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.

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).

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.

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".

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.

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.

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).

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