Editor: Jody Schipper, MSN, RN
  Professional Development Coordinator
  Phone: 235-3782
  Email: schippjm@ihs.org
  Deadline for article submission is the 5th of each month

Ryanne North, Nurse Manager, Digestive Health Center The Buzz welcomes Ryanne North as the Nurse Manager of the Digestive Health Center Logan site.  Ryanne comes to us with twelve years of nursing experience including home health, labor and delivery, NICU, and outpatient surgery.  She is married with three children.  In her free time, Ryanne enjoys spending time with her family, reading, and being outdoors.  Welcome Ryanne!

Sterile Water Solutions Intended for Single Use Only

Click here for an important message from Hospira regarding sterile water use.

Single Dose vs. Multiple Dose Sterile Containers
Chris Clayton, PharmD, MBA, Director of Pharmacy

There will be a major focus on this topic by surveyors due to some major events that have occurred at US facilities where thousands of patients were exposed to blood-bourne pathogens such as hepatitis and others. 

Products that are included under this standard are covered in this statement in the Iowa Code:

“any pharmaceutical preparations that are required to be sterile when they are administered into patient body cavities, central nervous and vascular systems, eyes, and joints, and when used as baths for live organs and tissues, including but not limited to injections (e.g., colloidal dispersions, emulsions, solutions, and suspensions), aqueous bronchial and nasal inhalations, irrigations for wounds and body cavities, ophthalmic drops and ointments, and tissue implants.”

What should RNs do to comply with this standard and infection control practices?

1. After opening a multiple dose sterile product, make sure the container is labeled
   with an expiration date that is at most 28 days from the date of puncture or
   opening.  If there are questions, contact the pharmacy.
2. Discard any single dose sterile products and multiple dose sterile products that
   are near empty or that you know will not be used again immediately.
3. If a multiple dose or single dose sterile product is found in the supply or in the
   department with no expiration date on it, appropriately discard of the product
   immediately.
4. Never use a single dose product for multiple patient administration.
5. Always use a new sterile syringe and needle for each entry into a single dose or
   multiple dose container, even if for administration to the same patient.
6. Always swab the stopper of a vial or the neck of an ampoule with an alcohol 
   swab prior to each entry.
7. Never combine non-sterile products with sterile products for sterile administration
   to a patient.

What is considered a Multiple Dose Sterile product? 

The manufacturer will specifically put on the container if the product is considered a “Multiple Dose” product and the product must contain an antimicrobial preservative to meet that definition.  If there is no marking that specifies the product as such, it should be considered a “Single Dose” product.

Follow up Q & A

I have had some great questions generated from the original communication and I wanted to share some of the questions and answers with everyone.

Question:  After I draw up the medication into a syringe from a multiple dose vial or a single dose vial, how long is that syringe good for?

Answer:  According to the standards, that syringe is only good for 1 hour when prepared on the unit.  For longer expiration dates the product must be prepared in the pharmacy using an ISO Class 5 control device located in a clean room.

Question:   I see the standard applies to things like inhalers, bottles of eye drops and tubes of ointment, do we need to mark these products with a 28 day expiration once opened?

Answer:  No, the 28 day dating for multiple dose sterile products only applies to those items that are administered parenterally and does not apply to these products.  I would recommend that you contact me with specific questions regarding this topic and I can help.  The standards are lengthy and have many facets to them, so while sterile inhalation, irrigation and eye drop products are covered in this chapter it is not always clear how to apply the standards to these products.

Question:  We use a sterile single dose irrigation bottle to rinse or cleanse something and we do not need the irrigation to be sterile, how does this standard apply?

Answer:  These standards do not apply if the product that you are using is not required to be sterile when administered.  The thing we need to watch out for is that the manufacturer’s label still says the irrigation bottle is a sterile single dose product, so once we open that bottle for non-sterile use, we need to make sure the remainder of the bottle does not get used for a sterile application past the 1 hour expiration for a sterile single dose product.  My recommendation for this is to use a bottle size that allows you to throw the remainder of the bottle away without a lot of waste to avoid the need for proper labeling.  For some of these products the label and the time it takes to label the product may result in a higher cost than just using a new bottle every time.

Again, great questions and keep them coming so we can be prepared for this standard when Joint Commission arrives.

Allen Nurses Furthering their Education

Congratulations to the following Allen RNs who have completed advanced degrees.

BSN
Elizabeth Neunsinger, Case Management: Allen College
Shannon Lindeland, 3 Surgical: University of Phoenix

MSN
Deb Lodge, Cardiology: Allen College
Ashley Trumm, 2 Heart: Allen College

Remember: If you have completed an advanced degree, we want to hear from you.

Welcome New RNs! From L to R: Brian Van Brocklin, RN, OR Supervisor, Surgery; Jordan Shafer, RN, ICU; Josh Weber, RNFA, CNOR, Orthopedic Team Leader, Surgery

A Note from Employee Health
Jenny Boevers, MSN, RN, Employee Health Nurse

According to the Iowa Department of Public Health (IDPH), the number of confirmed pertussis cases is on the rise in Iowa and it is possible the current trend will continue into 2011. The majority of the cases this year involve individuals ages 5-14 with higher concentrations falling between ages 10-14. The incidence of pertussis is cyclical showing increased activity approximately every 3-5 years. The last increase seen in Iowa was in 2004 - 2005.

It is important that healthcare workers have proper vaccination coverage against pertussis especially those with direct patient care duties and those who have regular contact with children. In 2005, a pertussis containing tetanus product (Tdap/Adacel) was licensed and is now offered to ages 11-64. Please take a look at your immunization records to determine if you have received the one-time Tdap booster. If you have not received it, Tdap is available in Occupational Health/Employee Health at no cost to Allen associates. Please contact Jenny in Employee Health (x 3730) if you have further questions. 

The IDPH recently released a fantastic resource comparing Influenza, Colds, and Pertussis. To view the resource, click on this link.  http://www.idph.state.ia.us/adper/common/pdf/flu/flu_colds_pertussis.pdf

In addition, the Associate Immunization Record Review is in full swing and has been a great success. Thank you to all the units who have been extremely helpful during this process.  Look for the mobile immunization cart on your unit soon!

Reference:
Iowa Department of Public Health. (2010). Infectious disease briefing: Iowa pertussis update (12/29/10). Retrieved from http://www.idph.state.ia.us/adper/common/pdf/pertussis/update_122910.pdf

Pharmacy Corner Linsey Schuldt, PharmD

Random Bits....

• Darvocet (propoxyphene/acetaminophen) -- all strengths-- is no longer available in the United States. On November 19, 2010, the US Food and Drug Administration requested that manufacturers voluntarily withdraw propoxyphene from the United States market due to new data from the multiple-ascending dose (MAD) study demonstrating serious cardiotoxicity (eg: significantly prolonged QT interval, prolonged PR interval, and widened QRS complex) in healthy adults who received recommended doses of propoxyphene (US Food and Drug Administration, 2010).
• Please make sure you write on all multiple dose vials when you opened the vial. A multiple dose vial is only good for up to 28 days after being punctured, some are even shorter if the manufacturer specifies as such. If it is not dated, it will have to be discarded.
• Pharmacists are located on 3 Heart-B side and 3 Medical (near the nursing stations) during the day shift Monday-Friday from 07-1530. If you have needs/questions, or a patient that needs extra education (including discharge counseling for your difficult patients) or medication reconciliation issues, etc., please feel free to utilize these pharmacists to the fullest. (They will be rounding in the ICUs in the morning, but typically will be available after 10:30 a.m.)  As always, you can also call down to the pharmacy for assistance.

Additions to Patient Rights and Responsibilities

Please note the following additions to the Patient Rights and Responsibilities policy. It is your responsibility to ensure the patient is aware of any restrictions. If the patient is designating visitors, the information must be documented in the record.

The patient has the right to:

44. Know which patient care areas have limited visitation and if admitted to one of these areas to have these limitations discussed with you (or support person as appropriate) at the time of admission. (Areas with limitations: NICU, Mental Health, PACU, ED and OB).

45. Receive the visitors you designate. Any specific requests by patients will be documented in the nurses’ notes.

46. Know that Allen Hospital does not restrict, limit or deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability.

47. Know that Allen Hospital is committed to ensuring that all visitors enjoy full and equal visitation privileges consistent with patient preferences.

Please see Allen SOP 1-P-8-0 Rights and Responsibilities of Patients for more information.

Brenda Collins						Lisa Sparks and Barb Burkle

Nursing GI Annual Conference a Great Success
Sarah Brown, MSN, RN, Director of Digestive Health Services

Current Issues in Gastroenterology: The Upper GI Tract was held on 12/1/10 at the Park Place Event Centre. There were approximately sixty nurses in attendance.  The program offered nursing CEUs as well as SGNA continuing education hours.  Attendees were educated on many facets of gastroenterology from a nursing perspective.

Barb Burkle, MSN, ARNP, presented “Evaluating Dysphagia” and explained the causes, assessment, and diagnostic strategies for this issue.  Brenda Collins, RN, CGRN, educated the group on “Percutaneous Endoscopic Gastrostomy (PEG) Tubes” which included indication, contraindications, and patient education.  Gayle Juhl, Speech Pathologist, discussed “The Role of the Speech Pathologist in Dysphagia” and helped the audience identify the stages of swallowing, the values of video swallow studies, and compensatory approaches for dysphagia.  Lori Fincher, MSRDLD, spoke about “Dietary Intervention for Dysphagia and Percutaneous Endoscopic Gastrostomy” which included the calculation of caloric needs and the dietician’s role in helping patients with this issue.  Stephanie Beenken, RD, LD, presented “Fructose Intolerance” and described dietary vs. hereditary intolerance and the dietary management of both.  Jane Schwartz, RN, BSN, CGRN, provided knowledge on “What all Nurses Should Know about H. Pylori” and identified patients at risk, diagnosis, treatments, and risks associated with this bacteria being untreated. 

Comments from attendees….

“The event was informative and well done. I thought all of the presentations were well done and applicable to practice. I found the fructose intolerance talk the most interesting because it was interesting to see how specified the dietary restrictions were” -- Andrea Johnson, Nurse Manager, 3 Medical

“I thought the event was very pertinent to our practice. All of the topics were interesting and very informative. The speakers presented at our level. I thoroughly enjoyed the entire evening” -- Jerilyn Miller, RN, Digestive Health Logan

“I felt the event was very educational and the objectives defined by each presenter were met. I felt that the presentation on dysphagia done by Gail and the information presented on H. Pylori were most applicable to my practice. The information presented on fructose intolerance was interesting as I had never learned about this disorder before. I also appreciated Gail's description of the results of the swallow test (not pass or fail)” -- Kim Neuhaus, SNT, Resource

Special Thanks go to Lisa Sparks, RN, CGRN, Barb Burkle, MSN, ARNP, and Brenda Collins, RN, CGRN for organizing this informative evening.

Upcoming Classes

January
1/18 BLS Instructor Renewal
1/19 Nonviolent Crisis Intervention – Refresher
1/19 Hiring and Selecting the Right Person
1/20 BLS Renewal
1/25 Respirator Fit Testing
1/27 Nursing Care for Telemetry Patients
1/31 BLS Instructor Renewal

February
2/8 Respirator Fit Testing
2/9 Nursing Care for Telemetry Patients
2/10 BLS Renewal
2/14 PEG Tubes: A Guide for Nurses
2/15 Ins and Outs of Chest Tubes
2/16 Nonviolent Crisis Intervention
2/22 Care of the Cardiac Surgery Patient for Critical Care Nurses
2/22 Respirator Fit Testing
2/24 BLS Renewal
2/25 Nonviolent Crisis Intervention - Refresher

Career Ladder Recognition Congrats to the following nurses for achieving or maintaining Career Ladder status! Maintain CL 3 Deb Hannan, ICU Pam Hart, UMP ASC Brittany Parker, 4 Tower Maintain CL 4 Helen Carlson, ER Cindy Powell, Surgery Julie Leary, PACU Teresa Hippen, ICU Maggie Pietryga, 4 Tower New CL 4 Shannon Lindeland, 3 Surgical

The Nursing Leadership Council assists with coordinating the activities and functions of all of the nursing councils. This council is made up of representatives from each of the four councils and an At Large Representative. The person in this At Large seat is selected by all of you to represent all of you on the Nursing Leadership Council.

Past Nursing Leadership Council At Large representatives have been Brenda Collins and Helen Carlson. They have made great contributions to the Nursing Leadership Council. It is now time to vote for a new representative. NetLearning assignments have been made to all areas that will be participating in shared governance in 2011 to allow you to vote on a new At Large Representative.

Please log in to NetLearning to vote on someone for the At Large seat by January 21, 2011.

Critical Results on Accucheks
Rhonda Bergmann MT (ASCP)

A result of “LO” or “HI” requires a repeat Accuchek to be performed.  If the result is still “LO” or “HI”, a “Stat” venous blood glucose needs be ordered immediately. When a Critical Result (including LO or HI) is obtained, a message will appear on the Accuchek screen.  The message will read “Critical Result. LO or HI result requires a lab draw.”  “LO” and “HI” results are also Critical Results and need to be called to the doctor and documented on the patient’s chart.

One can repeat the “LO” or “HI” result on the same machine as long as the quality controls have been performed on the machine.  Please take care when performing a fingerstick glucose.  Follow these steps:

• Make sure the finger is cleansed well with an alcohol prep (to remove any liquid or food that would affect the blood sugar).
• Wipe the alcohol off with dry gauze. Failure to follow this step will give very erroneous results. (Usually elevated glucose results)
• Puncture the finger.  (Avoid excess squeezing)
• Obtain one drop of blood and wipe this first drop off with a dry gauze.
  Test the blood sugar with the second drop of blood, making sure that the yellow portion of the strip is completely filled with blood.  (No yellow should be showing.
• Apply pressure to the puncture site.

Remember the glucose result you obtain is only as accurate as the procedure that you follow.  Good technique is the key to accurate results.

If you have further questions or comments, please feel free to contact me at the Point of Care office @5186.


Communicating Effectively with Clients Class 
Read more on this class.


Surgery Nurse Earns RNFA, CNOR Certification

Julie Klein, RNFA, CNOR, CL4, Surgery Julie enjoys reading, sewing, bowling, and working out. She has 3 daughters and 4 granddaughters.

Congratulations to Julie Klein for earning the Registered Nurse First Assistant (RNFA) and Certified Nurse of the Operating Room (CNOR) designation.

The Registered Nurse First Assistant (RNFA) is a “peri-operative registered nurse who functions in an expanded role. The RNFA is involved in the management of the patient throughout the entire peri-operative period” (Association of Operating Room Nurses [AORN], 2011). In order to become an RNFA, one must first earn CNOR certification which involves an extensive testing process itself.

Once CNOR is obtained, the candidate must complete a formal education program that meets the AORN education standards. Julie’s program consisted of online tutorials, 6 tests over various specialties, 120 hours of clinical internship with multiple surgeons in various specialty areas, completion of 3 templates on selected surgical procedures, completion of a case study which followed a patient through the entire process (from initial office consult through the post-operative phase and discharge), and a final exam. She also completed a 3-day suturing course in Denver, Colorado. The RNFA program can take up to 12 months to complete. Julie completed her requirements in 6 months!

Julie decided to pursue the RNFA, CNOR because she wanted to strengthen her surgical abilities and increase her knowledge to ensure better patient care. She feels the program has deepened her understanding of procedures and improved her ability to anticipate the needs of the surgeon and patient. Great job Julie!

Reference:
AORN (2011). Retrieved from http://www.aorn.org/CareerCenter/CareerDevelopment/RNFirstAssistant/ 

Denise Lundberg, RN, CL4, Infusion Services Denise enjoys reading, watching movies, camping, vacationing, and visiting family and friends. She particularly enjoys shopping at Barnes and Noble.

Denise Lundberg has received notification that her abstract, Anti-Reflux Devices on Central Lines at Allen Hospital, has been accepted for a poster presentation at the 18th National Evidence-Based Practice Conference: Connecting with Consumers for Evidence-Based Health Care hosted by the University of Iowa. The conference is being held April 28-29, 2011, with Denise’s abstract poster presentation scheduled for Friday, April 29, 2011.

The “abstracts underwent blind review and were selected based on scientific merit and relevance to the conference purpose and objectives” says Laura Cullen, MA, RN, FAAN, Evidence-Based Practice Coordinator for the University of Iowa.

The journey began two years ago when Denise attended an in-service in Cedar Rapids. She noted that her infusion colleagues from other area hospitals had not used heparin for central lines “for years”, whereas Allen policy still mandated the use of heparin for all central lines. This led to the big question…“Why are we doing this?”

Denise took this question to the Evidence-Based Practice Council and the group decided further investigation was warranted. Denise began researching best practice standards for central line management. She found that heparin flushes could be eliminated with the use of an anti-reflux/positive pressure valve. When the valves are used properly, heparin flushes could be replaced with saline without an increase in line occlusions (Jasinsky & Wurster, 2009; Mitch, 2008).

She then researched standard practice at various IHS affiliates. She received sample order sets and policy templates from St. Luke’s Cedar Rapids, Trinity Quad Cities, and Trinity Fort Dodge.

Her conclusion after thorough review of the literature was that “anti-reflux devices prevent occlusion of central lines, decrease nursing time in maintaining them, decrease the potential for thrombocytopenia, decrease costs related to heparin use and thrombolytic intervention, and increase patient safety and satisfaction” (Lundberg & Ambroson, 2010). This information was taken to the Medical Executive Committee in April 2010. Upon review of the data, the committee approved the practice change.

The next step was staff education. This was conducted in May 2010 through various in-services in which Denise trained “super-users”, who then took the information back to their respective departments. The focus of the education was proper use of the valves, the blood draw process, and signs/symptoms of a clot.

The practice change was implemented in June 2010. The standing orders were approved and implemented in August 2010.

Key Points of the practice change are:

• Heparin is no longer used to flush central lines including:
    -  PICCs
    -  Triple lumen subclavians
    -  Hickmans
    -  Jugulars
• All central lines must have positive pressure caps/anti-reflux valves in place on
  all lumens.
• Flush these lines as you would peripheral lines, every 8 hours with saline if
  not used. 
• Note: Mediports are NOT included in the practice change. Continue to flush
  Mediports with heparin every 12 hours.

How are things going?

The new practice has been in place for 6 months and there has been no increase in central line occlusions! This has greatly streamlined nursing workflow, diminished patient risk of heparin-induced thrombocytopenia, and produced cost savings (Lundberg & Ambroson, 2010).

Denise reports nurses have adapted very well to the practice change. She offers the following tips to nurses:

• Ensure that the line is flushed properly following a blood draw.
• Ensure that the caps/valves are changed every 24 hours (with the tubing).
• Ensure that the cap/valve change is documented on the IV Flowsheet in CareCast.

The Evidence-Based Practice Council felt this work was important to share. DeAnn Ambroson, PhD, RN, Professor at Allen College, has an extensive background in research and assisted Denise with the abstract submission for presentation at the 18th National EBP Conference. The two plan to submit the study for national publication in the near future.

What a great example of pursuing best practice and
providing ideal care for our patients!
Kudos!

References:
Jasinsky, L. M., & Wurster, J. (2009). Occlusion reduction and heparin elimination trial using an antireflux device on peripheral and central venous catheters. Journal of Infusion Nursing, 32(1), 33-39.
Lundberg, D., & Ambroson, D. (2010). Anti-reflux devices on central lines at Allen Hospital. Unpublished abstract.
Mitch, S. (2008). Revolutionary change in IV therapy utilizing the LifeShield® TKOTM-5 anti-reflux device. Retrieved from http://www.hospira.com/_docs/revolutionary_change_in_IV_therapy.pdf