Sales Roadmap Irrigation Fluid Warming Temperature Management

Key Challenge 1 1. Ecolab Benefit: The IntraTemp Fluid Warming System is easy to operate. Benefit Statements: Easily control and document the fluid temperature No programming needed Solution temperature can be accurately documented in the patient chart Unit will not operate if not set up correctly. Each drape is packaged to easily unfold to maintain a sterile field and be placed in the warmer. Two pockets on the side provide access to additional warm irrigation or IV fluid Tools Set up and in-use product demonstration, focusing on these benefits: – Single button operation – “plug and play” – Clearly visible temperature display – Volume markings inside of basin – Snap in basin activates the warmer and assures proper set up ___________________________________________________________________ Assure personnel are educated and compliant with product usage and clinical protocols and practices

Key Challenge 1 2. Ecolab Benefit: Highly trained, professional sales associates provide excellent training and support. Benefit Statements Dedicated Ecolab Surgical team can assist with solutions to help you reduce the risk of inadvertent hypothermia at your facility. Ecolab’s comprehensive approach to temperature management includes procedure assessment, gap analysis, normothermia education and full product training and in-service. Tools Schedule and conduct a Temperature Management (Hypothermia) Educational Event Complete surgical procedure assessment and intervention gap analysis Product demonstration In-service training to clinical staff Product Trial/Evaluation Form Rapid response to customer requests and any equipment repairs or field service ______________________________________________________________________ 3. Ecolab Benefit: Use of the IntraTemp Fluid Warming System helps minimize traffic into and out of the OR and nursing time. Benefit Statements Reduces procedure disruption and nursing time to retrieve additional fluid during the procedure Assures a consistent source of warm solution without having to leave the OR Reduces need to label and rotate saline bottle inventory Tools Set up and in-use product demonstration Storage and labeling requirements of saline bottles in warmer cabinets

Key Challenge 2 1. Ecolab Benefit: The IntraTemp Fluid Warming System helps to maintain normothermia by providing warm irrigation fluid throughout the procedure when and where it’s needed Benefit Statements Even mild inadvertent hypothermia can increase post-anesthesia recovery time, blood loss, morbid cardiac outcomes, and lengthen hospital stays. Maintaining normothermia should include using warm irrigation fluid administered to patients all procedures in which the use of warm fluid would provide benefit to the patient. The portability of the IntraTemp provides clinicians immediate access to continuously warm fluid at a known temperature Tools Temperature Management Platform Folder IntraTemp Product Sales Sheet Temperature Management Clinical Compendium Procedure assessment tool Actual set up and in-use product demonstration ( having warm fluid immediately available) Clinical Support “Perioperative temperature drops can be reduced by using heated irrigation fluid which is continuously warmed.” (Mirza, Oct 2007) “Use of warmed irrigating fluid is a reasonable means of decreasing heat loss and the risk of perioperative shivering and hypothermia, which suggests nurses should actively use warm fluids for irrigation during endoscopic surgeries.” (Jin, 2011) “None of the patients who received isothermic [warm body temperature] irrigation and warm intravenous fluid felt cold or shivered and their postoperative hospital stay was significantly shorter. … We recommend that both the irrigation fluid and the intravenous fluids used during TURP [Transurethral resection of the prostate gland] should be isothermic.” (Okeke, 2007) Improve Patient Outcomes

Key Challenge 2 Clinical Support Graph shows mean drop in core temperature in test (warmed fluid) and control (room temperature fluid) groups. “In conclusion we suggest that all arthroscopic shoulder surgery be performed with irrigation fluid warmed to 36°C.” (Board, 2008) Graph shows change in core body temperature during arthroscopic shoulder surgery in patients who received warmed irrigation fluid (solid circles) and room-temperature fluid (open squares). Error bars represent 95% confidence intervals. Asterisks represent significant difference between the 2 groups (P <.05). “Hypothermia occurred more often in shoulder arthroscopic surgery with room-temperature fluid irrigation than with warmed fluid irrigation. The use of warm irrigation fluid during arthroscopic shoulder surgery decreases perioperative hypothermia, especially in elderly patients.” (Kim, 2009)

Key Challenge 2 2. Ecolab Benefit: The IntraTemp Fluid Warming System is designed to prevent overheating of fluids to minimize risk of burns from hot solutions Benefit Statements The visible display on the ORS and IntraTemp warmer systems confirms the fluid temperature at the point of use System design and calibration assures accurate temperature readings Tools IntraTemp product sell sheet Temperature Management Clinical Compendium Set up and in-use product demonstration – Two visual displays of fluid temperature – Temperature alarm Clinical Support AORN Statement : “When using warmed irrigation solutions, the temperature of the solutions should be measured with a thermometer at the point of use and verified before instillation. Irrigating with hot solutions has resulted in patient injuries.” (AORN, May 2007) Study Conclusion: "We therefore suggest that the temperature of any warmed arthroscopic irrigation fluid be checked before and during its use, because the warming cabinet may have a wide range of temperatures within it despite an external thermometer and perhaps an unreliable temperature-setting system.“ (Huang 2003, case study)

Key Challenge 2 3. Ecolab Benefit: The sterile disposable ThermaBasin is designed to eliniate the risk of cross contamination Benefit Statements The IntraTemp ThermaBasin is puncture-resistant to surgical instruments and tools which may be placed in the warmer during the surgery. The ThermaBasin is packaged to easily unfold and maintain a sterile field as it is placed in the warmer. (Product design) Drape allows use of system in the sterile field Warmer drape is designed exclusively to work with the warmer system Tools Demonstrate the IntraTemp Snap-In ThermaBasin Packaging considerations to maintain a sterile field – Demonstrate maintaining a sterile field with proper draping techniques

Key Challenge 2 4. Ecolab Benefit: IntraTemp helps clinicians and hospitals comply with industry and clinical standards Benefit Statements From a leader in infection control, Ecolab offers temperature management solutions to help you improve patient outcomes, improve compliance to industry and clinical standards, and avoid costs associated with inadvertent hypothermia. Based on the identified risk and cost of hypothermia, industry organizations and clinical evidence support implementing comprehensive prevention standards to maintain normothermia on all patients under anesthesia for more than 30 minutes. Increased traffic into and out of the OR can increase the risk for cross contamination and infection. Use of the IntraTemp helps to minimize the traffic caused by repeated trips to retrieve additional fluids. Tools Temperature Management Platform Folder IntraTemp product sales sheet Temperature Management Clinical Compendium Clinical Support “Irrigation fluids should be warmed to normal body temperature (37° C [98.6° F]), and the fluid temperature verified before use. Instillation of warmed irrigation fluids minimizes heat lost through radiation. ” (AORN, 2007) “There is evidence to suggest that alternative active warming measures may maintain normothermia when used alone or in combination with forced air warming. These warming measures include: Warmed IV fluids, Warmed irrigation fluids, Circulating water garments, Circulating water mattresses, Radiant heat, Gel pad surface warming, Resistive heating.” (Hooper/ASPAN, 2010) “Core temperatures outside the normal range pose a risk in all patients undergoing surgery. … hypothermia is associated with an increased chance of blood products administration, myocardial infarction, and mechanical ventilation. These adverse outcomes resulted in prolonged hospital stays and increased healthcare expenditures.” (Specifications Manual for National Hospital Inpatient Quality Measures, SCIP Inf-10-1)

Key Challenge 3 OR Nurse Manager Drive efficiency in the operating room 1. Ecolab Benefit: The use of the IntraTemp helps to minimize traffic into and out of the OR, minimizing disruption to the procedure and staff. Benefit Statements The IntraTemp Fluid Warmer System provide clinicians immediate access to continuously warm fluid at a known temperature Minimizes the need to leave the O.R. to retrieve warm bottles of solution Two pockets on the side to warm extra irrigation or IV fluids if needed Tools In-use product demonstration Demonstrate pocket warmers IntraTemp Product Sell Sheet

Key Challenge 3 2. Ecolab Benefit: Large capacity allows for sufficient fluid capacity, especially for longer or more invasive procedures. Benefit Statements Large puncture-resistant molded basin Additional capacity in warming pockets on the side of the system Tools IntraTemp sales sheet In-use product demonstration __________________________________________________________________________ 3. Ecolab Benefit: Use of the IntraTemp Fluid Warming System can reduce the waste of discarding expired saline bottles and fluids and reduce nursing labor associated with labeling and managing inventory of fluids in a warming cabinet. Benefit Statements Eliminates labeling and rotating saline bottle inventory in warming cabinets (Sales sheet) Warmed saline bottles, once removed from a storage cabinet, must be used or discarded. Saline manufacturers have specific, often differing, expiration timing for solution warmed in a cabinet The chemistry of saline left too long in a warmed state changes making it unusable. Tools Set up and in-use product demonstration Storage and labeling requirements of saline bottles in warmer cabinets

Key Challenge 1 1. Ecolab Benefit: The IntraTemp Fluid Warming System is loaned to the facility, and therefore the facility has neither capital expenditure or maintenance costs. Benefit Statements Ecolab loans the machine to the facility based on a minimum purchase of the drapes. Loaned equipment is serviced by Ecolab Faulty or defective equipment is immediately replaced at no cost to the facility Tools Review concept of loaned equipment with purchase of drapes Equipment Agreement Drape Utilization (Business) Review with top customers Comparing and validating the product cost vs. clinical need

Key Challenge 1 2. Ecolab Benefit: Prevention of inadvertent hypothermia is less costly to the hospital than treatment Benefit Statements (See benefit statements under OR Nurse Key Challenge #2) Even mild inadvertent hypothermia can increase post-anesthesia recovery time, blood loss, morbid cardiac outcomes, and lengthen hospital stays. (Sales sheet) Maintaining normothermia should include using warm irrigation fluid administered to patients during surgery. (Sales sheet) Tools Education - hypothermia, its complications and costs Temperature Management Platform Folder IntraTemp Product Sales Sheet Temperature Management Clinical Compendium Clinical Support (See clinical support under OR Nurse Key Challenge #2) Total cost savings from maintaining normothermia is between $2,500 to $7,000. (Mahoney, 2005 & Mahoney 1999) It is estimated that SSIs increase postoperative hospitalization by an average of 4 days and result in an increased attributable cost of $8,000 to $25,000 (Ochsner estimates from the Infection Control Department, calendar year 2010) for each patient. (Hart, 2011)

Key Challenge 1 3. Ecolab Benefit: Use of the IntraTemp Fluid Warming System can reduce the waste of discarding expired saline bottles and fluids and reduce nursing labor associated with labeling and managing inventory of fluids in a warming cabinet. Benefit Statements Eliminates labeling and rotating saline bottle inventory in warming cabinets Warmed saline bottles, once removed from a storage cabinet, must be used or discarded. Saline manufacturers have specific, often differing, expiration timing for solution warmed in a cabinet The chemistry of saline left too long in a warmed state changes making it unusable. Tools Set up and in-use product demonstration Storage and labeling requirements of saline bottles in warmer cabinets

Key Challenge 2 1. Ecolab Benefit: A single code for ordering of the ThermaBasin is all that is needed. Benefit Statements Minimizes complexity. Replaces the basin currently in use for the ring stand Tools IntraTemp Product sell sheet (product portfolio) Minimize product codes to simplify purchasing

Key Challenge 3 1. Ecolab Benefit: Ecolab provides a consistently high service level, quality products, and quick response time. Benefit Statements Dedicated Ecolab Surgical team can assist with solutions to help you reduce the risk of inadvertent hypothermia at your facility. (Platform Folder) Equipment is set up, in-serviced, repaired and replaced by Ecolab in a quick, professional manner. Tools/Support On-time delivery statistics Made in the USA Quality statistics Canada based support team Manage vendors: service levels, response times, & professionalism

Key Challenge 1 1. Ecolab Benefit: The IntraTemp warmer helps to maintain normothermia by providing warm, point of use irrigation fluid throughout the procedure. Benefit Statements Even mild inadvertent hypothermia can increase post-anesthesia recovery time, blood loss, morbid cardiac outcomes, and lengthen hospital stay From a leader in infection control, Ecolab offers temperature management solutions to help you improve patient outcomes, improve compliance to industry and clinical standards, and avoid costs associated with inadvertent hypothermia. Maintaining normothermia should include using warm irrigation fluid administered to patients during surgery. The portability of the IntraTemp warmer system provide clinicians immediate access to continuously warm fluid at a known temperature Tools Temperature Management Platform Folder IntraTemp Product Sales Sheet Temperature Management Clinical Compendium Actual set up and in-use product demonstration ( having warm fluid immediately available) Clinical Support (See OR Nurse Manager, Key Challenge #2, Benefit #2) Improve patient outcomes & minimize risk to the patient and to facility

Key Challenge 1 2. Ecolab Benefit: The ORS and IntraTemp warmers are engineered to provide irrigation fluid at a known and controlled temperature to prevent overheating of fluids to minimize risk of burns. Benefit Statements The visible displays on the IntraTemp warmer system confirms the fluid temperature at the point of use Be confident that fluid is at the proper temperature without risking patient exposure to hot solutions Product design and calibration assures accurate temperature Tools IntraTemp product sell sheet Temperature Management Clinical Compendium Set up and in-use product demonstration – Visual display of fluid temperature – Temperature alarm Clinical Support AORN Statement “When using warmed irrigation solutions, the temperature of the solutions should be measured with a thermometer at the point of use and verified before instillation. Irrigating with hot solutions has resulted in patient injuries.” (AORN, May 2007) Study Conclusion: "We therefore suggest that the temperature of any warmed arthroscopic irrigation fluid be checked before and during its use, because the warming cabinet may have a wide range of temperatures within it despite an external thermometer and perhaps an unreliable temperature-setting system.“ (Huang 2003, case study)

Key Challenge 1 3. Ecolab Benefit: The use of the IntraTemp is designed to minimize the risk of cross contamination Benefit Statements The ThermaBasin is a sterile, single use drape The IntraTemp ThermaBasin is puncture-resistant to surgical instruments and tools which may be placed in the warmer during the surgery. The drape is packaged to easily unfold and maintain a sterile field as it is placed in the warmer. Warmer drape is designed exclusively to work with the warmer system Use of the IntraTemp can reduce the traffic into and out the OR during surgery which may reduce the risk of contamination from outside of the OR suite Tools Demonstrate the IntraTemp Snap-In ThermaBasin Study discussing the risk of contamination from excessive traffic into and out of the OR Packaging considerations to maintain a sterile field – Demonstrate maintaining a sterile field with proper draping techniques

Key Challenge 2 1. Ecolab Benefit: IntraTemp helps clinicians and hospitals comply with industry and clinical standards Benefit Statements From a leader in infection control, Ecolab offers temperature management solutions to help you improve patient outcomes, improve compliance to industry and clinical standards, and avoid costs associated with inadvertent hypothermia. Based on the identified risk and cost of hypothermia, industry organizations and clinical evidence support implementing comprehensive prevention standards to maintain normothermia on all patients under anesthesia for more than 30 minutes. (SCIP, IHI, AORN, Safer Healthcare Now!) Increased traffic into and out of the OR can increase the risk for cross contamination and infection. Use of the IntraTemp helps to minimize the traffic caused by repeated trips to retrieve additional fluids. Tools Temperature Management Platform Folder IntraTemp product sales sheet Temperature Management Clinical Compendium Clinical Support “Irrigation fluids should be warmed to normal body temperature (37° C [98.6° F]), and the fluid temperature verified before use. Instillation of warmed irrigation fluids minimizes heat lost through radiation. ” (AORN, 2007) “There is evidence to suggest that alternative active warming measures may maintain normothermia when used alone or in combination with forced air warming. These warming measures include: Warmed IV fluids, Warmed irrigation fluids, Circulating water garments, Circulating water mattresses, Radiant heat, Gel pad surface warming, Resistive heating.” (Hooper/ASPAN, 2010) “Core temperatures outside the normal range pose a risk in all patients undergoing surgery. … hypothermia is associated with an increased chance of blood products administration, myocardial infarction, and mechanical ventilation. These adverse outcomes resulted in prolonged hospital stays and increased healthcare expenditures.” (Specifications Manual for National Hospital Inpatient Quality Measures, SCIP Inf-10-1) According to Safer Healthcare Now! maintaining patient normothermia is one of the key components in reducing Surgical Site Infections Drive adherence to key quality initiatives