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.
  

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.

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: 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

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).

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.