JUNE/JULY 2013 | VOLUME 2, ISSUE 6
Mock Joint Commission Survey... How did we do? Our First Mock Joint Commission Survey Results 6/13 Several common themes were identified during the survey: 1. Infection Control Breaches Restricted areas without proper traffic control Negative pressure rooms – verification of functionality TB patient with room door open for a prolonged period of time Surgical Standards Covering facial hair Standardization of attire Equipment cleaning Dwell times for cleaning wipes General Cleanliness Issues
2. Documentation Issues
1 Min Dwell Time
5 Min for C Diff
Multiple handwriting types on the same form with a single provider signature: Leads to questions regarding the timing of the documentation What may have been added after signature? Forms with blank areas: Consent form for multiple procedures with numerous blank areas – need to mark N/A when appropriate Missing date and time on numerous documents Legibility concerns regarding provider documentation
3. Potential Nursing Scope of Practice Violations Broad dosing ranges with unclear parameters to support nursing decision making: Fentanyl 10 - 75 mcg- titrate to RASS of xx Multiple pain medications with unclear indications to support decision making Tylenol 650mg PO prn pain/fever Percocet ii tabs prn pain Dilaudid 2 mg IV prn pain Nursing writing order and obtaining provider signature
4. Patient Safety in Secure Areas and Monitoring of Restraint Use Allowing access to secured areas: Staff holding door open for pediatric unit Lack of timely response to door alarm in NICU Patient elopement risk in locked psychiatric unit Restraint use Ensure that patient demonstrates a need for restraint Order entry is required in a timely manner!
Respond to all Door Alarms in Secure Areas!
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What’s New @ UMMC? New Urinalysis Reflex Testing While analyzing our high CAUTI rates, we found that our urine culture rates are extremely high- and our experts suspect that unnecessary urine cultures may be being obtained. What? A new process for 2 step urine culturing is being created: Why? Purpose is to reduce the unnecessary urine cultures and antimicrobial therapy How? Providers will order a “Urinalysis with Reflex Culture” Who? Nurse will send 2 specimens with labels to the lab when the urinalysis is requested Two labels will print one for a urine yellow top tube and one for a urine grey top tube.
Both urine tubes may be sent to the lab together – the lab will run the urinalysis to determine the WBC. If WBC is >10— they will perform the culture. If WBC < 10, culture tube will be discarded*. * This testing may not be appropriate for neutropenic patients .
Coming in September! Alaris®
Infusion Pumps Model 8015
NEW!
►New Infusion pumps coming this fall - Rollout Date: September 25 th New processors– perform faster Increased Memory space Color Display Upgraded Operating System and Library reporting capability Wireless updates!
We Need You! There will be a series of meetings to review our current workflow processes to help determine the settings in the new pumps. We have a new library ready to install when the pumps arrive— that should help minimize the transition time to utilizing the new pumps—many things will look familiar.
SUPER USER TRAINING will occur in early September Stay tuned to your email for more information! 2
Clinical Practice Council Updates: Policy Review and Updates COP-015 Moderate Sedation: Policy changes will require that both nurses and providers update their competency every 2 years to include either ACLS, PALS, or Neonatal Resuscitation Program certification or completion of Moderate Sedation Module and airway simulation activity. The new competency standards for high-use areas that perform in daily practice that differ from standards for those who perform in daily practice. COP-020 Latex Allergy Policy will be deleted. This content will now be integrated into the main allergy policy. COP-006 Fall Precautions Little Schmitt added (pediatrics) links for event of a fall, RL6 reporting information added. Stay tuned- FALLS POLICY WILL BE UPDATED again in SEPTEMBER to simplify the assessment and interventions required. SP&CI-019 Blood Cultures Policy changed to match CDC guidelines– caps should be changed prior to drawing blood, and cultures should be drawn form new sterile cap. Standard volumes required for cultures have changed. SP&CI-014 Vascular Access Devices, Fluids and Infusions Policy updated to include hemodialysis catheter management (which will be matched to central line care standards) to include the use of biopatch and transparent dressings where possible. Arterial line standards have been added. SP&CI-019 Hemodialysis Catheter Management Policy will be retired. COP-039 Bladder Scanner Guidelines: In an effort to address high CAUTI rates, the Infection Prevention CAUTI subgroup is encouraging the use of bladder scanners and provides an algorithm that guides the process of what to do when a patient has not voided for 8 hours. COP-038 Intra-articular Antibiotics: This is a new policy that is used to salvage infected joint replacements (specifically knee hardware right now). Hickmans are placed directly into the joint space so that antibiotics is infused directly into the area. Data has shown that there is a potential to reduce the need for hardware removal and repeated surgical revisions
Policy Rollouts
Enteral Feeding Policy: Policy is complete and posted on the intranet. The major change is that all tubes (inserted by nursing) that will be used for feeding or medication delivery will now require x-ray confirmation. This includes both Cortrak tubes and other enteral feeding tubes- you may see new feeding tubes begin to appear on your unit as we begin to standardize supplies. Hazardous Medication Policy: Major changes will now require increased use of Personal Protective Equipment (PPE) during drug administration and when dealing with excreta for 48 hours post dose of hazardous drug. This content will be included in Fall Marathon. COP-023 Rapid Response Policy Policy has been revised to reflect the changes that have been in place since we rolled out a rapid response team— Peds documents have changes to reflect the use of the new Pediatric Early Warning Scoring (PEWS) system. COP-026 & COP-029 Restraint Policy Changes Effective Immediately! Changes mandated by CMS to obtain provider order immediately after applying restraints in an emergency situation. The term “immediately” is being interpreted by surveyors as within 15 minutes of restraint application.
Other Updates Status Epilepticus Guidelines Guidelines have been revised by Neuro ICU, there is an added a flow diagram, and Ketamine has been added as a medication for refractory seizures in an ICU setting.
Drug Shortages Continue... Shortages pertain mostly to electrolytes With low supply of calcium, magnesium and phosphorus; units with power plans for automatic repletion are not being activated.
VTE Prophylaxis added to the Regulatory Bundle A new Core Measure requires that SCD’s be implemented for all patients within the first 24 hours following admission where appropriate (and documented). The former standard only required SCDs in post-op pts. The term Pneumatic compression devices = SCDs! A single order is good for the entire stay! The regulatory bundle will help us capture the data that is required to meet the New Core Measure Standard.
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Nursing Code Blue Task Force Code Management is one of the most stressful events that occur on inpatient units. Because they occur with low frequency, but have critical outcomes, it is important that we standardize the response process for unit staff. As a result of several QOC reviews and feedback from both the Resuscitation Committee and unit staff, a Nursing Task Force was created to address some of the issues. The group identified several issues: Difficulty communicating in a loud and stressful situation Crowd control when an overhead code is announced Lack of Role Clarity when a large group arrives Lack of knowledge of Code Team Membership and inability to track responder names Inconsistent and/or missing documentation during and following the code Several solutions have been created including: Code Blue Educations days for nurses and PCTs Emergency Management Intranet Site Role Clarification Documents—including Charge Nurse Role Sheet Code Blue Role Call Sheet—to assist with identification of responder names & roles
Additional Code Blue Education Days are Coming Soon! September 23 and October 3. Please register in HealthStream to attend. Content includes interactive stations so nurses or PCTs could practice CPR and use scenarios to do scavenger hunts through the Crash Carts; stations to practice documentation on the Resuscitation Record and assembling Bristojets..
NOT intended to become part of patient’s permanent Medical Record
*COMING SOON!* Clinical Emergencies Web Page will be available on the UMMC Intranet. One central location for the following resources: Policies and Guidelines related to Clinical Emergencies Surviving a Code Power Point Presentation Roles during a Code Code Equipment and Supplies including pictures of the Crash Cart drawers Resuscitation Record Documentation Resources AED User Information Lifepak User Test And much more!
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Nurse Coordinating Council (NCC) Decision to create and administer an online survey to all nursing staff, focusing on communication/ information sharing between council members and units/end users. Goal date: August 2013 EPIC team updates provided including information regarding their first discovery session, non-EPIC work that continues for optimizing Cerner, and the request process; requests should go to cis_request@umm.edu. Workgroup formed on a possible idea to disseminate information via Healthstream. Recommendations will be created on rolling out a plan without burdening the staff. Reviewed Public Affair’s designs for a revised Rope model. NCC ultimately recommended that Public Affairs simply update the existing Rope design with C2X pillar colors and slightly modernize the "core" of the design. Governance council meeting frequency discussed. Request that council leaders discuss within individual councils. Donna Huffer shared Orientation Blueprint with the NCC. Process was approved; will be adopted as core competencies with expected July 1, 2013 rollout for inpatient area, and population specific plans will be created later.
Patient & Family Education Council TIGR On-Demand video system upgrade implementation plan given. The new system will have a looped feed of five short videos that support TJC initiatives: medical errors, infection, falls, medication safety, and pain management. There will also be a one minute welcome video by Lisa Rowen for patient viewing. A “Talk to Us” feature where the patient can directly link into to SOSC to report concerns related to housekeeping, etc is also being considered. TIGR kickoff will be late June.
Skin Care Committee New VAC instill function available on the Wound VAC – allows the ability to instill meds and irrigation fluids. The VAC is usually placed in the OR and medication or irrigation fluids should to be ordered in powerchart. KCI representatives are available to provide unit or individual instruction as requested. Contact: ebergstein@umm.edu
Newsletter Topics If you have news or updates, that you wish to be included in this newsletter, please send your information by the 7th of each month to: professionaldevelopment@umm.edu Newsletter Editorial Board Allison Murter, Susan Carey, Christine Provance, Greg Raymond
Nursing Research Council Discussion on EBP Fellowship for UMSON DNP students. DNP students may earn up to 3 credits for their work on projects needed by UMMC. Work group roles & responsibilities discussed. Updates: No term limit, chair must have MS, all council members must have CITI training. Members participated in an EBP readiness survey. Finalizing changes to the NRC Charter Approved new Scholarly Activities Policy and Procedure. This includes requirement that external presenters practice their oral talks with Director of Nursing Research in advance.
Clinical Education Council Divisional Marathon update, 870/900 nurses attended. Continuous bladder irrigation had many questions for the station owners. Task force to be assembled to clarify this therapy. Transfusion task force work presented, focusing on ATD forms, orders, new barcoded typenex, competencies, and audits. CHG training video on Healthstream and has been added to learning for RN and PCT staff. CAUTI handout with recommendations from HRET distributed. Hazardous medication policy changes discussed,
Congratulations Newly Certified RNs! Christine Provance, MS, RN, CCNS Send your certification news to: certification@umm.edu
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Clinical Information Council Meaningful Use: Modifications and additions to PowerChart were implemented to comply with federally mandated requirements for the Meaningful Use program. Changes to RN documentation in the Intake Triage are: inclusion of a set of Vital Signs, height as a required field, ethnicity, additional Questions about Smoking History Changes for Prescribers: inclusion of a Problem List with selection of a Diagnosis using standard terminology, documentation of Cause of Death in PowerChart â&#x20AC;&#x201C; if known, should be indicated in the discharge order. Video on Demand: By the planned Go-Live date of June 25th, RNs will be able to remotely prescribe/ assign videos for the patients and families to view. RNs will still need to document education in the Form Browser of PowerChart. The Video guide on the Hospital Channel will be the default station when the television is turned on. Contact Gena Stanek with questions. Post-pain Documentation - Current eMAR box for documenting post-pain scores for Scheduled medications has the same blue color as the eMAR box for administering a new dose. Possibly pose danger of double dosing. Plan: Re-educate RNs about the difference between a dosage box and a post-pain documentation box. Advise RNs to take extra caution reading, paying close attention to what the eMAR box indicates. Suggestion to place a "?" for the post-pain box is being looked into.
Charge Nurse Council Charge Nurse Reference Manual: Volunteers are reviewing sections of the current online reference for validity of information. Due date August 2013 meeting. FY13 and FY14 goals: New goals for FY14 were created and a few FY 13 goals were modified. Council members will review FY14 goals for relevance and accuracy. TJC: Group discussed ways that the units are preparing for TJC. A tracer tool was shared to help staff prepare for upcoming TJC visit, which is eminent. Charge Nurse Competency: The council has been working on a charge nurse competency.
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Announcements On-Demand TIGR Patient Education System June Upgrades The new system will have many new futures, including... •Nurses can remotely prescribe and monitor videos from PC desktop •Patients can easily select videos •More videos with population specific video groupings •Safety videos which give a standard TJC supported message! •A Care Channel with 24/7 guided imagery •Hospital channel with resources identified, welcome message from Lisa Rowen, CNO, and an accessible video guide You and your unit staff are key to it's success and ensuring our patients and families are able to benefit from the educational videos, NEW Guided Imagery & relaxation channels, as well as general hospital information such as parking and resources, etc. Make sure to view the online tutorial. August CPPD Courses Critical Care Nursing—20-21, 27-28 Preceptor Bootcamp—9 We Discover—20 Looking Good in Print—21 Charge Nurse Workshop—16 Nursing Grand Rounds—21 Please enroll via Healthstream contact Professionaldevelopment.umm.edu or call 8-6257 for more details.
Restraint Monitoring Process
Nursing Grand Rounds August 21, 2013 2pm—3pm
Changing Health Behaviors: Lessons Learned from Weight Management Presenters: Marcia Cooley, PhD, MS, BSN, RN Tara Kelly, MS, CRNP
A new restraint report for unit specific data will be coming daily to your unit leadership– The audit will be looking specifically for: Compliance with the new requirement to have orders added immediately upon restraint application Confirm that our data collection includes all patients on each unit in restraints All patients who are in restraints must have an updated order in Powerchart every 24 hours. The current process of having the activation of the restraint flowsheet generate an order request to the provider will soon be disabled– it does not allow the timely order entry required for regulatory compliance.
Details coming soon! 8