August 2012 Volume 1, Issue 7
UMMC Nursing Newsletter TAKE CHARGE OF PREVENTING FALLS IT'S EVERYONE'S RESPONSIBILITY! June 2012: Inpatient falls displayed by day of week
DID YOU KNOW?
During FY 12: UMMC had 418 inpatient falls and 102 of those resulted in Patient injury (24%)
What can you do to help prevent patient falls? 1. Frequent assessment and reassessment of patient risk -it can change based on clinical status! 2. Implement and maintain interventions to prevent falls: • Obtain information from nurses about the fall risk of your patients: standard, high, or critical. • Have a conversation regarding what interventions to prevent falls need to be in place • Make sure interventions are “on” ; for high and critical risk, bed and chair exit alarms are strongly advised to alert staff to assist patient • Educate your patients and families about why and how you are preventing falls. 3. Communication between caregivers, patients, and families is one of the most important interventions: • Include patient’s fall status information during shift report and at doorway or bedside. • PCTs, CNA, MHA and other caregivers must know the patients status, observe patients’ activities, and collaborate on maintaining precautionary interventions in place. • Encourage patient and family to partner with you by using the script "Call, Don't Fall" at the end of each contact with patients and families • Explain to patients and families that falls are likely to happen when patients use the bathroom or are getting out of bed/chair, so remember to teach your patients:
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TAKE CHARGE OF PREVENTING FALLS IT'S EVERYONE'S RESPONSIBILITY!
(con’t)
4. Documentation of Observations and Care • Assessments are documented on the Intake & Triage, Morse Fall Assessment (electronic form), and in patient’s paper medical record, where applicable. The Morse Assessment is to be completed during intake, each shift, and after any fall or change in clinical status. • Documentation should be systematic and regular, including periodic patient observations through hourly caring rounds. • Revise plan of care and interventions to reflect changes in score and/or minimize fall risk. • Document the reasons why an intervention is not in place, such as a patient refusing to have the bed alarm on or insisting on wearing his/her own slippers.
Day of the week and time of day are factors to consider when establishing hourly care rounds in your units – Each care area should review and understand it’s own falls data to identify trends in your area to provide better care for your patients. All team members can play an important part in this initiative! • Be involved: inquire how many falls there are in your unit, volunteer or lead Performance Improvement activities to eliminate falls, seek fall risk information about your patients, etc. • Encourage your patients watch the new Video on Demand #348 Turn the TV on and find it for them! • If a fall occurs: • Notify MD or NP- even if patient seems uninjured. • Complete incident report online (RL solutions) • Complete all ‘Post-Fall Management’ steps included in Fall Prevention Bundle - including a post-fall huddle— immediately after the event "every fall, every time"
DID YOU KNOW? Most patient falls occur in the patient’s room or their restroom. June 2012: Inpatient falls displayed by time of day when fall occurred
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What’s New @ UMMC? Hourly Caring Rounds "Hourly Caring Rounds" is a purposeful, autonomous intervention providing a surveillance mechanism to keep patients safe and comfortable by proactively meeting their needs. The process includes intentionally checking on patients, using standard measures, and at regular intervals. The act of making hourly rounds can be viewed as a bundle of interventions that promote comfort and safety of patients, but also increase efficiency and organization of workflow as staff anticipate and attend to patients' needs. As a result of "Hourly Caring Rounds", patients' anxiety is reduced as their uncertainties about the available nursing care are eased. Patient satisfaction with nursing care and the facility, increase in response to the intervention. Attending to patients' comfort, safety, and environmental needs has also been shown to prevent adverse events like falls, pressure ulcers, or unrelieved pain. Inpatient Research indicates • 83% reduction in call light use • 20% reduction total distance walked by staff • 77% reduction in fall rate (variable among studies) • 88% improvement in patient satisfaction ratings with anticipation of patient needs, timeliness of nurse response, and pain management • Anecdotal reports by staff of improved quality of care, resource adequacy, professional relations, and actually MORE time to complete tasks
Hourly Rounds should focus on the patient and family: For inpatient areas, the “4 Ps model” is the minimum standard for rounding: • Pain • Positioning • Personal needs (Elimination) • Proximity (of personal items) For procedural and ambulatory areas, the “PPD model” is the recommended minimum standard for rounding: • Pain • Plan (of care) • Delays KEYS TO SUCCESS ARE CHANGING OUR MINDSET (AND OUR WORDS) FROM: “Call me if you need me.” (Reactive) TO:
“Is there anything else I can do for you?”
(Proactive)
UMMC has a new intranet site: http://intra.umm.edu/ummc/nursing/hourly-caring-rounds.htm Tools available on the site: • Hourly Rounds Shift Audit • Hourly Rounds Unit Report • Living Excellence: The Impact of Purposeful Hourly Caring Rounds NEW • UMMC Professional Practice Model • Words that Care New email has been set-up to answer your questions: HourlyCaringRounds@umm.edu 3
Next Steps? Talk About It! Schedule It! Do It! Record It! Measure It!
Clinical Practice Council Updates: New Council Chair & Chair Elect! FY13 Chair: Bing (Vistacion) Casal Chair Elects: Pat Chambers & Christine Provance Safety Discussion Adherence to oral care protocol is low as defined by utilization of new oral care kits in comparison to ventilator days. Encourage proper utilization of kits of the oral care kits—the team is working on improving the accessibility of CHG cups & aligning the times on EMAR with times in kit packaging. Lab Safety Reminder Lab specimens have been arriving to the lab being unlabeled or mislabeled. Please check all specimens carefully before sending to the lab!
Furosemide Shortage In order to conserve the furosemide supply, we have changed the drip bags to a smaller volume BUT the same concentration. It will be dispensed as 200mg/100ml (2mg/ml concentration). Please note: this will NOT match the pump library so it will need to be manually entered. Insulin Scheduling Insulin scheduling on EMAR & meal delivery times do not always coincide… Insulin and oral hypoglycemic drugs are time critical in relation to meals– not the time scheduled on EMAR.
TENP Updates Central Line Kit Change: New vendor. Kit will be equivalent with two upgrades. Tegaderm with new grip technology that CT Reports IV Problems will aid in preventing line dislodgement and an upCT reported concerns with new microclave IV graded mask. All other contents are the same extension set. Upon investigation, it was found New PIV Start Kits—Coming soon! that the extension set was not power rated. This Will contain everything you need to start the IV. had caused patient IVs to become blown when SEPP, 2x2, tourniquet, dressing, extension set, 5 cc administering contract. UMMC has replaced all saline flush, and absorbent insertion field. Must extension sets with power capable sets. pull patient specific IV catheter separately. Remember: purple = power injectable. Negative Pressure Wound Therapy Contract KCI & their VAC therapy will continue to be the IV Push Manual = vendor of choice for Negative IV Administration Guidelines! Pressure Wound Therapy at UMMC. There was concern that IV push manual Contract negotiations continued until had been removed from intranet. It is still the final hour, and we were able to there, but has a new name. On intranet— achieve significant savings for the go to Pharmacy and IV Administration organization by remaining with the current vendor. Guidelines to review tables, medication (& we can still call it VAC Therapy!) We will be considerations, infusion parameters and scheduling additional staff education on the current much more. products for all units. http://intra.umm.edu/ummc/pharmacy/ ivadminisMany thanks to those who participated in the tration-guidelines.htm planning meetings for a transition to the Smith & Nephew Product! Your input continues to be New Policies important & your time is valued. COP-036 - Ultrasound Guided Peripheral IV Insertion. CPC approved. Needs to go thru PISC and Coming Soon: IV Pump Trials MEC for final approval. More to Come! On Thursday, August 23rd there was an IV Pump COP-035—Enteral Tube Placement & Feeding— Vendor Fair. The fair allowed clinical staff to learn work group has made major revisions to what was about the features of 3 different IV Pumps and have formerly called Enteral Nutrition Guidelines hands-on time to preview some of the available final review by team - coming soon to CPC! features. Response data is still being collated. The plan is to trial 2 of the IV pumps for an Policy Reviews upcoming conversion. MM-005 Dangerous Abbreviations -no changes The three pumps under consideration are: MM-008 Ribaviron -modifications to dosing Hospira Alaris Baxter schedules and new attachment for staff education. LDRSHP-205 -Value Analysis Program -minimal change 4
Governance Council Updates: • • •
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Nurse Coordinating Council (NCC) All Council leaders reviewed their FY12 end of year reports. Received overview of the Hourly Caring Rounds Initiative. Education is occurring, but full roll-out has been moved to end of August. Date TBA. Auburn University Medication Observer—Six staff were trained as blind observers to observe the process of medication administration and the accuracy of medication administration. Observation does not focus on a specific nurse, and observers have not seen the medication order until post observation. The focus in on process of medication administration, not individuals. Observations conducted during training found 78% accuracy on day one and 88% accuracy on day two. The following issues were identified: 1. Wrong timing (outside the CMS window of 1 hour before and after). 2. Wrong technique for administration. Plan is to conduct over 6,000 observations of medication delivery over the next year. • Each observer will observe over 15 medication passes every two weeks. • Trained observers will be randomly assigned to units. Goal is to identify systematic problems and fix them. The group will collect data and prepare periodic reports during this year long process. Clinical Information Council (CIC) Discussed the importance of nursing reviewing orders for appropriateness (based on level of care) prior to transferring patient to another unit. TJC new format for tracers will include a focus on patient hand-off. Audit of order management conducted in June (N=97). Results showed: • Patient location or level of care incorrect (patient admitted to multiple locations, the wrong location or no location) 27% of the time. • Duplicate orders appear in the chart 35% of the time. • Conflicting Orders appear 20% of the time. • Care provided without an order 20% of the time. • Old orders that no longer applied remained active 35% of the time.
Patient & Family Education Council Updates Reviewed the Patient Satisfaction Results Q3 • FY12 via the new Healthstream dashboard. Members encouraged to review them with their units. • FY13 Objectives were approved • • EBP project PICO has shifted from patient centered to a staff centered question . Next • meeting the council will refine the PICO and have a presentation on the process of evaluating evidence. •
Newsletter Updates If you have news or updates, then please send your information by the 7th of each month to: amurter@umm.edu or tfronczek@umm.edu Newsletter Editorial Board Allison Murter Christine Provance Susan Carey Trisha Fronczek
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Clinical Education Council BSN requirements for advancement remain confusing and unclear to staff: A PAC representative will be asked to attend August CEC meeting to address/clarify. Critical Care Course revisions presented and endorsed. August Marathon content discussed and revised. Congratulations Newly Certified RNs! Johanna Heilman, BSN, RN, ACRN (AIDS Certified Registered Nurse) 11 East Mandy Chavez, BSN, RN, ACRN (AIDS Certified Registered Nurse) 11 East
Send your certification news to: certification@umm.edu 5
Governance Council Updates: •
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Professional Advancement Council Updates Reviewed unit data delineated areas that have some type of professional growth in place while others have little to none. Work will be to focus on area with little to no growth. Review Team data has found six main barriers to successful applications for advancement: lack of supporting evidence backing up statements on CV, portfolio, and self-evaluation; lack of evidence supporting leadership role; poor clarity related to PI/EBP initiatives; not meeting basic/core requirements; poor understanding of what requirements mean; and leadership lacking understanding regarding Review Team processes and strict commitment to requirements when reviewing applications. To take back to units. FY13 Objectives for August approval. To add Charge Nurse and Certification objectives to PAC’s.
Meetings Canceled for July 2012 Clinical Practice Council Staff Nurse Council Nursing Research Council Medication Oversight Council
CODE STEMI EDUCATION The American College of Cardiology (ACC) continues with its initiative to standardize heart attack care throughout the country. The state of Maryland along with MIEMSS is actively involved in improving the MI response time from the field (Emergency Medical Services) through every hospital system to Cardiac Cath Lab interventions. An important initiative of the UMMS Code STEMI team continues to pursue is the goal of decreasing the time it takes to: TIME IS MUSCLE! 1... identify an ST elevation MI (STEMI) + 2... transport to the cath lab + 3… open the blocked vessel = Under 90 minutes An integral part of the performance improvement goal is continuing education to all potential care givers to remind them of the process and the appropriate contacts to expedite care. A short, 10-minute snapshot of the signs and symptoms that warrant an EKG, the EKG changes that signify a potential STEMI, and the process to notify the team of an impending STEMI case, can be presented to any units’ staff at staff meetings or huddles as requested. Those environments with more exposure to cardiac patients might prefer the 40-minute presentation that reviews a more in-depth discussion of the Code STEMI process and identifies the timed goals for each step of the process. Contact the Code STEMI team Jeanne Dailey, RN @ 8-6618 jdailey@medicine.umaryland.edu Documentation Format for Credentials The UMMC Standard for displaying of credentials is based on ANCC Guidelines. The preferred order is >> highest earned degree >> licensure >> state designations or requirements >> national certifications >> awards and honors >> other recognitions Examples: Lisa Rowen DNSc, RN, FAAN; Trisha C. Fronczek MS, RN-BC, CCRN; Meredith Huffines BA, BSN, RN; Paul Thurman MS, RN-CNS, ACNPC, CCNS, CCRN Check out the ANCC brochure for answers to your specific credential questions: http://www.softconference.com/Subs/ANCC/2012/SRC/ANCC_Credentialing_Brochure.pdf 6
VTE Education Sessions Available Debra Kording BSN, RN is a Clinical Nurse Consultant for Covidien’s Vascular Therapy Division. She has been providing education and CE offerings throughout UMMC. If you would like Debra to provide education on your unit, please contact: debra.kording@covidien.com Congratulations to the FY12 Q4 On-Demand Patient-Education video usage contest! 1st Place: Mother Baby Unit: Highest rate of overall usage (333 videos/ 22 Beds) 2nd Place: Weinberg 5, Surgical Acute: Highest rate of Pain/Falls videos usage (77 Pain videos/32 Beds) Winning units will receive a free catered breakfast! The On-Demand Subgroup thanks all units for improving patient and family education! Energy Medicine Network Meeting Minutes – July 24, 2012 Announced upcoming events: Center For Integrative Medicine classes on Yoga, Art, Acupressure, Meditation etc. Please contact mearley@compmed.umm.edu. Holistic Nursing Association: August meetings contact dsmith2@umm.edu or csalmond@umm.edu • August Speaker/modality: Maggie McGinnis on her 100 mile bike ride. • Plans: Working on volunteer team for Reiki from the Heart - Monday staff relaxation treatments. • In the works: Volunteer list for holistic practitioners - Pain Service planning conference wellness workshops in September. Peri Operative Conference coming in November. • Possibility: always offering Reiki-on-Unit sessions for any unit in need of Integrative Care info OR relaxation for your staff. Email Lolly lforsythe@umm.edu. Or Donna daudia@umm.edu. Next meeting: August 28, 2012 @ 8am ~ Pt. assembly room
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Did you know… We had a recent patient safety issue concerning a Corpak placed using the Cortrak device? The patient had removed their Corpak feeding tube. The nurse obtained a new tube, used the Cortrak device for insertion, and replaced the tube. Confident that tube was in proper position, the RN began feeds. Later, it was discovered that the tube was in the lungs and the patient had been receiving tube feedings into the lungs.
Corpak tubes always require X-rays prior to initial use!
How did this occur? Corpak insertions do not always guarantee proper tube placement. Initial placement and any replacement requires an order, even if reinserting a tube that you are confident is still required. Why? The order careset protects the RN from violating Nursing Scope of Practice, and it automatically generates a new order for a post insertion x-ray. All Cortrak x-rays must be read by an Attending or Fellow Radiologist (not house staff) prior to tube feeding start. Why? Prior patient safety issues at UMMC concerning pyloric feeding tube insertions have lead to these policy changes.
STAY SAFE - Always remain within your scope of practice and ensure an order is placed prior to insertion. Unsure about the Pyloric Feeding tube ins and outs? Check out policy SPP013 Pyloric Feeding Tube Insertion in Adult Patients for more information 7
From the August 21, 2012 Clinical Practice Update: Nursing-Related Powerchart Changes
August 2012 The Education Marathon Continues! We are 4 weeks into training– ask your unit trainers if you have not yet completed your training
This session’s content includes: Pressure Ulcer Prevention and Assessment
Blood Product Administration
CMS Changes R/T Medication Delivery
Enteral Nutrition Guideline changes
CAUTI Improvement Strategies
Environment of Care Rounds
New Products Information New items and intended use reviewed with staff, handout posted for unit reference
New Beds are making the rounds! We need to purchase additional beds for the critical care tower and to replace some of our older beds. Under consideration are: Linet ® Med Surg and Critical Beds & Stryker® S3 and Go Bed 2 Ask your coworkers or Wound Ostomy Continence Nurse for details! 8
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Trends in Clinical Care WHAT IS VAPOTHERM? Vapotherm that delivers highly concentrated oxygen flow via a device that looks WHATisISa technology VAPOTHERM?
similar to a nasaliscannula—but different! provides ventilatoryoxygen supportflow thatvia reduces work of Vapotherm a technologyisthat deliversIthighly concentrated a device that breathing, makes unstable is patient appear comfortable. looksand similar to aa potentially nasal cannula—but different! It can provide clinicians with support a false sense of security, should be and carefully It provides ventilatory that reduces workand of breathing, makesmonitored. a potentially unstable patient appear comfortable. It can provide clinicians with a false sense of security,
and should be carefully monitored.
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Announcements September Healing Touch Level 1 Course Scheduled The Healing Touch Level 1 course is set for Sept 18-19 (Tues-Wed) Healing Touch is a nursing based CE program for registered nurses, physicians, body therapists, counselors, psychotherapists, other health professionals, and individuals desiring an in-depth understanding and practice of healing work using energy based concepts. Feel free to share the site and visit it for registration information. www.healingtouchprogram.com
Save the Date!!! End of Life Workshop September 18th and 25th All Day Oral Systemic Link October 29 UMB Trends & Topics in Periop November 10th all day
The Oral Systemic Link: Creating Collaborative Initiatives Collaboration and interprofessionalism are hallmarks of innovative health care delivery. Join us for the first national conference highlighting dental hygiene and nursing collaborations! This conference will address the issues of interprofessional collaboration, institutional and policy challenges, and shared goals in providing optimal patient care. The symbiosis of oral and systemic health provides the perfect backdrop for interprofessional learning. Date: Monday October 29, 2012 Location: UMB Register and learn more at: http://nursing.umaryland.edu/oral-systemic CALL FOR POSTERS!
Clinical Practice Summit to be held Tues, September 18 and Wed, September 19 You are invited to participate by creating and sharing posters with an emphasis on fall prevention and hourly caring rounds initiatives. Other poster presentation ideas may include patient & family education, research and evidence-based projects, service quality and safety, unit operations and governance initiatives, process improvement initiatives, educational and professional development projects, etc. Please feel free to submit posters that have been displayed at previous summits. This would be a chance to give your work more exposure and provide opportunity for other staff to learn from your successes. Please submit your poster information to Chandria Anderson @ canderson5@umm.edu by Sept 11.
2 Day End of Life Nursing Care (ELNEC) Workshop Clinical Applications of Death & Dying and Fundamentals of Death & Dying, is scheduled for September 18th and 25th.
Nursing Grand Rounds was canceled for August
Although participants may register for one session, attending both sessions will best ensure an understanding of all aspects of end-oflife care. Please register in Healthstream and for questions contact Erica Bergstein ebergstein@umm.edu
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