JCAHO to visit Point of Care Dept.

Can we really be lucky enough to get two visits from The Joint Commission in a year? Yes, we are that lucky. Here's what you can do to prepare for their survey:

• Make sure you are up-to-date with your competency.
• Check testing materials (like control solutions, reagents, strips, etc.) for dates. All opened materials should have a "date opened" written on it, as well as an expiration date. Discard anything that is expired or opened without a date.
  
• Make sure all testing supplies are in the appropriate storage locations.
• Know where you can access Point of Care testing policies and procedures. Most of them are on Meditech. Some testing devices will have a small notebook stored with them.
  

If you have any questions, please contact Pam P. @ ext. 2475.

Post-op PPM changes

There is a change to the post-op pacemaker order sets. An antibiotic is to be administered immediately post-op when the patient leaves the cath lab. Where ever the patient goes after being cathed (CVC, 3W, ICU, etc.), the receiving nurse must give the antibiotic upon arrival and q 8 hrs. Antibiotics are not to be given beyond 24 hrs after surgery end-time. Pharmacy will time the administration of antibiotic on the MAR based on the surgery end-time. Questions can be directed to Tom O. @ ext. 5296.

Influenza Season Information

Employee Health will be offering three rounds of influenza vaccines this year: the seasonal flu vaccine, and two H1N1 vaccines.

Seasonal flu vaccinations will begin early this year. You will be receiving a schedule with this coming week's pay stub. The first day of clinics will be Tuesday 9/8/09 and will run until Wednesday 9/24, with evening clinic offered on Sunday 9/27/09. Seasonal flu shots will also be offered in clinical areas the week of 9/7. Be on the look-out for when and where these will be offered.

H1N1 vaccine consists of two injections, given 21 days apart. The hospital has not received these yet, and expects delivery of the vaccine in mid-October at the earliest. The hospital will be following CDC guidelines as to who can be vaccinated first.

Any employee who doesn't receive their seasonal flu shot by November 30, 2009 will be assigned an influenza education session and declination survey on Performance Manager. All employees who obtain the seasonal flu vaccine before October 31 will be entered in a raffle for one of two $300 Visa gift cards. 50 wellness points are also available.

Wound Care RN hours

Wound Care RN hours while Julie is on maternity leave until October are as follows:

Monday 8am-4pm, pager will be carried by Cris
Tuesday, Wed., Thurs, Fri, 2pm-10:30pm, the flow nurses Betsy and Laura will take messages from the Would Care voice mail and see patients for wound care consults. They can also be reached on their pagers.

Pneumococcal and Flu Vaccines for pts

Effective July 13, there is a new procedure for administering Flu and Pneumococcal vaccines.

• On the back of the Home Medication Reconciliation Form (I've also seen it as a form on it's own), you will find a Pneumovax/Flu assessment and consent form. Pneumovax is given year round, and seasonal flu vaccines are given Oct. thru Mar. only. If the patient has been immunized for both, then ignore this form.
• The nurse or pharmacist may assess the patient and order the vaccine(s) without the physician writing a specific order.
• Give the patient the vaccine information sheet for Pneumococcal PPSV23 or Influenza. Obtain their consent signature on the vaccine assessment form. Scan the order to pharmacy. The pneumococcal vaccine will be stored in the Pyxis refrigerator. I'm not sure about the influenza vaccine.
• Document the administration of the vaccine on the one-time order sheet, as well as on the front of the Home Medication Reconciliation form.
  

Insulin sliding scales

The hospital has stopped using the "SSICU" tight glycemic control sliding scale per the recommendations of the American Diabetes Association. We will now only use the sliding scale with a BS goal of 70-180 (correctional insulin starts at 150).

Nutrition Care Manual

Did you know that we have a great dietary information resource, right on the computers? Click on the "BCH Web Applications" icon on any unit computer. In the list of applications, you will find the "Nutrition Care Manual". It has information about the diets and how they relate to disease processes. You can navigate the manual via tabs at the top, or by searching.

The hospital and surrounding clinics have 2 subscriptions to this manual. If you find yourself "locked out", it may be due to too many people trying to access it at once. Just try again in a few minutes.

Communication with Pharmacy

Pharmacy is asking the nursing staff to help with the number of orders scanned at certain times of the day - around lunch and evening shift change (1900). They are getting disproportionate amounts of orders scanned at these times. Of course, this directly correlates to when the physicians are writing the said orders. They would like us to help out by scanning orders as quickly as possible after they are written, instead of letting the chart sit on the "to do" rack and waiting for the UC to take the orders off.

Pharmacy is also getting a high number of phone calls to check on the status of meds. They would rather that we save the phone calls for emergent or stat needs. Instead of using the phone, they are asking us to write a message on a paper and scan it like you would an order. This way it comes up on their Pyxis cue and can be addressed.

Wound Care RN coverage

Julie, one of our wound care nurses is out on maternity leave until sometime in October. In the meantime, Cris RN will be doing wound care rounds on Mondays. Tuesdays through Fridays, the flow nurses Betsy and Laura will be taking messages for wound care. This means that they may be at the Foothills campus some evenings. During those times, they will not be able to do admissions on Broadway. You can still page the flow nurses during normal hours; they will call you back to let you know if they are on campus.

Clinical Round-Robin, Hands-on Practice

Sorry for the late notice on this one!

(Tomorrow) July 23
7a-3p
Foothills Leo Hill Conference Center

Topics:

• Mediport Access Skills
• New Central Line dressing change kit
• Drawing blood cultures
• Stat Lock practice
• PCEA pumps
• Feeding tube tips, preventing clogs
• Diabetes boxes, Glucometer practice

A series of clinical "round robins" will be held monthly. This is a great chance to update your competencies. Look for future schedules here, Mox/email, and on the unit.

New Universal Protocol Policies

Universal Protocol = Verification of correct patient/site/side, etc.

New policies for Universal Protocol can be found on Meditech. This policy applies to invasive procedures (central line placement, biopsies, chest tubes, etc) or any time procedural sedation is used. Site marking is done by the physician on any procedure where laterality is involved and should be done while the patient is not sedated.

Joint Commission Survey Underway

The Joint Commission Survey began this morning. Please take this opportunity to review your Joint Commission Pocket Guide. The unit is looking great right now, please pitch in where you can to keep it that way.

Don't forget: Pump In, Pump Out!

TJC (JCAHO) expected soon!

The hospital is expecting surveyors from The Joint Commission starting Monday, June 22 or the following week of June 29. The unit is looking "survey ready", so please do your part to keep it in tip-top shape. Now would also be a good time to review your red booklets.

N95 mask fittings/PPD walk-in clinics

Don't forget that having your mask fit test and PPD completed in a timely manner is part of your job requirements. If you're due or past-due for these tests, you can come to one of these clinics without an appointment:

Monday, June 22
Foothills Chairman's Room
12-1:30 pm

Wednesday, June 24
Alcove outside Gene Wilson
12:30-2:30 pm

Diabetes Teaching Supply Kit

Beginning Monday, June 22, all nursing units will be stocked with a "ready to go" Diabetes Supply Boxes. Wahoo! Inside each box, you will find tote bags filled with items that your may need for education.

The contents are available in English and Spanish, and they will include:

• Educational video
• Comprehensive diabetes reference guide
• Meal planning guide and carb counter
• Pedometer
• Glucometer and instructions
• Schedule of support groups and meetings

Patients may take these tote bags and their contents home. They are free of charge for patients who begin their diabetes education with us. The boxes are restocked by the flow nurses.

If you have any questions, please contact Emily W. @ ext. 2379.

O2 tanks

Storage for oxygen cylinders is in the respiratory closet. If you have an O2 tank that is low or empty and needs replacement, purchasing will only switch it out if the tank is in the storage area. Tanks that are in wheeled carriers in the hallways and patient rooms will not be switched out because purchasing considers them "in use".

Patient belongings

Patient belongings should be charted and described specifically upon admission. For instance, instead of simply documenting "clothes", write "blue jeans", "wool sweater", "fur coat", etc. Do the same with jewelery, but you need to be general with this as we cannot determine what is a diamond or 14 karat gold. An example would be "ring with white stone", "gold pendant necklace", etc. Specific documentation can protect the hospital from litigation if a patient claims that the hospital misplaced their fur coat. If you have any questions, please see Peggy.

Assignments with 4-5 pts in a shift

If you are assigned to 4-5 pts for a shift, write your name and date on a sheet found in the purple binder (you know, the "old schedule" binder). You will find this sheet behind the LOL list.

Guidelines for H1N1 flu

The CO Dept. of Health has issued updated guidelines for caring for pts with suspected or confirmed H1N1 flu.

These pts can be placed in Droplet Precautions (not negative pressure room) with the use of standard precautions UNLESS a procedure is being done that would cause secretions to be aerosolized (intubation, bronchoscopy, nebulizer treatments). If aerosolization may occur, staff should wear the N95 mask.

3W MDRO Precautions

As stated in an earlier post, 3W will be implementing formal isolation procedures for our pts with infections requiring protective isolation. May 18th is the day that these procedures will become official, so now is a good time to familiarize yourself with what you need to do.

• Isolation carts: The contents of the carts have all been standardized. A contents list is secured to the top of all carts. In the list you will find the ordering number for each item, should you need to replenish the stock. The staff discharging the pt is responsible for restocking the cart.
• Nurse servers: These must be closed and secured with "caution" tape whenever a pt is placed in isolation. Two old IV trays have been converted to stock items that are normally found in the nurse server. These supplies are additionally bagged in biohazard bags. Only bring into the room whatever supplies you actually need. Remember that everything that comes out of the room must be cleaned or disposed.
• Linen bags: You may still use these as usual. Clean linen should only be brought into the room on an as-needed basis.
• Room equipment: If a piece of equipment is not needed, remove it from the room before the pt arrives. Equipment that can be removed from the room (such as IV poles) will be tagged with the "Clean/In Use" tag. Items that stay in the room are not tagged. The person removing the equipment from the room is the one responsible for cleaning it. Keep walkers in the room until discharge; when they are no longer needed, clean them and store in the PT office. O2 tanks will be tagged; clean appropriately when removing from an isolation room. Equipment that is tagged and can be removed from the room will stay with the pt for their entire hospitalization.
• Tergo wipes: Keep an eye on these. If you find any with mold growing on them, place them in a garbage bag and place outside of Melissa's office. We should be checking the bin of Tergo wipes once a week or so to monitor for mold. Alert Melissa if you have any issues.

Please contact Melissa if you have any questions. More information will be coming soon!

Showers for OHS pts

Per Peggy, OT is not required to do the first shower with our open heart pts. It is a good opportunity for the primary RN to assess the pt and begin teaching. RNs should check to make sure that all dressings are removed, PICCS/peripheral IVs are covered, and pacer wires are insulated before the shower. Any moisture at invasive sites promotes to growth of bacteria. Peggy is working on a new post-chest tube-removal dressing that would allow the patient to shower the same day as chest tub-removal. For now, pts must wait 24 hours after the tubes are removed before showering.

Need a good laugh?

Check out this "educational" video about AV node blocks..thanks to Michelle Mo for the link!

Isolation Precautions

Melissa has posted educational posters about our 3 West Isolation Precautions/Procedures in the education room and the staff restroom. Here's what you need to know!

• Proper Identification of the Pt: Do they have a hx of MRSA/VRE? Is there Gram + cocci (GPCs) in clusters reported from the lab? Notify Infection Prevention @ ext. 2336 when pt identified.
• Proper Room Set Up: Equipment tag In Use, tape the nurse server closed (but use the linen bag as usual). Make sure there is disposable equipment in the room such as a thermometer, stethoscope, and BP cuff.
• Proper Education: Provide pt, family, and visitors with written information (found in Meditech under policies -> infection prevention, available in English and Spanish). Remind other staff (transporters, PT, OT, RT, etc.) as needed. Remind physicians of standards if you notice them not adhering to them (like taking the chart in the room).
• Proper Attire: Use shoe covers as needed. Make sure the isolation cart is well-stocked. Use MAR paper covers.
• Proper Discharge Procedure: Dispose of everything, strip bed linens, leave isolation signs on the door for EVS. Restock the isolation cart for the next pt.
• For all equipment like Dash monitors, walkers, O2 tanks, etc., clean with Tergo wipes (or spray/blue microfiber cloths for C. diff) between pt use.
  

Melissa is putting together a "tool box" to place on the nurse server for things that are usually accessed in the nurse server drawers. It will be minimally stocked with the basics like alcohol wipes and tele stickers, since most things will need to be disposed at discharge.

Infection Prevention Reminders

The flu in the news is a good reason to remember the basics when it comes to infection prevention.

• Wash your hands, wash your hands, wash your hands. It's the #1 way to prevent the spread of communicable disease.
  
• Cover your cough. All patients who have an active cough or upper respiratory symptoms must wear a surgical mask. The patient must also perform hand hygiene each time they sneeze or blow their nose.

The Infection Prevention department is keeping abreast on the developments with the H1N1 flu. If you have any questions or concerns, feel free to contact Beth @ ext. 2229 or Leslee @ ext. 2336.

Evaluations

As you may remember from a staff meeting a while back, the SQR (Service Quality Review) is being replaced by the SEE (Service Excellence Evaluation). The gist is that your annual performance evaluation looks at how well you meet your personal goals and how you contribute to organizational goals. This in turn is tied to whether or not you receive an annual pay increase (or if you happen to be at the top of your pay grade, you receive a topout bonus).

The SEE can be completed on Performance Manager, just like the current SQR set-up. After June 1, all evaluations will use the SEE tool. After October 31st of this year, all employees will be evaluated from that date until January 31, 2010.

Annual salary increases will continue as scheduled up until October 31, 2009. All increases after that date will be moved to January 31, 2010 and will be prorated accordingly. Everyone who is eligible for a topout bonus (employees at the top of their pay grade) will receive their bonus around February 19, 2010. Employees who receive a written reprimand or letter of final warning between 6/1/09 and 1/31/10, or do not meet Encore values will not be eligible for a pay increase or bonus.

Job Requirements

As of July 1, 2009, you must keep up to date on the following or you will not be allowed to work:

• On Performance Manager: Fire Safety, Hazardous Materials, Emergency Preparedness, Hand Hygiene, Bloodborne Pathogens, Understanding TB, and Infection Control.
• Employee Health: Documentation of immunity to measles/mumps/rubella, PPD & N95 mask fit test, proof of immunity to Hep B (or sign waiver declining vaccine).

These requirements must be fulfilled by June 30, 2009 or you cannot work. You will be sent a letter 90 days before the due date reminding you if you are due for employee health requirements. Directors will get a list of those not in compliance on a monthly basis.

To schedule an appointment with Employee Health, call ext. 2108. If you have questions about Performance Manager, talk to Kate in HR @ ext. 2426. Don't forget, there is a link to Performance Manager on the lower right hand side of the blog!

Campaign to Improve Blood Transfusion Outcomes

BCH is looking to improve outcomes in patients undergoing blood transfusion. We know there are risks involved, but what do we really know?

• 1 or 2 of every 100 blood transfusions result in some form of transfusion reaction
• The chances of acquiring an infection increases by 50% with each unit of allogenic blood transfused
• 1 in 350 transfusions is associated with transfusion-related circulatory overload (TACO), which can lead to respiratory problems, HTN, and lung disease.
• 300-500 deaths occur each year from transfusion-related acute lung injury (TRALI).

The Blood Utilization Steering Committee is devising ways we can all work together to update our practices in blood transfusion. Look in the Scoop and here on the blog as more information is available.

Swine Flu public info sources

• Centers for Disease Control: www.cdc.gov/swineflu - This is a great resource, with pretty much everything you'd ever want to know. You can sign up for email updates through the CDC here.
• Boulder County Public Health: http://www.bouldercounty.org/health
• Colorado Dept. of Public Health: http://www.cdphe.state.co.us/

Click on the green box on the lower right hand side of the blog to link to the Dept. of HHS and CDC. More information will be posted that is specific to BCH when it becomes available.

Are you current on your N95 mask fit test? Call Employee Health to get your fit test completed.

Legalities in Documentation Class

If you were unable to make it for this class, Emily (the nursing education coordinator) is compiling the notes so that you can take a look at them.

Reminders

• We cannot secure O2 tanks to IV poles with tape. There are several IV poles with holders for O2 floating around the unit. Come to Melissa if you have questions about this.
  
• Don't forget to chart your pt's BMs. 'Nuff said about that...
• If you need to administer a medication that requires rotation of sites, please document the site the med was given.
  
• Check the alarm limits on your pt's tele monitor. This can be dangerous if not set properly. For example, a pt was in SR, but went into afib and the alarm never sounded when the HR was 165. It was soon discovered that someone on a previous shift had changed the HR alarm limit to 180!
  

When In Doubt, Throw It Out

Pharmacy has made a change in regards to injectable narcotics. Meds that are placed in the Pyxis return bin will be taken to pharmacy and destroyed. This will decrease the likelihood that pt could receive a tampered medication. Keep this is mind and try to make sure your pt really wants the med before you take it out of the Pyxis (save $ wherever we can).

Varicella Titers

Employee Health is sending out memos for everyone to provide proof of immunity to varicella. Please wait to receive this memo before you have a blood titer drawn. The lab requisition must accompany the blood specimen in order for it to be processed correctly.

Programs for cheap meds

I recently read this article about people who are forced to skip doses or split their meds because they cannot afford the medication. Med compliance is so important, especially for our HF patients. If you have someone that might need help with the costs of meds, here a few internet sources:

• Patient Assistance Programs - www.rxhope.com
• NeedyMeds - www.needymeds.org
• Patient Assistance Programs - www.patientassistance.com
• Patient Advocate Foundation - www.patientadvocate.org
• Partnership for Prescription Assistance - www.pparx.org

On the side bar on the lower right hand side of the blog, I have a list of links to the low-cost programs from Wal-Mart, Walgreens, Target, and Costco.

New Meals On Wheels program for hospital patients

Meals on Wheels of Boulder is offering a new service for recently discharged patients from hospitals and rehab facilities. They can deliver one hot meal per day for five days, prepared for any dietary restriction. There is no restriction on income to take advantage of this service. For more information, go to www.mowboulder.com.

Skills Lab next week!

Don't forget, Skills lab will be held next Tuesday and Thursday!

STAT team

A couple of changes have been made with regards to utilization of the STAT team. The option for a phone consultation with a STAT team member instead of a bedside assessment is no longer available. The STAT team activation will remain a team approach and response.

For emergent and urgent transfers to the ICU, activation of the STAT team is highly encouraged. This is not to second-guess the abilities of the nurse or physician involved with the patient, it is to promote the smoothest hand-off possible between care providers. During these emergent transfers, hand-off communication is often poor, the receiving unit is not prepared, and patient transportation is not as safe as possible. With STAT team involvement, the following can occur: a face-to-face hand-off, assessment of any tests needed during transport (to cut down on "road trips" after ICU arrival), a nurse-escorted transfer, monitoring during transport, additional support if the situation turns into a Code Blue, and time for the receiving nurse to set up for the patient.

When transferring a patient to the ICU, don't forget to fill out a hand-off form. Of course this may be the last thing on your mind when trying to stabilize your patient, but it may be competed after the transfer. This form allows a back-up just in case any information is lost in the transfer.

If you have any questions, please direct them to Holly P. (director of ICU/ED), or Tracy N. (manager of ICU).

Meditech upgrade begins this October, Mox exits in July

As you may have read in The Scoop, our Meditech software will begin the first phase of upgrade October 1, 2009. The project has been dubbed NORMA, which stands for No One Runs Meditech Alone. The goal is to achieve a fully electronic medical record. The project is slated to take 5 years total. The federal government is requiring hospitals to have fully electronic medical records by 2014.

In other technology news, we will bid farewell to the Mox mail system this summer (approximately July). The Mox email system will be replaced by Microsoft Outlook 2007. All persons with an "@bch.org" email address will automatically be converted to Outlook so that the hospital will only be using one email method. With Outlook, you will have a global directory of hospital email addresses to select and send emails to (which is much easier than the current system). Outlook will also provide a calendar which will help you keep track of meetings or other important events. The calendar will also allow you to see who is busy and who is free.

Policies in Mox will be moved to an online Internet portal system called SharePoint. SharePoint will keep track of the changes in policies and alert you when changes are made. SharePoint promises to be more user-friendly when searching for policies. SharePoint will be the central location to view important announcements and access the latest edition of The Scoop.

In the meantime, you are encouraged to clean out your Mox inbox and delete whatever files you do not want. This will make the transition from Mox to Outlook much easier and less time-consuming.

Key dates:

• July 2009 - Mox replaced by MS Outlook, Mox Policies replaced by SharePoint.
• October 2009 - Meditech MAGIC, Client/Server functionality will be replaced. This includes Admissions, Lab, Pharmacy, Imaging, Order Entry, Billing, Materials Management, and everything else that works off Meditech today.
• 2010 - OR will replace their current system, PICIS, with new online clinical documentation.
• 2011 - Online Nursing documentation and medication dispensing.
• 2012 - Physician order management and clinical documentation.

More information and training will be coming up in the months ahead.

Looking for Something?

Do you remember seeing something on the blog, but aren't quite sure how to find it? Here are a couple of ways to find what you need:

• At the very top of this page is a navy blue bar. In the left-hand side of the bar, you will notice a white box, followed by a button that says "search blog". You can type in a phrase into the white box, then click "search blog". Matches to your phrase will appear.
  
• For an even easier way to find what you need, you can use the index method. Scroll down the blog page, and on the right-hand side, you will see a section titled "Subjects and Labels". I have indexed all of the postings under their appropriate label. Say you are looking for a class...click on "nursing education", and all of the class details will be shown. If you are looking for details on an upcoming meeting, click on "meetings".
  
• For classes and meetings, I will post the details about when/where/registration in a regular blog post. The date/time/place only will be posted in the side bar, in order to save space. Use the index method I explained above to search for a class.

If there is something you would like to see on the blog, please send me an email: BCH3Westblogger@gmail.com

Class Offering: Basic/Intermediate EKG

Dates: May 14th (0900-1700) in HBB, and May 15th (0900-1400) in GWA. Another session will be held September 3rd & 4th.

Cost: Free for class, $25 for workbook. You cannot clock in for this class.

Focus: Beginners, those who are "rusty" with their rhythms. 35 rhythms are covered, as well as their causes and treatment. You can attend both days of the class; those taking this class as a "refresher" can attend both days or just the second day.

Registration: Call Cardiopulmonary @ ext. 2095. If you register, but are unable to attend, please call to cancel your spot so that others can sign up.

Questions: Mox Curtis Stringer (who is teaching this class)

Class offering: Care of the Patient with Acute Coronary Syndrome

Care of the Patient with ACS will be offered on Tuesday, April 28th from 0900-1500 in the BCH conference center. Sign up through Vicki C. @ ext. 2074.

NANDA Nursing Diagnosis

Click here for a link to a list of 2007-2008 NANDA-Approved Nursing Diagnoses.

TRALI - What you need to know!

What is TRALI? It is an acronym for Transfusion-related Acute Lung Injury. If you haven't heard much about it, you will soon! Peggy has more education about it in the pipeline. In the meantime...an introduction:

"TRALI should be suspected in all cases of dyspnea and hypoxia temporally related to blood transfusion. Dyspnea due to bronchospasm associated with allergic/anaphylactic reactions can be readily identified based on the accompanying urticarial rash. Dyspnea associated with pulmonary edema after transfusion may result from TRALI or from transfusion-associated circulatory overload (TACO). Differentiation between TACO and TRALI is important from patient treatment and blood donor management perspectives. Recently an algorithm was developed to help eliminate clinicians and researchers in managing patients with respiratory symptoms associated with blood transfusion. Hydrostatic (TACO) and permeability (TRALI) pulmonary edema may coexist. Hence, evaluation by a critical care specialist may be necessary."

Reference: Blood Bulletin, July 2006. Volume 8, No. 2

OHS Audit Tool

We have a new OHS audit tool that needs to be filled out. There is a now section that we need to fill out PRE-op. Any questions can be directed to Melissa.

RN Recognition

Don't forget...RN recognition packets are due this Tuesday, March 31!

Class Offering - Documentation and Legal Issues

"Thorough Documentation: The Best Evidence of Care"

April 8, 11:30 am to 1 pm

Gene Wilson

BCH will hosting a speaker who is an expert at legal issues in nursing documentation. This class will provide nurses with an overview of legal implications of documentation and practice. Our speaker will help you identify "pitfalls" in documentation and practice, list four elements that establish professional negligence, and discuss liability issues in practice and documentation.

Any questions can be directed to Emily W. at ext. 2379.

New PCEA pumps coming!

Broadway will be receiving new PCEA pumps soon that are already in use at the Foothills campus. They are touted as "more user friendly" than the current pumps. Training sessions will be held to allow you to familiarize yourself with the new equipment:

• Monday, April 13, 7-11 am in Gene Wilson B
• Wednesday, April 15th, 2-6 pm in Homer Ball

If you are interested in or designated to be a "super-user", the training session for that will be Monday, April 17, 8-10 am in Gene Wilson A.

Contact Emily W (Nursing Education Coordinator) at ext. 2379 if you have any questions.

Diabetes Education Classes for Pts

Starting in April, BCH will hold a bi-weekly Diabetes update class. These classes are informal, taught by a Certified Diabetes Educator. They are open to patients, families, and healthcare providers. Registration is not required and you may attend as many classes as you want. The classes will be held throughout the year on the 2nd and 4th Mondays of each month. The upcoming schedule is as follows:

• April 13th and 27th, 1-4 pm in Homer Ball
• May 11th and 18th, 1-4 pm in Homer Ball
• June 8th, 4-8 pm in Gene Wilson A
• June 22nd, 1-4 pm in Homer Ball
• July 13th, 4-8 pm in Gene Wilson A
• July 27th, 1-4 pm in Homer Ball
• August 10th, 4-8 pm in Gene Wilson A
• August 24th, 1-4 pm in Homer Ball

Fall and winter classes will be held the 2nd and 4th Monday per month at the Broadway campus. Please encourage your patients to attend these classes. If you have any questions, please Mox or call the Nursing Education Coordinator, Emily W., at ext. 2379.

From Infection Prevention Land...

If a pt is placed in Clostridium difficile precautions due to a positive C. diff toxin assay (different from a C. diff culture), they will remain in precautions for the remainder of their stay. A patient can only be removed from precautions during their stay if they have a negative C. diff culture. The catch? The C. diff cultures are not done in-house, they are sent to the lab at Mayo Clinic and usually take about 7 days. We cannot use a negative C. diff toxin assay to remove someone from precautions.

C. diff yucky equipment and other stuff is cleaned with the blue microfiber cloths and Sanimaster spray. The blue microfiber cloth literally picks up the C. diff spores (can you say "shamwow!"?) Use Tergo wipes for non-C. diff cleaning. Speaking of Tergo wipes...did you know that there have been a few instances in which mold was seen growing under the lid? Ew. We can prevent this by rinsing out the canister (after it has expired) with water and drying it with a blue microfiber cloth. Then refill as usual. Don't forget to write the expiration date...90 days from the fill date. Beth can answer your questions about any of this at ext. 2339.

Policy Update: Reporting Critical Labs and Tests

• When notified of a critical lab or test, record it in the pt record. Record the date and time info was received, and read back the information to verify.
• Report this information immediately to the pt's primary RN.
• RN must notify MD in a timely manner as dictated by nursing judgment, but within 2 hrs. Do not leave the critical value on an answering machine or give to the answering service. It is OK to relay the critical value to office staff. Ask the person receiving the result to "read back" the result to ensure that it was heard correctly. Document the date, time, and the name of the person the message was given to. A call back from the MD is expected within 30 min.
• For EKGs, MD is to be notified stat if the machine reading says AMI, VF, or VT. (Did I really just write that? You can thank Captain Obvious for this one.)
• Critical diagnostic imaging results will be communicated from radiologist to MD. Exams ordered stat will be called right away, those ordered with "call report" will be called within 2 hrs. If you are concerned about a critical result when a test is ordered in Meditech, be sure to enter "notify physician of results" in the comments section.

Reference: Guideline: Reporting of Critical Test & Results, # 2.120

Policy Update: Med Reconciliation

This is a really good policy to review in light of TJC's upcoming visit. Here are the key points...

• Med Rec happens upon admission, transfer to another level of care (including surgery), at discharge, and before outpatient procedures. Form 17 must be used when transferring levels of care and at discharge.
  
• Upon admission, the RN, pharmacist, mid-level provider, or physician will complete the Home Medication Admission Orders form. Consult the pt's PCP, home pharmacy, and/or family in order to obtain the most accurate list. Fill out the form completely, including immunization history, allergies, herbals/supplements, etc. Any discrepencies must be clarified. This whole process must be completed within 24 hrs of admission.
  
• If additional medication history becomes available after the form has been scanned to pharmacy, the med history may be updated by completing an additional Home Medication Admission Orders form. The MD still need to complete and sign the additional form.
• Herbal medications and supplements can be ordered on the Physician Orders form. Since BCH does not supply herbals, pts must bring the ones ordered by the MD from home. The herbals must be then given to pharmacy for identification. The pt would then be allowed to take them per Patient Own Med policy.
• When a pt is transferred to surgery, all previous orders are cancelled. New orders must be written post-op.
• Upon discharge, the home medication list must be reviewed with the Form 17 for DC.

Reference: Medication Reconciliation, # 2.122

Policy Update: Med Admin Unanticpated Events

This isn't really anything new, but it was reviewed this past January. Here are the highlights, please refer to the policy for full text.

An unanticipated event is considered a medication error or adverse drug event (reaction).

A med error is defined as:

• A med given that was not ordered
• Wrong dose or extra dose given
• Omission of a dose without a reasonable explanation documented on MAR
• Drug given in wrong form, wrong route, or wrong patient
• Drug given at wrong time. Exceptions for surgery or procedures must be documented. A 2 hour window is OK for most standard meds. Antibiotics need to be given within 30 minutes of scheduled time.
  
• Any circumstance that pharmacy and nursing believe is a med error.

An adverse drug event is an undesirable or unexpected result from a drug that requires discontinuation of the drug, modification of a dose, prolonged hospitalization, or providing supportive treatment.

If one of the above occurs, notify charge nurse and attending MD. Also notify for medication refusals by the patient.

Document:

• Acutal drug, dose, route, etc. of drug given in error on the MAR.
• When a drug is not given (and why) or refused.
• In the patient record - the event, the outcome, and who was notified.
  
• File an Occurrence Report, but do not chart that an Occurrence Report was filed.
  

Policy Update: Post-Cardiac Cath care

This policy was reviewed this past January, and while it looks pretty much the same, I thought it might be good just to put remind us what needs to be done.

Monitoring:

• Catheter site: continuously for 5 minutes post transfer. VS q 15 min x 4, q 30 min x 2, q 1 hr x 2, then q 4 hrs. Check catheter site with VS. Don't forget to document this :).
  

Pt Education:

• Remain on bedrest per MD order.
• Intake fluids PO or IV (or both)
• Hold pressure on groin when: coughing or sneezing, raising head off of bed, while shifting hips in bed.
• DC instructions: Procedural sedation, groin management, management of complications that may arise, med reconciliation, physician follow-up.

DC criteria:

• VS stable
• Catheter site stable, no signs of bleeding or hematoma
• Pedal pulses are at pre-procedure state
• Pt meets DC criteria for procedural sedation (policy #13.016)
• Pt ambulatory has returned to pre-procedure status

Reference: Cardiac Catheterization: Post-Procedure # 7.013

Policy Update: Medication Order Management

The highlights...please refer to the policy on Meditech for full text.

Medication orders must include:

• Date and time order was written
• Drug name, dosage, unit of measure, route of administration, and frequency
• PRN orders must have a clearly stated indication. Multiple therapies for the same indication are not accepted.
  
• Range orders must contain only one set of range limits (replaces policy for Range Orders Standard #13.026).

Order must be clarified if:

• The order is incomplete, unusual, illegible, or unclear (includes look alike/sound alike)
• Contrary to current prescriptive recommendations
• Contraindicated for the pt's condition
• At risk for drug interactions

When transferring level of care:

• Form #17 required for transfer to different level of care, or after surgery.
• The sending unit must take off all transfer orders.
• NOT ACCEPTABLE: "resume all meds" or any other blanket orders.

Telephone and Verbal orders:

• Verbal orders are only acceptable when the prescriber is not physically present
• Orders must be read back for verification
• Document: Physician's name, name of person relaying the order, and date/time. Use acceptable abbreviations.
• Orders are signed off once they are transcribed
• Verbal and telephone orders will be flagged at the time of transcription to signal the MD to sign the order.

Taking off orders:

• Orders can be signed off by an RN or UC. You must "bracket" the order from top to bottom, then sign and time/date.
• When double-checking orders that have been transcribed by a UC, the RN must bracket them and include a date, time, and signature.

Please reference the policy for a list of who is allowed to take a verbal order (in addition to RNs). Use the rule of thumb: If it is outside the scope of practice to administer the medication, it is outside the scope to take a verbal/telephone medication order.

Reference: Medication: Order Management, Standard #13.029

Policy Update: Med Administration

The highlights only...please refer to the policy on Meditech for the full text. You'll notice a few changes to the policy, so please be aware of this!

• Know the pt's identifying information. Know allergies, weight/height, lab values, current medications, diagnoses/co-morbidities, ability to swallow.
• Know what the drug does, normal doses, side effects/adverse reactions, interactions, effects on lab values.
• You may refuse to administer any drug that: you deem inappropriate for the pt's condition, is outside the scope of nursing practice, or the setting is inappropriate.

Procedure for giving meds:

• Rights: patient, medication, does, time, route, documentation (date, time, signature), allergies, refusal, education given.
• Medications for only one patient are removed from the Pyxis, prepared, and administered at a time.
• Verified medications are transferred to the pt's room in the original package, or if prepared, the med name is labeled on the container (e.g. meds in a syringe or cup must be labeled). Transport of meds to pt's room must be secure, not carried in pockets.
  
• Bring MAR to bedside, verify pt's armband with indentifying information on MAR. Use 2 identifiers for verification.
• Observe the pt swallowing oral medications. If giving med by IVP, stay with pt while med is infusing (don't put it on the IV pump and leave).
• Monitor pt's response. If unexpected response, refer to new policy: Medication Administration Unanticipated Evens #13.003.
• Document medication administration on MAR.
  
• Education must be given to pt and/or family before initiating new medications. Include: name of med, expected action, possible side effects/interactions, danger signs to report, schedule of administration, and to question anything that isn't familiar or hasn't been explained completely.

Medication Initiation Times:

• Now and Stat orders - within 30 minutes
• ASAP - within 1 hr
• Initial doses of IV meds take priority over other treatments and medications, and are given ASAP after any ordered cultures are done.
• For severe sepsis, septic shock, or pneumonia, antibiotics are given within 1 hr of MD's order, following blood cultures.

Other information to know:

• All IVPB are mixed in the pharmacy. In the event of an emergency, RN may mix medication. The RN who mixes the medication must administer it. Label drug with pt name, med, concentration, date/time, name of person preparing. All non-pharmacy mixed drugs must be discarded within 12 hrs.
• For IV meds: if adjustments to infusion rate are based on sliding scale or lab test, consider verifying adjustment with another RN.
• Please refer to policy for specifics on transdermal, IVP, IVPB, and extravasation.

Reference: Medication: Administration, Standard 13.001

Policy Update: PCA pump management

As stated in an earlier post, a few of the hospital policies have been revised and/or updated recently. I recommend looking up the policies on Meditech and reading through them. On the blog, I will touch on the highlights. For PCA pump management:

• No concomitant PCA/epidural infusions. Do not infuse PCA and epidural at the same time.
• The physician must use the PCA order sheet. Non-standard doses may be ordered for chronic pain or pt on prolonged opiate regimen with verification of pharmacist and/or pain physician.
• Pts using PCA basal rates (continuous infusions) must be on continuous heart rate and SpO2 monitoring (excludes end-of-life care pts).
• Only pt or nurse is allowed to push the PCA button. Give PCA information sheet to family.
  
• PCA settings/meds must be checked and documented by two RNs: on initial PCA set-up, upon receiving an admission or transfer with a PCA, when settings are changed, and when a new syringe is inserted into the pump.
• Clear pump volumes at the end of each shift and document on PCA flow sheet.
• Use a dedicated IV line whenever possible. Check compatibility of IV fluids when combined with opiate.
  

Document:

• At the initiation of PCA and dosing changes: HR, BP, RR, SpO2, and level of sedation q 1 hr x 4, and then RR q 2hr until PCA is DC'd.
• For respiratory depression, give O2 and Narcan per PCA order sheet.
  
• Pt's pain level on Daily Nursing Assessment form.
  
• When PCA is DC'd - amounts of med used and wasted, co-sign waste in Pyxis.

Reference: Management of the Patient Using PCA Pump for Pain Control, Standard 13.002

New Employee Health Requirement

Employee health is now requiring all employees, physicians, and volunteers to provide proof of Varicella (chicken pox). Proof of immunity includes one of the following:

• 2 documented doses of Varicella vaccine
• A copy of a "positive" Varicella blood titer
• A copy of a signed statement from your physician stating you have had the chicken pox or shingles (edited 3/19/09 @ 8:40 pm).

Employee Health will be sending out memos and lab requisitions to everyone who does not have the above documentation in their file. The memo will give you instructions for obtaining the blood draw and charging it to Employee Health.

It will take a while to get everyone up-to-date, and memos will go out to employees throughout 2009. Once you receive the memo, you have 3 weeks to obtain documentation or blood test. The titer results become part of your Employee Health immunization record. You will be contacted by Employee Health only if you are not immune to Varicella.

Please call any member of the Employee Health Staff if you have any questions 3-441-0451.

Links to Rx discounts for patients

Let's face it, our patients take a lot of meds! Many of the national pharmacies are offering generics at $4 for 30-day supply or $10 for 90-day supply. Most of the common heart failure meds are discounted. In the "Links" section of the blog (on the right side of the page), I've added links to the pharmacies offering discounted medications. You can print these out to give to patients if they are interested.

Cardiothoracic surgery discharges

As of 3/1 all DC paperwork for patients of Dr. Mark D. and Dr. Thomas M. must be reviewed by the Clinical Lead before the patients leaves and before the documents are faxed to the physicians' office. This is to prevent missing medications and/or INR blood draws. Please refer any issues or questions to Kim @ ext 2231.

Policy updates and revisions

Policy updates and revision notifications can now be found in your Mox mail. I will list the most pertinent ones for us that have been revised. Later this week, I will post what the specific changes are. For brevity's sake now, here are the policies you should be on the look out for changes:

• PCA pumps
• Reporting critical lab results
• Metered dose inhalers (MDI) with spacers
• Cardiac Catheterization post-procedure care
• Medication Administration
• Orthopat infusions
• PICC lines
  
• Medication order management
  

Temporary Pacers

If your patient is using a temporary pacemaker, please remember to check and document at each shift that all connections are secure and a strip of the underlying rhythm. Per Colleen CNS, as long as you have capture, a perfusing pulse, and an asymptomatic patient, you do not need to check threshold and sensitivity every shift.

Changes for isolation signs

If a patient has MRSA in their sputum, you would normally find 2 isolation signs posted on the door: a green "contact precautions" sign and a teal "additional precautions" sign (to protect your mucous membranes from contaminated sputum).

According to universal precautions, we should always protect our mucous membranes if we anticipate potential contact with a patient's body fluids (not just MRSA infections). Therefore, the teal "additional precautions" sign will no longer be used. If you have any questions, please call Beth in Infection Control at ext. 2339.

Form 17

A reminder from our fearless leader: Form 17s should only be printed on the day of discharge. Do not print it out a day or more ahead of time in anticipation of discharge (even if the physician asks you to). We had an instance of a "near miss" where the form 17 was printed out 2 days prior to discharge. On the day of discharge, 2 meds were changed. One of our stellar nurses caught this oversight before the patient was sent home. Also don't forget to compare the discharge medications with the home medication form, as this also prevents serious omissions (like a CHF patient not getting their Lasix).

Blood Transfusion Safety Class for RNs

"Nursing's Emerging Role in Blood Management and Transfusion Safety" is being offered for all BCH RNs on Tuesday, March 10th. It's only an hour long - from 11:00 am to noon, in Gene Wilson A. The discussion will be about institutional best practices for improving the safety of blood administration. CEUs will be available. Any questions can be referred to Emily @ ext. 2379.

Schedule due today

Don't forget to put in your schedule requests! Please also remember the skills labs and staff meetings are April 14 and 16, so don't schedule yourself to work the floor both of those days.

On a personal note

Please keep Tori (PCA) in your thoughts and/or prayers. She has a friend who is hospitalized in the ICU right now. Let's give Tori extra support as she navigates through this rough time. We wish you the best Tori, and please know that we are here for you.

From Melissa

Melissa will be on vacation from March 5, returning to work March 16. I will be back to do Kronos, so write it on the board or call my extension with any updates.
Thanks for being such wonderful staff--see you at the Safety Fair!

Continuing Education Offerings for RNs

Here are some opportunities for continuing education (CE) for nurses. Fill out the registration forms and return to Kim. BCH is taking care of the fees for classes, as well as compensating you for your time (wahoo!).

CO Patient Crisis: Identify the Signs and Symptoms Before the Patient Crashes Seminar
(click on the link above to access registration form)
Tuesday, March 17 8:30 am to 4:30 pm
Hotel Boulderado

Managing Cardiac Issues in the Acute and Critical Care Patients
Thursday, April 16 8 am - 5 pm
Foothills Campus Leo Hill Room
(click on picture below to show form on its own page, then print).

TB skin test/mask fit walk-in clinics

If you are due or past-due for your annual TB skin test or N95 mask fit, you may attend one of the three clinics being held this month. No appointments are needed.

March 2 - Foothills Chairman's Room, Noon - 2 pm
March 16 & 17 - Broadway alcove outside Gene Wilson, 7:30 am - 5 pm (during the Safety Fair)

RN recognition program

Don't forget - packets for the RN recognition program are due to Kim by March 31st! Don't miss this opportunity to be recognized for all you do (and get some $$ in the process).

Glucose meter upgrade

The glucose meters have been upgraded to a newer version of the PCX. The new meters work the same way as the old ones, with minor differences. The same testing strips will still be used. Look for a poster outlining the differences and sign-off sheet on the unit.

Free Cardiac Education for Patients

If your patient wants or needs more education about cardiac disease, you can now refer them to the Cardiac Rehab lecture series. The series covers a variety of topics such as diet, exercise, and emotional support. And the best thing of all is that it's free!

The lecture series is held 4 times a year (3 sessions are left for 2009). A schedule is posted in the bathroom and education room. Patients who are interested may attend while an inpatient, or their family may attend if the patient is too sick to travel.

For now, we are doing this on a trial basis to see how many people will actually attend. The goal is to refer one or two patients per class. If you need extra fliers to give patients or families, please see Melissa.

Annual BCH Safety Fair

Just a friendly reminder that the Annual BCH Safety Fair is
March 16 &17
THIS IS A REQUIREMENT FOR YOUR ANNUAL COMPETENCIES.
There will be 12 stations, so plan on two hours.
Please direct all questions to Melissa
Thank You

Shhhh!

Message from Melissa:

Hello All-
There has been a lot of noise at the front nurses station recently. I know that we have students and that compounds the noise problem.
Please respectfully enforce the noise ordinance and remember that other staff, patients, and families are watching you! If you don't need to be in the front nurses station, please respect everyone enough to locate yourself to your work area.
Feedback Welcome!
Thank You
Melissa V

Originally posted as a comment, posted here for better visibility.

Blog 101 (repost!)

In honor of the "official" blog launch, I'm re-posting some information that might be helpful to you if you are new to the world of blogs.

• On the right hand side of this page, you will find a heading for "Links". Clicking on any of the underlined words will take you to the website of the named item. I can also post links in the text of the blog like this: Google
• You can leave a comment or question without having to email me. At the bottom of each post, you will see the time the post was created, followed by "x Comments". Click on comments, and it will pop open a new window. Type the comment in the box. At the bottom of the text box, you will see choices for how you would like to identify yourself. If you have a Google account, you can select that and type in your login. Another choice is OpenID (Live Journal, WordPress, TypePad, AIM). You may also leave just your name by selecting "Name/URL". Just type in your name, the URL is not necessary to post a comment. You may also leave a comment anonymously by selecting "Anonymous". When you are finished, click "Publish your comment".
• Also on the right side of the page is a heading for "Blog Archive". By clicking on the triangles next to the text, you can expand or collapse the listing of previous blog entries. Click on the title of the post, and that particular post will be shown.
• You can search the blog by using the search box at the top of the page in the navy blue bar. Type in the keyword you want, then click "search blog".
• You can subscribe to this blog's RSS feeds by scrolling down to the bottom of the blog entries (at the bottom of the page). Click on "Subscribe to: Posts (Atom)". What is an RSS feed? This website explains it better than I can.
• This blog is public domain and can be viewed by anyone. Please keep this in mind when commenting. I have been purposefully discrete about posting identifying information about us on this site.

Skills Lab change, Journal club

The remaining skills labs for the year will be combined RN and PCA. The dates are April 14 or 16, July 21 or 23, and October 13 or 15. Please refer to the unit schedule below. Click on the picture to make it bigger. The education day in March has been moved to the 17th to coincide with the hospital-wide Safety Fair.


Journal club will be meeting Tuesday, March 17 @ 2 pm in the education room. The article to be discussed is A Model of Medication-Taking Behavior in Elderly Individuals with Chronic Disease (The Journal of Cardiovascular Nursing: Volume 22(5) September/October 2007 pp 359-365). You can pick up a copy of the article outside of Melissa's office. Contact her @ 2479 with any questions. Come to Journal Club prepared to discuss the article. Click on the picture below to view the flier enlarged.

D/C forms change, Daily Assignments

Our standard Discharge Home 3-carbon sheet has changed. It can now be found on FormsFast (do I hear a collective "YAY!"?). There is now a section at the bottom that requires us to fax a copy of the sheet to the pt's PCP. This does bring up a HIPAA issue, and there are people in administration working to clear that up. For now, the patient may opt-out of having this information sent to their PCP. It is required by the Joint Commision that we do this for continuity of care. Please remember to make appropriate copies of the DC form - one for the pt, one for the chart, and one for the med room for follow-up calls. The Spanish version of the DC form is still the same and can be found in its usual place by the UC desk.

Changes have been made to the daily nursing assignment sheet. RNs will be given ACLS assignments for the day (team leader, medication admin, chest compressions, etc.). PCAs will be given specific duties for the environment of the unit (garbage/linen, trays/water pitchers, PCX QC, etc.). If you have any feedback about this, please see Melissa or Kim.

One other reminder: please remember to turn off oxygen (wall units and portable tanks) when not in use. While the air we breathe is free, O2 most certainly is not :). Please help keep costs down by remembering to turn flowmeters off.

Blog 101

Here are a few pointers for those of you new to the world of blogs:

• On the right hand side of this page, you will find a heading for "Links". Clicking on any of the underlined words will take you to the website of the named item. I can also post links in the text of the blog like this: Google
• You can leave a comment or question without having to email me. At the bottom of each post, you will see the time the post was created, followed by "x Comments". Click on comments, and it will pop open a new window. Type the comment in the box. At the bottom of the text box, you will see choices for how you would like to identify yourself. If you have a Google account, you can select that and type in your login. Another choice is OpenID (Live Journal, WordPress, TypePad, AIM). You may also leave just your name by selecting "Name/URL". Just type in your name, the URL is not necessary to post a comment. You may also leave a comment anonymously by selecting "Anonymous". When you are finished, click "Publish your comment".
• Also on the right side of the page is a heading for "Blog Archive". By clicking on the triangles next to the text, you can expand or collapse the listing of previous blog entries. Click on the title of the post, and that particular post will be shown.
• You can search the blog by using the search box at the top of the page in the navy blue bar. Type in the keyword you want, then click "search blog".
• You can subscribe to this blog's RSS feeds by scrolling down to the bottom of the blog entries (at the bottom of the page). Click on "Subscribe to: Posts (Atom)". What is an RSS feed? This website explains it better than I can.
• This blog is public domain and can be viewed by anyone. Please keep this in mind when commenting. I have been purposefully discrete about posting identifying information about us on this site.
  

Mg protocol, reminders

The Magnesium replacement protocol has slightly changed. Replace Mg for lab values 1.9 and under. The old value was 2 and under.

Just as a reminder, no scissors, needles, saline flushes, or meds in your pockets or pt rooms. This is per Joint Commission.

I have updated the side bar with meeting times and BLS dates.

Welcome to our Blog

We are starting this blog for the employees of 3W to stay connected to what's going on. Some of us may be away from the unit for a while due to a leave of absence, while others only work a few shifts here and there. You may find yourself coming into work one day and being blindsided by a new policy. You think, "Why didn't someone tell me about this?"

This blog is to help bridge the gap of information. We will post information that you need to know such as policy changes, best practice updates, meeting reminders, educational requirements/opportunities, and hospital news.

Please feel free to leave a comment or send an email with feedback to BCH3Westblogger at gmail dot com. If you have something to contribute or there something that you want to see, contact me. Remember, this blog is for you, so whatever I can do, please let me know.

Rebecca Stadler
Per Diem RN and BCH3Westblogger!