UMMC Nursing Newsletter by UMMS

February 2013 Volume 2, Issue 2

UMMC Nursing Newsletter Facts About Falls UMMC Falls Oct– Dec 2012

Important Fall Statistics 38% occurred in patient’s room or restroom 54% did not specify the location of the fall Most falls happened during the time between: 8a and 1p and 5p to 9p 42% of patients scored as standard fall risk

Falls With Injury Rate 0.96 (up from 0.46)

Out of the 55 falls reported in Jan, only16 events had post fall huddle reports submitted to CPPD

Issues identified in January post-huddle forms received by CPPD: • • • • • • •

Standard fall precautions were NOT in place by the time of a fall: i.e., non-skid socks, bed/chair alarms *on*, etc. Most falls related to toileting. Of 8 falls from the bed, only 1 patient was in a low bed and the alarm was on. 21% of units not conducting huddles. 83% of units who conduct huddles discussed falls during daily huddles. 100% had the falls tracking board posted. 78.4% of boards had a post-fall huddle form posted.

Food for thought: • • •

Is your unit conducting daily huddles? Does the huddle include discussions about what patients are at a higher risk of falling and are preventive interventions in place? Does your unit review the monthly falls data together? Everyone thinks differently and can help provide valuable insight into strategies to prevent falls.

Total Falls Trending: Past 12 Months

January’s total falls = 53 (up from 41)

What’s New @ UMMC? FY13Q2 Update on CAUTI and CLABSI Rates CAUTI results are in and showing a lot of improvement!

Areas that reduced UTIs by 1/2 or more since Q1: NTCC, MTCC, Select ICU, CSICU, Medical IMC, and MTIMC ZERO CLABSI in Q2: SICU, NTIMC, MTIMC, Select IMC, Surgical IMC, C3E, 3DS

UMMC CAUTI Rates July 2011 ‐ December 2012

CAUTI

CAUTI per 1000 Catheter Days

ZERO CAUTIs in Q2: PICU, C3E, 3DS, Neuro IMC, Cardiac Step down, 10 East, 11 East, C5E, C5W, Pediatrics and 4 STA

5 Better

0 Jul‐Sep 11

Oct‐Dec 11 ICU

Apr‐Jun 12 Acute care unit

Jul‐ Sep 12 IMC

Oct‐Dec 12

Benchmark

CLABSI

Areas that reduced CLABSI by 1/2 or more since Q1: PICU and Select ICU CLABSI rate in the ICUs and floors are trending upward. We need to be vigilant in our efforts to decrease our rates. Goal is zero!

What can you do to prevent infection? 1. Always use the central venous catheter (CVC) insertion checklist when placing a CVC. 2. Perform hand hygiene immediately prior to the procedure. 3. Use maximal sterile barrier precautions which include nonsterile cap and mask (all hair should be under cap, and mask should cover nose and mouth snuggly), sterile gown, sterile gloves, large sterile drape covering patient's head and body. Maintain a sterile field throughout procedure. 4. Use 2% Chlorhexidine (CHG) for skin antisepsis unless patient allergic (Did You Know?... The FDA loosened restrictions in CHG use in infants?) 5. Remember that the subclavian vein is the preferred site for non-tunneled catheters in adults. Avoid use of the femoral vein for placement of CVCs in adult patients. 6. Use antibiotic/antiseptic impregnated catheters; the Cook minocyline/rifampin-coated catheter is the preferred catheter unless contraindicated due to patient allergy or pregnancy. 7. Assess line necessity daily and promptly remove any unnecessary lines. 8. Follow good care and maintenance practices of the line site. 9. Assess the dressing daily. Is the dressing dry and intact? If not, replace dressing promptly. 10. Any time the dressing is changed, inspect the site for erythema or purulence at the insertion site and note any other signs of infection. Report these findings immediately to the care team. 11. Before accessing any port, ALWAYS scrub the hub for 15 seconds with an alcohol wipe. Please feel free to email us any comments, questions or suggestions to: InfectionControl@umm.edu 2

Clinical Practice Important Practice Announcements •

•

After one week of electronic Braden Forms, 820 referrals were made to WOCN team. This has generated an unrealistic workload—so we had to change the process. Please call WOCN if your patient requires a wound care consult! Fall Update – Continue reinforcing with staff to complete Post Fall Huddles. See page 7 for information on the Creative Campaign for Preventing Falls.

Pharmacy Updates Medication Scanner Pilot—The new scanner in pharmacy does not require the pharmacist to hand sign labels. The machine provides a check in a checkbox, which will allow for easier tracking due to electronic signature. You will see the sign off initials on the electronic label. New Estrogen Requirements—The FDA will require that package inserts and education be performed when administering estrogen to patients. Practice to start on Feb. 19, 2013 with education to follow. See page 6. Multi-Dose Products at Discharge – The label must reflect the dose, concentration time and administration, and storage instructions.

Infection Control Updates •

•

CAUTI – The ICU rate dropped from 113 to 76; IMC & acute care areas are trending down. It is considered a UTI if patient has a urinary catheter, febrile and white count >100,000. Criteria for temp-sensing catheters is in development. Remind rehab services that they can empty urinary bags prior to working with patient but need to inform nursing staff for documentation needs. CLABSI Rates– All rates are trending up. ICU up by 2.4; IMC up by 1.5; Acute care unit up by 1.7. Please reinforce central line care maintenance. Congratulations to stellar CLABSI units: W5, Gud 8, SICU, Surg IMC Hand Hygiene Rates- Nurses are doing great! Issue with physician compliance. Latest audit scores are 87% which is below the 90% target.

MOLST Training coming in March Medical Orders for Life Sustaining Treatment is a new state law that replaces the MIEMSS forms and required for all patients admitted except those with psychiatric conditions, pregnancy and under 18 not requiring life sustaining treatment. New forms are valid everywhere in Maryland. Watch for announcements and additional training to come. _________________________________________

Policy revisions in progress

• • •

COP-015 Moderate Sedation under revision COP-035 Enteral Tube Feeding ADF-007 Patient Care Model _________________________________________

Product Updates and In-services: Chair alarm pads and yellow stethoscopes can now be reprocessed through Hygia. Flyers will be updated and announcements to follow. Stryker bed in-servicing and maintenance on 3 zone bed alarms and scales are continuing Carefusion pump IUI replacements are in progress from Feb 25th thru March 5th.

If your pump or module does not have a red sticker— call 8-8088 for a replacement! Baxter Sigma infusion pump pilot to be held March 11th-16th. Pilot areas include: PICU, Peds Hybrid OR, Adult Cardiac OR, CSICU, NeuroTrauma ICU, Labor and Delivery, Stoler Pavilion. Drug libraries have been created to mirror our current listings. Education will occur in areas prior to pilot and on-site clinical support will be available during the pilot. KCI Wound VAC in-services Friday, Feb 15th thru Sunday Feb 24th for all inpatient, procedural, and outpatient areas. Times are 10 a.m. - 1 p.m. & 9 p.m. -12 midnight. Each in-service takes about 10 minutes.

Important Reminder! Surgical Instruments Remember to use the enzymatic foam on instruments prior to sending to Central Sterile Processing. This issue was cited in prior TJC visit. Always ensure products have been sterilized before using for patient needs. 3

Governance Council Updates: •

• • •

Nurse Coordinating Council (NCC) Drug diversion is a nationwide issue and a nursing strategic priority. Drug diversion specialist reviews Omnicell for users, frequency, etc. to find flags of diversion until managers are notified of potential issues. Council leaders to discuss this topic at their monthly meetings and gather feedback as needed. CAUTI: Successful 3 month pilot in Multitrauma reduced rates by 70%. Pilot now in all ICUs and all units in STC. Winter education marathon focused on CAUTI with plans to educate 3,370 staff members on CAUTI prevention and reduction. Feedback received from all councils on the Professional Practice Model. Model will be modified to reflect feedback and presented to the VP/Directors of Nursing group. Many upcoming clinical practice changes in process. Changes: Monitor Safety (includes adult and pediatric updates), MOLST training with March target date, electronic Braden Scale (see page 7 for details) and enteral tube placement policy changes.

Nursing Research Council Reviewed the Professional Practice Model and • gave feedback as needed. • Council broke into taskforces: • Planning of NRC workshop and • seminars • EBP training for nurses • Define NRC roles and expectations • Revise/enhance the translation section • of the JHH EBP model

•

• • • •

Patient & Family Education Council Continued their work on EBP project by reviewing articles. More articles were distributed for next month’s meeting. Education materials on foley insertion were reviewed and found to be too high of a grade level. A member to work with developer to reduce the grade level. Reviewed Hourly Caring Rounds brochure. Other Hourly Caring Rounds materials are available on the intranet.

Clinical Education Council Update provided on the Jan./Feb. CAUTI prevention marathon. Over 200 nurses trained to be trainers. AccuChek fair will be in March for a week. Preceptor Boot Camp started Feb. 1st. This class and Charge Nurse class are being added to the end of the new graduate cohort classes. Changes to the ENP course presented. Class will be done online and with observations on the units over a 6 week period. Recertification for bariatric program presented. Education for the staff is being developed for future education. Details on unit based education can be sent to kseidl@umm.edu for Magnet redesignation.

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

Congratulations Newly Certified RNs! Robert Leikus– congrats on your Advanced Certification in Critical Care (CCRN) 4

Governance Council Updates: Staff Nurse Council

Professional Advancement Council

Preliminary Q2 inpatient satisfaction results were presented. With the implementation of Hourly SCN Leadership Development Caring Rounds as a strategy for safety and service, Curriculum was presented to group. our overall scores have shown an increase and are Curriculum to be presented to DON/VP group moving in the right direction. In particular the before changes are made. Goal is to implement scores for Courtesy/Respect jumped 3.6 %. program with January cycle’s advancements. Council members were asked to join the Nurses Q & A Sessions will be held at the May 8th and Week planning committee. 9th Clinical Practice Summit. Additional nonsummit dates will be in March, September and Had a discussion on: “How have we harmed or December. Portfolios will be available for review almost harmed each other?” with a volunteer to assist the staff nurses. Topic will be further discussed as part of FY 13 More information to come. goals of RN-RN Interaction.

Professional Advancement Council Clarity on Advancement Requirements: In order to provide more clarity regarding some of the requirements for advancement, the Professional Advancement Council made minor language changes on the SCN I and SCN II evaluation forms. SCN I evaluation form under "professional growth": • Teaching using formal teaching process: Added "for required elements, refer to Teaching Activities Template under Portfolio Resources on the PAM Intranet page (http://intra.umm.edu/ummc/advancement/portfolio.htm) • Member of a board/committee: Added "professional association, not a hospital committee" • Active specialty certification: Changed to "current & active specialty certification" SCN II evaluation form under "professional growth:" • Specified the time frame of two years for meeting one of the requirements • Member of a board/committee: Added "professional association, not a hospital committee" • Active specialty certification: Changed to "current & active specialty certification" Due to these improvements, the council asks that nurses preparing applications for advancement obtain their forms from the intranet and not from old manuals or saved materials. The Professional Advancement Model Intranet page has always the most updated information to guide you to a

Charge Nurse Council

Clinical Information Council

Council discussed Work Place Violence • policy. Members to strategize with managers how to handle all types of violence on the unit. Charge Nurse Checklist has been finalized and will be added to the Charge Nurse Manual on the intranet. The manual will be reviewed and updated by the council at the next meeting. • Additional topics being considered include: Behavioral Standards, Active Shooter Policy, Work Place Violence, Patients Leaving Unit and • RRT. CPC has asked that Staffing Guidelines be reviewed by the council at the next meeting.

A new insurance denial reduction initiative related to level of care and transfers was presented to the council. The council identified process concerns that caused this initiative to be delayed until clarification around process concerns were addressed. New electronic Pediatric falls assessment tool (Little Schmidt) approved. Release scheduled for 2/19/13. Group discussed obstacles perceived by nursing staff related to managing patient care orders. Information will be shared with other councils for feedback. 5

March is National Nutrition Month Enjoy these tips adapted from the Academy of Nutrition and Dietetics “13 Health Tips for 2013”. Eat breakfast

Make half your plate fruits and vegetables Watch portion sizes

Be active

Fix healthy snacks Get cooking

Dine out without ditching your goals Enact family meal time

Banish brown bag boredom

There is no better way to start your day than a healthy breakfast. Include whole grains for fiber, fruit, and lean protein. Add some vegetables in as well, such as peppers and onions in an egg-white omelet. Try oatmeal cooked with skim milk, sliced almonds and berries, or top a whole grain waffle with fat free Greek yogurt and fruit. Find more quick breakfast ideas at www.eatright.org/nutritiontipsheets. Fruits and veggies add color, flavor and texture, along with vitamins, minerals and fiber to our plate. Make 2 cups of fruit and 2 ½ cups of vegetables your daily goal. See “20 Ways to Enjoy More Fruits and Vegetables” at www.eatright.org/nutritiontipsheets. Get out the measuring cups and see how close your portions are to the recommended serving size. Using smaller plates, bowls and glasses can help you keep portions under control. Use half your plate for fruits and vegetables and the other half for grains and lean meat, poultry, seafood or beans. Visit www.choosemyplate.gov. Regular physical activity lowers blood pressure and helps your body control stress and weight. Start by doing what exercise you can for at least 10 minutes at a time. Children and teens should get 60 or more minutes of physical activity per day, and adults should get two hours and 30 minutes per week. Drink mainly water or other non-caloric fluids. Try to drink primarily water to avoid the extra sugar and calories from sweetened beverages. Choose from the MyPlate food groups: whole grains, fruits, vegetables, low-fat or fat-free dairy, lean protein or nuts. For snack ideas, see “25 Healthy Snacks for Kids” and “Smart Snacking for Adults and Teens” at www.eatright.org/nutritiontipsheets. Cooking at home can be healthy, rewarding and cost-effective. Resolve to learn some cooking and kitchen basics, like how to dice an onion or how to store herbs and spices. The collection of How do I… videos at www.eatright.org/howdoi will get you started. You can dine at a restaurant and stick to your eating plan! The key is to plan ahead, ask questions and choose foods carefully. Think about nutritious items you can add to your plate—veggies, lean meat, poultry or fish—and look for grilled, baked, broiled or steamed items. Research shows that family meals promote healthier eating. Plan to eat as a family at least a few times each week in 2013. Turn off the TV and other electronic devices to encourage mealtime talk. Get kids involved in meal planning and cooking, and talk about good nutrition. For more family mealtime tips, visit www.kidseatright.org. Incorporate healthy lunch ideas. They’re easy to fix the night before and ready to go in the morning. Try whole-wheat couscous with chick peas or black beans; whole-wheat tortilla filled with chicken, mushrooms, onions and tomatoes; or spinach salad with sliced pear, red onion and low-fat feta cheese. Keep lunches safe with tips from http://homefoodsafety.org.

For a referral to a registered dietitian and for additional food and nutrition information: visit www.eatright.org

February 19th Pharmacy Changes Label Changes • “CONCENTRATED” strip label has been added to the nonstandard IV infusion. • Electronic signature check boxes have been added as a visual cue of prep and check. Estrogen Product Insert Distribution Mandate by the FDA The FDA has mandated the distribution of the patient package insert (PPI) for patients on estrogen products with the first dose and every 30 days. • Pharmacy will now send the estrogen PPI with the first dose of all estrogen products. • For identified medications, a comment has been added on the order stating that the nurse will distribute the PPI prior to first dose. • Estrogen medications now have a 30 day automatic stop order, so the prescriber will be prompted to re-order at 30 days to prompt for another PPI to be distributed to the patient. 6

UMMC and UMMS Falls Prevention Campaign Contest Announcement! Want to show off your creativity and your dedication to Preventing Patient Falls? Submit an entry for the Falls Prevention Campaign contest. create safe area ►Our hospital winners will be announced in May 2013. assess risks • 1st Place will receive $100 and will be UMMC’s entry in the UMMS reduce risks evaluate plan finalists contest ►The UMMS winners will be announced no later than June 1, 2013. • 1st Place will receive $250 and their winning campaign message will be featured in various campaign messages throughout the UMMS system hospitals and community ►Here is how to join the fun: • All UMMC entries will be reviewed by our Falls Committee for winner selection. • Entries can be sent in by an individual or a group. ► Submit your message to Luiza Lima by April 1, 2013. Email to llima@umm.edu or send to: Clinical Practice & Professional Development Office at 110 S. Paca Street, 2nd floor.

Changes to Charting Effectiveness of PRNs New fields have been added to scheduled and PRN medication tasks to document post assessments results. This affects short and long acting analgesics. These changes include: • An eMAR task to document scheduled pain medication post-administration assessments. • For long acting analgesics, the task will trigger at Approximate Peak Pain Effect Time. • Two new fields have been added to document post response including “See lab results and VS” and “Slow acting medication too soon to evaluate (for stool softeners)”

Preventing Infections Related to Use of Point of Care Testing Equipment Studies have shown that a major contributor to nosocomial infections is point of care testing devices such as glucose meters. Devices used on multiple patients that are inadequately disinfected and/or placed in contaminated storage areas are the primary cause of these infections. Another factor is the failure to change gloves and cleanse hands between patients. Personal items such as pens and keyboards are possible sources of pathogenic contaminates as well as pathogens contacted at the bedside. Many pathogens can live for days to months on surfaces if the surface is not adequately disinfected. The FDA issued the following guidance in 2011: “If dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use following the guidelines provided in device labeling.” UMMC Point of Care Services incorporated this practice into AccuChek training in 2011. At the time the UMMC policy also prohibited taking meters into rooms of patients who were on contact/droplet precautions. In 2013 the policy was revised to allow the meters to be taken into all patient rooms provided that the meter is adequately disinfected with the hospital approved disinfectant (currently Oxivir ® Tb Wipes) after each use. The only time that it is acceptable to use Dispatch® Wipes on the AccuChek meter is after exposure to C. Diff. (Clostridium Difficile). Care must be taken to remove excess moisture from the wipes to avoid damaging the meter. But what about the vials of test strips? Contamination of the vials may also occur; therefore, it is also recommended that test strip vials be left in the patient’s room and not shared between patients. For questions regarding use and care of the AccuChek Inform glucose meters or any other point of care testing device, contact the POC Services staff at 8-5686 or email to pointofcare@umm.edu. 7

The Down and Dirty on Maintaining Clean! FACT: Did you know that patient care equipment can easily become contaminated with bacteria that persists on dry inanimate surfaces for long periods of time UNLESS cleaned regularly. Organism duration of persistence (range) Acinetobacter spp. 3 days - 5 months Clostridium difficule) 5 months Escherichia coli 1.5 hours - 16 months Enterococcus spp, including VRE 5 days - 4 months Influenza virus 1 – 2 days Norovirus 8 hours – 7 days Staphylococcus aureus, including MRSA 7 days – 7 months What about your hand held devices and computer keyboards? Researchers say that there are 200 X’s more bacteria on keyboards and cell phones than on a toilet seat. Keyboard germs are microorganisms such as flu virus, MRSA, the common cold virus etc. When you touch a keyboard or cell phone, those germs are transferred to your hands, and then to everything else you touch. This cycle continues from person to object, object to person and so on.

How to maintain a clean work environment, protect your patients and keep yourself healthy. 1. Keep surfaces in your patient’s room free of clutter so that high touch surfaces can be THOROUGHLY and regularly cleaned by HHS. • Routine disinfecting high touch surfaces with a hospital approved disinfectant is the best way to keep down the bacterial bioburden in a patient’s room. 2. Clean all shared items between patient use. When in doubt, CLEAN the item before you use it. Shared mobile equipment items includes blood pressure cuffs and glucometers. 3. Properly label and store equipment so that your colleagues know what you have cleaned and what needs to be cleaned. • Green tags indicate clean equipment • Red/orange tags are for soiled equipment • Brown tags are for soiled equipment that has been in an Enhanced Contact Precautions room (thus requiring a 5 minute cleaning contact time with a bleach product - as opposed to 1 minute required for other pathogens) 4. Routinely clean your cell phone and the computer keyboards where you work. 5. Practice good respiratory hygiene. Cough or sneeze into your sleeve. If you forget, then please clean your hands immediately! Other Reminders: • Change your gloves frequently. From the patient’s perspective, gloves are no different than your hands. If you have touched something with gloves on they are now contaminated! • Clean your hands frequently, upon room entry and exit, even before touching patients if you have touched other items in the room. • All patient care equipment (IV pumps, syringe pumps, SCDs, etc.) should be SOILED removed from patient rooms when patient vacates room after a (discharge or EQUIPMENT transfer). Used equipment should have a Soiled tag attached and be placed in the soiled pickup area. • If it is a specialty piece of equipment that is unit-owned, attach soiled tag and move to an area where cleaning can be performed by unit staff (electronic thermometers, bladder scanners, SonoSites, vital sign machines). These items continue to be the unit's responsibility to clean. • There is no tagging of any items that are a permanent part of a room turnover. All items should be cleaned as part of the room cleaning. (bedside tables, overbed tables, standard beds or cribs) • Specialty beds must be surface wiped down prior to being put into hall for pickup. Please avoid placement of beds in areas of units where they will impede flow, or are likely to be touched by patients and visitors!! • Specialty Beds for pickup should be labeled with the name of the patient for whom they were used- and should have a SOILED TAG placed on them, even after the initial wipe down occurs (as this does NOT constitute a full clean or readiness for another patient).

Announcements Save the Date!!! Pediatric CCRN Review Course March 18 and 19, 2013 UMMC Certification Breakfast March 20, 2013 Trends in Nursing Practice Conference May 1, 2013 March CPPD Courses • Chemotherapy for Non-Cancer Units—15 • Critical Care Nursing—5-6, 12-13 • Fundamental Critical Care Support—21-22 • How to Build your CV & Portfolio Step by Step—20 • Oncology Nursing Basics—5-6 • Adult Phlebotomy—27 • Preceptor Boot Camp—22 • Med Surg Review Course—22, 26-27 • Team Management of Diabetes—12 • Nursing Journal Club—26 • Certification Day —19 • Nursing Grand Rounds—20 Please enroll via Healthstream or contact CPPD @ 8-6257 for more details

Team Management of Diabetes Conference Date: March 12, 2013 Time: 8:15am - 4:15 pm Location: UM SMS Campus Center Conference objectives: • Discuss advances in research, technology, and clinical practice that improve diabetes management. • Identify resources available to support optimal diabetes self-management. • Adopt a patient-centered approach to making lifestyle changes to better manage diabetes. To register, please visit: www.tmdummc2013.eventbrite.com CulinArt, Inc comes to SMC Campus Center CulinArt, Inc is officially opened in the SMC Campus Center.

Nursing Grand Rounds: Wednesday, March 20, 2-3 PM in the UMMC CulinArt proudly serves Starbucks coffees, teas Auditorium and specialty drinks on the first floor. The 'To Go' "Meaningful Use of Data: A Call for Nursing area also provides grab and go options such as salInnovation and Leadership" ads, soups and sandwiches for those on the run. Nursing Grand Rounds will be presented by: The second floor dining area is open for both Marisa L. Wilson, DNSc MHSc RN-BC breakfast AND lunch. Assistant Professor and Director of Masters CulinArt Café opens at 7:00 AM serving hot meals Programs in the morning and then a wide variety of lunches University of Maryland School of Nursing beginning at 11:30 am and closing at 3:00 pm. The American Recovery and Reinvestment Act authorized CMS to provide incentive payments to eligible professionals and hospitals who adopt, implement, upgrade, or demonstrate meaningful use of certified electronic health record (EHR) technology. Is this all about implementing technology or is it about changing the very nature in which we interact with patients using technology? We will explore these issues.

REMINDER NOTICE! Change in Annual Training schedule, starting February 1. Deadline for completion of required training is now June 30. 9