News and Views
News & Views is published quarterly by the Department of Nursing and Patient Care Services of the University of Maryland Medical Center.
news views Winter 2013 A Publication of the Department of Nursing and Patient Care Services University of Maryland Medical Center Conquering CAUTI: Preventing Catheter-Associated Urinary Tract Infections Will Save Lives David G. Hunt, MSN, RN, Director of Nursing and Patient Care Services, Cardiac Care, and Radiology Urinary tract infections (UTIs) are tied with pneumonia as the second most common type of health care-associated infection, second only to surgical site infections. UTIs account for more than 15% of infections reported by acute care hospitals. Virtually all health care-associated UTIs are caused by instrumentation of the urinary tract – in particular, the placement of a catheter. Catheter-associated urinary tract infection (CAUTI) is serious and can lead to such complications as cystitis, pyelonephritis, gram-negative bacteremia, prostatitis, epididymitis, and orchitis in males. Less commonly, these infections can even lead to endocarditis, vertebral osteomyelitis, septic arthritis, endophthalmitis, and meningitis. Examining the Cost Complications associated with CAUTI cause discomfort to the patient, prolonged hospital stay, and increased cost. It is significant to note that more than 13,000 deaths a year in the US are associated with UTIs. Tracing the Causes Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter. Between 25% and 30% of hospitalized patients receive urinary catheters during their hospital stay. The most important risk factor for developing a CAUTI is prolonged use of the urinary catheter. Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed. Best Practices to Prevent CAUTI: ◗◗ Insert catheters only for appropriate indications. ◗◗ Leave catheters in place only as long as needed. ◗◗ Ensure that only properly trained staff insert and maintain catheters. ◗◗ Insert catheters using aseptic technique and sterile equipment (acute care setting). ◗◗ Following aseptic insertion, maintain a closed drainage system. ◗◗ Maintain unobstructed urine flow. ◗◗ Standardize correct specimen collection. ◗◗ Practice care provider hand hygiene, patient catheter hygiene, and standard (or appropriate isolation) precautions according to CDC HICPAC guidelines. UMMC Joins New Nationwide Effort Last year, UMMC joined other hospitals in Maryland in a national CAUTI reduction program. This was locally sponsored by the Maryland Hospital Association (MHA) and sought to drive down the incidence and look for ways to eliminate CAUTI. The focus continued on page 5. Lisa Rowen’s Rounds: Our Safety Journey Lisa Rowen, DNSc, RN, FAAN, Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services At last month’s Staff Nurse Council (SNC), I asked the question I ask at every SNC meeting: “How have we harmed or almost harmed a patient since the last time we met?” The point of the question is to have an honest and transparent safety discussion, so we can discover potential and real safety challenges in our organization. During these open conversations over the years, we have unearthed safety trends that are specific to certain units and others that spread throughout the Medical Center. I’m sure many of you will remember the IV pump issue from a couple of years ago, when we learned our pumps were randomly going blank and ceasing to work when jostled or bumped. After an intensive root cause investigation, we learned we were cleaning the pumps incorrectly, causing too much cleaning fluid to get in between the connections, resulting in the pumps not working reliably. Although this worrisome safety issue happened to many nurses over a period of months across the Medical Center, we only heard about it for the first time at the SNC in our safety discussion. My point is that instead of assuming this could be a hospital-wide issue, each nurse it occurred to assumed it was a single pump issue and did not document the problem. continued on page 8. 2 Winter 2013 In This Issue 1 Conquering CAUTI 1 Lisa Rowen’s Rounds 2 Corporate Compliance 3 Delirium Recognition and Management 4 Hand Hygiene: Patient Perspective 5 NDNQI Pressure Ulcer Survey 5 Omnicell Restocking 6 Falls Prevention Update 7 Falls Creative Campaign 9 Core Measures 10 Enteral Feeding Tube Management 11 UMMC Patient & Family Partnership Council 12 Honorable Mention 13 Collaborative Care in Shock Trauma 14 MOLST Implementation at UMMC 15 We Discover 16 Certification Corner 16 Psychiatric Nurses Present Posters 17 Trauma Resucitation Unit 17 C2X Healing Arts Team 18 Nurses Deployed to Hurricane Sandy 19 Nursing Professional Advancement 20 Clinical Practice Update Corporate Compliance Christine Bachrach, UMMS Vice President and Chief Compliance Officer and Toya Jackson, UMMC Compliance Manager In each issue, the Medical Center Compliance Program provides a Frequently Asked Question (FAQ) section. This is one method to reach out to UMMC employees and raise awareness of compliance issues. Please let us know what you think, or provide topic suggestions by e-mailing email@example.com or firstname.lastname@example.org. Compliance FAQ Q: I had surgery at the Medical Center last week, and I am concerned that my coworkers may have accessed my medical record information. They knew specific health information that had not been disclosed to anyone. Can I request an access audit? A: Yes. You can request a medical record access audit if you believe that your protected health information may have been accessed inappropriately. A request can be made by e-mailing Corporate Compliance at email@example.com or calling 410-328-DUTY. Find News&Views online at http://www.umm.edu/nursing/newsletter.htm and on the UMM Intranet at intra.umm.edu/ummc/nursing-dept/newsviews.htm Editor Anne E. Naunton, MS, RN-BC Professional Development Coordinator Clinical Practice and Professional Development Editorial Board Susan S. Carey, MS Professional Development Coordinator Clinical Practice and Professional Development Mary Ellen Connolly, MS, CPNP Pediatrics Suzanne Leiter Executive Assistant to the Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services Greg Raymond, MS, MBA, RN Director, Nursing and Patient Care Services Clinical Practice, Professional Development, Neuroscience, Behavioral Health and Supplemental Staffing Lisa Rowen, DNSc, RN, FAAN Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services Mihae Shin-Diep, MS, CRNP Interventional Radiology Angela Sintes Tyrrell, MS, RN, CNL Clinical Education Specialist Clinical Practice and Professional Development News & Views is published quarterly by the Department of Nursing and Patient Care Services of the University of Maryland Medical Center. Scope of Publication The scope of News & Views is to provide clinical and professional nursing practice topics that focus on inpatient, procedural, and ambulatory areas. Submission Guidelines Send completed articles via e-mail to firstname.lastname@example.org. Please follow the guidelines provided below. 1. Font – Times New Roman – 12 pt. black only. 2. Length – Maximum three double spaced typed pages. 3. Include name, position title, credentials, and practice area for all writers and anyone named in the article. 4. Authors must proofread the article for spelling, grammar, and punctuation before submitting. 5. Provide photos and embedded images in separate .jpg files. 6. Submit trend data in graphic format with labeled axes. 7. References must be numbered consecutively and provided at the end of the article. 8. Editor will seek expert review of articles to verify and validate content. 9. Articles will be accepted based on appropriateness of content and availability of space in each issue. 10. Articles that do not meet the above guidelines will be returned to the author(s) for revision and resubmission. Issue Spring 2013 Summer 2013 Fall 2013 Winter 2014 Due Date April 8, 2013 July 8, 2013 October 7, 2013 January 6, 2014 Displaying Credentials The UMMC Standard for displaying of credentials is based on the ANCC Guidelines. The preferred order is: • highest earned degree (can list more than one if in different fields) • licensure • state designations or requirements • national certifications and honors • other recognitions Nurses with two or more nursing degrees (MSN, BSN) should only list their highest nursing degree, along with other degrees obtained. Example: Betty Smith, MSN, MBA, RN. Why this order: The education degree comes first because it is a “permanent” credential, meaning it cannot be taken away except under extreme circumstances. The next two credentials (licensure and state designations/requirements) are required for you to practice. National certification is sometimes voluntary. Awards, honors, and other recognitions are always voluntary. If you would like additional information, please visit http://www.nursecredentialing.com and search using the word “credentials”. news &views The APN Role in Delirium Recognition and Management in the Medical ICU Tracey Wilson, MSN, CRNP and Kimberly Bowers, MSN, CRNP, Medical ICU Delirium occurs in approximately 30% of all inpatient admissions and up to 80% of critically ill patients.1 It is associated with increased morbidity and mortality and can lead to residual neurological and cognitive impairments. The Medical ICU (MICU) APN team has made delirium recognition and management a priority. Patients are screened daily for risk factors that may contribute to delirium. Definition and Risk Factors Delirium is characterized as changing and fluctuating mental status, inattention and disorganized thinking, which may or may not be accompanied by agitation.2 Confusion may stem from multiple factors, such as acute medical conditions, side effects of commonly prescribed medications and changes in the environment. Patients may experience three types of delirium. ◗◗ Patients with hyperactive delirium will demonstrate agitation, restlessness, or combative behavior. These patients typically have increased reactions to stimuli. ◗◗ In hypoactive delirium, the patient is lethargic or apathetic and displays slow speech and movements. ◗◗ The third type is a mixed delirium. The majority of patients have a combination of both hyperactive and hypoactive symptoms with periods of fluctuations. In non-ICU settings, the prevalence of subtypes are 30% hyperactive, 24% hypoactive, and 46% mixed delirium.3 There are both modifiable and non-modifiable risk factors for development of delirium as listed in the following table:4 Modifiable Risk Factors Non-modifiable Risk Factors Fever, Nutrition, and Hydration Use of Restraints Metabolic Derangements Untreated Pain Natural Daylight/Sleep Cycle Noise Levels Visitor Presence Many Medications (including benzodiazepines and narcotics) Acute Illness History of Cognitive Impairment Increased Age Male Gender Multiple Co-morbidities Malignancy Alcohol Use Poor Functional Status Screening and Early Prevention for Delirium Early screening tools are utilized by the APN team during daily assessments. The Confusion Assessment Method (CAM) and an adapted tool for the ICU, CAM-ICU, are widely used and highly reliable and validated screening tools. The tools can be completed in two minutes with 98% accuracy, which is comparable to the results in the traditional full DSM-IV assessment. Since the hallmark characteristic of delirium is a fluctuation in mental status, the key for success in detecting the syndrome relies on frequent monitoring with an approved assessment tool such as the CAM or CAM ICU.5 Once delirium is recognized, further decline and removal of the possible insulting agent are both important variables. Modifying underlying metabolic derangements, removal of any unnecessary medications and restoration of an appropriate sleep/wake cycle are early key steps that can be taken to reverse the condition. Treatment Options Currently, there are limited treatment options for acute delirium. As discussed, removing the insulting agent is typically the first step. Providing a safe environment and supportive care are also key interventions. If the patient has significant symptoms and combative behaviors, haloperidol can be used to control symptoms. Haloperidol exerts a stabilizing effect on cerebral function by antagonizing dopamine-mediated neurotransmission at the cerebral synapses and basal ganglia.6 Some of the other atypical antipsychotics, such as quetiapine, are currently being investigated as alternative treatments for delirium. A common pitfall is the use of benzodiazepines, which can worsen the delirium.7 Case Study Mr. S. is a 54-year-old male who underwent liver transplantation and presented to the intensive care unit with CMV infection and sepsis. He is malnourished and weak. On day 12 of his hospital stay, the nurses describe the patient as alert and oriented but “not quite right.” Mr. S. is noted to be picking at his gown, IV lines and other tubing. Since the patient is alert and easily redirected, his behavior is overlooked. Later that day he becomes combative and nearly removed his central line and endotracheal tube. He is now restrained, which further aggravates his behavior. His wife visits and finds her husband restrained and severely agitated, which upsets her. If his risk factors and symptoms were appreciated earlier by using a screening tool, he would have been screened as CAM-ICU positive and steps could have been taken to avoid his severe symptoms and family distress. The APN and RN teams are crucial in the early detection, screening and potential avoidance of delirium. It is vital that delirium screening continues to be a part of daily assessments in the ICU setting. Early detection and diagnosis can save a patient’s life. 1 2 3 4 5 6 7 Plaschke, K., von Haken, R., Scholz, M., Engelhardt, R., Brobeil, A., Martin, E., & Weigand, M. A. (2008). Comparison of the confusion assessment method for the intensive care unit (CAM-ICU) with the Intensive Care Delirium Screening Checklist (ICDSC) for delirium in critical care patients gives high agreement rate (s). Intensive Care Medicine, 34(3), 431-436. Ely, E. W., Margolin, R., Francis, J., May, L., Truman, B., Dittus, R. & Inouye, S. K. (2001). Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine, 29(7), 1370-1379. Nelson, L. S. (2009). Teaching staff nurses the CAM-ICU for delirium screening. Critical Care Nursing Quarterly, 32(2), 137-143. Honiden, S. and Siegel, M. (2010). Analytic reviews: managing the agitated patient in the ICU: Sedation, Analgesia and Neuromuscular blockade. Journal of Intensive Care Medicine, 25: 187. Devlin, J. W., Mallow-Corbett, S., & Riker, R. R. (2010). Adverse drug events associated with the use of analgesics, sedatives, and antipsychotics in the intensive care unit. Critical Care Medicine, 38, S231. Devlin, J. W., Mallow-Corbett, S., & Riker, R. R. (2010). Adverse drug events associated with the use of analgesics, sedatives, and antipsychotics in the intensive care unit. Critical Care Medicine, 38, S231. Devlin, J. W., Mallow-Corbett, S., & Riker, R. R. (2010). Adverse drug events associated with the use of analgesics, sedatives, and antipsychotics in the intensive care unit. Critical Care Medicine, 38, S231. 3 4 Winter 2013 Hand Hygiene: The Patient Perspective In Ambulatory Care Jacqueline Rodriguez, BSN, RN, Sr. Quality and Compliance Coordinator, Ambulatory Services Hand hygiene is critical in the prevention of infection for patients and health care workers. According to the Centers for Disease Control and Prevention (CDC),1 “In the United States, hospital patients get nearly two million infections each year or about one infection for every 20 patients. Infections that patients get in the hospital can be lifethreatening and hard to treat. Hand hygiene is one of the most important ways to prevent the spread of infections.” Various direct observation techniques have been utilized by UMMC to collect data for evaluation of hand hygiene compliance. These methods have inherent problems for the ambulatory care setting. Patients in the ambulatory setting are seen by the clinical staff behind closed doors which makes it difficult for an observer to monitor hand hygiene in the room. Even in cases where hand sanitizer gels are mounted outside clinic exam room doors, an observer cannot accurately account for hand hygiene done inside of the room. Recent literature has promoted the use of patients to observe hand hygiene. Recruiting patients in the observation process to monitor hand hygiene supports the Joint Commission’s National Patient Safety Goals to reduce infection, but also engages the patients in their care.2 Patient observation of hand hygiene compliance was piloted in three outpatient clinics at UMMC. Patients were given a survey card and instructed about the hand hygiene observation process by the front desk personnel at the time of check-in. Patients preformed the observations and placed the card in a drop box after their visit. Cards were retrieved weekly and results were analyzed by the project lead. Physicians, nurses, and clinical staff were educated about the patient observation method. Posters were developed using pictures of clinic staff to help promote the concept of a team approach to hand hygiene. The initial results are promising for using patient observation to monitor compliance with hand hygiene. Table I shows the pilot results of an overall clinic staff hand hygiene compliance rate of 93%. Table 1 Hand Hygiene Compliance Scores Initially, a concern was raised that this activity could have a negative impact on the staff and patient relationship. However, what was discovered through the pilot phase was the just the opposite. Many patients commented to staff or documented on the survey card their appreciation for including them in a strategy to measure the quality of their care. Based on the success of the pilot project, UMMC rolled out this process in phases in all the UMMC ambulatory care clinics. These clinics will continue to use the direct-observer process for monitoring hand hygiene. In addition, the patient observation approach will be performed on a quarterly basis to supplement the data and to correlate the results with the direct observation technique. The goal is to provide a complete account of hand hygiene compliance in the ambulatory setting and positively impact the overall quality of care. 1 2 www.cdc.gov/handhygiene.html Bittle, M. & LaMarche, S. (2009). Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. The Joint Commission Journal on Quality and Patient Safety, 35, 10AP1. Handwashing Survey Card news &views 2013 NDNQI Pressure Ulcer Prevalence Survey Omnicell Restocking The batch for Omnicell restock is automatically generated in the pharmacy storeroom. The amount to restock is generated based on the quantity on hand versus the PAR level. The storeroom technicians pull medications from the carousels for Omnicell restock. Most units have a batch generated twice daily, and Gudelsky units have a oncedaily restock. All inpatient units have a restock at least once every 24 hours. If at any time the nurse needs a medication that is out of stock prior to the daily restock, please request it on a patient-specific basis from the pharmacy satellite. The pharmacy satellite should supply enough doses until the machine is restocked. If nurses or technicians notice items frequently out of stock, please report it to your pharmacy manager. Please contact Bethany Shelbourne via email at bshelbourne@ umm.edu if you have additional questions about this process. Issues about Omnicell can be emailed to email@example.com. Mark your calendars for the 2013 NDNQI Pressure Ulcer Prevalence Survey on these dates: Survey 1 - February 20 or 21 Survey 2 - May 22 or 23 Survey 3 - August 21 or 22 Survey 4 - November 20 or 21 In each of the four survey periods, unit champions will complete the survey on one of the days. Champions should arrange schedules accordingly to allow for survey completion. Units should identify a staff member who is working on one of the two days to conduct the survey. Please contact the Wound Ostomy Continence nurse who covers your unit to identify the person responsible for completing the survey or you can leave a message at ext. 8-6448. Conquering CAUTI, continued from page 1. was on best practice and the use of data to develop processes that maximize care outcomes. Several units at the Medical Center were commended for their participation and efforts. Recently, however, the MHA notified UMMC that we had a significant rate of CAUTI despite earlier efforts. These outcomes are now publicly available data. Creating Solutions – What Are We Doing? We’re making CAUTI a priority and focusing on evidence-based practice (EBP) prevention efforts, starting where they could have the greatest impact. Internal data from our own infection prevention team clearly identifies the fact that 75% of the CAUTIs that occur at UMMC do so in an ICU setting. We are looking at these units first and working with leadership for those areas to standardize best practice. Considerable focus is on: ◗◗ Reaching consensus over standardizing goals for urinary catheter removal in the ICU. This will include consideration regarding which patients require hourly urine output measurement. ◗◗ A standardized EBP approach to obtaining cultures – instituting a trial that revises the fever protocol. We think this will have an impact on reducing the false positive results that could be making our outcomes appear worse. The pilot will add a twostep process for obtaining a urine white blood cell count from the urinalysis as a screening tool to identify patients who may not need a culture. ◗◗ Implementation of a new all-in-one catheter kit that includes additional infection prevention tools: • wipes for perineal care prior to catheter insertion; • labels for the bag and patient chart to remind staff to remove the catheter as soon as appropriate; • a securement device that has been shown to prevent catheter migration; and • educational literature to help engage patients and families in their care. New Interdisciplinary Efforts A large interdisciplinary performance improvement team that contains strong leadership and expertise has formed and begun to work on projects and solutions that will have an impact. They have initiated an evaluation of current equipment and bladder scanner use. In addition, they are evaluating current policy to ensure that we focus on evidence-based best practice. A new fever protocol has been initiated in the adult ICUs, as well as the Shock Trauma Center. Nursing has initiated a large scale CAUTI education marathon with a focus on standardized urinary catheter insertion procedure, standardized EBP approach to supportive care (collection bag below patient when in bed and below knee when ambulatory), timely patient hygiene, and emptying collection bags before transport. Next Steps The performance improvement team will be generating a centralized “public” dashboard for CAUTI. The team will also conduct a complete equipment review and implement a more standardized equipment plan, including the creation of a urinary-retention protocol that utilizes bladder scanners and a straight catheter regimen that will reduce the prolonged utilization of indwelling catheters. The team is working through a proposal to standardize repair and recalibration of our bed scales to improve their accuracy and to recalibrate them any time they are returned to equipment distribution. The team is also evaluating concepts for improving care coordination and communication, such as daily goals forms and nursing involvement in interdisciplinary unit rounds. You Can Help We need all bedside caregivers at the Medical Center to make it a priority to prevent CAUTIs. Always ask the question, “Does my patient really need this catheter?” If not, ask to have it discontinued or follow the catheter removal protocol for nurses. It is critical to our success to pay attention to detail on the best practices listed in this review and available on your unit. Together, we can have a big impact on reducing the incidence of urinary tract infections and continue to provide the best evidence-based care for our patients. Magill SS, Hellinger W, et al. Prevalence of healthcare-associated infections in acute care facilities. Infect Control Hosp Epidemiol. 2012;33:283-91. 2 Scott Rd. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention, 2009. Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases, Coordinating Center for Infectious Diseases, Centers for Disease Control and Prevention, February 2009. 3 http://www.cdc.gov/HAI/ca_uti/uti.html 1 5 6 Winter 2013 UMMC Falls Prevention Program … How Are We Doing? Luizalice Lima, MS, RN-BC, Professional Development Coordinator, Clinical Practice and Professional Development The UMMC Falls Prevention Program was successfully implemented in October 2012. Departments were busy educating their clinical and non-clinical staff in November, including Supplemental Staffing, Rehabilitation Services, and Clinical Nutrition. The non-clinical selflearning module was translated into Spanish to meet the needs of our Spanish-speaking employees. In December, the unit-based falls champions conducted a compliance audit with the different components of the program. The results were collected in “Survey Monkey” and were compiled by the falls committee leadership. Call Don’t Fall Thirty-eight units and services were audited; the results are listed below: Daily Huddles-how often? None: Once/day: Twice/day: Three/day: 21% 10.5% 55.3% 13.2% Are falls discussed during daily huddles? Yes: 83.3% No: 16.7% Yes No Board & Components Fall tracking poster visible? 100% Poster up to date with days without falls? 92.2% 7.8% Poster displays overall unit “Goals and Expected Outcomes”? 97.4% 2.6% Poster displays “Action Plan and Interventions” in case of a fall? 89.5% 10.5% Poster displays post fall huddle? 78.4% 21.6% 91.1% 8.9% Poster displays “Falls News, Updates, and Data”? Post-fall huddle forms should be faxed by charge nurses and/or unit champions to the falls committee’s leadership for analysis. Frequently, the forms are incomplete and do not portray what happened at the moment of the event. For example, what was the patient trying to do when the fall occurred? Occasionally the prevention interventions post-fall are the same as pre-fall, even if a patient fell from a bed or chair and alarms were not on (still not “checked” on the form) and the fall risk did not increase by at least 15 points after a fall (score remains the same). Unit managers and champions were contacted regarding these cases. Month # Falls # Huddle Forms % November 46 19 41 December 44 12 27.3 January 2013 53 16 28.5 Of all the huddle forms received in November and December, most falls were preceded by “hourly caring rounds” within 60 minutes of the fall. Also, falls were mostly related to toileting and reaching out for personal items. This brings to mind a question … Are purposeful hourly caring rounds being done? Do they include the “4 Ps” and the question, “Is there anything else I can do for you?” Purposeful rounding is a proactive tactic to engage patients and families. When performed properly, rounds demonstrate a positive impact on nursing quality indicators, such as falls. Instead of increasing hourly rounds as suggested on many of the post-fall huddle forms, making effective and purposeful rounds may generate better results. A few falls occurred while patients were in the chair without a chair alarm. The falls committee will continue to analyze data from these forms in order for us to learn more about falls. Please make sure to fax them to Luiza Lima at 8-8258. In collaboration with the UMMS Fall Prevention Task Force and UMMS Corporate Quality Office, the UMMC Falls Committee provides a monthly fall report to senior leadership and nurse managers. This report includes the number of falls in any given month (not by inpatient days), number of falls with injuries, the top 10 units with the highest fall rates, three-month comparisons, day of the week and time of the day when falls occur and missing fields on incident reports. If you want to receive this report on a regular basis, please contact Jennifer Motley, BSN, RN, Senior Clinical Nurse I, Multitrauma IMC, Falls Committee Chair, by emailing firstname.lastname@example.org. The next phase of the Falls Prevention Program will be a contest from February 1 to April 1, 2013. This is an opportunity to engage staff by working as individuals or teams to create a unique, appealing, and memorable message that can be used throughout the various UMMS facilities to intensify staff and patient awareness of fall risks and prevention strategies. Entries can vary … posters, videos, songs, mascots or super heroes! Each organization will hold its own contest to select winners and award prizes. The first-place winning entry from each organization will be submitted to UMMS Corporate Quality for the selection of system winners. Cash prizes will be awarded. Karen Doyle, MBA, MS, RN, NEA-BC, Vice President of Nursing and Operations, R Adams Cowley Shock Trauma Center and Emergency Nursing, is the executive sponsor and a great supporter of falls prevention at the Medical Center. If you want to join the UMMC Falls Committee, please contact Luiza Lima at email@example.com. news &views ► Guidelines ►Want to show off your creativity and your dedication to Preventing Patient Falls? Then submit an entry for the Falls Prevention Campaign contest to Luiza Lima between February 1st and April 1st, 2013. ►Our hospital winners will be announced in May 2013. o 1st Place will receive $100 and will be our hospital entry in the UMMS (University of Maryland Medical System) finalists contest o 2nd Place will receive $50 and o 3rd Place will receive $25 ►The UMMS winners will be announced no later than June 1, 2013. o 1st Place will receive $250 and their winning campaign message will be featured in various campaign messages throughout the UMMS facilities and community o 2nd Place will receive $150 and o 3rd Place will receive $75. o All other UMMS finalist entries will receive an honorable mention and will be highlighted in a Here is how to join the fun: • All entries, including the winning entry, will become the property of UMMS. All hospital entries will be reviewed by the hospital Falls Committee for selection of hospital winners. UMMS finalists will be reviewed by the UMMS Falls Committee members, who will select the UMMS winners. • Entries can be sent in by an individual or a group. To be eligible to submit an entry, you must be an employee, auxiliary volunteer or member of the medical staff in one of the UMMS hospitals. ► Submissions will be judged on: • • • • Creativity & originality ► Submissions will be judged on: Conveying the message about how important it is to CARE about preventing falls • Creativity & originality Conveying the message of how important it is to with patients andfalls their families to prevent falls • Conveying the message about how important it ispartner to CARE about preventing • Conveying the message message of(ex.: how poster, importantvideo, it is to mascot, partner with patients and their families prevent Create a campaign etc.) that reminds others to that falls falls are a major • Create a campaign message video, mascot, that reminds responsibility. others that falls are a major problem for hospitalized patients(ex.: andposter, that preventing fallsetc.) is everyone’s problem for hospitalized patients and that preventing falls is everyone’s responsibility. ► Submit your message to Luiza Lima by April 1, 2013. Entries can be emailed to firstname.lastname@example.org or sent via ► Submit your message to Luiza Lima by April 1, 2013. Entries can be emailed to email@example.com or sent via interoffice mail to:mail Clinical Practice & Professional Office S. Paca Street, 2nd floor. interoffice to: Clinical Practice & ProfessionalDevelopment Development Office at at 110110 S. Paca Street, 2nd floor. that include copyrightedmaterial material must must provide that that shows that that NOTE:NOTE: EntriesEntries that include any any copyrighted providedocumentation documentation shows copyright permission has been obtained or that it can be obtained. copyright permission has been obtained or that it can be obtained. For more information contact Luiza Lima – firstname.lastname@example.org For more information contact Luiza Lima – email@example.com Have fun – it’s contagious! Have fun – it’s contagious! 7 8 Winter 2013 Rounding Report, continued from page 1. Nurses are excellent at fixing things, so each nurse either fixed or switched out his/her own pump and continued on with patient care, and didn’t consider entering it as a safety event in RL Solutions Event Reporting System. I understand why no one considered documenting the situation. In the busy shift of a nurse, you are moving so quickly and multi-tasking at such a rapid pace, the notion of documenting a random pump issue is not appealing and may seem to have no value. It would require time and energy and it may not even make sense to you. Why not just remove the pump from the pole, tag it as broken, replace it with a functional pump, and move on? Here’s why: By choosing not to report a random safety event about a process, piece of equipment, communication, or system, we will not learn of and address existing safety trends. If we know one pump has broken, it is one broken pump. If we know 20 pumps have broken, it raises a red flag and requires some investigation. If we know 100 pumps have broken, it is a crisis and must be immediately addressed. Observable trends highlight safety issues, by shining a spotlight on them and requiring action to address their root causes. One of our biggest challenges in addressing safety issues is that we have multiple ways to report issues. Because of the many ways to report or document an event, we have unintentionally created a diluted and diffused reporting environment, where we do not have one data repository of all our safety issues. If a safety event occurs, depending on the type and magnitude, you can do one or more of the following actions: ◗◗ Tell the charge nurse on your shift ◗◗ Verbally tell your manager ◗◗ E-mail your manager ◗◗ Call your manager ◗◗ Text your manager ◗◗ Send an e-mail to the manager of another area ◗◗ Enter a report in RL Solutions ◗◗ Call Risk Management ◗◗ Call SOSC ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ Call Security Call Rapid Response Call in-house Emergency Call the Exposure Hotline Call Human Resources Call Infection Control Call 8-SAFE Call the Help Desk Call the Compliance Line Enter a report to the Code of Conduct Committee Do some other creative thing Tell no one because you’ve addressed it on your own Ignore it (this is a worrisome option and should not be used) We are on a never-ending quest to make the Medical Center the safest possible environment for patient care provision. In this effort, I believe we need to do three things: First, we need to consider all potential and real safety events, even those that seem like a random one-time event, important enough to report. Second, we need to take the time and demonstrate the care to report all potential and real safety events. Third, we need to report all potential and real safety events in one consistent manner. Only when we have achieved these three things, will we be able to review the data and reports, separate the one-time events from the trends, and systematically address and improve our safety issues. As the SNC continues to look at our multiple event-reporting venues and explore alternatives with our internal experts, please share your thoughts and experiences with your representative on the Council. Your insight and suggestions will help us move to an easier and standardized approach to support the continuous advancement of our safety culture. Keynote Speaker: Vicki D. Lachman, PhD, APRN, MBE, FAAN Clinical Professor, Drexel University College of Nursing and Health Professions Topic: "Moral Courage" Additional Topics Include: Cultural Competence The Impaired Nurse Drug Diversion 8:00 AM - 5:00 PM Online Registration begins March 4, 2013 Register at trends2013.eventbrite.com For additional information, email firstname.lastname@example.org www.umm.edu Medical Ethics & Decision Making Professional Boundaries & Social Media Mock Trial news &views Core Measures Sylvia Daniels, BSN, RN, Manager, Regulatory Compliance & Outcomes, Clinical Safety and Quality All Joint Commission accredited hospitals are currently required to collect and submit data for four core measure sets. In January 2014, this requirement will be expanded to six. Four of the six measure sets will be mandatory for all general hospitals that serve specific patient populations addressed by the measure sets and related measures. These measure sets include acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN) and the Surgical Care Improvement Project (SCIP). These core measure sets are common to several federally legislated programs and selected most frequently by hospitals to meet their ORYX requirement. The Medical Center has reported these measure sets to the Joint Commission since 2002 and to the Maryland Health Care Commission since 2010. For hospitals with 1,100 or more births per year, the perinatal core measure set will become the mandatory fifth measure set. The Joint Commission chose the perinatal care measure set because of the high volume of births in the United States (four million per year), and because it affects a significant portion of accredited hospitals. The Medical Center has more than 1,500 births a year. Therefore, we will collect, submit and work to improve the measures in Table 1 in the perinatal core measure set. Table 1 Measure Description Patients with elective vaginal deliveries or elective cesarean sections at >=37 and <39 weeks of gestation completed. PC-01: Elective Delivery PC-02: Cesarean Section Nulliparous women with a term, singlet baby in a vertex position delivered by cesarean section. PC-03: Antenatal Steroids Patients at risk of preterm delivery at >=24 and <32 weeks gestation receiving antenatal steroids. PC-04: Health Care-Associated Bloodstream Infections in Newborns Staphylococcal and gram-negative septicemias or bacteremias in high-risk newborns. PC-05: Exclusive Breast Milk Feeding Exclusive breast milk feeding during the newborn’s entire hospitalization. Our sixth measure set will be children’s asthma care (CAC), which we currently collect and submit to the Maryland Health Care Commission. This is used to meet the measurement requirement for our Joint Commission Pediatric Asthma Certification. The CAC measures are: 1. Relievers for Inpatient Asthma (CAC-1) 2. Systemic Corticosteroids for Inpatient Asthma (CAC-2) 3. Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver (CAC-3) The data derived from CAC and the other core measure sets are used by the Medical Center for internal quality improvement, by the Joint Commission, as part of the accreditation process, and by CMS and the Maryland Health Care Commission to monitor the quality of care provided to hospitalized patients. The core measure data is publicly reported on the Joint Commission’s website at Quality Check, on CMS’s website at Hospital Compare, and on the Maryland Health Care Commission’s website at Maryland Performance Evaluation Guide. Below is a graph showing our performance on CAC for fiscal year 2012: Asthma Care (CAC) Children's 105 100 Rate The Joint Commission Expands Core Measure Requirements 100 100 92.4 95 90 85 99.9 99.6 85.8 80 75 CAC-1 CAC-2 UMMC TJC CAC-3 Childrens Asthma Care (CAC) 9 10 Winter 2013 Interprofessional Task Force Uses A Collaborative Approach For Enteral Feeding Tube Management Christine Provance, MS, RN, Clinical Education Coordinator, Neurocare Acute and IMC Allison Murter, MSN, RN, Professional Development Coordinator, Clinical Practice and Professional Development The placement of nasogastric (NG) feeding tubes is a common practice for patients who are unable to take oral feedings or medications. This skill is a component of basic nursing education and a required competency for the successful completion of new graduate orientation. The methods that were taught to many nurses to confirm the blind placement of NG tubes have recently been deemed ineffective. The auscultation method has shown to be unreliable in distinguishing between respiratory and gastric placement. NG feeding tubes are malpositioned in 1.3% to 3.2% of all insertions, and 28% of tube malpositions result in pneumonia or pneumothorax.1 Over the past year at the Medical Center, multiple incidents have occurred where the placement of blindly inserted NG tubes has caused patient harm. During Clinical Practice Council (CPC) meetings, the subject of malpositioned feeding tubes has been discussed several times, with the subsequent identification of inconsistencies in verification practices among nursing units. The review of the literature revealed that the American Association of Critical Care Nurses (AACN) guidelines recommend radiographic confirmation of NG (enteral) tube placement prior to initial use for feedings or medication administration as a best practice.2 With this knowledge and the potential impact of changing institutional practice, registered dietitians from CPC volunteered to collaborate with nursing by collecting data on enteral tube insertion and verification practices throughout the Medical Center. Nurses and dietitians created a data collection tool to track all enteral feeding tube placements over a two week period. The results are shown in Table 1. This data revealed that only 53% of the NG tubes placed for feeding had been X-rayed. Of that 53%, 11% of tubes that had been X-rayed were found to be in a less than optimal position, and those patients were being fed via the NG tube. Table 1 Enteral Feeding Tube Placement Data (N = 95) Criteria CorFlo Post-Pyloric Tubes Nasogastric Tubes Number placed 59/95 total tubes 36/95 total tubes Placement X-ray done (58/59) 98% (19/36) 53% % of X-rayed tubes in correct position (50/58) 86% (17/19) 89.5% Tubes not X-rayed (1/59) 2% (17/36) 47 % CorFlo* tubes in correct position (48/54) 89% placed in ICU in correct position (3/5) 60% placed in acute care in correct position *Used by ICUs 98% of the time The Director of Clinical Nutrition presented this data to CPC, and a riveting discussion ensued. There was concern on many levels that the number of tubes not confirmed by X-ray posed a significant risk to our patients. The group recognized the implications of a proposed practice change to require radiologic confirmation of all enteral feeding tubes. This included clinical and financial resources as well as provider support. Numerous council members volunteered to participate in a task force to develop a proposal for improving the safety of enteral tube insertion and placement verification. The task force included nursing, radiology, clinical nutrition, risk management, and nursing governance council leadership. The task force began with a review of the current Medical Center enteral feeding guidelines, located in the Clinical Practice Manual. In accordance with the CPC standard for policy revision, the task force also reviewed the Lippincott Nursing Practice Manual 3 and performed additional literature searches for best practice recommendations. This information provided compelling evidence to support the standard for radiologic confirmation after initial insertion of an enteral feeding tube.4 It required the revision of the current guidelines into a formal hospital policy to reinforce best practice among all disciplines. Over a two month period, the group met on a weekly basis to resolve issues and incorporate evidence-based standards in a new hospital policy for enteral tube management. Numerous challenges at the organizational level were identified as a consequence of establishing a standard of radiologic confirmation after initial insertion of an enteral feeding tube. Such a standard could potentially impact patient care and providers in numerous ways and included: ◗◗ The patient impact of additional exposure to radiation and delay in feeding and medication administration while awaiting placement confirmation. ◗◗ The additional requirement for providers to order and document placement of enteral tubes. ◗◗ An increased workload for radiology staff due to higher volumes of films and readings. ◗◗ The additional time required for nurses to verify orders and await placement confirmation. ◗◗ The system impact of additional charges for radiology films. ◗◗ IT implications for changing order sets to match the new standard of care. ◗◗ Pharmacy review of medication administration components and recommendations regarding the use of methylene blue. continued on page 11. news &views Introducing… The UMMC Patient and Family Partnership Council Kerry Sobol, MBA, RN, Director, Commitment to Excellence and Patient Experience Team On November 7, 2012, the UMMC Commitment to Excellence Patient Experience Team convened the inaugural meeting of the newly formed Patient and Family Partnership Council (PFPC). After a full year of planning, the Patient Experience Team, under the executive leadership of Lisa Rowen, DNSc, RN, FAAN, Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services and Kerry Sobol, MBA, RN, Director, Commitment to Excellence and Patient Experience Team, launched the Medical Center’s first patient and family advisory group in many years. Although there are patient and family advisory groups in the Greenebaum Cancer Center and Neonatal ICU, there has not been a broadly based group in place at UMMC for many years. Using resources, such as the Institute for Patient and Family Centered Care and the Institute for Healthcare Improvement,1 the team developed a plan to create a council made up of patients and their families with the following purposes: ◗◗ Improve and sustain the UMMC journey to excellence in patient and family centered care through empowerment, education, and engagement of the patient, family, and staff. ◗◗ Generate ideas, gain perspective, and understand the experiences and opinions of our patients and families, as it pertains to our current and future operations and services. The group has had two meetings. Dr. Rowen and Jeffrey Rivest, UMMC President and Chief Executive Officer, attended the kick-off meeting to share their appreciation for the team and their commitment to helping us further our understanding of the patient experience. Leonard Taylor, Senior Vice President, Operations and Support Services, attended the second meeting and shared his Enteral Feeding Tube Management, Standing left to right: Gena Stanek, Anne Naunton, Rick Bounds (patient), Michael Yater (patient), Melissa Parker (patient), Joseph Blount (patient), Eileen Chiat (patient/ family member), Jerome Chia, (patient/ family member), Lucy Miner, Kerry Sobol Sitting left to right: Marjorie Fass (patient), Connie Noll, Diana Macfarlane, Mary Lou Watson (family member) Photo reprinted with permission from patients and family members. extensive knowledge of our buildings and the history of our growth over the years. In addition, he led a building tour where the group visited the Patient Placement Center, the Stoler Pavilion, the laboratory, the Surgical and Endoscopy Suite, and the MASTRI Center. The group was so enthusiastic, that the tour will be continued at a future meeting. The Patient Experience Team looks forward to building a relationship with this group and expanding their input into everything from choosing colors to writing policies and procedures that affect the patient experience. 1 Balik, B., Conway, J., Zipperer, L., & Watson, J. (2011) Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care. IHI Innovation Series White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement. Available: www.IHI.org continued from page 10. Each of these issues were discussed in detail and considered when the enteral feeding tube management policy was developed. The biggest barrier identified was the availability of a radiologist to review non-emergent X-rays in a timely manner during off shifts. Radiology technologists communicated the proposed policy to their attending group, and an agreement was made to meet this need. The draft of the enteral tube management policy was presented at multiple forums, and it was reviewed by the interprofessional team that included nursing, providers, radiology technologists, radiologists, clinical nutrition, risk management, and pharmacy. The policy underwent revisions based on the feedback from these groups. This resulted in a collaborative policy that is comprehensive and addresses issues brought forward by each of the stakeholders. There is confidence that this practice change will improve the safety and quality of care and reduce the risks associated with enteral feeding tube placement. 1 2 3 4 Sorokin, R. & Gottlieb, J.E. (2006). Enhancing patient safety during feeding-tube insertion: a review of more than 2000 insertions. Journal of Parenteral Nutrition, 30, pp. 440-445. http://www.aacn.org/wd/practice/content/feeding-tube-practice-alert. pcms?menu=practice http://procedures.lww.com/lnp/view. do?pId=48092&s=p&fromSearch=true&searchQuery=nasogastric+insertion Baskin, WN. (2006) Acute complications associated with bedside placement of feeding tubes. Nutrition Clinical Practice, 21, pp. 40-55. 11 12 Winter 2013 Honorable Mention UMMC Named Leapfrog Top Hospital Seven Years In A Row The University of Maryland Medical Center (UMMC) ranks among the nation’s top hospitals for the seventh year in a row, according to the annual Leapfrog Group survey. The survey analyzes patient safety and quality performance measures from nearly 1,200 hospitals. UMMC is one of only two hospitals in the country, and the only hospital on the East Coast, to make the list every year since its inception in 2006. The Leapfrog Group’s annual hospital survey measures performance on a number of key patient safety and quality outcomes. Hospitals must meet Leapfrog’s stringent criteria, including standards focusing on core areas of hospital care. UMMC Honored For Environmental Success The University of Maryland Medical Center (UMMC) was honored for environmental health achievement with a Trailblazer award from the Maryland Hospitals for a Healthy Environment (MD H2E). Trailblazer awards are given annually to hospitals that have shown leadership in advancing sustainability in their operations. The Trailblazer award was given to the Mother/Baby Unit, which launched a pilot for new mothers to reduce newborn exposures to pesticides. This program, the first of its kind, provides education to new mothers on the health risks associated with pesticides. Mothers are given a tool kit that includes an educational DVD, a booklet, and non-toxic product samples, all provided in a reusable tote. R Adams Cowley Shock Trauma Center (STC) Program Wins Best Practice and Poster Award Ruth Adeola, MS, RN, Injury Prevention Program Coordinator and Alyson Schuster, BSN, RN, Senior Clinical Nurse I, presented the poster titled, “R Adams Cowley Shock Trauma Center Hospital-Based Prevention Program” at the Trauma Center Association of America annual conference in Charleston, SC in October, 2012. The poster highlighted all the prevention programs provided at STC through the Center for Injury Prevention and Policy (CIPP). The poster was voted “Best Practice and Poster Winner” from the thirty five entrees submitted at the conference. CCU Achieves Beacon Status Congratulations to the Cardiac Care Unit, which successfully achieved Beacon status from the American Association of Critical Care Nurses (AACN). This award recognizes individual clinical units that distinguish themselves by improving every facet of patient care. There is only one other clinical unit in a Maryland hospital that currently holds Beacon status. A beacon is defined as a signal for guidance, a source of inspiration, or a call to assemble for some great purpose. For patients and their families, the Beacon award signifies exceptional care through improved outcomes and greater overall satisfaction. For critical care nurses, the Beacon award can mean a positive and supportive work environment with greater collaboration between colleagues and leaders, higher morale, and lower turnover. In 2011, the AACN created three tiers of the Beacon award to be given to hospital units that meet highly stringent criteria. These tiers are bronze, silver, and gold level designations. The CCU at UMMC was awarded the silver level designation, which will remain in place for the next three years. Silver level recipients demonstrate continuous learning and effective systems to achieve optimal patient care. The only other current Beacon award unit (at any level) that has achieved a silver designation in the State of Maryland is the CVSICU at the Washington Adventist Hospital. Left to right: Tara Reed-Carlson, Ruth Adeola, Alyson Schuster news &views Professional Advancement Model Promotions Congratulations to the following UMMC nurses promoted in October 2012 Senior Clinical Nurse I (SCNI) Courtney Cioka, BSN, RN Select Trauma IMC Kelly Ables, BSN, RN Select Trauma IMC Courtney Turnbull, MS, RN Select Trauma ICU Emily West, BSN, RN Multitrauma ICU Stacy Hopkins, RN* Trauma Acute â€“ 4STA Kathleen Lee, BSN, RN, CNOR Shock Trauma OR Barbara Burns-McCoy, BS, RN, CNOR, RNFA Shock Trauma OR Elizabeth Henry, BSN, RN Electrophysiology Lab Sarah Woodring, BSN, RN Medical IMC Michele Frock, BSN, RN Medical IMC Kathryn Mello, RN, CMSRN* 13 East/West Amanda Kelly, BSN, RN 13 East/West Tonnette Branch, RN, CMSRN* 13 East/West Christina Miller, BSN, RN Transplant Elisa Jones, MS, RN, CNL Transplant Bobbie Perreault, RN* PICU Victoria Phelps, BSN, RN-BC Medical Progressive Care Sonya Tanner, RN* 10 East Jane Munoz, RN, IBCLC* NICU * Commitment to enroll in a BSN program and graduate by July 1, 2015. Senior Clinical Nurse II (SCNII) Breighanna Wallizer, BSN, RN, CCRN Multitrauma ICU Katrice Royster, MS, RN, OCN Hematology/Oncology N8W/N9W Deborah Grau, MS, RNC-OB Labor & Delivery Victor Giustina, BSN, RN, CLNC Trauma Resuscitation Unit Programs Enhancing Collaborative Care in R Adams Cowley Shock Trauma Center (STC) Center for Injury Prevention and Policy (CIPP) and Trauma Prevention Nursing Council Alyson Schuster, BSN, RN, Senior Clinical Nurse I, Trauma Prevention Nursing Council Chair Ruth Adeola, MS, RN, Violence and Injury Prevention Program Coordinator In 2011, the R Adams Cowley Shock Trauma Center created the Center for Injury Prevention and Policy (CIPP), led by director Mayur Narayan, MD, MPH, MBA and Tara Reed Carlson, MS, RN. This center is comprised of an interprofessional team that is focused on injury trends and development of injury prevention education programs. The established mission of the CIPP is to reduce preventable injuries and violence and reduce the consequences while establishing a culture of injury prevention in Maryland. A Trauma Prevention Nursing Council was created in May 2012 to collaborate with CIPP for facilitation, planning and implementation of trauma prevention programs. The council is chaired by Alyson Schuster, BSN, RN, Senior Clinical Nurse I. The membership consists of representatives from each trauma unit. High school educational programs are provided by the Trauma Prevention Nursing Council in the state of Maryland. These educational assemblies focus on impaired and distracted driving. In 2012, 61 programs were conducted, with a reach of 16,862 teens. In addition, on-site injury prevention classes are provided once a week to at-risk teens. Teens receive a curriculum on trauma prevention and decision making followed by a tour of the STC. These teens come from Howard, Anne Arundel, Fredrick, Carroll, Baltimore, and Cecil counties. In fiscal year 2012, approximately 400 teens attended the on-site injury prevention classes at STC. Trauma Survivors Network Katharine Moore, Trauma Survivors Network Coordinator, STC Established in 2009, the Trauma Survivors Network (TSN) is a community of patients and families who are looking to connect with one another and rebuild their lives after a serious injury. The TSN has many components that provide efficient access to information. One component is peer support from trauma survivors who meet with current trauma patients to provide encouragement and perspective. Left to right: Katharine Moore, This is an effective strategy coming from a survivor who Ruth Adeola, and Nicole Otto has had the personal experience in STC. Another component is training of providers to promote patient use of the TSN program services, monthly support group meetings, and Next Steps, an online program to help survivors adjust to life after trauma. The TSN currently has about 250 active members, 20 of which are trained as peer visitors. Their mission is to provide programs and resources to trauma patients and their families to manage their recovery and improve their lives. The Trauma Survivors Network participated in the Baltimore Running Festival as a charity team for the second year in October 2012. Team TSN had 80 runners, who collectively raised just over $20,000. Registration to join Team TSN in the 2013 Baltimore Running Festival will open soon. Violence Prevention Program Nicole Otto, MSW, LCSW-C, Clinical Supervisor, Violence Prevention Program, STC The Violence Prevention Program (VPP) is determined to reduce the frequency and severity of recidivism for violent injury and criminal activity among persons living in and around Baltimore City. The VPP includes several component services: Violence Intervention Program (VIP); Promoting Healthy Alternatives for Teens (PHAT); and My Future-My Career (MF-MC). 13 14 Winter 2013 Medical Orders for Life-Sustaining Treatment (MOLST) Implementation at UMMC Karen Kaiser, PhD, RN, Clinical Practice Coordinator, Clinical Quality and Safety Diane Gregg, LCSW-C, MSSA, Director, Social Work & Human Services The Maryland State Legislature passed a law to implement Medical Orders for Life-Sustaining Treatment (MOLST) to increase the likelihood that a patient’s wishes to receive or deny care are honored throughout the health care trajectory These orders do not expire and are portable. The Medical Center is expected to comply with MOLST, unless it is medically inappropriate. Health care providers must take a more active role in asking about and documenting admitted patients’ medical care wishes during hospitalization. Upon admission, all patients (including infants and children) will be screened for the presence of MOLST or similar documents (see Table 1). There is a new state form for MOLST, so it may be unfamiliar to patients. This process is similar to screening for and obtaining the Advance Directive (AD). Since most patients will have a discussion about MOLST during their hospital stay, it is important that patients and their families are prepared. Nurses should focus the patient education about MOLST on the talking points that are highlighted in Table 2. A new patient handout, “Ten Things Everyone Should Know About Maryland MOLST,” is a good resource for this discussion. Versions are available for the patient, as well as for the Authorized Decision Maker (ADM), in English and Spanish. Since the pediatric patient is unlikely to require MOLST, applicable children’s ADM education is deferred until closer to discharge after the primary team has determined that MOLST is applicable. The existing MOLST orders are transcribed into PowerChart/First Net by the primary team. Code status and treatment limitations orders are being updated to reflect MOLST options. Treatment limitations specify patient/ADM wishes regarding blood transfusions, antibiotics, fluids and nutrition, dialysis, medical workups, etc. Goals of care and treatment modifications may occur during a hospital stay based on the patient’s condition and the on-going dialogue with the patient or their ADM. The primary team reflects these changes by voiding existing MOLST documents. A progress note should document the discussion, as well as the revision of the code status and treatment limitations orders. The primary team may elect to complete MOLST on admission, but it must be completed before discharge for applicable patients. Patient legal exclusions from MOLST are listed in Table 3. The completion of MOLST also applies to patients discharged from and admitted to our hospitals on the University of Maryland Medical Center campus. For example, it applies to a Shock Trauma discharge that becomes a psychiatry admission, or a psychiatry discharge that is being admitted directly to a UMMC medicine unit and vice versa. Since MOLST must be signed by an attending physician or nurse practitioner licensed in the state of Maryland, all members of the health care team must be vigilant to ensure MOLST is completed before discharge for applicable patients. Patients/ADMs must receive a copy of MOLST as part of the discharge instructions. A copy of MOLST must accompany patients who are transported by ambulance in non-emergent conditions and sent to receiving inpatient and outpatient health care facilities (see Table 4). Transport services may refuse to transport patients and facilities may refuse to accept patients without MOLST. Fines may be levied by the state of Maryland if MOLST is not completed for applicable patients. Some Maryland health care facilities have already implemented MOLST, so you will see these patients if they are treated at UMMC. Until the MOLST implementation occurs at UMMC in mid-March, you should honor the intent of the MOLST within our current documentation framework. Mandatory education in Healthstream for MOLST will begin in early March at UMMC. Outpatient areas should treat MOLST similar to an AD before and after the implementation. MOLST should be placed with an AD in the chart if the patient provides one, or complete one if patient requests or condition warrants. By working together, we can help our patients receive the care they desire. Further information about MOLST is available in the Summer 2012 edition of News & Views or at the following website: https//intra.umm.edu/ummc/molst. Table 1 Forms With Names Similar To MOLST ◗◗ ◗◗ ◗◗ ◗◗ Maryland EMS DNR (MIEMSS) order form Life-Sustaining Treatment form Physician’s Order for Life-Sustaining Treatment (POLST) Orders for Life-Sustaining Treatment (OLST) Table 2 MOLST Patient Education Talking Points ◗◗ The intent is to make sure a patient’s wishes to receive or deny care are honored across health care settings in Maryland. ◗◗ The patient/ADM may take wishes expressed in an AD or living will and apply it to current and future situations. ◗◗ MOLST is a form that contains medical orders about life-supporting treatments. ◗◗ MOLST is developed with the patient’s physician or nurse practitioner. ◗◗ The orders are applicable in all Maryland health care settings such as hospitals, assisted living facilities, nursing homes, inpatient hospices, dialysis settings and home health care. ◗◗ The orders are enduring and don’t need to be re-written unless the situation changes. ◗◗ The patient/ADM can refuse to have a MOLST completed by talking with their doctor or nurse practitioner. continued on page 18. news &views We Discover Journal Club: Horizontal Hostility Among Nurses Anne Johnston, BSN, RN, CCRN, Senior Clinical Nurse II, Interventional Radiology Patricia Woltz, MS, RN, Nurse Researcher, Patient Care Services Article Wilson, B. & Diedrich, A. (2011). Bullies at Work: The Impact of Horizontal Hostility in the Hospital Setting and Intent to Leave. Journal of Nursing Administration, 41(11), p 453-8. Over 50 attendees were present for the October 2012 journal club led by Anne Johnston, BSN, RN, CCRN, Senior Clinical Nurse II, Interventional Radiology, on the topic of horizontal hostility (HH). Also known as bullying, lateral violence, or peer incivility, HH is associated with an increase in job stress and a decrease in job satisfaction, group cohesiveness, and communication. Additionally, HH is associated with nurse retention. Nursing turnover is associated with increased financial cost, higher nurse-to-patient ratios, and compromised patient care. The article reported on a study that surveyed nurses about the frequency and extent of HH at a small Southwest community hospital and its effect on sick call frequency and intent to leave. The authors hypothesized that nurses who experience HH, fear of hostility, or are uncomfortable pointing out hostility in a peer, are more likely to consider leaving or intend to leave their employment. Nurses from all departments in the Southwest community hospital were invited to participate. Surveys were handed out in sealed envelopes by nursing research council members. Completed, anonymous surveys were returned over a two month period to marked collection receptacles. Modeled after two other validated surveys, the survey was a 28-item questionnaire that measured three independent variables (extent of HH, fear of hostility, and comfort in pointing out hostility to a peer) and one dependent variable (intent to leave because of HH). One hundred thirty surveys were collected for a response rate of 26%. The majority of participants were female (91%), age 30-50 years (73%), direct patient care providers (62%), bachelor’s prepared (45%), and had greater than 10 years nursing experience (53%). For those who observed or experienced HH behaviors, 85% had seen HH behaviors in the last 6 months, 90% had difficulty with confronting someone exhibiting HH behaviors and 20% had called out sick due to HH. When asked about intent to leave due to HH, 40% were definitely going to leave due to HH or were considering it. Horizontal hostility and fear of hostility scores were significantly higher in those who intended to leave compared to those did not intend to leave. In hierarchical multiple linear regression modeling, HH observation was a significant predictor of intent to leave. Significant to note, age, gender, and education were not predictive. The authors projected that if 40% of the respondents terminated their employment due to HH, the hospital would incur a cost of $3.7 to 5 million. The authors addressed a few study limitations. They acknowledged the effect of a small sample size on study power. However, low response rate was not mentioned. Low response rate threatens the representativeness of the sample. Nurses who had experienced HH or were intending to leave were probably more likely to complete the survey. Also, the authors did not use a reliable and valid survey, and the scoring of some questions was unclear. Without including the survey, the reader was unable to assess if the survey would be likely to produce similar results with subsequent testing. Apart from the study, the authors offered recommendations. Beginning with awareness of the impact that HH can have on nurse satisfaction and a healthy work environment, preventative measures were addressed. These included: ◗◗ staff education on conflict management; ◗◗ modeling professional, respectful behavior at all levels; ◗◗ ensuring participatory leadership and consensus building; and ◗◗ skill building for managers and educators to coach new nurses on methods to deflect HH. Group Discussion The group agreed that HH in the workplace is unhealthy and unacceptable, but nevertheless occurs in varying degrees at UMMC. Most participants felt the accountability for HH should be managed at the unit level. Some felt that management should take a more active role in addressing such behavior, while managers in attendance pointed out that HH behaviors are often not brought to their attention. All agreed that HH can be difficult to confront and address. Participants shared de-identified stories that illustrated the complex issues involved. Even with intervention, the primary offenders may fail to recognize their own passive-aggressive tendencies or have difficulty correcting lifelong behaviors. Organizational strategies for dealing with HH were reviewed. Some managers have found that an additional contract with unit staff for behavioral conduct raises awareness and clarifies expectations. The UMMC Department of Human Resources offers classes on the recognition and management of HH, in addition to an interactive course on conflict resolution. The Employee Assistance Program (EAP) is available for counseling and employee support. In summary, the study did not generate strong evidence for the clinically significant issue of HH in the workplace. Additional research on the prevention, mitigation, and ramifications of HH is warranted. 15 16 Winter 2013 Certification Corner The Benefits of Certification Tiffanie Moran, BSN, RN, CCRN, Senior Clinical Nurse I, Medical Intensive Care Unit At the end of 2010, I had barely been off orientation a year when I first heard of the CCRN certification for critical care nurses. I was unaware of all the benefits of certification. Since I started as a graduate nurse in the MICU, I was feeling less overwhelmed in my role transition and looked forward to broadening myself professionally. My quest for certification began. The process started with a two day CCRN review conference in Dover, DE. This review class really opened my eyes to how much I didn’t know and humbled me greatly. It confirmed that there is always room for improvement and new knowledge to gain. I obtained my CCRN in February, 2011. The sense of pride I felt was rewarding. Certification has become the first of many goals I want to accomplish. I soon realized that it is never too early in a career to take on a challenge. There is so much I learned as a result of studying for my CCRN exam. Two years later, I still reference my study notes. In addition to the knowledge I gained, another benefit is that I feel fortunate to work in an institution that promotes continued education. I used the $500 in my continuing education fund to attend the review seminar. This increases to $1,000 a year now with certification … another perk of being a certified nurse. Psychiatric Nurses Present Posters At National Convention Dennis Brumbles, BSN, RN-BC, Senior Clinical Nurse II and Jessica Page, BSN, RN, Clinical Nurse II, Adult Psychiatry For the second year in a row, two teams of psychiatric nurses from the Medical Center’s Department of Behavioral Health adult service line presented posters at the American Psychiatric Nurses Association convention. The posters were presented during the 26th annual conference in Pittsburgh, PA from November 7-10, 2012. Left to right: Jennifer Myers, Jessica Page, and Aline Dagdag Left to right: Dennis Brumbles, Connie Noll, Jennifer Myers, Aline Dagdag, and Jessica Page Connie Noll, MA, BSN, RN-BC, Nurse Manager, Psychiatric Emergency Services; Zelda Falck, MS, RN-BC, Senior Clinical Nurse II, Psychiatric Emergency Services; Dawn Clayton, MSN, RN-BC, Nurse Manager, Adult Psychiatry; Dennis Brumbles, BSN, RN-BC, Senior Clinical Nurse II, Adult Psychiatry; and Nancy Hedden, MS, BSN, RN, PMHCNS-BC, CSP, Nurse Manager, Geriatric Psychiatry, presented the poster, “Safety, Violence and Recovery in the Psychiatric Emergency Department: Paradigm Changes and the Reduction of Seclusion and Restraint.” The poster addressed efforts to reduce seclusion and restraints in the psychiatric emergency services (PES) by utilizing the recovery model of psychiatric care. The paradigm change in the title refers to the ongoing efforts to change the culture of how seclusion and restraint is used not only in PES, but across the entire behavioral health service line. We have implemented a number of strategies, including education, careful monitoring, and creation of a multidisciplinary panel, which carefully reviews each seclusion and restraint event. We are encouraged that as we continue to implement recovery-based intervention, our seclusion and restraint use is decreasing. Jessica Page, BSN, RN, Clinical Nurse II; Jennifer Myers, RN, Clinical Nurse II; and Aline Dagdag, BSN, RN, Clinical Nurse II, Adult Psychiatry, presented the poster, “Medical Emergencies in Inpatient Psychiatry: Preparedness for Best Possible Outcomes.” This program was created in response to the increase of medically complicated patients being treated in adult psychiatry, and in response to the increased interest among the interprofessional staff to improve our emergency preparedness. In collaboration with the MASTRI Center, we created a mock code-blue program and role played medical emergencies. After attending the mock codes, staff reported increased knowledge of medical emergency preparedness, improved staff communication and teamwork, and increased confidence in their skills. news &views Trauma Resuscitation Unit Staff Share Knowledge Around The State Lynn Gerber Smith, MS, RN, Senior Clinical Nurse II, Trauma Resuscitation Unit, R Adams Cowley Shock Trauma Center (STC) The fall of 2012 was a busy time for the Trauma Resuscitation Unit (TRU) nursing staff of the R Adams Cowley Shock Trauma Center. The TRU staff presented at numerous educational venues from the Eastern Shore to Southern Maryland On October 28, Diana Clapp, BSN, RN, CCRN, CEN, NREMT-P, Senior Clinical Nurse II and Lynn Gerber Smith, MS, RN, Senior Clinical Nurse II, presented at the annual pre-hospital conference, “Pyramid,” held in Southern Maryland. Clapp presented “All That Collides,” a case review based on the examination of patient care from EMS to discharge, which was attended by 60 participants. Smith presented, “Care of the Adult Trauma Patient With Special Needs.” On November 30 in Ocean City, MD, Clapp presented at the Peninsula Regional Medical Center trauma conference. Her presentation, “Bikes and Beaches,” was based on the review of two patient cases treated for traumatic injuries in the region. Two new presenters from the TRU staff, Heidi Halterman, RN, NREMT-P, Clinical Nurse II and Kristen Ray, MS, RN, Clinical Nurse II, spoke to the Caroline County EMS on the topic, “Mechanism of Injury.” The presentation focused on mechanism of injury specific to the region. Finally, the December 5th EMS evening education broadcast from the STC featured Ellen Plummer, DL, MJ, MSN, MBA, RN, CCRN, Senior Clinical Nurse II. Plummer spoke on the topic “Geriatric Trauma Emergencies” to more than 80 field providers throughout the state. Left to right: Kristen Ray, Heidi Halterman Ellen Plummer C2X Healing Arts Team Rachel Hercenberg, BA, Special Projects Coordinator Clinical Practice and Professional Development Calling all artistic UMMC staff. Please spread the word to your colleagues and family members! UMMC’s newest C2X team, the Healing Arts Team, has partnered with the National Arts Program® to host an art exhibit and reception at UMMC. The Healing Arts Team exists to provide opportunities for integrating art into daily life and promoting art as a vehicle for personal growth, self-expression, and healing. All artists will have the opportunity to exhibit their work and compete for cash prizes provided by the National Arts Program®. Winners will be selected by professional artists in the following categories: amateur, intermediate, professional, youth (age 12 and under), and teen (ages 13 to 18). There is no charge to enter your work in this art exhibit. All participants must be UMMC employees or immediate family members. The submitted artwork must be original. Submission dates and entry details will be communicated soon. Find News&Views UMMC art exhibit dates and locations: Registration: Summer 2013 Reception: Wednesday, October 9, 2013 5 p.m. – 7 p.m. Wall of Honor, Gudelsky Bldg. 1st Floor Exhibit Dates and Location: Wednesday, October 9 through Wednesday, October 23, 2013 Weinberg Atrium Please contact Rachel Hercenberg via email email@example.com for more information. online at http://www.umm.edu/nursing/newsletter.htm on the UMM Intranet at intra.umm.edu/ummc/nursing-dept/newsviews.htm 17 18 Winter 2013 Lynn Gerber Smith, MS, RN, Senior Clinical Nurse II, Trauma Resuscitation Unit R Adams Cowley Shock Trauma Center Trauma Resuscitation Unit Nurses Deployed For Hurricane Sandy Relief Since she joined the National Disaster Medical Service (NDMS) two years ago, Andi Ball, RN, CCRN, CEN, Clinical Nurse I in the Trauma Resuscitation Unit, has been ready for the call…a call that came in November 2012 when she was deployed to aid the victims of Hurricane Sandy in New Jersey. From November 11 through December 1, 2012, Ball was a staff member at the mobilization center. Her role was to prepare staff or “in briefing.” Prior to being sent into the field, staff needed to be briefed on what they would see, checked for safety, and fit-tested for medical equipment. Stationed in Newark, NJ, the NDMS is part of the Department of Health and Human Services and serves those in New Jersey and New York. Ball said, “When you saw the amount of devastation, the long days went by quickly.” Also on the mission was Bonjo Baton, MS, CRNA, a nurse in the Shock Trauma Center. Baton was part of a medical triage team. Ball and Baton previously volunteered in Haiti as part of the Medical Center’s sustained disaster relief effort. In addition, Ball’s expertise in critical care nursing has been utilized by the Mobile Acute Care Nurse Practitioner Team to teach critical care skills. Left to right: Andi Ball and Bonjo Baton Unanticipated Events – Post Event Actions For continuous process improvement, we need to know of any unexpected events occurring at the front line – please enter any unanticipated events into the RL6 event reporting system. This is not for the purposes of disciplinary action! Documentation of near misses as well as actual events helps us prevent similar issues from occurring in other areas. In the aftermath of an incident, especially one in which a patient was harmed, we need to ensure that we have addressed all needs –patient & family members, staﬀ, investigation, and risk management. MOLST Implementation continued from page 14. Table 3 MOLST Legal Exclusions When an event may have resulted in harm to a patient, staﬀ should ALWAYS: Care Provide medical care as necessary Help Notify Attending Physician Notify the Charge RN Notify the RN Manager/Supervisor ◗◗ Less than 18 years old and life-sustaining treatment unlikely. ◗◗ Psychiatric patient, unless dementia, delirium or medically related psychiatric condition. ◗◗ Primary diagnosis related to pregnancy. ◗◗ Outpatient - ED, procedural areas, ambulatory care, observation, extended recovery patients. Assess (RN & Manager/Charge RN) Table 4 Applicable Health Care Facilities Notify* ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ ◗◗ Hospitals Rehabilitation Facilities Nursing Homes Assisted Living Hospice - Inpatient and Outpatient Community Dialysis Center Outpatient Health Care Service - PT, OT, Speech Therapy, Home Health Assess the situation & document the conditions If there is a medical device malfunction: Remove the device from use Sequester the device, accessories and disposables For Equipment Sequestering, REMEMBER: • • • • Do NOT turn oﬀ or reset. Do NOT clean or discard packaging, pharmaceuticals or supplies. Keep tubing and medications attached. Complete & place a “Repair Hang Tag” on the medical device 1 CALL/SOSC (8-5174) for environmental safety issues and Clinical Engineering notiﬁcation. Pharmacy, if medication is involved. Complete incident report online - accessible on UMMC intranet – click ‘Nursing’ or ‘Physicians’ in top banner and the link to event (incident) reports will be in the bottom right section. Call Risk Management if the patient was seriously injured – daytime hours at 8-4704; after hours, weekends, and holidays page the on call Risk Manager for urgent matters at (410) 5081105. If equipment was involved in the event, click “yes” in the “equipment involved” ﬁeld in the online incident report and note: unit, equipment name, serial #, product names, and lot #. For events involving serious harm, have patient’s attending physician notify the patient/family of the known facts about the adverse event, steps taken to treat the patient, any anticipated change in the plan of care, and reassure them that updates will be provided as more is known. Support the involved staff. Always complete the C.H.A.I.N.S of post event follow up! * Please make sure that your RL6 password is working, and that you know where to �ind it in the future! news &views Creating A Successful Application For Nursing Professional Advancement Michele Zimmer, MS, RN, CCRN-CMC, Cardiac PCU Luizalice Lima, MS, RN-BC, Professional Development Coordinator, Clinical Practice and Professional Development The Professional Advancement Model (PAM) at UMMC continues to attract bedside nurses who are interested in professional growth and recognition. The last two portfolio submission cycles in July and October 2012 for advancement produced 38 newly promoted nurses to Senior Clinical Nurse I and seven to Senior Clinical Nurse II. There is a trend of an increase in the number of applications submitted over the previous submission quarter from last year. This increase in submissions speaks volumes to the high caliber of nurses working at UMMC today. Registration for these classes is through Healthstream. The Professional Advancement Council (PAC) is a group that meets monthly to discuss the PAM and the advancement process. Although a small group, the members represent nursing from all of the divisions in the hospital. The PAC is charged with advancing and supporting ongoing professional growth opportunities for the registered nurse at UMMC. The goal for the PAC is to provide resources for nurses exploring the idea of advancement and to provide support for those already involved in the portfolio development process. Members of the PAC receive extensive training in coaching and portfolio building, and are another resource for those seeking guidance. PAC members can give advice and support in building a portfolio and will provide a “first pass review” to ensure the portfolio portrays the applicant’s professional story. They can also identify areas that may require fine tuning. Portfolio coaching by a PAC member does not guarantee a promotion, but PAC members are committed to the success of UMMC nurses. The PAC will also be offering multiple informal portfolio building sessions throughout the year. The purpose of these sessions is to offer support to any nurse at any level contemplating advancement and to help those at any level of portfolio preparation. Dates, times, and locations are being planned now. The PAC and the Professional Advancement Review Team look forward to increasing the number of successful applications at every cycle by providing mentorship and direct coaching to UMMC nurses. If you would like additional information, please contact a council member or e-mail Michele Zimmer at firstname.lastname@example.org or Luiza Lima at email@example.com. The contents of a portfolio are an illustrative story of one’s professional growth, skills, experiences, and contributions to the profession of nursing, nursing practice, and patient outcomes. Similar to one’s professional growth that happens over time, the building of a strong portfolio also requires time. The examples contained within one’s portfolio should showcase professional experiences. For many, the idea of putting together an extensive product for advancement may seem daunting. However, the rewards are equivalent to the effort. There are many resources to assist nurses to assemble successful applications and portfolios, whether they are just getting started or need help completing the final touches. The Professional Advancement Council Membership instructions on how to assemble Representative Division/Service and submit an application are available on the Nursing intranet Julie Brown-Busseau, RN Perioperative Services (PACU) page in the section “Professional Carolyn Bryant, BSN, RN Medicine/Surgery (10E) Development” and under the Bridgette Casserly, MS, RN-BC, CPN Children’s Div. (Gen. Peds) tab “Professional Advancement Model” - http://intra.umm.edu/ Dianne Constantine, BSN, RN, CPN Procedural Areas (IR) ummc/advancement/index.htm. Mylene De Vera, BSN, RN, OCN Cancer Center (C9W) Two educational Patricia Gent, MS, RN, CCRN Outpatient/Procedural (GI Lab) workshops are offered in advance of the deadlines Joji Patterson, BSN, RN Ambulatory Services for the portfolio submission Laura Hearson, MS, RN Cancer Center (N8W, N9W) cycles (January, April, July, Donna Holl, BSN, RN, CCRN Shock Trauma (TRU) and October). Looking Good in Print: How to Develop Your Stacey Hydorn, RN Adult ED/Shock Trauma CV and Portfolio is a one-hour Tina Larson, MS, RN Womens’ Division (L&D) class that focuses on how to Luiza Lima, MS, RN-BC Facilitator (CPPD) develop a curriculum vitae (CV), utilizing the PAM template, and Stacie Mann, RN Shock Trauma (Multitrauma ICU) what constitutes evidence in the Joyce Matthews, RN Neurocare ((Neuro IMC) portfolio. In the four-hour class, Ann Rigdon, MS, RN, OCN Cancer Center (Educator) How to Build a CV and Portfolio Step-by-Step, one-on-one Marylyn Solomon, MSN, RN Behavioral Health (Child Psych) tutorial assistance is provided Stacey Trotman, BSN, RN, CMSRN Medicine/Surgery (13W/E) for CV writing and preparing Michele Zimmer, MS, RN, CCRN-CMC Cardiac (PCU) & Chair evidence within one’s portfolio based on the PAM requirements. Greg Raymond, MS, MBA, RN Executive Sponsor Email Address Jbrown5@umm.edu firstname.lastname@example.org email@example.com firstname.lastname@example.org email@example.com firstname.lastname@example.org email@example.com firstname.lastname@example.org email@example.com firstname.lastname@example.org email@example.com firstname.lastname@example.org email@example.com firstname.lastname@example.org email@example.com firstname.lastname@example.org email@example.com firstname.lastname@example.org email@example.com 19 22 South Greene Street Baltimore, Maryland 21201 www.umm.edu Clinical Practice Update Urinary Catheter Specimen Sampling Procedure Occlude Tube Key Practice Point: Always send urine samples from the sampling port and not from the urinary drainage bag. When an order is placed for a urine culture and sensitivity (c/s) with or without urinalysis (UA): Gather Equipment: Clean gloves, alcohol pads, male leur lock transfer device (blue tip), specimen label/request, collection tube(s). Yellow tube required for urinalysis. Gray tube required for urine c/s Procedure: 1. Identify patient, explain procedure and educate patient/family. 2. Perform hand hygiene and put on clean gloves. 3. Drain all urine from drainage tube into collection bag. 4. Occlude drainage tubing a minimum of 12 inches below the sampling port. 5. Allow time for the urine to fill the tubing from the point where occluded to slightly above the sampling port. 6. Discard gloves and perform hand hygiene. When there is sufficient urine to collect the specimen: 1. Perform hand hygiene and put on clean gloves. 2. Clean the tops of the collection tubes with an alcohol pad. Scrub recessed areas for 15 seconds minimum. 3. Prepare sampling port by scrubbing with an alcohol pad for 15 seconds. 4. Allow sampling port surface to dry. 5. Insert the male luer lock access device into the sampling port and rotate clockwise until it fits securely. 6. If a urine c/s is ordered, fill one gray urine c/s tube first. A gray tube holds 4 ml. 7. If UA (or additional urine test) is ordered, fill yellow tube(s) last. Each yellow tube holds 8 ml. 8. Invert tubes 8-10 times. 9. Disconnect male luer lock access device. 10. Remove occlusion from the drainage tubing after collecting the specimen to allow urine to flow freely. 11. Dispose of equipment properly. Remember to discard the male luer lock access device into the sharps container. 12. Label the collection tube(s) in the presence of the patient. 13. Seal tubes in a laboratory biohazard transport bag, and send to the lab immediately. 14. Perform hand hygiene. 15. Document procedure on the flow sheet, including patient/family education. Include specimen collection in handoff communication. Contact Allison Murter via email firstname.lastname@example.org for additional information. Scrub Port Draw off Sample Remove Occlusion