feedback with the mentee that others will not. In stark contrast to the Gray Gorillas, there can be a dark side to mentoring. The presenters refer to this negative mentoring as The Darth Vader Syndrome. Characteristics include hoarding information, being a “puppet master,” taking the credit, “throwing others under the bus,” and being selfish. Before the session, Applegeet and Phippen had obtained feedback from past and present AORN leaders who had been mentored by and had themselves become Gray Gorilla mentors. Based on the feedback, six degrees of separation was established between AORN founder Edith Hall, RN, and outgoing AORN President Susan Banschbach, RN, MSN, CNOR. That signifies 54 years’ worth of positive mentoring relationships.

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Applegeet brought the session to a close by sharing a quote from Diane Fossey, an American zoologist who conducted an extended study of gorilla groups over the course of 18 years. “When you realize the value of all life, you dwell less on what is past and concentrate on the preservation of the future.” BRIANNA DAVIS ASSISTANT EDITOR

IMPLEMENTING

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ELECTRONIC MEDICAL RECORD

In her session “OR EMR Implementation: Lessons Learned,” Cheryle S. Davis, RN, BSN, CNOR, shared the expertise she gained from implementing an electronic medical record (EMR) in 27 acute care facilities with a combined total of 140 ORs in eight states. The implementation took four years (ie, 2004 to 2008) and involved standardizing forms, procedures, and supply and equipment files. Project phases included conducting a gap analysis and process review; developing naming conventions; building the database; training the users; and testing, activating, and evaluating the product. GAP ANALYSIS AND PROCESS REVIEW. In explaining the gap analysis, Davis said, “People make it sound like a big deal, but it is really just a tool for comparing what you are doing with what you want to do.” It is an opportunity to identify areas with room for improvement. “This is your chance to stop workarounds,” she added. Davis advised looking at every form and documenting every process because the goal is to create an electronic process for every current process. She also suggested involving as many people as possible in the process review. NAMING CONVENTIONS. Naming conventions are one of the most important aspects of the implementation because they will be used throughout the EMR development for procedures, supplies, equipment, medications, positions, and anything on a preference card. System users need to be able to gain useful information from the name. For example, if the naming convention for every type of suture begins with “suture,” personnel will spend less time searching for the right item. It is important to avoid “naming collisions” in which items are named in duplicate ways that

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show up in multiple places within the system. Davis provided a number of examples of naming collisions she encountered, such as: • Synthes small fragment, • Small fragment Synthes, and • Sm fragment Synthes. Naming collisions create “a maintenance nightmare,” Davis said. She also warned against using nicknames for equipment (eg, big ugly, lemon squeezer, Big Brother). Even though personnel in one facility may be familiar with these names, this system needed to be useful in multiple facilities. It is important for the project coordinator to formalize expectations for the naming conventions and promote consistency within the team. For example, each name could follow the convention “noun, adjective, type, size.” Consistency also enhances the professional appearance of the end product. THE DATABASE. Building the database may seem daunting. “When we start, we think this is the biggest job,” Davis commented. “It is the most time consuming, but you are already a master of this information.” Items that need to be built into the database include procedure files; item files; code sets (ie, predefined, drop-down menus); pick lists; preference cards; and documentation. Preference cards are an electronic representation of the traditional preference card. It is a good idea to involve others who are interested when building the preference cards. These people should have clinical experience and basic computer skills. Through their work in developing the preference cards, they will become experts in working with the system. “If you can get some people invested in your process, the more likely you’ll be successful,” Davis suggested. The documentation component of the system should meet recommendation standards and regulatory requirements and be adaptable and applicable for all kinds of procedures. AORN’s Perioperative Nursing Data Set language can be built into the pointof-care documentation. TRAINING. Training teams should include a primary leader for the class, a “driver” who manages the computer display during class, and a proctor who supports the students during instruction and return demonstrations. The

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Cheryle S. Davis emphasizes that during an electronic medical record implementation project, the project coordinator should promote consistency.

preference card builders can also support the primary users at activation. Super users, who are self-selected based on interest, can also be trained to help the primary users at activation. TESTING. Testing involves determining how the system works and whether it is doing what it is supposed to do. One way to find problems in the system is to use it during a real procedure at the same time the old system is being used. The system should also be tested to make sure it integrates with other systems at the facility. Mock scenarios can be used to go through steps for each area: scheduling, registration, admission, the OR, and the intensive care unit. After working through the documentation, the tester can determine whether every part was actually documented. “Make sure what you expect to happen happens. Does it do what you want? Look how you want? End up located where you want?” Davis asked. ACTIVATION. At the activation phase, “your work is done,” said Davis. Now it is time to help the end user. It is important to provide a positive environment, a timely response to support requests, and plenty of praise. EVALUATION. The evaluation phase involves identifying what is working successfully and what could be improved or revised. Allowing AORN JOURNAL •

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processes to stabilize can help prevent impetuous changes. “Don’t get talked into changing anything the first week,” Davis advised. “Wait two to four weeks to make any changes.” After something is changed, everyone should be trained on the new part of the process. Before opening the session up to questions, Davis had one more piece of advice for the attendees. “[Complete] the steps properly and thoroughly,” she warned. “If you don’t, you will have lots of ‘oh, I didn’t think of that’ moments.” LIZ COWPERTHWAITE SENIOR MANAGING EDITOR

HEALTHY WORK ENVIRONMENTS Pamela Hunt, MSN, RN, detailed concepts that every nurse could use in his or her work and personal life as she presented her session, “Something to Talk About: Creating Healthy Work Environments Through Communication.” She opened the discussion with the question, “How often have you witnessed disruptive behavior?” To this, an impressive number of hands were raised. Hunt shared that research shows that both physicians and nurses have witnessed this type of behavior, yet disruptive behavior continues. In fact, problematic communication leads to 60% of medication errors and 80% of medical errors, as well as delayed treatments, omission of treatment, and lack of order clarification. To combat this problem, Hunt suggested working to create a healthy work environment. By doing so, health care facilities can experience lower recruitment and retention costs, lower morbidity and mortality, and improved reimbursement, as well as potentially pursue Magnet™ status. Hunt then identified four communication styles in the workplace that should be addressed and corrected to create a healthy work environment: intimidation, gossip, passive/aggressive behavior, and never satisfied/whining. To clearly identify each style, Hunt featured clips from four popular movies that illustrated the various communication styles. After each clip, she explained ways to change the behavior. INTIMIDATION. Intimidation was illustrated in a clip from A Few Good Men. This style of com-

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munication uses blame and justification. Hunt explained that some of the reasons for using intimidation could be an above-the-law attitude, a lack of desire to be questioned, a lack of collaboration, or a situation in which someone is wrong and tries to cover it up. The key to responding to this type of behavior is to “stay in the moment.” It is important to listen; separate emotion from the facts; talk and respond calmly; be aware of nonverbal cues (eg, crossed arms); and request that the person speak calmly (eg, “You’re talking so loud, I can’t hear you”). Ultimately, it is important to try to take the emotion out of the communication and listen intently for the actual problem. GOSSIP. Gossip was illustrated by the movie Something To Talk About. Hunt stated that this type of communication occurs because “there are always people who want to capitalize on other people’s pain.” Some reasons for this type of behavior are that the person wants to boost himself or herself by bringing others down, does not have the nerve to confront the person that he or she is gossiping about, and is not interested in making things better. The best response to this type of behavior is to not listen to the gossip and speak up about the problem. Before speaking, however, it is important to ask, “Is what I’m going to say going to lift up my coworker, improve our patient care, or be of benefit to our team? If not, why am I sharing it?” Asking these questions provides the opportunity to stop gossip at the source and move on to something productive. PASSIVE/AGGRESSIVE. Passive/aggressive behavior was illustrated in the movie Monster in Law. Some examples of passive/aggressive behavior include rolling the eyes, silence, or throwing an instrument in the OR. Some people who participate in this form of communication do so because they want others to share their opinion without making any commitment to that view, they want to set up the issue while pretending to be the nice guy, or they simply have no backbone to just say what they think. Regardless of the reason, some questions to ask the person in response to this behavior are: • Are you sure that you are OK with this? • What did you mean by that? • How would you have done things differently?

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•

Why did you roll your eyes? By asking these questions, the person is essentially asked to take responsibility for his or her feelings, which will help to uncover the real problem so that it can be addressed and solved. NEVER SATISFIED/WHINING. The communication style of being never satisfied/whining was illustrated by the movie Overboard. Hunt described people who communicate in this style as always seeing the glass half empty, desiring attention, having a victim mentality, making others think something is wrong, and not seeing themselves as part of the problem. People experiencing to this type of behavior should not join in; rather, they should help the person focus on the solution and engage him or her in problem solving. CONSTRUCTIVE CONFRONTATION. Hunt then discussed proper ways to engage in constructive confrontation to address problems while also maintaining a healthy work environment. First, a person who is confronting someone who behaves disruptively should open with facts and explain why and how the behavior in question is in violation of policy. Next, he or she should problem solve, determine an action plan and follow-up, and end on a positive note. Hunt recommended always keeping the desired outcome in mind during the confrontation. Some confrontation techniques that Hunt highlighted include depersonalizing the event, maintaining mental integrity, involving a third party if necessary, managing nonverbal communication, and pointing out any escalating emotions. To begin the conversation, Hunt suggested saying, “I understand that . . . ” or “I want to talk to you about. . . . ” BEING CONFRONTED. Hunt offered some suggestions for handling situations in which one is confronted. The confronted person should • take a few deep breaths and remain calm; • verbally thank the person who is confronting him or her for bringing attention to the issue, as it was most likely not an easy thing to do; • engage in some self-talk and remember that confrontation is an opportunity for improvement because perception is 99% of relationships; • resist the urge to bring others into the situation unless absolutely necessary; • offer to think about what the person has

Pamela Hunt describes four workplace communication styles that should to be addressed and corrected.

said and ask to get back to him or her; and be sure to follow up with the person when there has been time to reflect on what was said. WORKING TOGETHER. Hunt challenged attendees to try case scenarios with their team members to practice these responses and confrontation techniques. Another suggestion was to provide opportunities for everyone to work together (eg, by including physicians in social gatherings or sending nurses and medical staff members to educational conferences together to promote unity). Hunt closed the discussion by reminding the audience, “If you permit [disruptive] behavior, you’re promoting it.”

•

Editor’s note: Magnet is a trademark of the American Nurses Credentialing Center, Silver Spring, MD.

HOW TO CROSS-TRAIN IN AN AMBULATORY SURGERY CENTER Marilyn K. Christian, RN, BSN, CNOR, CASC, led an informative discussion on the value of cross-training in an ambulatory surgery center (ASC) during the session “CrossTraining in the ASC.” Cross-training maximizes resources, enhances the quality of patient care, and benefits everyone involved, from AORN JOURNAL •

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Marilyn K. Christian says that all staff members should be considered during cross-training efforts in the ambulatory surgical setting.

patients to physicians to staff members to the bottom line. Cross-training also can help to develop staff members’ skills and abilities, balance the limited number of staff members with staffing requirements, and plan for potential downsizing and cost-saving measures. Additionally, cross-training can increase the marketability of each nurse, nurture a team-oriented environment, break up the monotony of the day, and reduce downtime. Approximately 22 million procedures are performed each year in any of the nearly 6,000 licensed ASCs in the United States. Some of the specialties served in this setting include urology, orthopedics, bariatrics, podiatry, dermatology, interventional pain management, and general surgery. Ambulatory surgery centers are community-based businesses that benefit the community by providing reasonably priced surgical care to patients and services to local charities, contributing to local property and income tax bases, and offering a familyfriendly work environment for staff members. “One of our hallmarks is our 98% to 99% patient satisfaction,” Christian said. Seventy percent of ASCs have 20 or fewer full-time employees. Having a limited number of staff members within the facility increases

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the need for cross-training and maximizing the resources available. Initiating a cross-training program may meet some staff member and physician resistance to change. Some of their concerns can be alleviated by clearly defining the expectations of physicians, staff members, and administrators, as well as emphasizing that cross-training will save thousands of dollars and will maximize the staff members available. Christian went on to discuss how nurses can take the next step to get their facility involved in cross-training. Her first recommendation was to identify a physician in the facility who would be willing to support cross-training in their OR. When a physician has agreed to allow the training in his or her OR, nurses should determine the greatest need, skill, or weakest specialty. By prioritizing the needs, nurses can train to compensate for any shortages in those areas. This will also gradually build up the strength of the nursing team. As other physicians see how well the cross-training is working in the first physician’s OR, they will want to incorporate crosstraining in their ORs as well. Christian said that cross-training will take “one to one-anda-half years to get your whole facility fully trained.” She also recommended that all policies and procedures be written down and kept up-to-date so that they are easily accessible to anyone at any time. Nurses who are successful in the cross-training program seem to have similar characteristics and work ethic. These successful nurses are punctual, flexible, intuitive, receptive, reliable, self-directed, and responsible. Most of all, nurses should be able to multi-task, have a desire to learn new skills, and have the ability to adapt to change and shift gears quickly and efficiently. When using cross-training in an ASC, Christian indicated that all staff members should be considered. For instance, a staff member whose primary job function is administrative could be trained to set up or clean up a surgical room. Conversely, a nurse could be crosstrained to help on administrative duties. When the skill sets of all employees are maximized, patients receive better and more efficient care.

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PREPARING NURSES

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FOR INFORMATICS

Diane J. Skiba, PhD, RN, FAAN, FACMI, spoke to a full audience about an informatics initiative during the session “TIGER Initiative: Technology Informatics Guiding Education Reform.” The initiative was born from four goals: inform clinical practice, interconnect clinicians, personalize care, and improve population health. The TIGER vision is to “enable nurses to use informatics tools, principles, theories, and practices to make health care safer, more effective, efficient, patient-centered, timely, and equitable by interweaving enabling technologies transparently into nursing practice and education, making information technology the stethoscope for the 21st century.” The seven pillars of the initiative are • management and leadership, • education, • communication and collaboration, • informatics design, • information technology, • policy, and • culture. To achieve the vision of transforming nursing education through technology and informatics, the TIGER initiative established nine collaborative teams, each with its own specific purpose and agenda. TEAM 1. The first team is responsible for identifying the most relevant health and information technology (HIT) standards, assessing whether there is sufficient representation of the TIGER perspective on those standards, and taking action to close any gaps. This team also is responsible for communicating the existence and importance of the standards and initiatives to the nursing community and developing tutorials for standardizing data elements. TEAM 2. The second team is responsible for identifying HIT agendas and policies that are relevant to the TIGER vision, as well as assessing whether there is adequate representation of the TIGER initiative on those policies and agenda items and closing any gaps that may exist. This team also is responsible for communicating the existence and importance of the national HIT agenda and policies to the overall nursing community.

TEAM 3. The third team works to harmonize and establish informatics competencies in nursing education (eg, diploma, associate, undergraduate, graduate) and nursing practice. Additionally, team members advocate for and support including informatics competencies in specialized certifications. TEAM 4. The fourth team is responsible for creating programs and resources that assist faculty members with increasing their knowledge of and developing their skills and abilities in informatics. Team members also develop strategies to recruit, train, and retain nurses in the areas of informatics, education, practice, and research, as well as collaborate with industry and service partners to offer informatics tools within the nursing curriculum. TEAM 5. The creation of competency-based, cost-effective staff development, continuing education programs, and training strategies for informatics is the undertaking of the fifth collaborative team. This team also collaborates with industry, service, and academic partners to improve and expand current nursing informatics education programs and the use of technology and informatics in nursing practice. TEAM 6. The sixth team engages in improving the clinical applications used by nurses. They do this by supporting standardized terminology and evidence-based practice, enabling collaborative

Diane J. Skiba explains the TIGER initiative.

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and interdisciplinary care, working with system developers to maximize clinical system effectiveness and efficiency for nurses, and providing seamless access to published literature. TEAM 7. Creating a virtual demonstration center is the job of the seventh team. Team members share their knowledge of informatics lessons, best practices, research results, case studies, and more through many outlets including conferences and meetings, published articles, workshops, and web casts. Additionally, team members fund efforts to demonstrate the value of informatics and technology in nursing, as well as create public and private financial incentives to support the adoption of innovative technologies. TEAM 8. Engaging and supporting nursing leaders is the main priority of the eighth team. To do this, team members develop programs for nursing executives that stress the value of technology and informatics in nursing practice. TEAM 9. Finally, the ninth team engages and supports health care consumers by helping to develop literacy in informatics. This team also

Congress Education Sessions

works with personal health record advocates and developers to optimize the health record as it relates to nursing. Skiba indicated that there are some obstacles for fully integrating informatics and technology into nursing practice. For instance, some nurses feel that technology interrupts the work flow, whereas others simply do not have the knowledge or skills needed to fully understand and embrace the new technology. In either case, however, the solution is to incorporate more training and education. Some opportunities for learning more about informatics include certificate programs (eg, from the University of Colorado Denver and AORN [http://www.nursing .ucdenver.edu/grad/off_prof_dev2.htm#aorn]); graduate degree programs; weekend immersion nursing informatics programs; and online tutorials from informatics organizations (eg, the Alliance of Nursing Informatics). JENNIFER BRUSCO ASSOCIATE EDITOR

AORN Connections Receives ASHPE Gold Award

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he American Society of Healthcare Publications Editors (ASHPE) awarded AORN Connections the Gold Award for Best Single News Article for “Hidden dangers,” by Carina Stanton, senior news editor/ writer for AORN’s News Department. “Hidden dangers” originally appeared in the July 2008 issue of AORN Connections and can be accessed online at http:// www.aorn.org/News/July2008News/HiddenDangers.

AORN Connections is produced online monthly and is available in print nine times each year. The ASHPE annual awards competition recognizes “outstanding editorial excellence and achievement in health care publications.” AORN Connections was awarded a plaque and a certificate to denote the honor. For a full list of award winners from this year’s ASHPE Awards Competition, visit http://www.ashpe.org.

Congress Session Materials Now Available

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ducation session materials from the 56th annual Congress, held March 14 to 19 in Chicago, Illinois, are now available. AORN has partnered with Content Management Corporation to provide access to the 2009 Congress education sessions. Sessions are available in the following formats: • Interactive CD-ROM—the full conference, including select Education sessions, General Sessions, and Intensive sessions, is available in one CDROM set with audio and slides (where available) from the presentations.

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• Audio—individual audio-recorded sessions can be downloaded online as MP3 files or ordered on CD. • Video—select individually recorded sessions are available on DVD. In addition to audio/video offerings, the handouts from more than 80 select sessions are available. To access these handouts, visit http://www. softconference.com/aorn and click on “Annual Meeting” then select “Click here for content from the Meeting.” The complete Congress or individually recorded sessions are available for purchase.