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JUNE/JULY 2013 | VOLUME 2, ISSUE 6

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 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 appro-

priate

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!

Mock Joint Commission Survey... How did we do?

1 Min Dwell Time 5 Min for C Diff

Respond to all Door Alarms

in Secure Areas!

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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

What’s New @ UMMC?

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 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!

NEW!

There will be a series of meetings to review our current work-

flow 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 utiliz-

ing the new pumps—many things will look familiar.

SUPER USER TRAINING

will occur in early September

Stay tuned to your email for more information!

We Need You!

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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 sit-

uation. 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..

*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!

NOT intended

to become

part of patient’s

permanent

Medical Record

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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

Congratulations

Newly Certified RNs!

Christine Provance, MS, RN, CCNS

Send your certification news to: certification@umm.edu

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 competen-

cies with expected July 1, 2013 rollout for inpatient area, and population specific plans will be created later.

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 add-

ed to learning for RN and PCT staff.

CAUTI handout with recommendations from HRET

distributed.

Hazardous medication policy changes discussed,

Patient & Family Education Council TIGR On-Demand video system upgrade implementa-

tion 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 house-

keeping, 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

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 Proce-

dure. This includes requirement that external present-

ers practice their oral talks with Director of Nursing

Research in advance.

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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 terminolo-

gy, documentation of Cause of Death in PowerChart – 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

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.

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.

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

Restraint Monitoring Process

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!