UMMC Nursing Newsletter

AUGUST /SEPTEMBER 2013 | VOLUME 2, ISSUE 7

NEW IV PUMPS ARE HEADED YOUR WAY! Infusion Pump Rollout on September 25, 2013 UMMC has purchased updated models of the CareFusion (Model 8015) large volume infusion pump. The updated pumps have additional library space and enhanced quality reporting available to help us assess and customize our library settings.

One of the major upgrades is that these pumps are now on a wireless network so that library upgrades will occur much more efficiently.

A generic pump operation training module is also available in Healthstream– listed under Alaris System– IV set and Accessories– Basic.

Pump Training has been coordinated with Fall Nursing Marathon “Train the Trainer” Marathon Education Sessions include pump Super User Training Alaris (Carefusion) training has been scheduled beginning September 4 through September 18 ‐ there are lots of sessions, including end‐user classes and super‐user classes. Night and weekend times are available.

Nursing Training: ♦ Anyone who has already registered (or plans to register) as a Fall Marathon Trainer for their area will receive super user pump training during the Marathon Train the Trainer sessions. ♦ Register for Train the Trainer 2013 ♦ For nursing staff who are not also Marathon Trainers– there are additional sessions for super user and end‐user training classes in Healthstream as well: ♦ Register for Alaris Pump End User 2013 or ♦ Alaris Super User 2013 Training.

All 3 training options are available at www.healthstream.com/hlc/umms

Pharmacy Training: There will be special sessions for Pharmacists ‐ has been scheduled on Wednesday, September 11 @ 2:30 PM in T1R15. Contact Mehrnaz Pajoumand for questions related to Pharmacy sessions.

Anesthesia Training: Anesthesia training sessions will be scheduled on Wednesday, September 11 and Thurs‐ day September 12 @ 11:30 AM in the GOR workroom & TOR workroom during the anesthesia meetings.

Equipment Distribution Training is scheduled on Monday, September 9 @ 2:30 PM.

Please see new Alaris pump webpage @ http://intra.umm.edu/ummc/clinical/alaris‐pump.htm for training documents and resources. Please email questions or concerns to Alaris@umm.edu

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What’s New @ UMMC? Restraint Order Changes Did you know?

Changes to restraint ordering process were recently made as a result of CMS Reporting requirements New policy requires that when restraints are applied by nursing as an emergency intervention— ♦ Provider notification and order entry is required immediately (this is interpreted by surveyors as within 15 minutes of restraint application) All orders for continuous or ongoing restraints must be renewed DAILY ‐ ♦ Providers may place restraint orders as a specific order or by approving a nurse’s request to implement Medical Surgical Restraints

Unit leadership is now receiving a daily report of patients who are in restraints, so that they will be aware of restraint use in their unit. The overall goal is to minimize the use of restraints, and to assist with gaining compliance with the new ordering requirements.

Feeding Tubes Require XRay Confirmation… New Ordersets Available

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CAUTI Update Urinary tract infection represents almost 40% of all healthcare‐associated infections, with the vast majority due to the indwelling urinary catheter. Over 900,000 patients develop a catheter‐associated urinary tract infection (CAUTI) in a U.S. hospital each year.

Urinary catheter‐related infection leads to substantial morbidity. The incidence of bacteruria in catheterized patients is about 5% per day. Among patients with bacteriuria, 10 to 20% will develop symptoms of local infection, while 1 to 4% will develop bloodstream infection. The presentation of catheter‐associated infec‐ tion varies from asymptomatic bacteriuria to overwhelming sepsis and even death.

Clinical manifestations of CAUTI may include: ♦ local symptoms as lower abdominal discomfort or flank pain ♦ systemic symptoms such as nausea, vomiting, and fever. ♦ Patients with bloodstream infection may present with fever, confusion, and hypotension.

A key first step leading to CAUTI is the colonization of the catheter with organisms. Indeed, urinary cathe‐ ters readily develop biofilm – a collection of microbial organisms on a surface of an indwelling catheter that is surrounded by an extracellular matrix – on their inner and outer surfaces that provides a protective envi‐ ronment for microorganisms.

Many of the infectious complications of the urinary catheter could be prevented by using the catheter only when necessary and promptly removing it when no longer needed.

So What Does Our Data Tell Us? At UMMC, 447 patients developed a CAUTI between July 2012 and June 2013. While this represents a 23% reduction in CAUTI from the prior year, our rates remain much higher than national benchmarks. Catheter usage was reduced by 7% (48,634 catheter days), down from 52,215 catheters days in 2012. We are improv‐ ing but we still have work to do!

What Should We Continue to Focus On? Before placing an indwelling catheter, please consider if these alternatives would be more appropriate: • Bedside commode, urinal, or continence garments: to manage incontinence.

• Bladder scanner: to assess and confirm urinary retention, prior to placing catheter • Straight catheter: for one‐time, intermittent, or chronic voiding needs.

• External “condom” catheter: for males without urinary retention or obstruction.

If We Do Need a Catheter, What Can We Do to Prevent CAUTI? • Adhere to general infection control principles (e.g., hand hygiene, surveillance and feedback, aseptic insertion, proper maintenance, and education) • Ensure that patient has an appropriate indications to have an indwelling catheter: • Acute urinary retention: due to medication (anesthesia, opioids, paralytics), or nerve injury • Acute bladder outlet obstruction: e.g., due to severe prostate enlargement, blood clots, or urethral compression • Need accurate measurements of urinary output in the critically ill during initial stabilization period • To assist in healing of open sacral or perineal wounds in incontinent patients • To improve comfort for end of life, if needed • Patient requires strict prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fracture) • Selected peri‐operative needs • Remove catheter as early as possible, using the nurse‐initiated removal protocol! Catheter removal even just a day or 2 early may precvent your patient from developing a CAUTI 3

Chlorhexidine Daily Bathing Protocol for ICU patients Purpose: Providing a daily Chlorhexidine (CHG) bath to ICU patients has been used to assist with reducing the risk of blood stream infections (BSI’s) and multidrug‐resistant organisms (MDROs) such as MRSA and VRE, as well as colonization with Candida.

Studies have demonstrated that CHG bathing can significantly reduce the number of microorganisms on the patients’ skin and reduce bloodstream infections and resistant organism colonization and infection in this vulnerable patient population1.

Background: CHG has been available as a topical antiseptic for over 50 years. CHG has both a rapid onset of bactericidal action and prolonged antimicrobial efficacy through residual effects.

Indications: All critically ill adult & pediatric patients who have no known allergy to chlorhexidine should receive a daily chlorhexidine bath from their chin to their toes (with the exception of very low birth weight infants).

Give CHG 4% whole‐body bath (excluding face and scalp) as soon as possible after admission and continue CHG 4% whole‐body baths daily.

Responsibility: All ICU RN’s and PCT’s

Procedure: • Wipe bath basin with disinfectant wipe (Oxivir‐TB or Dispatch).

• Mix the contents of 4% CHG soap with warm water in a basin, as you do with the regular soap.

• Bathe patient from neck down (exclude the face and scalp).

Use a separate washcloth (total of 8 or more) for each body zone.

(each arm, each leg, anterior trunk, posterior trunk, anterior perineum and posterior perineum).

Keep out of eyes, ears, mouth and any open wound. Rinse with cold water if accidental contact.

• If irritation occurs, rinse with cold water right away and notify a provider.

• Retain 4% CHG soap on the patient’s skin for at least 2 minutes to receive maximum contact time.

• Rinse the 4% CHG with warm tap water and towel‐dry the patient.

• Use CHG compatible lotion to moisturize skin and prevent dryness and skin breakdown. Some lotions and oils are not compatible with CHG soap. Omit this step for a presurgical bath/wash.

• Perineal area may be cleaned using chg bathing process. After cleansing the area, you may replace barrier creams if incontinence is a concern.

• 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.

• Wipe basin with disinfectant wipe.

Contraindications: • Known or developed allergy to CHG and very low birth weight neonates.

References: Climo MW; Yokoe DS; Warren DK; Perl TM; Bolon M; Herwaldt LA; Weinstein RA; Sepkowitz KA; Jernigan JA; Sanogo K; et al.Effect of Daily Chlorhexidine Bathing on Hospital Acquired Infections. New England Journal of Medicine, 2013 Feb 7; 368 (6): 533‐42. Milstone AM, Passaretti CL, Perl TM. Chlorhexidine: expanding the armamentarium for infection control and prevention.

Clin Infect Dis. 2008;46:274‐281.

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Patient Safety Issues: Tops of Tubes are Much More than Color Coding Serious patient errors can result from using the wrong tube types in blood collection. Please remember that the tubes for blood specimens are specific for the tests to be performed in that tube.

Collecting specimens for lab testing in the correct phlebotomy tubes is critically important. Under no circumstances should specimen that was mistakenly collected in the incorrect tubes be transferred (poured) into the correct tube. Each type of collection tube has a different color cap that signifies a specific additive necessary for appropriate measurement of specific tests. Using the wrong tube can result in the error of reporting of incorrect critical values for certain lab tests and the potential for inappropriate treatment.

To identify the correct collection tubes for specific laboratory tests, consult the Laboratories of Pathology ‘Professional Services Manual’ on the UMMC intranet, contact the laboratory at extension 8‐3704 or refer to your “Blood Draw Order” badge card (these can be obtained from Clinical Practice & Professional Development ‐ stop by the kiosk near the Gudelsky entrance).

There are instructions to serve you for labeling tubes and the order of draw on the Intranet under Departments & Services, Laboratory, Professional Services Manual, and then Blood Draw Instructions.

Below is a listing of tube types, additive, and most common tests:

Tube Top Color

Green Gold Blue Lavender

Additives

Commonly used for

Lithium Heparin CMP, BMP, HFP Separator Gel HCG, Hepatitis testing, RPR Sodium Citrate PT, PTT, Fibrinogen Potassium EDTA CBCAD, Platelet, Manual Differential

Remember…

Always double check patient ID and label specimens at the bedside!!!

Lab Integration Team

Intranet Updates: We have created 2 NEW websites for your Information: http://intra.umm.edu/ummc/clinical/alaris‐pump.htm for New Alaris/Carefusion pump train‐ ing & information...

Clinical Emergency Resources http://intra.umm.edu/ummc/clinical‐emergency‐resources/ for educational resources pertaining to Code Blue, Rapid Response, Stroke (BAT team), and Code Stemi

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Governance Council Updates Nursing Coordinating Council (NCC)

Professional Advancement Council (PAC)

♦ New EKG program MUSE 8 is expected to begin a roll ♦ Council has been discussing the follow up regarding out in November, 2013. All EKGs will require an order promotions granted with the commitment to obtain a be placed so that they can be processed by Cardiology BSN. Greg Raymond has reviewed with the Directors staff and have results reported in the electronic system. and a standardized plan will be developed with a process to follow in the event that all expectations are ♦ Council members should inform staff of new PAM not met. process for BSN Requirement: Managers will utilize BSN ♦ PAC is completing a communication survey amongst Requirement Tracking Form on bi‐annual basis to ensure that all RNs are in compliance. its members to identify how information is shared. ♦ Charge Nurse Council developed a charge nurse Advanced Practice Council (APC) orientation checklist that was being taken to CEC for ♦ Jan Kriebs reviewed the details review. and outcomes of her national project: “A Successful Model of Collaborative Staff Nurse Council (SNC) Practice.” In open discussion, Jan ♦ Badia Fadoul presented a plan Kriebs suggested that NPs participate for unannounced mock codes in the interview process for Residency in adult non‐ICU clinical areas Candidates and Faculty Physicians, as starting in July 2013. a tool to increase successful collabora‐ This is a safety and quality tion. This could also increase the level of involvement in improvement initiative based their orientation. on three QOC events.

Issues identified as contributing factors to a lack of Clinical Education Council (CEC) coordination during codes were: distractions, over‐ ♦ Behavioral Emergency Response Team (BERT): Pilot in crowding in the room, no clearly identified team process in MICU and 4STA leader, unclear roles, and decrease collaboration. ♦ Charge Nurse Guidelines and intranet resource page: ♦ Mock codes will be simulation exercises based on developed by Charge Nurse Council.

ACLS mega codes. They will be videotaped with a Nursing Research Council (NRC) debriefing afterwards to discuss staff performance. ♦ July NRC meeting canceled ♦ In continuation with the council’s discussions on drug Patient and Family Education Council diversion, shame and empathy, Lisa presented The ♦ The council voted and selected Crystal Jefferson as the Ethics of Substance Abuse in Nursing. This is an issue council Chair Elect. that impacts all of us, not just the person suffering ♦ The On‐Demand subcommittee has rolled out the On‐ from this illness. We have a moral obligation to Demand upgrade. Tools available on the Intranet page provide safe, competent, and ethical care. Council include dashboard access to view individual patient/unit members were able to hear the personal journey of progress and a tutorial for how to use the system. recovery from a nurse.

Update on Chair Alarm Receivers: Clinical Engineering has had requests to repair chair alarm “boxes”. These items are considered a disposable item, and are not repairable.

BUT… before you discard a box that is not working, please try replacing the batteries!

1. Turn box over 2. Remove chair clamp 3. Open battery cover 4. Replace with 2 AA batteries

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Conferences & Lectures

Maryland Stroke Conference November 8, 2013 Doordan Health Sciences Institute Anne Arundel Medical Center, Annapolis, MD

Register at http://ummcstroke2013‐es2.eventbrite.com/?rank=3

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Announcements

Tele ICU: Telemedicine Care Delivery Model for the ICU September 19 Presented by Anite Witzke, RN, MSN, Director of University of Maryland eCare.

Franklin Square Hospital Center

CCRN/PCCN Exam Review Course October 2—4 Levindale Health Center

Register at chesapeakebaychapter‐aacn.com

CPPD Course Offerings Chemo/Biotherapy for Non‐Cancer Units

September 6 Critical Thinking

September 10 Trauma Theory

September 10 – 11 & 17‐18 VAC Training

September 11 End of Life Nursing Course

September 18 & 25 Clinical Practice Summit

September 17 – 18 We Discover

September 17 Chemo/Biotherapy (ONS)

September 19‐20 Code Blue Education Days

September 23 & October 3 Moderate Sedation Simulation Lab

September 26 ACLS Instructor Course October 26

HR Course Offerings

Myers Briggs Type Indicator (MBTI) and Conflict

September 12 Microsoft Excel 2003 – Level III

September 17 Retirement Readiness for Age 50+

September 18

Nursing Grand Rounds A Discussion of Two Fall Prevention EBP Projects A Discussion of Two Fall Prevention EBP Projects Designed & Implemented at the Unit Level Designed & Implemented at the Unit Level Facilitated by Kristy Gorman September 18 2pm—3pm

Nursing Journal Club

“Patient Perceptions of Pain Management Therapy: A Comparison of Real A Comparison of Real‐‐Time Assessment of Patient Education and Satisfaction and Registered Nurse Perceptions” September 24 12pm—1pm

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