December 2012 Volume 1, Issue 11
UMMC Nursing Newsletter STOP Catheter Associated Urinary Tract Infection (CAUTI) UMMC has alarming CAUTI Rates! FY 13 CAUTI Rates ο During fiscal year 2012, UMMC had 573 CAUTIs. Nov YTD ο 388 of the 573 occurred in intensive care units. 30 169 ICUs ο For this year, our overall CAUTI rates are reported to 1 34 IMCs be 3-4 times higher than the national average for hospitals similar to ours. 4 14 Floors Totals 35 217 Proper Catheter Maintenance is key to stopping CAUTI ο Perform meatal care with soap & water. ο Maintain a sterile, closed drainage system. ο If breaks in aseptic technique occur during insertion, or if disconnects or leakage occur later, replace the catheter and collecting system using aseptic technique. ο Use urinary catheter systems with pre-connected, sealed tubing connections whenever possible. ο If you are breaking the seal to add a urimeter bag—ask yourself: “is this required for patient care?” - if not essential—don’t add it - it opens the system to risk of infection! ο Maintain unobstructed urine flow– checks for kinks.
Keep the Pee Below the Knee! ο Empty the collecting bag regularly using a separate, clean collection container for each patient. ο Do not routinely place your adult patient in diapers—it is better to allow air flow when possible. A closed diaper creates a breeding ground for infection and contributes to skin breakdown. ο The use of absorbent underpads (and barrier creams as needed) are preferred for the management of incontinence. ο Adult diapers should be reserved for patients who are out of bed in a chair or ambulating. ο DO NOT clean the periurethral area with antiseptics to prevent CAUTI. It is not necessary! Routine hygiene is sufficient. Remove catheters ASAP! ο The best way to prevent a CAUTI is to remove the catheter as soon as possible! ο Make sure your patient has an order for the catheter removal protocol so that you can act immediately when catheter can be removed. ο Do not automatically change indwelling catheters or urinary drainage systems. ο Use condom style catheters for male patients as appropriate. ο Use portable ultrasound bladder scanners to detect residual urine amounts, and avoid the need to catheterize of possible. ο Obtain fresh urine specimen for urinalysis and urine culture. Do not obtain specimen from catheter drainage bag! Occlude the tubing and draw sample from sample port. 1
What’s New @ UMMC? Clarification of Orders for IV fluids for Continuous vs Bolus Administration There has been some confusion regarding the duration of continuous IV fluid orders. The potential exists for patients to receive too much or too little IV fluids. • When continuous fluids are ordered, the bag volume may appear to be the total amount of IVF ordered. This is only represents the total amount of fluid in that bag. • The total amount of fluid to be received is determined by the way that the order is entered. When the end point of the order is unclear, always clarify with the prescriber and recommend they specify the duration of the order under details.
Leaks in Carefusion (Alaris) pump tubing? There have been several reports of leaking pump tubing with two possible reasons:
Safety Flash!
1. Improper loading of tubing into pump -or2. We have a defective tubing lot To help us identify the root cause, we need your help: If you experience a leak (or any other unanticipated problem) with pump tubing, first see to your patient, and then please do the following: • Retain the set in a plastic bag. If hazards are present, double bag and note these on the outer bag. • Send a note to Paul Ricks (pricks@umm.edu) with the following information: ο What happened (e.g., tubing leaked at upper fitting, repeated pump alarms for occlusion) ο When did it happen (i.e., date, time)? ο Did the leak happen when starting infusion, mid-infusion or later? ο If the tubing has been hung for some time, how old is it? ο Drug or fluid involved ο Was the set installed properly? ο Patient Name & ID number ο Any other details we should be aware of? ο Who can we talk to for more information? ο If available, please retain original tubing bag so a lot number can be located. Tips for Proper IV Tubing Loading: 1. Always follow manufacturer recommendations for proper loading. 2. Open the door, and place the blue fitting in the upper recess first– do not force. 3. Place the bottom fitting in the lower recess - press the tubing into the air-in-line detector. 4. Do not over stretch tubing. 5. Close and latch the door. 2
Clinical Practice Council Updates: • • •
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Important Practice Announcements Monitor Safety: January - February 2013, proposed IT order changes is the next step Equipment Alarm Projects: a group is working on this initiative to differentiate alarms VTE Prevention: SCIP Core Measure Compliance (Surgical Care Improvement Project), see Clinical Practice Update 11/27/12 (page 6) UMMC Adult Impatient PI Council will begin reporting to CPC in January 2013 MOLST (Medical Orders for Life Sustaining Treatment) will replace the MIEMS forms; only attending physician and NP can sign the form; mandatory training by February 2013 Preferred Language Changes to Intake and Triage – When completing the Intake and Triage Form, The Joint Commission requires the patient's Preferred Language to be selected on this form, it is now added. Fall Bundle Update - Dec 2012 – Audits will be conducted to assess compliance with program as provided in Education Rollout
Resuscitation Documentation Reference
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Patient identification: - Patient name on Resuscitation Record and completed QA form - Arrest location - Date and time of event Required signatures: - Physician team leader signature and name printed – this authorizes all verbal orders! - Recorder signature and name printed Assure the record clearly reflects: - Accurate times. Each line should have a 24hour clock time recorded. NO VOIDS in time. - BLS care given (ongoing pulse checks, CPR/ ventilations performed). - Rhythm documented at each intervention. - Energy for each defibrillation/cardioversion - Drug doses should be entered as milligrams or mEq., not ampules. - Resuscitation team members should be clearly indicated. Print all names. -Patient outcome. Other points to remember: A resuscitation record and QA sheet must be completed for each cardiac or respiratory arrest or each acute medical event for which the crash cart is opened. QA Sheet is a great review item with staff & easy to fill out when reviewing the event.
Policy revisions completed Policy Website will be reorganized- Policies searchable in the front page; can be searched by policy number, topic, and or content. • COP-035 – Enteral Tube Placement updateJanuary is the earliest rollout date. • EOC-021- Care of Inmates- multiple changes, instructions now included in attachment. • COP-015- Moderate Sedation (Announced as in progress, major changes expected). • EQU-004 Alaris Medley Infusion Pump - No changes, now– pending new pumps coming. • PROE 111 – Receipt of Legal Notices – Risk Management. • TS- 004 – Brain Death in Infants and Children – requires 2 physicians (separated from adults). • TS-002 Brain Death – Adults only. • SKI-003 Pin Care – needs to clarify from Ortho since Lippincott listed 2% CHG to clean pin site and our policy listed hydrogen peroxide to clean pin site. • ADF-007 – Patient Care Services – no changes pending Magnet model to be adapted • ADF- 008 Staffing and Scheduling Principles, Strategies, and Guidelines: Seeking feedback from Charge Nurse Committee to review and update. • EOC- 003 Tobacco Free – electric cigarettes, cigars, etc. prohibited on campus. • COP-001 Defibrillation Policy with AED function added – Life Pak 20 education for all staff coming soon
Key Items in first 1-2 minutes 1) Time of arrest 2) Witnessed? 3) Monitored? 4) Resp status 5) Pulse status 6) 1st documented rhythm
Governance Council Updates: •
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Nurse Coordinating Council (NCC) Current Professional Practice Model discussed. Our Rope Model to be reviewed and discussed at council meetings in Jan. Question to eliminate, keep, or modify current model to meet our nursing needs. Councils to share in their December meetings and provide feedback. At NCC’s December meeting, group will compare and contrast our model with others. Each council reviewed FY13 Objectives. New Core Measures have been added: Stroke and VTE. NCC will work with nursing leadership to ensure they are part of FY13 Objectives and assigned to a council for monitoring. Nursing Research Council Reviewed the FY13 Nursing Strategic • Priorities (NSP) and how the NRC will assist in achieving the hospital goals All members are joining subgroups to work on the FY13 goals. Subgroups are: • 1. Planning of NRC workshops & seminars. 2. Complete FY12 unfinished business: EBP training for nurses 3. Define NRC roles and expectations. 4. Revise poster and presentation support and • guidelines. 5. Revise/enhance the JHH EBP translation model.
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Clinical Information Council Presented current compliance with order management. No improvement seen. Identified barriers to compliance and plans to follow up with both nursing and prescriber leadership. Medications not given should be timed and dated on the eMAR at the time and date when the decision was made not to give the medication. Documentation for skipped doses should contain the reason why it was skipped and the full name of the provider who was notified. (CMS regulation) An Alarm Clock will show up in the eMAR to help navigate towards late medications. If you click on the clock, it will take you directly to the overdue task. In patient summary, the last given dose is shown with when the next dose is due. Be diligent in looking at medication times.
Clinical Education Council • HealthStream® Competency Center purchase is cost prohibitive. Alternative education framework plans in development. • • Recent event involving Life Pak 20 discussed. “Pop Quiz” with answers distributed for huddle discussion and review as a short term PI. • Code STEMI fact sheets reviewed and Patient & Family Education Council distributed for unit education. • Council is currently reviewing articles for their EBP project. All articles are to be • Essentials of Nursing Practice (ENP) survey reviewed by 2 persons. results shared. Much of the course content will be shifted to on-line learning and unit • Council has been charged to assist with based skills validation. Preceptor training and improvement of measured results for support tools in development. initiatives such as hand hygiene and pain management. Will modify objectives to aid • March, 2013 Education Marathon discussed. with initiatives. Newsletter Updates Congratulations Newly Certified RNs! If you have news or updates, then please send • Erica Caudill, BSN RN CPN: Acute Care your information by the 7th of each month to: amurter@umm.edu or tfronczek@umm.edu Pediatrics • Brigitte A Fechter OCN, Newsletter Editorial Board RN: Bone marrow Transplant Allison Murter, Susan Carey, • Laura Strother BSN, RN, Christine Provance CCRN: SICU Greg Raymond, Trisha Fronczek Send your certification news to: certification@umm.edu 4
Governance Council Updates: • •
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Professional Advancement Council Updates Meetings Canceled PAM cycle update: 23 applications submitted (19 SCNI and 4 SCNII). 6 for November 2012 ο Medication showed letters of commitment for BSN. All 23 were promoted. Oversight Members discussed SCN Role leadership qualities. Recommendations Council from the discussion include: leadership classes should occur before one becomes SCNI; a leadership series should be developed that is open to all with various leadership topics; a SCNII should be polished leader; C2X objectives under Leadership, Management and Operations covers leadership behaviors effectively; development of a SCNI mentor program that pairs a mentor with another SCNI outside of their unit; and to develop a program that assists CNIIs to discover the SCN role.
Staff Nurse Council
Graduate Nurse Advisory Committee (GNAC) • • •
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The Charge Nurse Council
Safety concerns discussed: The Pharmacy will send Nimodipine • Express Care patients arrive to unit with no (medication for hemorrhagic strokes) in clearly marked oral syringes instead of the report prior to transport. Additionally, many capsule to prevent withdrawal from capsule patients need different level of care after administration errors. initial assessment. Many Lab Safety Issues were discussed and • IV antibiotics mislabeled by pharmacy. Please reported to lab leadership to expedite their compare manufacturer and pharmacy labels. resolve. • Patient’s consent was missing physician Discussed SEIU (Service Employees signature and was found on wrong chart. International Union) and NNU (National • Patient on AFB precautions had order to D/C Nurses Union) labor union presence at prior to test results obtained. RN did not UMMC. SEIU has a 90 day access to UMMC remove and patient was positive for TB. employees. At this time, NNU has not been • Kim Nash, Director of Cultural Competence granted this access. and Inclusion spoke about diversity issues. Peer Review Process enculturation at UMMC She gave the council food for thought on how was discussed. All areas agreed that the procto role model a respectful work environment ess is present in their areas. For more that is inclusive of all cultures. information: http://intra.umm.edu/ummc/ • Plans to include ideas in 2013 Charge RN advancement/index.htm Workshop. • Continued work on Charge Nurse Checklist.
Beginning December, GNAC will no longer meet as a subgroup of CEC but will be a recurring agenda item at CEC. 2 New Graduate Nurse Resident EBP Abstracts submitted to UHC for Annual Nurse Residency Program Meeting. Members to encourage previous nurse residents to complete survey during month of December. Goal is to have results back for 2013 cohort planning. 2 year new grad resident retention data presented, no significant change since pre-residency program. Improved retention rates after June-September 2010 mass hiring.
New mechanism of delivery with Combivent Respimat inhaler Key points are: 1. Device requires some assembly. 2. Multiple priming activations of device before any drug is released. 3. You have to turn the canister to release a dose to be delivered. 4. Dose is dispensed by pressing a button- not by the usual pump action.
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SCIP (Surgical Care Improvement Project) Measure: VTE Prophylaxis Provision & Documentation What are Core Measures? Core measures are standard, evidence-based performance metrics that hospitals report to TJC, CMS and, the Maryland Healthcare Commission (MHCC). They measure the standard processes we use to deliver patient care and the outcomes patients experience for disease processes. VTE prophylaxis is part of the SCIP Measure to ensure the care of surgical patients Documentation of two methods of VTE prophylaxis in post-operative clinical care is required: pharmacological methods [such as SQ heparin] and mechanical methods [such as TEDS & Covidien Sequential Compression Devices (SCDs)]. What is expected? Nurses receiving post-op patients are expected to include in their assessment of the patient and clinical care orders (at time of patient hand-off) the presence of both pharmacological and mechanical VTE prophylaxis and ensure they are documented. Specifically: • If either pharmacologic or mechanical VTE prophylaxis is lacking, nurses must communicate with prescribers to address. Document this discussion. These efforts must be completed and documented as such within 24 hours of surgery end. • Complete HealthStream training in Covidien SCD usage. ο PACU nurses must assess & document for VTE prophylaxis orders, especially in patients who stay in the PACU for the first 24 hours post-op. For more information, please contact: Josephine Brumit, DNP, RN at jbrumit@umm.edu.
Update from Point of Care Services – Upcoming CAP Inspection!
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The Laboratories of Pathology, which include Point of Care testing, are due for inspection by the College of America Pathologists (CAP) as part of our laboratory accreditation program. The CAP inspectors are here for 2 days and thoroughly inspect operations and quality systems of all aspects of the laboratories. Inspectors may visit patient care areas where point of care testing takes place to question staff regarding procedures for POC testing as well as to observe the testing process. How can you help to ensure a successful inspection? Use the checklist below to examine POC testing in your unit. Check carefully to ensure that: • all reagents and supplies are properly stored and labeled with the correct expiration date • there are no out of date reagents/supplies in stock or in use • all staff have current and complete competency assessments for the each POC test they perform • the required quality control and, as applicable, instrument maintenance (daily/weekly/monthly/ quarterly) has been done and documented. • any out of range quality control results have corrective action taken prior to patient testing • any critical results have the full name of the caregiver who was notified legibly documented along with that critical result on the flow sheet/patient medical record. • please do a clean sweep of the unit when it is announced that the inspectors are on site (communication will be sent to unit managers upon CAPs arrival) Point of Contact: If you have any questions or see any deficiencies that need to be corrected, call Point of Care Services at 8-5686 or email pointofcare@umm.edu.
Norovirus- ‘Tis the Season for about 21 million of us!
Annually, Norovirus Noroviruses, or norwalk virus, named after the first place the virus was causes about 21 million discovered (Norwalk, Ohio), are group of viruses that are the most common illnesses, contributes to cause of gastroenteritis. Norovirus infections can occur at any point in the approximately 70,000 year, but outbreaks are more common in the winter months when more people hospitalizations & 800 spend time indoors. deaths. Transmission Norovirus can be spread from an infected person, contaminated food or water, or by touching contaminated surfaces. It is a very contagious virus. Transmission usually happens by: • eating food or drinking liquids that are contaminated with norovirus • touching contaminated surfaces or objects, then putting your fingers in your mouth • contact with someone who is infected with norovirus Individuals infected by Norovirus are most contagious; • when they are sick with norovirus illness, and • during the first 3 days after recovery (resolution of symptoms) from norovirus illness. People typically become ill 24 to 48 hours after exposure, and usually last 1-3 days.
Symptoms The stomach or intestines to become inflamed (acute gastroenteritis). Symptoms include: • abdominal pain, nausea, diarrhea, vomiting • fever, headache and general body pain • gastroenteritis caused by Norovirus is self-limiting. (Elderly persons, young children, and those with underlying medical conditions are at increased risk for complications due to dehydration). Treatment There isn’t any medication or vaccine for norovirus. Drink fluids to reduce becoming dehydrated. Preventing Norovirus Infection Preventing norovirus is simple. Practice good personal and hand hygiene, observe appropriate foodhandling procedures and stay home if you are ill .Individuals handling food and health care workers involved in direct patient care should stay home for up to 3 days after resolution of symptoms. Proper Hand Hygiene The CDC recommends hand washing consist of a minimum of 20 seconds using soap and warm water. These 20 seconds should include friction to all hand surfaces. This is critically important for the mechanical removal of enveloped viruses such as Norovirus. Additional Considerations: • Promptly clean and disinfect contaminated surfaces with a bleach based product. • Wash fruits, vegetable and seafood thoroughly. • Do not prepare food or care for other individuals while sick. • Sharing of finger foods, such as popcorn, should be avoided in the workplace. • If you have vomiting or diarrhea you should not be working. You may return to work 48 hrs after the resolution of symptoms, without the aid of medications. • Consistent hand hygiene before and after patient care and thorough hand washing after using the restroom and before eating are important to prevent acquisition and transmission of norovirus. Caring for Patients with Norovirus • Place the patient on Enhanced Contact Precautions. • Maintain Enhanced Contact Precautions for 72 hours after resolution of patient symptoms. • Maintain clean room surfaces using bleach-based products. • Wash hands with soap & water after patient contact and when exiting a patient’s room. 7
Lab Series Part 3: Labeling Tubes (Part 1) Lab tubes must be labeled prior to sending to the lab. Unlabeled tubes = rejection How to label: • CPOE labels have a notch on one side and tubes have a colored notch (same color as their top) • Place label on the tube so that the 2 notches line up. Colored notch will be visible thru the CPOE notch • Label that is not placed correctly causes a delays in processing because the technologist must manually enter all information. If you need your labs performed on time, and then follow the notch alignment! There are 3 types of labels used for microcontainers. 1. Fastform label – placed vertically on the Chemistry microcontainers: green, amber, or red and pinched at the bottom (middle figure) 2. Medium sized CPOE label – placed on the lavender Hematology microcontainers vertically and pinched at the bottom (bottom figure) 3. Phlebotomy label – used only by phlebotomists is wider than the others labels and placed vertically on the microcontainer with the edge folded. (top figure) For blood culture bottles, label placement is very important. The label should be placed above the skew number vertically so that it does not cover the bar code or the empty white box. The white box is to write the date, time, and location of collection.
For blood gases and small syringes, place the center of the label lengthwise on the syringe. Press the label around the syringe so that it meets itself and press together to make a tab. Place the label as close to the plunger as possible. As you can see, when the syringe is labeled this way, all parts of the label can be viewed. For further information use the link to access the "Blood Draw Instruction" module. http://www.umm.edu/cernertraining/elearning/preLabSpecimen/ BloodDrawEducationModule/BloodDrawEducationModule.htm A label is placed correctly when: a. The notch is placed horizontally and the label wrapped around the tube b. The CPOE notch is lined up with the notch on the tube and placed vertically so the color can be seen thru the CPOE notch.
What label is to be used for the Chemistry microcontainers? a. b. c.
The Typenex label The CPOE label The fast form label from the chart
Infection Control Question form staff (cont from pg 7) Why do we switch to bleach cleaning for patients with Clostridium difficile and other diarrheal illnesses? Clostridium difficile (C.diff) is a spore-forming bacterium that produces toxins causing mild to severe diarrheal disease in humans. Alcohol based cleansers and other routine hospital cleaners are Ineffective against the spores and in some strains may exacerbate the formation of these spores. Disinfectants containing bleach (hypochlorite) have been proven to be effective in killing C.diff and other diarrhea causing bacteria. For more info: http://www.cdc.gov/hai/organisms/cdiff/cdiff_faqs_hcp.html 8
Announcements The 2013 CPPD Educational Calendar is ready for your to view:
Save the Date!!! Infusing EBP Concepts into Nursing Curricula January 8, 2013 Pediatric CCRN Review Course March 18 and 19, 2013 UMMC Certification Breakfast March 19, 2013
http://intra.umm.edu/ummc/clinical_ed/ docs/cppd-calendar.pdf or go to the Clinical Education section of the Nursing pages Webinar: Applying Critical Thinking at the Bedside and Beyond Attention All Nurses! Join us for a 1 Hour Webinar When: Thursday, January 31, 2013 @ 10:00 AM Where: UMMC Auditorium Topics include: •'Thinking like a nurse' is critical thinking •Multi-dimensional thinking •Qualities and traits of critical thinkers •8 elements of critical thinking •Applying EBP and healthcare research •Application of critical thinking skills in a variety of settings •Improving patient safety Register today via Healthstream
Call for Trainers! January, 2013 Marathon Trainer Education CAUTI Reduction Focus 1. February Education Marathon Trainer Sessions have been rescheduled for January, 2013. 2. Urgent UMMC CAUTI reduction initiatives require trainer support in staff education. Urinary catheter content focus will include: • Alternatives • Indications • Contraindications • Order management changes • Insertion technique • Culture technique • Maintenance • Removal 22 Trainer Sessions have been scheduled in January! All sessions are two (2) hours AccuChek Trainer Renewal offered at each session! Sign up in HealthStream
Evidence-based Practice: Infusing EBP Concepts Into Nursing Curricula Date: Tuesday, January 8, 2013 Time: 9:00am - 4:00pm Location: UMSON Speaker: Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN Associate Vice President for Health Promotion University Chief Wellness Officer Dean and Professor, College of Nursing Professor, College of Medicine: Department of Pediatrics, Department of Psychiatry The Ohio State University RSVP: For more information http://nursing.umaryland.edu/ calendar/event/4536
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January CPPD Courses Critical Care Nursing: 15-16, 22-23 Essentials of Nursing Practice (ENP): 30, 2/1,4 How to Build your CV and Portfolio: 16 Mastering CRRT: 28 Phlebotomy (Skills Only): 23 Journal Club Nursing: 22 Journal Club Managers: 2
For the seventh year in a row, the University of Maryland Medical Center has been named to the Leapfrog Group's list of top hospitals for patient safety and quality care. Congratulations to our fabulous staff!
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