UMMC Nursing Newsletter by UMMS

April/May 2013 Volume 2, Issue 5

UMMC Nursing Newsletter CHG Bathing - Coming to an ICU Near You! Providing a daily Chlorhexidine (CHG) bath to ICU patients helps reduce the risk of blood stream infections (BSI’s) and multidrug-resistant organisms (MDROs) such as MRSA and VRE, as well as colonization with Candida. CHG has been around as a topical antiseptic for over 50 years. It has both a rapid onset of bactericidal action and prolonged antimicrobial efficacy for a lasting effect.

Common Chlorhexidine Forms Product

Contains

CHG Concentration

Healthcare Uses

Topical Combination Solution (70% alcohol + chlorhexidine)

Sponge applicators Swab sticks Ampules

2% or 3.15% With 70% isopropyl alcohol

Skin preparation for surgery, invasive procedures, central lines to prevent SSI and BSI Not for all over general use

CHG cleansing solution For bathing

Liquid detergent (sudsing base)

2% or 4% aqueous

Daily bathing in ICU patients and preoperative showering/bathing May be used on any part of the body below the neck.

CHG Impregnated Cloths

Impregnated single-use washcloth

2% aqueous

Alternative to CHG wash in time sensitive situations

Oral solution

Oral rinse (must have a provider order)

0.12%

Decontaminate oral cavity (ventilator-associated pneumonia prevention protocols)

Gauze dressing

Cotton-weave gauze dressing

0.5% with paraffin

Wounds or burns

Catheter dressing

CHG pad or integrated with transparent dressing

2% gel pad or foam disk

Peripherally inserted central catheters Central line dressings

Surgical hand scrub

Waterless 1% CHG in an alcohol antiseptic hand base with emollients gel

Hand scrub for healthcare personnel (nonsoiled hands)

Indications for CHG bathing: 1. All critically ill adult & pediatric* patients who have no known allergy to CHG should receive a daily chlorhexidine bath from their chin to their toes. • NOTE: with the exception of very low birth weight infants. 2. Preoperative Patients in the ICU who are bathed daily with CHG and who have had two consecutive daily CHG baths, one within the most recent 12 hours will be considered compliant with meeting the presurgical bathing requirement. 3. Preoperative Patients who are ambulatory or inpatients not in an ICU should receive the 2 CHG baths within 24 hours prior to surgery– one the night before, and one morning of surgery.

Check Healthstream assignment for new CHG bathing module -complete by June 1st 1

Clinical Practice Council Updates: Code Blue Taskforce Update Clinical Emergency Management intranet site in development. The site will be a resource for clinicians containing the module on code documentation and related links. Medical Center-wide Mock Codes TBA. Blood Transfusion Taskforce Update Taskforce has representation from all clinicians involved in the blood transfusion process. Upcoming changes: blood bank will start scanning the product; authorization to dispense form will be available in Formfast minimizing the transcription error and eliminating the yellow copy. Blood bank personnel are expected to check the actual written orders in Powerchart instead of relying on the dispense forms. Non Formfast areas will need to continue to use the paper forms available. White stickers for administration record may be revised. Reminder: transcription of ID bands is done at the bedside. Falls Committee Update Reeducation on the Morse Fall Risk Assessment tool will be covered in September Marathon with clarification of the definition for fall. Actual demonstration of Egress test performed. Rehab is piloting a mobility tool on Weinberg 5. Pharmacy Updates Estrogen – FDA requirement to send packaging insert on day 1 and 30 of administration. Drug Shortages IV phosphate – tablet form available, that can be chewed and crushed IV Magnesium – still in shortage, replete through IV as needed. If Mg level is >1.4, use a PO substitute instead of IV if possible. Atropine SO4 – change in concentration dose from 1 mg/ml to 0.4 mg/ml.

Policy Revisions EOC-008 Safe Handling of Hazardous Medications - Changes all focused on putting safety in the forefront. New standards for the safe administration: chemo grade isolation gowns, chemo gloves, face shield required not a mask; list provided of hazardous meds and how to dispose, a sign is required, patient remain contaminated for 48 hours post administration of medication. Approved. ADF-008 Staffing and Scheduling Principles, Strategies and Guidelines - Approved. Product Updates and Inservices: • Chlorhexidine bathing ICU policy - initiative and education to come. Excludes NICU. • IV Pump Pilot – Baxter trial complete. Carefusion trial education to begin. Pilot Units: CSICU, L & D, OR and PICU, Neurotrauma ICU and Stoler. • Safety Needle conversion from BD to Magellan – safety mechanics more robust. • New bladder scanners will soon be available;. Guidelines on when to scan and urinary retention protocol—see page 7. • BP Cuff Adapter—Please alert Biomed when a BP Cuff adapter is in need of repair. These cables are reusable and are fixable. Biomed will work to repair the cable. • EPS/Medi-Dose Ampule Breakers—Available in MDC. HEMM# 391521. Par levels upon request.

Risk Management Report Staff has increased their number of reports through the RL6 solution—Keep up the reporting! 800 near misses reported and were mostly due to medication errors. Severity Level 1 (death) Events: 5 incidents Wound Assessment Changes medication error related to PINCH drugs including • Wound/Ostomy RN’s will use heparin, chemo and insulin; fall with a fracture; the ARANZ wound camera for stage 3 pressure ulcer -WOCN recommendations assessing wounds. Picture will not carried out. feed to Cerner and Epic. The camera is a portable device, measures the cir- Severity Level 2 (permanent harm) Events: cumference and depth of wounds, and tracks/ 2 incidents – accidental infant skull fracture by graphs as you constantly check the wound for mother, medication related – entire Heparin drip infused over 15 minutes with additional issue of healing pump not sequestered for Biomed to review; bag • April 29- May 31, 2013 – Pilot of the new and tubing unsaved. camera in the following areas: CSICU, REMEMBER: Tag the equipment & save all of the MICU, Trauma 5 South and SICU. disposables involved in a patient event! 2

Governance Council Updates: • • • •

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Nurse Coordinating Council (NCC) Potential topics for Fall Cycle Education Marathon reviewed and provided feedback for topics to include, remove, and add to the list. The Nursing Research Council (NRC) shared UMNursing Partnership Initiative proposal for DNP student partnership in conducting EBP projects, and discussed MOPAT Training Tool. NRC shared results from their communication survey (about NRC membership & communication). This inspired NCC to discuss creating a similar survey for all governance council members. Donna Huffer created a document to organize practice change roll-outs, to enhance communication and coordination. Document will be shared with DON/VP group pending edits. Patient & Family Education Council The new and improved On • Demand video system is tentatively planned for a late June rollout. The new system will allow for patient individualization and tracking of viewing. More offerings to even include a relaxation channel. Council members will be trained as resources for the new • system, as well as basic training for all staff. Council Intranet page in need of revision. EBP project remains ongoing; there was no • time in the April meeting to discuss any more articles, but article review will resume in May. Medication Oversight Council Hazardous medication policy to final councils for approval. Anticipate education and roll-out in Fall as well as par/ resource adjustment. Missing dose pilot update: Currently reconfiguring medications in the unit based Omnicells to address most frequently utilized medications. More to follow! Override rate policy changes were approved and put into effect. Will run override report and Pharmacy turn-around reports in May to quantify impact of change.

Newsletter Updates If you have news or updates, then please send your information by the 7th of each month to: amurter@umm.edu or tfronczek@umm.edu Newsletter Editorial Board Allison Murter, Susan Carey, Christine Provance Greg Raymond, Trisha Fronczek

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Charge Nurse Council Christine Provance shared the code blue roll call sheet designed to help the charge nurse with crowd control during a code and with identifying code team members. The council approved this and suggested that it be placed in the packet with code documentation. FY 13 goals were reviewed. Some of these revised and will carry forward to FY 14. FY 14 goals were discussed and finalized. Charge nurse reference manual will be reviewed and updated. Clinical Education Council Accu Chek Fair: 500 staff attended. Feb/Mar Marathon: trained over 1800 RN’s (~ 70% compliance) 500 UAP’s (~ 50% compliance) CHG bathing video in production. Will be assigned to staff in HealthStream®. UMSON to sponsor preceptor simulation labs per Janice Hoffman, more details TBA. UAP orientation tools now on the UMMC Nursing intranet site. Luiza Lima presented Chair Alarm Program update. It was requested that fall prevention content inclusion in next Education Marathon. Congratulations Newly Certified RNs!

Shereena Sorrell, MS, RN, CNRN, CCRN, Neuro ICU, added CCRN to her advanced certification title. Send your certification news to: certification@umm.edu 3

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Professional Advancement Council Twenty portfolios were submitted for advancement for the April cycle. The Certification Committee had an enormous turnout for the annual certification breakfast in March, and they will consider accommodating a larger turnout next year. The Certification Committee worked with Public Affairs/marketing on the creation of a "certification t-shirt" now available for ordering.

Clinical Information Council Presented overview of eCare system and unit. eCare is remote care that leverages critical care experts and decreases the amount of time between assessment and intervention. Provided updates on the EPIC project; discovery sessions took place the last week in April. The next phase, validation, begins in June. Reviewed safety concerns, such as, that post pain scores can be on Emar in red when past due with scheduled meds. Be sure not to give a duplicate dose thinking the medication is past due.

Nursing Research Council • Proposal approved to provide EBP training using Healthstream modules with content additions and possible face to face follow-up class. • We will request that CEUs for APNs and RNs be available. • Library EBP links are being updated. • NRC member roles and responsibilities were revised. Final Council approval pending.

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Staff Nurse Council The FY13 objective on peer review has been revised to accurately reflect the current state. The revised objective is: Provide support for nursing peer review at the unit level. As a continuation of discussions regarding patient and worker safety as it relates to disturbances between visitors and patient, council members discussed work place safety. Anecdotal situations are used to develop the appropriate strategies for correct reactions when situations arise.

Blood Bank Pointers: What we really need… Authorization to Dispense Blood Components • Top right of form for patient information – can use fast form label here. • If more than one unit is ordered, then the units must be administered at the same time through multiple IV sites. • If the units are to be administered sequentially, then individual forms must be submitted as needed. • Take your time when filling out the Typenex number on the form. This is the blood bank’s only identification & contact with the patient. It must be correct. A small sticker from the armband can be used instead of handwriting the number. • If the unit is to be picked up, then the name of the person picking up the unit must be on the form. Information required on the Typenex label: 1. Patient Name 2. Date of Birth 3. Medical Record # USE THE PATIENT ID BAND TO OBTAIN INFO FOR 1-3 4. Date of Draw 5. First initial and full last name of person collecting specimen \ NOTE: Submit pink top tube with Typenex label and CPOE order to Blood Bank. When blood products are requested : 1. Fill out the “Authorization to dispense blood components” form completely using Powerchart and the patient paper chart. 2. Day of draw is considered day zero and is good for 3 more days from date of draw. 3. At the bedside, compare information on the Authorization form to the patient ID band and Typenex band before transcribing the Typenex ID band number on the form. 4

Infection Control Updates CAUTI – The Q3 CAUTI ICU rates are improving compared to Q2, but have stabilized since Feb. The IMCs and floors have seen a slight improvement, but remain stable. The following recommended practices are likely to reduce CAUTI rates: 1. DAILY collaboration with prescribers to address all patients with urinary catheters: why does the patient still need the urinary catheter and when is the goal removal date? 2. Assistance with urinary catheter insertion to insure that sterile technique is followed. 3. KEEP PEE BELOW THE KNEE! Insure urinary catheter drainage bag is below the bladder. Empty bag prior to transfer of patient in chair/ gurney, or before leaving unit. 4. The red tamper evident seal should remain intact. If not intact, the urinary drainage system has been opened and compromised, so consider changing the urinary catheter. 5. Utilize other methods of assessing I's and O's for less critically ill patients, if possible. 6. Utilize condom catheters, if possible. 7. All patients with urinary catheters should have orders in place. Think TB. So far this year, there has been 1TB Exposure in the OR. Those at high risk: 1. Classic symptoms: productive cough (with or without hempotysis), fever, night sweats and weight loss 2. Foreign born (TB is often endemic in other countries) with symptoms consistent with pneumonia or extra-pulmonary lesion 3. Immune suppressed foreign born patients Dialysis Catheter Management: HD catheters should be accessed only by trained ICU or dialysis staff, except in an emergency. HD catheter dressing should always be kept clean, dry, intact and dated. Policy update: Large Biopatch dressings are to be used on HD catheters. Central line Management – utilize the central line checklist every time to ensure key items are addressed CLABSI – The Q3 CLABSI aggregate rates are: 1.6 ICU; 1.5 Acute Care floors; 1 IMCs 1. Please remember to "scrub the hub" for 15 seconds prior to accessing the port / line. Studies have shown that brief cleaning of port prior to accessing does not adequately clean the hub or lower the CLABSI risk. 2. The central line insertion checklist is meant to be completed in "real time", as the procedure is being done, if at all possible. Dressing should be clean, dry, intact and dated. C-diff – Most common hospital acquired infection; Utilize enhanced contact precautions with bleach cleaning of rooms for known or suspected C. diff. Please leave the alcohol hand sanitizer in the room, just add sign nearby to wash hands upon exiting. VAP – Q3 Rates: SICU 0, CCU VAP 4.9 Flu season is over. During this season, UMMC saw a total of 169 cases. We had 6 influenza-related deaths, all were community acquired. There were 4 hospital acquired cases. It is important to remember that staff should not be working if they are ill with a viral respiratory illness. Visitors should also be screened for the presence of viral illness and asked to not to visit until they are 24 hours asymptomatic. H7N9 virus and Corona Virus – Persons with ILI (influenza-like illness) as defined below: Acute respiratory infection, which may include fever (≥ 100°F) with a cough and/or sore throat; 1. .. and a history of travel from China or the Arabian peninsula (within 14 days of onset of illness); 2. … and not already explained by any other infection or etiology, including all clinically indicated tests for community-acquired pneumonia These individuals should be placed in an airborne isolation room with airborne, droplet and contact isolation ordered (Gown, gloves, N95 respirator and eye shield or PAPR) and Infection Control should be immediately paged (pager 5757) 5

Use a Bladder Scanner to Avoid Unnecessary Catheterizations!

Patient ID Entry Errors in the AccuChek Inform Meter The UMMC Patient Identification Policy COP—033 states that staff who provide direct patient care must do the following: • Verifies correct and accurate patient identification using patient name (always required), and date of birth or MRN prior to any blood or medication administration, treatment or procedure by matching two identifiers with information on the patient’s ID band and/or having patient verify information, if they are able. • Applies a patient ID band to the patient who has lost, removed or damaged their ID band. • Selects the correct patient from any patient list or clinical database by using two identifiers i.e. patient name (always required), and date of birth or MRN. Occasionally, an incident occurs where the incorrect MRN is entered into the AccuChek Inform meter when performing a point of care glucose test. In the event that this occurs, and the error is not noticed until after the fingerstick sample has been added to the test strip, there are several immediate corrective actions that must take place. However, the action varies depending on when the error is recognized. If the test result is still displayed on the screen, you can prevent the result from interfacing to the patient’s electronic medical record as follows: 1. Touch “comment” at the bottom of the screen. 2. Select “OPERATOR ERROR” or “DO NOT CHART” from the comment list. 3. Touch the forward arrow icon. 4. Enter the correct medical record number into the meter and repeat the test. **No further corrective action is required. If the error is noticed after the result screen disappears, this result will appear in the EMR of the patient whose medical record number was entered, so several steps are required immediately: 1. Place the meter in the docking base making sure that the meter completes a “transmitting” cycle. 2. Notify the patient’s caregiver that this result is an error and must be disregarded. 3. Call Point of Care Services at 8-5686 or email pointofcare@umm.edu to report the error and provide the following information: • Your name, unit, contact phone number. • Full patient name, DOB and MRN of the patient whose EMR has the wrong result posted. • Date and time the test was performed. • Glucose test result. 4. Enter the correct MRN into the meter and repeat the test. Point of Care Services staff cannot change any result that is in the EMR, however a correction comment will be added stating to “disregard due to patient identity error.”

Staff Safety Alert: Laboratories Stop Accepting Blue-topped Urine Cups The blue topped urine cups are used for specimen collection and are designed for the filling of the gray and yellow tubes for testing in the lab. A needle is attached to the lid of the blue topped cup for this purpose. The laboratory requests that only the yellow and gray tubes be sent for testing. We have recently experienced an increase in the submission of blue topped cups either alone or with the tubes in the sample bag. This creates a major safety issue for our lab staff by introducing an unnecessary risk for possible needle stick. The laboratory can no longer accept these blue topped cups. We appreciate your cooperation with this important process change. 7

Announcements Annual Training is now OPEN! The window for Annual Training is now open and will run until June 30, 2013.

Save the Date!!! Context and Measurement June 26th

Access mandatory compliance training through your Healthstream account. Locate the assigned courses under the "My Learning" tab, listed as "UMMC 2013 Rapid Reg Compliance" either Clinical I & II, Non-Clinical I & II, or only Non-Clinical II. All UMMC/UMMS Staff are required to complete their assigned Annual Training by June 30. Innovative Methods for Implementation Science: Context and Measurement When: Wednesday, June 26th 11 am—8pm Location: UMSON This session will focus on the state of the science specifically related to the measurement of context and innovative measurement methodologies for implementation science research. For more information and to register: http://www.nursing.umaryland.edu/ku13registration

Summer Institute in Nursing Informatics (SINI) July 17-19, 2013

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June CPPD Courses Cardiac Rhythm Interpretation—25, 27 Chemotherapy/Biotherapy for Non-Cancer units– 21 Charge Nurse Workshop—21 Critical Care Nursing-Mastri Center—18 Looking Good in Print—19 Managing Challenging Situations through Crisis De-escalation—26 Moderate Sedation Sim Lab—27 Preceptor Boot Camp – 14 UAP Education Series—5 We Discover Series—18 Fundamental of Critical Care—6-7 Nursing Grand Rounds—19 Please enroll via Healthstream or contact CPPD @ 8-6257 for more details.

Nursing Grand Rounds: “The Future of Health Care Delivery in Maryland” June 19, 2013 2:00-3:00 PM UMMC Auditorium Federal health care reform, state health care reform, hospitals in financial crisis, workforce shortages…what does all this mean for health care delivery in Maryland? Health care is undergoing dramatic change-lawmakers and regulators are writing new rules for payment and performance. Maryland is unique among the states in the way we pay for hospital care and that system, too, is changing. care, what it means for nurses and hospitals and what it means for care at the bedside.

Featuring: Carmela Coyle President & CEO Maryland Hospital Association