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!