UMMC Nursing Newsletter by UMMS

January 2013 Volume 2, Issue 1

UMMC Nursing Newsletter New Enteral Feeding Policy Enhances Patient Safety Over the past year, multiple incidents have occurred where the placement of blindly inserted NG tubes has caused patient harm. At Clinical Practice Council (CPC) meetings, the subject of malpositioned feeding tubes has been discussed several times. AACN Guidelines recommend that feeding tubes have placement confirmed by xray. Data was collected on all tubes placed over a 2 week period. (See Table). This data revealed that 53% of the NG tubes placed for feeding had been x-rayed. Of that 53%, 11% were found to be in a less than optimal position. ENTERAL FEEDING TUBE PLACEMENT DATA Data collected by Clinical Nutrition Staff: n = 95 total feeding tubes placed Corflo = post-pyloric tubes

Gastric = nasogastric tubes

59/95 tubes placed were post-pyloric

36/95 tubes were blindly placed gastric tubes

(58/59) 98% of Corflos were xrayed

(19/36) only 53% of gastric tubes

(50/58) 86% were in good position

(17/19) 89.5% were in good position

1 Corflo tube was not xrayed

17/36 47% of gastric tubes were not xrayed

The data also showed that:

ο 48/54 or 89% of Corflo tubes placed in ICUs were in good position ο 3/5 or 60% of Corflo tubes placed on the floor (outside of an ICU) were in good position ο 15/22 Corflo tubes required repositioning due to improper placement Feeding tube placement is a commonly performed and necessary procedure to promote optimal nutrition and healing in our patients. The standard of auscultation for placement verification, as many of us were taught, is now thought to be ineffective. Evidence shows that radiologic confirmation of feeding tubes is the most effective method to determine safe placement prior to the initiation of feeding or delivery of medications. Numerous challenges were identified with radiologic confirmation standards for gastric tube insertion at the organizational level and how this standard would impact patient care and providers including: ο Requirement for providers to order and document placement of tube tip ο Increased workload for radiology staff due to increased volumes of films and readings ο Nursing impact of additional time to verify orders and awaiting verification ο The potential patient impact of additional exposure to x-rays required, and potential delays in feeding and medication administration while awaiting tube confirmation ο The potential system impact of additional charges for radiology films ο IT implications for changing order sets for new standard ο Pharmacy review of medication administration components, and recommendations regarding the use of methylene blue. The group worked through these challenges to create a new standard. The enteral tube management policy is expected to be finalized in the next few weeks. We expect that our new standard will include x ray confirmation of tube placement to protect our patients from unintentional harm. 1

What’s New @ UMMC? Urinary Catheter Specimen Sampling Procedure Key Practice Issue: Always send urine samples from the sampling port and not from the urinary drainage bag or urimeter! 1. When an Order is placed for Urine Culture and Sensitivity +/- Urinalysis: Gather Equipment: Clean gloves, alcohol pad, male leur-lock transfer device (blue tip), specimen label/request, collection tube(s) {yellow tubes required for UA and gray tube for urine c/s}. Procedure as follows: a. Identify patient, explain procedure, patient/family education as needed. b. Perform hand hygiene, put on clean gloves. c. Drain all urine from drainage tube into bag. d. Occlude drainage tubing a minimum of 12 inches below the sampling port. e. Allow time for the urine to fill the tubing from point of clamp to slightly above the sampling port. f. Discard gloves and perform hand hygiene while waiting for urine to collect. 2. When there is sufficient urine to collect the specimen: a. Perform hand hygiene, put on clean gloves. b. Clean the tops of the collection tubes with an alcohol pad. c. Prepare sampling port with an alcohol pad, scrubbing for 15 seconds. d. Allow sampling port surface to dry! e. Insert the male luer-lok access device into the sampling port and rotate clock-wise until it fits securely. f. If a urine c/s is ordered, fill the grey c/s tube first (grey tube holds 4ml). g. If a u/a is ordered, fill one yellow tube last (yellow tube holds 4 ml). (If additional tests are ordered, add a second yellow tube if indicated). h. Invert tubes 8-10 times. i. Disconnect BD male luer-lok access device. j. Remove item used to occlude the drainage tube after collecting the specimen to allow urine to flow freely. k. Dispose of equipment properly. Remember the male luer-lok access device goes in the sharps container. l. Label the collection tube(s) in the presence of the patient. m. Seal in a laboratory biohazard transport bag and send to lab immediately. n. Perform hand hygiene. o. Document procedure on the flowsheet including patient/family education. Include in handoff communication.

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General Safety Around UMMC Walk in pairs or groups, particularly in the evening. Be aware of your surroundings. Remain alert at all times. Escorts from Guest Services & Security are available; call 8-6400 at least 10 min. in advance. If you are in danger or see any dangerous activity outside UMMC, then call 911 immediately. Cell phones have a great deal of street value to thieves. Don't make it easy for them to steal your phone or discover any personal information you have stored on it. Do not use cell phones in public places. You become an easy target for thieves. See the complete list of Tips from the UMMC Security Department on the hospital Intranet: http://intra.umm.edu/ummc/docs/security-tips-20130107.pdf

Clinical Practice Council Updates: Important Practice Announcements Electronic Braden Score will go live on 1/24/13. ο It will be on the same form as the Morse Fall Risk Assessment for ease of use. ο Category descriptors can be viewed by right clicking on the item. ο There will be an automatic WOCN consult notification for scores below 16 or when patients have any 3 co morbidities out of the 5 (existing pressure ulcer, malnutrition, diabetes mellitus, etc.) listed on the form. ο Assessment will be done twice daily. Hourly Caring Rounds Update: Audits show compliance issues with inconsistent documentation of hourly rounding on new boards. Units that achieve higher compliance have used a team approach to rounding. Remember to address all 4 Ps every hour! Patient Safety is Everyone’s Responsibility! Patient Identification: Procedural Areas are seeing an increased number of patients without allergy bands on extremities. Please ensure that patients with documented allergies have an allergy band. Procedural areas will ask for nurses to come to the area, identify their patient, and place allergy band if warranted for procedure to continue. PICC Line Occlusions? When using Alteplase to unclog a central line or PICC line, the caps must be changed. The PICC team is finding that if they change the cap– the occlusion is resolved!

Risk Management—Ask the Expert! Staff Question: Should nurses have their own liability insurance? Answer: No, as long as you are employed here at UMMC and practicing within your scope. You are a bigger target if you have your own insurance. If you are moonlighting, or working for an agency then yes—you should consider. Staff Question: What if I am not longer employed at UMMC and a lawsuit is filed? Answer: As long as the incident occurred during the time that you were employed at UMMC, you would be covered. Policy revisions SKI-003 Pin Care Updated: 1/2 strength hydrogen peroxide and sterile water to be used for pin care. COP-001 Patient Defibrillation policy allows early use of AEDs by clinical staff trained in BLS TENP Updates: New Products Coming Soon! • Improved all-in-one urinary catheter kits • PIV Insertion Kits • New central line kits with upgraded Tegaderm • New IV Catheters in CT and Adult ED for power injections

Risk Management Report

Event Reporting FY 12 Quarter 4 & FY 13 Qtr 1 show that our highest number of reported incidents appear to be related to the following: Blood Transfusion – have the highest incidence • of reported events including: - transcription errors in demographics - expired blood bands • - documentation issues New Type and Cross bands will have a space to enter patient DOB and a barcode which will be used in the blood bank which to reduce potential dispensing errors • Lab Specimens— we have multiple reports of errors related to patient identification for specimen labeling. Falls – increase incidence from 130 to 172 total. Please document all interventions utilized to protect your patient. Complete your Post-fall Huddle Reports~

Meetings Canceled for December 2012 • Clinical Information Council • Magnet Champion Group • Skin Care Committee

Professional Advancement Council Membership is working on promoting the council’s work and to increase availability for consultations with staff working toward advancement. After discussion, council approved language changes to the SCN I and SCN II evaluation tools with modifications. Available tools will be updated following the January 2013 promotion cycle. Council reviewed a recommendation to expand the “professional growth” evaluation category to capture professional growth activities such as speaking/presenting at national conferences or publications. Recommendation was to have these options fulfill the requirement rather than the limit it to standard “certification” and “enrollment in a degree program”. To be continued on next agenda.

Governance Council Updates: • • •

Nurse Coordinating Council (NCC) Council leaders shared feedback related to Professional Practice Models and UMMC’s Rope. General consensus supports keeping the current visual model with modifications. FY 13 Objectives: majority of councils have finalized their council objectives, although some are still working on the finalization. Mike Harrington shared information about the Center for Performance Innovation and the Performance Innovation Process, the Simpler Business System model, and how UMMC uses Enterprise A3, Value Streams, and Rapid Improvement Events.

Nursing Research Council

Patient & Family Education Council

Council approved FY13 Objectives. Council reviewed and gave feedback Articles were reviewed for inclusion/exclusion on the Professional Practice Model. in the EBP project. Anita Moore presented on how to Pat Woltz provided some guidance on the obtain informed consent (IC) and the assent procevaluation of qualitative research. ess when doing research studies here and the UniMembers are asked to come prepared to the versity of Maryland. Key topics included: January meeting with articles reviewed. • Reviewed the principles and elements of IC • Who can obtain consent Clinical Information Council • Legal Authorized Representative (LAR) New electronic version of the Braden Score is • IRB approved documents being finalized and a Go-Live 01/24/2013. • The consent process The lab label date format has changed to the American format (mm/dd/yyyy). Clinical Education Council No issues reported. Agenda focused on CAUTI reduction initiatives. UMMS is switching Cerner to the Epic system by March 2014. The goal is to have one system Winter Marathon focus changed to address throughout UMMS for electronic documentation CAUTI Reduction with time frame of January and view labs and radiology, thus facilitating flow 28th thru March 29th of information between the hospitals. CAUTI Content will include: ο Urinary catheter alternatives Congratulations to Our ο Catheter indication/contraindications Newly Certified RNs! ο Order management changes • Carol Loeb RN, HNB-BC—Holistic Nurse ο Insertion & removal technique (includes Baccalaureate - Board Certified new catheter kit education) ...and to our group of SICU Nurses: ο Culture technique • Alex Halstead BSN, RN, CCRN ο Daily maintenance

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 4

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Leann Greise BSN, RN, CCRN Morgan Johnson BSN, RN, CCRN Ranae Zurawski BSN, RN, CCRN Ann Whiting BSN, RN, CEN, CCRN Lindsey Griffiths BSN, RN, CCRN Mary Mosaad BA, BSN, RN, CCRN Daniel Lunde BSN, RN, CCRN Rebekah Friedrich BSN, RN, CCRN Jennie Spelta BSN, RN, CCRN, PCCN

Send your certification news to: certification@umm.edu

Governance Council Updates: Staff Nurse Council During safety discussion, council members identified and discussed concerns related to medication safety, Omnicell stocking and overrides, and inadvertent defibrillator charge of a patient during monitoring with quick pads. Council members worked with Maryland Express Care to follow-up on issues re: communication and appropriateness of level of care. Lisa Rowen queried council members on the effectiveness of using open forums to meet with nurses as a communication strategy. Lisa was able to meet with over 800 RN’s and APN’s during the open sessions.

The Charge Nurse Committee Safety concerns discussed. Remind self and staff: ο PINCH meds and blood products require an independent double check. ο Documentation of medication administration should be done ASAP and delayed until the end of the shift. ο Check patient identifiers with IV drips. Discussed the article “Nurturing Charge Nurses for Future Leadership Roles”. This article will be presented at Nursing Journal Club on January 22nd.

Influenza Update Per the latest FluView report from CDC.gov, flu is still on the rise, with most of the country experiencing high levels of influenza-like-illness (ILI). Twenty nine states are reporting high ILI activity, and forty-one states reporting widespread ILI. In Maryland, after a relatively mild season last year, flu hit us early this year in mid-December. UMMC has already reported 53 influenza cases to the health department, surpassing last years total flu season report of 32 cases. Just as hand hygiene remains the single most important means of decreased transmission of infection, the CDC also recognizes annual vaccination as the most important measure to prevent transmission of seasonal influenza. Thanks to everyone, the medical center staff has achieved a high vaccination rate this year, which is a vital step in decreasing transmission of influenza. Influenza viruses are primarily spread through large respiratory droplet transmission (a person coughs or sneezes within 6 feet of a susceptible person). Contact with contaminated surfaces is another source of potential transmission (someone touches a contaminated surface, and then touches mucosal tissue of the mouth or nose). Flu symptoms usually appear abruptly, and may include fever, myalgia, headache, nonproductive cough, sore throat and rhinitis (plus nausea and vomiting in children). Average incubation period (exposure to symptom onset) is 2 days, and illness typically resolves after 3-7 days. Adult infectivity begins one day prior to symptom onset to roughly 7 days after symptoms appear. To minimize influenza exposures, we must remain vigilant in surveillance of patients, families and visitors to the institution. Visual alerts have been posted at entrances and waiting areas to guide patients and visitors. Ambulatory areas should have masks, tissues and hand hygiene gel readily available, and encourage respiratory hygiene and cough etiquette. Patients admitted with viral respiratory symptoms should be placed on droplet/contact precautions and have viral respiratory panel testing. Visitors should be screened and discouraged from visiting patients if they are sick. NOTICE: In order to protect our patients, visitors & staff from the spread of the flu, we are instituting more restrictive hospital-wide visitor policy into effect on January 17, 2013 until further notice. To get the latest information on influenza, visit: http://www.cdc.gov/flu/ or http://ideha.dhmh.maryland.gov/influenza/SitePages/Home.aspx 5

New Adult Emergency Department—Opened January 16th The new facilities, which will accommodate nearly 60 patients simultaneously, feature: • Expanded triage/intake capacity for evaluating patients on arrival New • Peripherally-located treatment areas for less acute patients, aimed at reducing their Adult in-and-out times ED! • Additional treatment bays, some of which can be divided to handle multiple patients during “surges” • New entrance for EMS personnel to bring patients more efficiently into the ED • A co-located 12 bed observation unit, managed within the ED, for longer-term evaluations, diagnosis and treatment while determining discharge vs. admission New signage will direct patients, families, EMS, and UMMC staff to the appropriate entrances into the new Emergency Department. The public entrance will remain on Lombard Street. Departments who routinely send patients to the AED should contact Tom Crusse at tcrusse@umm.edu for specific instructions on how best to navigate from their location to the new AED. Nursing: A 4 Part Webinar Series Sponsored by Drexel Online Enjoy a free, interactive webinar series featuring Drexel University’s College of Nursing and Health Professions’ faculty and deans for the latest investigations into nursing trends and best practices. Webinar 1: Wednesday, January 30, 2013 6:00 P.M. – 8:00 P.M. 2015: A Pivotal Year for APNS - Consensus Regulatory Model for Advanced Practice Nurses and Is the DNP required for entry into Practice as an Advanced Practice Nurse: Monumental change is on the horizon for Advanced Practice Nurses. Webinar 2:

Tuesday, February 26, 2013 6:00 P.M. – 8:00 P.M. Simulation is Fiction, Your Decisions are Real

Webinar 3:

Wednesday, March 6, 2013 6:00 P.M. – 8:00 P.M. Clinical Nurse Leader-The Expanded Role For The Future of Nursing

Webinar 4:

Wednesday, April 17, 2013 Wicked Problems in Healthcare

6:00 P.M. – 8:00 P.M.

NDNQI Pressure Ulcer Prevalence Survey On February 20 or 21, UMMC will participate in the quarterly inpatient NDNQI Pressure Ulcer Prevalence Survey. Please identify a staff member who is working on one of the 2 days to conduct the unit survey and notify your WOC nurse of the selection. You can leave a message at ext. 8-6448.

Your Unit Coverage of Wound Ostomy Continence Nurses WOCN

Coverage Areas

Contact Info

JOAN SELEKOF

SICU, Pediatrics, MBU, 5 Weinberg, 9IMC 10E, Trauma

Voicemail 410-328-6448 Pager 6448 Voicemail 410-328-7109 Pager 8834 Voicemail 410-328-4459 Pager 6030

GWENDOLYN WILLIAMS KEISHA MCELVEEN

BRET ANDERSON JEANETTE MASSABNI

4IMC, C5EGud, C5WGud, 6WGud, 7ICU, C7EGud, 11E, 11W, 12E, 12W, 13E, 13W CCU, PCU, CSICU, 6Weinberg, C6E Gud, N8W, N9W, 9BMT 8E & W Gud, 10W, MICU

Voicemail 410-328-7448 Pager 9173 Voicemail 410-328-2068 Pager 2068

From 7am—7pm Please text page with a call back number and your name. After 7pm, please leave a message on your WOCN’s voicemail 6

Clinical Practice Update: Code Communication & Documentation Calling a Code? Have 1 person call the UMMC operator staff and have the recorder log the time of the event on the arrest record. Include: the building, floor, and room number of the patient for the operator. Important - Be aware that the operator has a 2 step process: 1. Send out a page via alpha system to those with the code beeper. 2. Announce the code via an overhead page

Remember to document all care but pay close attention to the items in the red box and circle. Also, Practice Makes Perfect!

Clinical Practice Update: Bumetanide Safety Due to a furosemide shortage, bumetanide continuous infusions are being used instead of furosemide. Alaris® pump guardrails are not in place for bumetanide infusions, but will be after the next upgrade. Bumetanide Facts: • 1 mg bumetanide = 40 mg furosemide • If given in excessive amounts, the patient may have excessive dieresis with electrolyte depletion & nephrotoxicity. • Monitor sodium, potassium, and renal function periodically during treatment. Adult Dosing: • Initial bolus is 1mg IV (maximum bolus of 8mg) given over 1-2 minutes, followed by an infusion of 0.5 - 2mg/hr. • The maximum infusion rate is 2mg/hr. • Patients are titrated to response, so dosing may vary. • Bumetanide is more potent than furosemide, so please consider this when titrating to effect. Pediatric Dosing: • Pre-term and Term Neonates: • 0.01 - 0.05 mg/kg per dose every 12 - 48 hours • Infants and Children: • 0.015 - 0.1 mg/kg per dose every 6 - 24 hours (maximum dose: 10 mg/day) • If an infusion is needed, infuse at 0.01 - 0.03 mg/kg/hr which equals 0.2 - 0.8 mg/kg/day (compare to 0.08 - 0.32 mg/kg/hr of furosemide = 2 - 8 mg/kg/day furosemide). 7

Lab Series Part 4: Labeling Tubes (Part 2) Lab tubes must be labeled prior to sending to the lab. Unlabeled tubes = rejection Cerebral Spinal Fluid (CSF) is irretrievable so it must be labeled correctly. • Collect in a special clear container that has markings down the side for volume measurement. • Place the label vertically with notch near the lid of the container – so that markings are visible Other Fluids and Specimen Types: • A fluid that is submitted in a cup should have the label placed vertically on the side. • Please do not place the label on top of the cup because the barcode reader cannot read a bent label Urine Samples: • Remember 1 tube per label • Typically 2 Yellow top tubes are needed. 1 Yellow top is needed for the urine chemistry screen plus microscopic. A special dye is injected into the tube which makes it unusable for further tests. 1 Yellow top is needed for additional urine tests ordered. • Urine cultures go in a grey top tube. • Label with notches matching vertically • For pediatric specimens: Place the collection bag inside the cup with the blue lid with the label placed vertically down the side. Typenex Label for Blood Bank Specimen • The top arrow shows where to break the band to make a bracelet • The rest of the band if for small labels to be used for the specimens and blood products • The CPOE label is to be placed on the pink tube or the “carry” tube for microcontainers. The small red sticker is to be placed on the tube or microcontainer when collected. The rest of the strip of labels should be “partially stuck” to the specimen and included with it when sent to the lab. • All patients over 4 months old require a full pink tube for blood bank requests. For neonates under 4 months old, please send 2 purple microcontainers If you have a urinalysis, urine pregnancy test, and urine GC Chlamdyia DNA tests ordered, then how many yellow tube urine tubes will you need? a. One b. Three c. Five

The “tail” of small labels on the Typenex label should be sent with the Blood Bank specimen to be applied to the blood product when it is sent back for the patient. a. True b. False

For further information use the link to access the "Blood Draw Instruction" module.http:// www.umm.edu/cernertraining/elearning/preLabSpecimen/BloodDrawEducationModule/ BloodDrawEducationModule.htm Laboratory staff will be submitting columns monthly on various tips and information. Please feel free to email them any comments, questions or suggestions you may have to: dmacfarlane@umm.edu

CPR Challenge! When? Thursday, February 28, 9am - 6pm Where? Weinberg Round Room All staff are invited to participate in this exciting challenge to demonstrate their CPR skills. Zoll Corporation will be on hand test your skills with REAL CPR Help built into the defibrillator and pads. All units/clinical areas are encouraged to send their best CPR performer to compete for prizes! Sign up in Healthstream or call 8-6257. 8

Announcements The 2013 CPPD Educational Calendar is ready for your to view:

Save the Date!!! CPR Challenge February 28 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 Health-

Preceptor Boot Camp •

New content and new tools! • One day course • Enroll all preceptors: experienced and those new to the role! Here's a taste of the content: • Creating a "Welcome Wagon" environment. • Orientation accountability belongs to the unit, the preceptor and the preceptee. • What should a preceptor look like? • Precepting for retention! • Communication, personality and learning styles of preceptor and preceptee. • "Zero to fully functional in you say how long"? What's the plan of action? • Giving crucial, timely feedback: even when the news is not pretty! • Preceptor tools on the intranet and a whole lot more - at your fingertips! • When the fit is not right.... • Advice from the pro's.... • Core requirements for orientation. • “Are you smarter than a preceptor"? Join us February 1st for the first boot camp! 9

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February CPPD Courses Cardiac Rhythm Interpratation—19 & 21 Chemo & Biotherapy—7 & 8 Charge Nurse - 15 Critical Thinking—12 End of Life Nursing—6 & 13 Essentials of Nursing Practice—1 & 4 Looking Good in Print: How to Develop Your CV & Portfolio - 20 Managing Challenging Situations through Crisis Deescalation—27 Moderate Sedation Simulation - 28 Preceptor Boot Camp—1 Trauma Theory—12-13 & 19-20 UAP Role Development—6 V.A.C. Training Beginner & Advanced—13 We Discover Series—19 Nursing Grand Rounds—20

Labor Union 1199 SEIU Update From Mr Rivest’s correspondence 1/22/13: The labor union 1199 SEIU United Healthcare Workers East has been present at UMMC for the past 90 days. They have been soliciting technical and service employees for union membership. The “access agreement” that provided the union access to our facility ended on January 20, 2013. Because the union did not present the authorization cards necessary to trigger an election, the union has agreed that it will not seek to represent employees at UMMC for the next three years. Please be assured that no one at UMMC will be treated differently based on their views about unions, whether they expressed them before, during or after the access period. If you feel that you have been treated differently on this basis, please contact Human Resources at 8-7412, to discuss any concerns you may have.