UMMC Nursing Newsletter by UMMS

March 2013 Volume 2, Issue 3

UMMC Nursing Newsletter Safe Injection Practices... One Needle, One Syringe - Only One Time! One Insulin Pen – Only One Person! Did you know? Over the last decade, syringe reuse and misuse of medication vials have resulted in dozens of outbreaks and a need to notify over 100,000 patients to seek testing for blood borne pathogens such as Hepatitis B, Hepatitis C, and HIV. In a recent CDC survey of 5,000 US healthcare professionals: • 1% “sometimes or always” reuse a syringe on a second patient. • 1% “sometimes” reuse a single dose vial for additional patients after accessing it with a used syringes. • 6% use single-dose or single-use vials for more than one patient. • Insulin pens have been implicated in transmitting infections when used for more that 1 patient– even when a new sterile needle is used. There are multiple reported outbreaks of Hepatitis C traced to Unsafe Injection Practices

Injection Safety Practices from the CDC include: • • • • • • •

Never administer medications from the same syringe to more than one patient– even if the needle is changed. Once a syringe or needle has been used to enter or connect to a patient’s IV, it is contaminated and should not be used on another patient or to enter a medication vial. Never enter a vial with a used needle. Never use medications packaged as single-dose vials for more than one patient. Assign medications packaged as multi-dose vials to a single patient whenever possible. Always use aseptic technique when preparing and administering injections. Insulin pens and other injection equipment are for single patient use— Never “borrow” an insulin pen from one patient for use on another patient.

For more information, please visit: http://www.oneandonlycampaign.org or http://institution.myflexpen.com 1

Clinical Practice Council Updates: Important Practice Announcements Code Blue Management Update Subgroup of CPC and PI Council called the Nursing Code Blue Task Force was created to develop resources for staff in ICU and non-ICU settings to clarify information involving a code situation. Task force will also be charged with an Emergency Management Resource intranet page. Charge Nurses will review a Charge Nurse Code Blue Roll Call Sheet that has been developed. Order Management Sept 2012 Audit Audit found many concerns: wrong “admit to” transfer, level of care orders, duplicate orders, contradicting orders, not applicable orders, incomplete orders, inappropriate for level of care. Barriers that were identified: • It is the “provider’s job.” • No time to perform task, low priority, RNs afraid of being accused of practicing outside of scope • RNs do not want their names associated with changing or deleting orders. Audit results taken to various groups for input. \\\

Remember: Document patient safety concerns via RL6 and 8-SAFE.

Skin Update Reviewed definitions of pressure wounds: • Avoidable pressure wounds – where a breach in the standard of care occurred. • Unavoidable pressure wounds – preventative measures were in place, but unavoidable issues contributed (i.e.: 18-20 hour OR cases). Always look at the Braden or Braden Q risk score as a tool to identify what prevention measures are appropriate for your patient! Pain Update Top pain management performers: 10 East, C5, W6 • A PI group is working to improve all patient’s pain scores. • Consider multi-modal pain management actions rather than just a single modal. • Documenting “asleep” in the post pain score is discouraged . The RN should go back to modify once a pain score is obtained. Barriers to effective pain management and interventions to improve pain management were discussed. Some future interventions include: survey on knowledge and attitude of staff about pain management, educational modules and best practice implementations like multi-modal RTC pain medication administration.

Seclusion and Restraint Assessment/Behavioral Restraints : In electronic format with go live date Policy revisions in progress • EOC-008 Safe Handling of Hazardous of 3/19/2013. Medications Falls Update • ADF-008 Staffing and Scheduling Principles, January audit data: Strategies and Guidelines • 21% of units not conducting any huddles • 100% units have fall tracking board Product Updates: • 78.4% of boards had a post-fall huddle PIV Insertion Kits are available on the units. Not included are J-loop and the IV catheter. Central Line Kit –Found the gloves are too small Bedside Meal Choice Program and easily tear; accidentally went out to some units New software installed that can interface with EMAR. Meal Attendants will be coming to units outside the pilot program. (with their own computer) to assist Infusion Pump Pilot Updates: patients in making menu selections. The program will increase accuracy and Baxter pump pilot completed. provide more food choices for patients as appropriate to their ordered diet. Go live date: 3/24/2013

Late admissions will continue to receive boxed lunches.

Carefusion pilot to begin 1st week of April.

Infection Prevention Update: Instrument Cleaning At UMMC, thousands of invasive procedures involving contact of a patient’s sterile tissue or mucous membranes with a medical device or surgical instrument are performed each year. A major risk of such procedures is the introduction of pathogenic microbes that may lead to infection. Proper cleaning and sterilization or disinfection of the instruments used in these procedures significantly reduced the risk of introducing pathogens via the instruments.

Cleaning? Doesn’t Central Sterile Processing( CSP) do that? CSP does clean instruments; however a very important step of the cleaning process starts on the unit and procedure areas. Cleaning is the initial step almost immediately after the instrument has been used on the unit/ procedure area and before the items are sent to CSP for further cleaning, disinfection or sterilization. The goal of cleaning at or close to the point of use is to reduce the bio-burden, preventing organic encrustation and the amount of post- operative residue on the instruments before the items are transported to (CSP) for disinfection and sterilization. *Enzymatic cleaners are the main cleaning agents used to prevent build up on the instruments. They should be available in the soiled/dirty utility room (or other area designated for this process). At the end of a procedure: • Transport the contaminated instruments to the soiled utility room; • Wear gloves, mask and eye protection; • Spray instruments thoroughly with enzymatic foam spray; and • Return to CSP in a designated container or red biohazard bag as soon as feasible So what does CSP do? CSP continues the cleaning process (mechanical cleaning) and also sterilizes and disinfects instruments. CSP is responsible for providing sterile and disinfected equipment where and when they are required. Disinfection eliminates most harmful microbes. Sterilization destroys all microorganisms- harmful or not. This process inactivates a broad spectrum of micro-organisms. It is important that any instrument that may come into contact with a patient’s sterile tissue is sterile.

How do I know my instruments are sterile? Sterile instruments are usually accompanied by visual indicators that are meant to indicate that adequate sterilization has occurred. 1. 2 cards on the sides of each set will have a brown line if the set is sterile. The brown line will not be present if adequate sterilization has not been achieved. 2. Locks on the instrument boxes will be brown, if sterile, orange, if not sterile. 3. Filter immediately inside the package/ set will have a brown/black dot if sterile and a yellow (hard to see) dot, if not sterile 4. Indicator inside the set will be blue if sterile,and white if not sterile. *If any of one these indicators does not indicate sterility, DO NOT use it. Get a new instrument and assess similarly. Reminders • Spray all instruments with enzymatic foam immediately after use. • Transport all soiled instruments to CSP in approved containers or red biohazard bags. • Inspect all sterile instrument sets for package integrity. Ensure they are not torn, wet or punctured • Check the sterility visual indicators. • Evaluate ALL instruments prior to use for visible residue. Visible residue on instruments, even if the sterilizer indicators were all met, would indicate that adequate cleaning may not have taken place. The instruments should not be used. Please feel free to email us any comments, questions or suggestions to: InfectionControl@umm.edu 3

Governance Council Updates • • •

Nurse Coordinating Council (NCC) Professional Practice Model discussed and approved. Colors will match the C2X pillars and Public Relations will finalize the figure. E-Care presented concepts about telemedicine and plans for the first center in Maryland. Go live date is April 30, 2013 with 75 patients in six different hospitals. The service will expand in the fall to cover UMMS hospitals. Medication override list issues and plan discussed. Ten additional medications were included on the override list but they need approval from P&T. A clinical practice update will go out communicating this change.

March comes in like a LION... •

Nursing Research Council Continue to work in subgroups on workshops and seminars.

•

• •

•

Clinical Education Council Next marathon cycle is Oct/Nov. September trainer education dates are in Healthstream for registration. Content topics: restraints, hazardous med policy changes, blood product transfusion changes. Discussed clogged PICC lines. Changing the MicroClave® and flushing often solves the problem. Change cap every 96 hours with tubing changes. Alteplase should not be administered through the MicroClave®; PICC team encouraging staff to view the on line video from Alteplase. Life Pak 20 being converted to AEDs on acute and outpatient units for independent defibrillation. More information and education to come. CHG solution (4% liquid) or wipes (maroon packaging) are to be used for inpatient pre-op scrubbing. Order is built into the pre-op checklist. Roll-out of plan to be April 1st with education.

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, Greg Raymond, Trisha Fronczek

•

• • •

Patient & Family Education Council On-Demand video system upgraded; update given. Implementation set for late February. New system will automatically allow the TVs to populate with the hospital channel, and offers an introduction and menu of choices to patients. A predetermined list of “preferred” videos selected by the units will be populated and highlighted on TVs in those units. An improved guided imagery/relaxation channel will also be available. Continued to work on their EBP project discussing inclusion and exclusion criteria. Charge Nurse Council Scheduling guidelines were reviewed. Areas to revisit in March are: vacations, managing multiple employees on vacation and FMLA. Discussed with Jeff Jones from HR the SCN Leadership Development Curriculum and its benefits to charge nurse development. Task force of members to create a charge nurse development curriculum.

Meetings Canceled for February Skin Care Committee Groups no longer meeting: GNAC

Congratulations Newly Certified RNs! Chona Rizarri, BSN, RN, PCCN Two PES nurses are now ANCC Psych/Mental Health certified. They are: • Leida Lamas Sheldon, CNII, BSN • Nicole McFarland, CNII, BSN Send your certification news to: certification@umm.edu

Governance Council Updates Staff Nurse Council Group met with planning and marketing representatives to discuss input in the UMMC 5 year plan (2014-2018). Homework given to council members for feedback. • During safety discussion, council discussed patient and worker safety as it relates to disturbances between visitors and patients. Council will invite security to an upcoming meeting to provide anecdotal scenarios and possible responses. • During civility discussion, discussed RN to RN interaction as it relates to social media, inappropriate postings on Facebook that are public and unprofessional, creating a culture of negativity. Council members will discuss broad topic at unit level. • RL6 Solutions task force created to further explore this topic. • Council viewed and gave positive feedback to the new “you&ummc” website created for the on boarding of new nurses.

• • • •

Professional Advancement Council Seven portfolios were accepted for promotion to SCNI in the January submission time frame. There were no portfolios submitted for SCNII. A breakfast celebrating our certified nurses for Certified Nurses’ Day will be held March 20, 2013 from 7am to 10 am in the Weinberg Round Room. All certified nurses are welcome.

Medication Oversight Council Council restructured membership and changed meeting time. Focus is to provide more time for discussion of medication related issues and then detailing the "charge" and the assigned group for issues. Override issues have continued. Thorough review of overrides will need to be completed by each inpatient unit with recommendations sent forth for updates to override report.

Clinical Information Council Updated pre-op checklist (live Feb 19th ) revisions were presented to include the new policy on CHG use preoperatively and on the day of surgery. New Behavioral Restraint From approved after discussion and changes made to terms used. Will have required documentation for nurses to complete when behavioral restraints are applied. Roll-out date and education to follow. Go live scheduled for 3/19/2013. Task force formed to review EBP on keyboard decontamination. Proposal to add additional data requirements for narcotic sign off. Plan to add sedation assessment (RASS or SBS) and respiratory rate as required fields when signing off opioids from the eMAR. IT has concern that change may affect ALL analgesics not just opioids. Follow-up to occur and if implementation to occur, then education would be required of all staff.

• • • •

From the Feb 25 Clinical Practice Update: Diet Order Changes in Powerchart New diet orders are consistent with Academy of Nutrition and Dietetics Nutrition Care Manual, and are evidence-based. Changes were presented to key stakeholders for feedback, and appropriate modifications made. Outdated, redundant and/or consuming diet orders were removed or altered. Note: Please order diets via the drop-down menu; no free text information (diet order comments) can be acted upon.

From the March 3rd Clinical Practice Update: Medication Verification Override In order to support consistent compliance with TJC standard MM.05.05.01, only medications listed in policy MM-009d.pdf will be available for override on 3/19/13. If a medication is required emergently, please call the pharmacy to explain the urgency and request order verification. For a full list of approved override medications, please see http://intra.umm.edu/ummc/policies/ From the March 3rd Clinical Practice Update: Do Not Crush Medications Medications written for a certain route should not be given via an alternate route without the consent of the prescribing physician. Crushing medications and administering via a wrong route can increase the risk of side effects if they were not intended to be crushed.

Always check your MAR icons for additional information.

Always confer with prescribing physician if there is a discrepancy with route of administration.

Announcements Save the Date!!!

6th annual regional trauma symposium: “All in a Day’s Work” Date: Thursday, April 18, 2013 Location: Baltimore Hilton

Patient Safety and NPSG Webinar April 16, 2013

The highlight of this year's conference is the keynote address given by Dr. Gregory Jurkovich, Director of Surgery and Trauma Services at Denver Health Medical Center. His lecture is entitled "Humanism in Medicine."

All in a Day’s Work April 18, 2013 Trends in Nursing Practice Conference May 1, 2013 Nurses Week 2013 May 6-12, 2013

Please visit the Maryland Committee on Trauma's website: www.mdcot.com for registration and additional information.

NDNQI Survey May 6-26, 2013

April CPPD Courses Informative Webinar: • Cardiac Rhythm Interpretation—2, 4 Patient Safety and National Patient Safety Goals • Chemo and Biotherapy (ONS) - 11, 12 • Charge Nurse Workshop—19 Date: April 16, 2013 • Critical Care Nursing— 23-24, 30, 1 Time: 10 am—11:30 am Location: North Hospital (N2E14C) • Looking Good in Print: How to Develop Your CV & Portfolio—17 Register today via Healthstream • Managing Challenging Situation thru Crisis (Space is limited) De-escalation—27 For questions, contact : • Managing Diabetes Bedside RNs—10 professionaldevelopment@umm.edu • Moderate Sedation Sim Lab—25 • Mastering CRRT—29 • Preceptor Boot Camp—12 • We Discover Series—16 • OCN Exam Review Course—2 Please enroll via Healthstream or contact CPPD @ 8-6257 for more details

Nursing Grand Rounds “Drug Diversion: Rumors, Truths and Realities” Wednesday, April 17, 2-3 PM UMMC Auditorium Have you ever wondered... “How can I recognize if a colleague is diverting drugs?” “What happens when a staff member is accused of drug diversion?“ “How can I ensure that my practice does not raise suspicions of drug diversion?”

These are questions you may have asked and been unclear on what is rumor, truth or reality. Come find out at this Nursing Grand Rounds where we will explore these and other questions surrounding this important healthcare issue. 7