Editor: Jody Schipper, MSN, RN
Professional Development Coordinator
Deadline for article submission is the 5th of each month
Pain Clinic Consults
Kimberly Prinsen, RN, BSN, Clinical Director Allen Hospital Pain Clinic
Remember to call 319-235-7246 when you have a Pain Clinic consultation. Please do not page the Physician on call directly.
It is important that these calls are logged via the clinic staff or the answering service for tracking and response purposes.
If you have any questions about this process please let me know.
Nurse Call Pull Cords
Steven Cusher, Environmental Safety Officer/Emergency Management Coordinator
Safety is everyone’s job at Allen Hospital. You may ask yourself “what can I really do to make this a safer place.” It is usually the small things that end up causing the biggest issues. For example, anyone can see if a nurse call pull cord is in a proper position for a patient to use. They should never be wrapped around grab bars. If the cords are wrapped around the bar, patients can not activate the nurse call when they need it most. Another item to look for is the distance of the cord. Nurse call pull cords should be close to the floor. If a patient has fallen on the ground they should be able to grab the cord. If you find that cords have been cut short please call the Call Center at 2273 so Bio Medical Services can install a new cord at the proper length. Taking a little bit of time to look at the small things will make a big difference for the safety of our patients.
WELCOME NEW NURSES!
Front Row from L to R: Carrie King, RN, Resource; Tina Auge, RN, 3 Medical; Molly Weber, RN, 3 Medical
Back Row from L to R: Christine Erbele, RN, MHU; Melissa Freeseman, RN, 4 Tower; Amy Petersen, RN, ICU; Rachel Dancer, RN, Pain Clinic; Angela Leggitt, RN, ICU
Dena Wygle, RN, Rosewood
9/16 BLS Renewal
9/17 Computer Workstation Ergonomics
9/21 Take Charge with Confidence
9/22 Hemodynamics 101
9/24 Nonviolent Crisis Intervention
9/28 Respirator Fit Testing
9/30 BLS Renewal
9/30 Hemodynamics 101
10/1 Fire Extinguisher Training
10/4 Fire Extinguisher Training
10/6 TNCC – Provider
10/8 TNCC – Recert
10/12 Fire Extinguisher Training
10/13 Hemodynamics 102
10/14 BLS Renewal
10/18 Fire Extinguisher Training
10/19 Understanding 12 Lead EKGs: Ischemia, Infarct & Necrosis
10/20 Identifying Cardiac Dysrhythmias
10/20 Nonviolent Crisis Intervention
10/22 Fire Extinguisher Training
10/26 Understanding 12 Lead EKGs: Axis Deviation, Blocks & Conduction Defects
10/26 Respirator Fit Testing
10/28 BLS Renewal
10/28 Fire Extinguisher Training
10/29 Hemodynamics 102
10/29 Nonviolent Crisis Intervention - Refresher
WAY TO GO!!
Career Ladder Recognitions for
Maintaining CL 4 status:
- Cathy Gabbard, RN, 3 Surgical
- Jerrilynn Miller, RN, DDC
Increasing from a CL 3 to a CL 4 status:
- Christa Lerch, RN, 4 Ortho
Joint Commission Identifies Top 10 Sentinel Events
The Joint Commission created the sentinel event database in January 1995. As of June 30, 2010, a total of 6,923 reports of sentinel events had been reviewed nationally. These events affected 7,064 patients with 4,726 (67%) resulting in patient death.
It is important to note that most events are reported voluntarily. Therefore, a larger portion of events may be occurring that are not reported. The 10 most frequently reported sentinel events, nationally, are:
Allen Hospital takes great care to protect our patients. Our commitment to patient safety and the National Patient Safety Goals helps us to prevent sentinel events in our facility.
Remember: The safety of our patients must be our first priority.
Reference: Joint Commission Online (August 18, 2010). Retrieved from http://www.jointcommission.org/SentinelEvents/Statistics/
Lab Orders Lost through the Care Cast/Mysis Interface
Lisa Franzen, RN, BSN, Nurse Manager, ICU
A problem was signaled by Donna, ICU secretary, that lab orders were being deleted in the lab system (Mysis), but still showing as active orders in Care Cast. It appeared to the Care Cast user that the labs were still awaiting completion, however the order had actually been discontinued in Mysis. When investigating this event I discovered the following:
- When a lab order is placed in Care Cast and there are other orders for the same patient and same time already in place, all orders get bundled together as they pass through the Care Cast/Mysis interface. Lab personnel view the orders through the Mysis system, not Care Cast. Therefore, the lab personnel see the bundled orders.
- When the lab orders are bound together and one of those orders are discontinued, the interface automatically discontinues all lab orders in that bundle. Lab personnel are not manually discontinuing these orders, the interface is doing this automatically. Care Cast still shows the orders as active.
I reviewed this information with five frontline staff and we have recommended several counter-measures, including staff education in the following areas:
Placing and Discontinuing Orders
When placing a new order, make sure to check the existing orders. If you place the same order, the interface may automatically cancel all orders.
Make sure that you call lab and x-ray with any order that you have discontinued in the computer to ensure it is properly carried out. This must happen every time.
When you want to discontinue an order you must select “CANCEL” on all labs and x-rays. If you choose “discontinue”, it will not cancel in the lab or x-ray system.
Care Cast Order Review Screen
When reviewing the Care Cast Order Review screen, make note of the codes beside each entry (Table-1). Please note the screens are in alphabetic order, so you may have to scroll down (F8) to view all codes.
See Table-2 for an explanation of the priority codes and their meaning. Please note the difference between the codes used by Care Cast versus the codes used by Mysis. Care Cast users see a single letter, whereas Mysis users see more. This is especially a problem if the lab tells you to order “EX”. See below.
Make sure to call the lab with STAT and Expedite orders to make sure that the orders have crossed to the lab.
Example: You have a daily protime with an “E” priority. If you order another protime with “E” priority, the interface cancels ALL of them, as it is a duplicate.
Please note: You can not mix priority codes during an ordering session. For example, if you order a CBC stat and a protime routine, the system will not send either test through the interface. The tests will appear to be ordered in Care Cast, but the lab will not receive them.
Results and Midnight Orders
Both Care Cast and Mysis allow orders with a collect time of 2400, however the interface does not. Results from 2400 will not cross to Care Cast or HMED.
The problem is sometimes invisible. For example an hourly HGB starting at 2000 leads to an order 4 hours later of 2400.
To avoid losing results in the interface, use a start time that is not on the hour. In the above example, the hourly HGB should have been ordered at 1959 or 2001.
Let us Know
If you find current lab orders that are not completed, signal the problem to your manager. This will allow us to re-evaluate the counter-measures.
Do Not Remove Telemetry for Showers
Sarah Brown, MSN, RN, 3 Heart/Centralized Monitoring/CPC Manager
Do not take patients off of telemetry in the shower. Put the telemetry box in a glove and hang it somewhere. If a patient is to be monitored per a physician order, then they should not be removed from monitor without a physician order. The only exceptions are MRI and very few radiographic procedures.
Below is information taken directly from policy T-3 Telemetry Monitoring and Management Protocol.
8. Patients will be monitored at all times with the exception of changing
electrodes or per physician order.
a. The person responsible for taking the patient off the monitor
must communicate with the appropriate ACC.
9. Alarms indicating “Lead Off” or “Cannot Analyze” will be acted upon
If you choose to remove your patient from telemetry for bathing, you are not practicing within hospital policy. Our common goal is safe, quality patient care.
Thank you for making our patients’ safety our highest priority. Please let me know if you have any questions. Read COMPLETE policy here.
Mark Your Calendars…
Two more dates available to complete the Point of Care Competency Review
Rhonda Bergmann, Nursing Point of Care Coordinator
Clinical Staff performing any of the following tests are required to attend in order to validate their competency:
- pH Nitrazine
If you attended an orientation class in 2010 for any of the above testing, you are still required to attend one of these sessions.
If you missed the sessions earlier in the month, there are additional sessions being held on the following dates:
- September 27, 0700-1000 and 1400-1830
- September 28, 0700-1000 and 1400-1830
All sessions will be held in Meeting Rooms 2 and 3.
No pre-registration is necessary.
New Heparin Orders for Central Lines
Denise Lundberg, RN, CN 4, Infusion Services
A new policy was recently implemented for central lines. Heparin is no longer required. This means that PICCs, Hickmans and subclavians no longer require heparinized saline flushes. They only need to be flushed every 8 hours with saline if heplocked. Mediports still require the saline and heparinized saline flushes every 12 hours if heplocked.
Remember: The clear positive pressure caps must be on all lumens of the lines. This is the key to prevent occlusions of the central lines.
Note: ICU patients whose central lines are being used for monitoring must not have the cap on to ensure accurate monitoring. Make sure that once monitoring is done, the positive pressure caps are replaced.
When blood is pulled from a central line, shut off the infusion for 1 minute, then flush with 20ml of saline and pull back 5 ml of waste before the blood sample is collected. Then flush with 20ml of saline after the blood is collected.
Positive pressure caps must be changed with all 96 hour and 24 hour tubing changes.
New standing orders for central lines were approved by the Medical Executive Committee and rolled out in August. This means that you do not have to call the doctor for Mediport flushes. Pull the orders from the Intranet, initiate the orders, and send them to the pharmacy. The attending physician can sign them when they round next.
Remember there are super trainers on all units and all RNs should have completed their competencies for their units.
Linsey Schuldt, Pharm.D.
Did you know that Allen Hospital employs 16 pharmacy technicians? On a typical weekday we have 5 to 7 technicians working the day shift, 2 to 3 working 2nd shift, and one technician working overnight. All of our technicians are nationally certified. To earn certification, each technician had to pass a rigorous exam. This exam qualifies them to perform various tasks throughout the pharmacy. A few of the tasks that technicians can help nurses with are:
- Trouble-shoot Pyxis problems
- Help locate missing medications – including IV products
- Replace code carts, RSI kits, and amiodarone kits
- Refill bulk items (e.g. inhalers, eye drops, lotions)
- Take messages regarding one time doses and time changes
Please take the opportunity to utilize our technicians to their full potential! They enjoy helping you and making your job easier!
Please remember to scan all orders to pharmacy, even those that are on the chart from pharmacists. This ensures that the orders get double-checked and completes the patient’s profile in the Pyxis system. Thanks!
Allen College To Offer Doctor of Nursing Practice Degree
Phone Etiquette Reminder
Remember to properly identify yourself when communicating with others by phone. This applies to both placing and receiving calls. Make sure to always state your name and department.
Safe Injection Practices
Bill Farmer, RN, Infection Control Specialist
Due to 4 large outbreaks of Hepatitis C and Hepatitis B in the past, a July 14, 2010 Joint Commission publication was issued to remind staff to use safe injection practices.
Please review the following safe injection practices:
- Do not re-insert needles into multi-dose vials or solution bags.
- Do not use single dose needles or syringes to administer IV medication to multiple patients.
- Do not prepare medication in the same area where syringes are dismantled.
- When possible use single-dose vials rather than multi-dose vials.
In the near future, Theresa Schaefer, IHS Joint Commission Coordinator, will perform a walk-through audit and complete a tracer on these and many other measures.
Please contact me with concerns.
October is Fire Safety Month!
Remember to attend Fire Extinguisher Training.
Read more here regarding dates and additional information.
Gear Up for Flu Season Documentation
Sandra Thurm, RN, BSN, CDE, Quality Improvement Specialist
For our patients over the age of 50:
Our documentation of influenza vaccination status is measured on discharges from October to March for our patients diagnosed with Pneumonia. The options are:
- Vaccine given and documented during this hospitalization
- Vaccine received prior to admission during current flu season = begins when this season’s flu vaccine is made available to the public (Sept, 2010 if available through March). Thus in order to answer current flu season, the patient must have received their vaccination starting Sept, 2010.
- Documentation of patient refusal
- Documentation of allergy/sensitivity to vaccine OR medically contraindicated because of bone marrow transplant within the past 12 months OR prior history of Guillian-Barre’ syndrome.
For our patients over the age of 65:
Our documentation of pneumococcal vaccination status is measured on our patients diagnosed with Pneumonia. The options are:
- Pneumococcal vaccine given and documented during this hospitalization
- Patient received pneumococcal vaccine anytime in the past. Please be sure your documentation in CareCast reflects this information.
- Documentation of patient’s refusal
- Documentation of an allergy/sensitivity to vaccine OR is medically contraindicated because of bone marrow transplant within the past 12 months OR currently receiving a scheduled course of chemotherapy or radiation therapy, or received chemotherapy or radiation during this hospitalization.
IV Access for CT Scans
Marsha Haugen, RN, MA, Clinical Nurse Specialist, Oncology
The purpose of “Power PICCs” and “Power Ports” is to withstand the extra pressure exerted when CT contrast is rapidly injected. This rapid injection is necessary for proper imaging. Most PICCs placed at Allen are “Power PICCs.” and are easily identified as they are purple. We also have some patients who have a “Power Port.” They can be identified by palpating the port site where you will feel they are triangular in shape and have 3 bumps on the lip of the port that, in most cases, can be felt.
A regular venous access port or regular PICC will not be used as the IV access for CT scans. A peripheral IV will be started. If you are starting an IV and know the patient will be having a CT, the needle should be a 20 gauge or larger and ideally should be placed in a good vein in the forearm rather than the back of the hand. If the IV is not started, it will be placed in CT; they will most likely place them in the antecubital.
To notify CT of the kind of port being used, it is being added to the contrast checklist
New Pre-op Diabetic Anesthesia Orders
Angie Sampson, RN, BSN, CMSRN, CNIV, 3 Surgical
To better serve our increasing diabetic population that are having surgery, the Inpatient Diabetes Quality Team has worked with anesthesiologists in revising the pre-op diabetic anesthesia orders. The new forms are NOT standing orders, so an actual order needs to be obtained from Anesthesia. The new forms may be found on the Intranet and in surgical packets. We owe it to our patients to address their diabetic needs. Utilization of this form is a great way to provide the best care for every patient, every time.
New Mandatory Reporter Training Requirements
In response to new legislation enacted by the Department of Inspections and Appeals (DIA), the training requirements for mandatory reporters of abuse have changed. The DIA now considers all hospital employees to be “caretakers” and, therefore, mandatory reporters of suspected abuse.
The DIA defines “Caretaker” as the following: [Iowa Administrative Code 481-52 (235E)]
Any person who is a staff member of a facility or program who provides care, protection, or services (either directly or indirectly) to a dependent adult.
Excluded from this requirement are volunteers, contracted builders, and contracted repair workers (e.g. those individuals who are in the facility for a very limited purpose).
The Net Learning module Mandatory Reporting of Child Abuse and Dependent Adult Abuse has been updated to further describe the new regulations, abuse reporting process, and training requirements. Allen Hospital SOPs 1-D-50-1, 2-M-10-1, and 2-O-10-1 have been updated as well.
All associates must complete the new Mandatory Reporting of Child Abuse and Dependent Adult Abuse module by 12/1/2010.
Please note: Completion of the new Net Learning module is required regardless of whether you have recently completed mandatory reporter training here or elsewhere.
This training is mandated by the DIA and we must reach 100% compliance by the end of 2010.
Please contact Professional Development with any questions.
Lisa Solberg, RN, Case Manager, ICU
Lisa enjoys attending sporting activities for her kids and is currently pursuing her BSN.
Angie Devries, RN, Infection Control Specialist
Angie enjoys traveling and spending time with her family.
Kathleen Heise, RN, BSN, ICU
Kathleen is busy building a new home and home-schooling her children. In her spare time, she likes to kayak.
Teresa Hippen, RN, BSN, CN4, ICU
Teresa is currently pursuing her Acute Care Nurse Practioner degree. In her spare time, she coaches soccer and enjoys spending time with her family.
Erin Fanton, RN, BSN, ED
Erin just got married in June and will soon becomer an aunt for the first time.
Jody Schipper, MSN, RN, Professional Development Coordinator
This month the Buzz will continue its focus on quality measures with a targeted look at Severe Sepsis. There are an estimated 750,000 cases of severe sepsis in North America each year. The mortality rate is quite high at 30-35% for severe sepsis and approximately 50% for septic shock (Society of Critical Care Medicine, 2010). We can help improve the chances of survival by quickly implementing the appropriate treatment. The Severe Sepsis quality measures help us do that.
Severe Sepsis Quality Measures: What are they?
The measures are a set of evidence-based interventions shown to improve outcomes for patients with severe sepsis. The specific measures are as follows:
- Serum lactate measured
- Blood cultures obtained prior to antibiotic administration
- Broad-spectrum antibiotic administered within 3 hours of ED admit or 1 hour of non-ED ICU admit
- Protocol followed for hypotension and/or lactate > 4 mmol/L
- Deliver an initial minimum of 20 ml/kg of crystalloid solution
- Administer vasopressors to maintain mean arterial pressure (MAP) ≥ 65 mmHg
- Protocol followed for persistent hypotension (septic shock) and/or lactate > 4 mmol/L
- Achieve central venous pressure (CVP) of ≥ 8 mmHg
- Achieve central venous oxygen saturation (ScvO2) of ≥ 70 %
Angie Devries, RN, Infection Control Specialist, reviews all severe sepsis cases for compliance with the quality measures. The outcomes must be achieved within 6 hours of hospital arrival. Allen Hospital sees 5-10 cases of severe sepsis each month. They are most often admitted through the Emergency Department to the Intensive Care Unit.
Quality in Action
The results are in! The second quarter of 2010 was outstanding, showing 100% compliance in all qualifying cases. Way to go!
Angie says we have done extremely well with the serum lactate measurement, drawing blood cultures prior to antibiotic administration, and the administration of the antibiotic within the appropriate time period.
Areas of needed improvement are the last two measures; the protocols for hypotension and persistent hypotension. If the patient has a systolic blood pressure less than 90 or a lactate greater than 4, the hypotension protocol must be initiated. This includes the administration of a fluid bolus and a vasopressor. If these interventions do not raise the blood pressure, the next protocol for persistent hypotension must be initiated. This includes the placement of a central line (if not already done), and a measurement of both CVP and ScvO2. Angie reports that these are sometimes not ordered by the physician, or they may have been ordered, but the results are not documented on the ICU flowsheet.
Remember to document the CVP and ScvO2 on the ICU flowsheet!
Tools for nurses
Here are some tips that your patient may be septic.
The Severe Sepsis pre-printed orders are a helpful tool as well. Once a diagnosis of sepsis is determined, the pre-printed orders should be used. The orders include best practice standards and feature the quality measures.
Allen nurses are leading the charge
In general, the septic patient will first be seen in the Emergency Department. Upon admission to the ED, the nurse uses the sepsis screening tool in HMED to determine if SIRS criteria is met. If so, the nurse notifies the physician to see this patient immediately. The HMED system also automatically flags the chart with a sepsis icon, to further communicate the needs of the patient. Erin Fanton, RN, BSN, ED, reports the screening tool is helpful. “It is important to involve the physician as quickly as possible,” she says.
Teresa Hippen, RN, BSN, CN 4 and Kathleen Heise, RN, BSN are ICU nurses who see septic patients regularly. They each have great insight into providing ideal care to these patients.
“There is a lot of evidence-based research that gives treatment parameters, but not as much literature on outcomes. It is important for us to implement these protocols, educate staff, and provide performance feedback to continually improve the care we provide” says Kathleen. Kathleen’s advice to nurses working with septic patients is to use the tools provided for them. “Pull the orders sets, read them, know them. Ideally you should be comfortable with the orders before you are faced with a septic patient. Many of the interventions are sequential, so you want to make sure you are prioritizing and sequencing appropriately” she says. “The evidence shows that the speed and appropriateness of treatment is directly related to the rate of survival” says Kathleen. Knowing the orders will help ensure the appropriate interventions are implemented in a timely manner, thus improving outcomes for our patients.
Teresa agrees. “The order sets are helpful. You must constantly be thinking about the big picture. There are so many details to address with these patients. They are often dehydrated and hypotensive. You must start the fluid bolus, get the appropriate labs, ensure the antibiotic was given, continually monitor their pressure, get the art line and the CVP as quickly as possible. You need to get a detailed history and complete a head-to-toe assessment in order to identify the origin of the sepsis. Look for wounds, cough, and fever.” she says.
Teresa has found that the bed-side care conferences are beneficial. It is a multi-disciplinary meeting held in the patient room with the patient and family present. Team members that attend are usually the clinical nurse specialist, chaplain, dietician, case manager, social worker, pharmacist, nurse, and, at times, the medical director. “It is great to have everyone review and discuss the case with fresh eyes. The patients and families really appreciate being involved as well” she says.
As a final check, Lisa Solberg, RN, Case Manager, ICU reviews the chart. She ensures that the blood culture was drawn and the antibiotic was given. “The nurses are usually right on” says Lisa. “The blood culture and antibiotic are almost always done in the ED before the patient comes to the unit, and if not, the ICU nurses catch it.”
Every member of the team provides a valuable service in the pursuit of ideal patient care.
Remember to ask questions
Angie wants to encourage all staff to contact her with any questions regarding Severe Sepsis measures. She is happy to help!
Again, congratulations to Allen Nurses for the great work being done to ensure the best outcomes for every patient, every time!
Keep up the great work!
Reference: Society of Critical Care Medicine (2010). Retrieved from http://www.survivingsepsis.org/Introduction/Pages/default.aspx