Nursing Practice Alert May 2015 Directions for Completion 1. This program is to be completed by RNs & nursing staff and may be applicable to others. Review should be completed by June 15, 2015 2. Before proceeding to the posttest, be sure you have read the following information. 3. Exit and complete the posttest which is final step of this education. Take Test. Remember, no attendance record is needed. Completion of the posttest will be sent electronically to your EduTracker record once a 100% is achieved. Print the Certificate of Completion for your records if desired. 4. Comments, question, or suggestions can be directed to your manager or supervisor.
Nursing Practice Alert May 2015 COUMADIN Teaching Core Measures have not gone away! Our performance in achieving acceptable performance especially with documentation elements related to VTE prophylaxis (specifically Coumadin teaching) has declined over the last 12 months in publicly reported data. What does this mean? Hospital Compare has information about the quality of care at over 4,000 Medicare-certified hospitals across the country. People can use Hospital Compare to find hospitals and compare the quality of their care. The information on Hospital Compare can help people make decisions about where to get health care and to encourage hospitals to improve the quality of care they provide. Want to see more? CTRL + click to follow link Hospital Compare SLB CY 2014 Summary Met the Measure Venous Thromboembolism Prophylaxis 366 368 99.46 Intensive Care Unit Venous Thromboembolism Prophylaxis 101 102 99.02 Venous Thromboembolism Warfarin Therapy Discharge Instructions 52 59 88.14 Total Rate SLB CY 2015 YTD Summary Met the Measure Venous Thromboembolism Prophylaxis 60 61 98.3 Intensive Care Unit Venous Thromboembolism Prophylaxis 19 19 99.02 Venous Thromboembolism Warfarin Therapy Discharge Instructions 15 21 71.4 Total Rate What do we know? The data in the tables above shows gaps in documentation. In 2014 at Bethlehem, we met the measure 88% of the time; we need to be 100%. Following the downward trend, the second table shows our further decline in the first few months of 2015; we met the measure only 71% of the time and need to be at 100%. Our current electronic documentation system does not make it easy for the RN to record necessary information. The good news it will be better in Epic. Until then, we need to be extra vigilant in ensuring we thoroughly document required elements because we need to take credit for the work we do but may forget to document adequately. What are we going to do? To help improve our compliance, there are several steps to be taken: Distribute RN Practice Alert to inpatient RNs to provide background Primary RN must check & sign the DC checklist for each discharged patient and submit to PCM Develop & distribute pocket card with reminders about Core Measures, VTE Prophylaxis, & where to document Coumadin teaching Charge RN responsibility for generating Clinical Reports for Coumadin & follow-up with RNs (more to follow) Documentation Reminders for Coumadin/warfarin: 1. Whenever a Care Alert for Coumadin fires, perform and document teaching (both Teaching Screen & DC Portal) - If only Food & Drug Interaction teaching is addressed, it does not meet all the other required Core Measure components! 2. If Coumadin appears on any Med Rec (admission, transfer or discharge), perform and document teaching even if the order is not active (both Teaching Screen & DC Portal) 3. The RN can document Coumadin teaching in the DC Portal at any time during the admission 4. The places to document Coumadin teaching are highlighted below; BOTH screens need to be completed any time Coumadin teaching is done.
TEACHING SCREEN The fact that it is labeled Mechanical VTE Ed does not make it easy, but it s what we have to work with for the next 8 months! 1) All of these boxes must be checked 2) Also NEED to select all items in each drop down DC Portal The RN should document Coumadin teaching in the DC Portal any time teaching is done during the admission. Patient Admit Orders Patient Safety All patients need the following orders upon arrival to the unit: Admit to service of Patient Status Why? Recently a patient was admitted with an inpatient status order but no service was ordered; there were orders for labs, diet, etc. & the patient received appropriate care, but the patient was not seen by a physician/ap for 46 hours! Actions needed: 1) RNs: ensure a Service/Attending and Status are ordered for all patients when confirming initial orders 2) UCs/PCAs: ensure both a service/attending and status are ordered; these are also required areas on the Chart Audit Matrix (please contact Gretchen Cole to obtain template if needed) Follow up to obtain appropriate orders is required if either is missing.
-------------------------------------- Patients at Risk for Elopement* Elopement = when a patient who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving facility unsupervised, unnoticed, and/or prior to their scheduled discharge. At St. Luke s, elopement is defined as a patient s leaving the hospital without notifying the physician or hospital staff of their intention to leave (APPM Network - Leaving Against Medical Advice #40). While most patients who elope from the acute care setting return without any adverse consequences or injuries, other patients may commit suicide or violent acts or become the victims of violent acts. Patient elopement may also reflect poorly on the hospital s reputation in the community and is a top Joint Commission safety concern. So it is important to understand who is at high risk for elopement and what circumstances may lead to elopement so that steps may be taken to minimize the risk. Who is at risk for elopement? The following patients should be considered potential elopement risks: All patients on continual observation All patients with history of elopement Patients with behavioral health/psychiatric diagnoses o Younger in age o Male o Substance abuse o History of violence Implications: Potential danger to patient/staff/community safety and well-being The potential for injury or death of a missing patient is the worst-case scenario Elopement is a serious concern for providers and comes with the possibility of regulatory or financial sanctions What to do? Elopement prevention and management is everyone s responsibility in the behavioral health setting. If a patient is identified as at risk for elopement : Notify PCM/CC/charge nurse who can determine if Hospital Supervisor & Security should be notified Huddle with team members at start of and throughout shift to ensure increased awareness and observations Pass on information in change of shift report; update SBARs Visually make sure that there are no patients at the doorways to stairwells Be observant for patients lingering at the nurse s station or in the hallways Observe for patients dressed in street clothes who are still wearing SLUHN ID bands Upon discovery that a patient is missing, a search of the unit is conducted and the RN notifies the PCM/Supervisor, Security, and patient s physician. If it is a witnessed patient elopement, the staff member shall verbally attempt to detain the patient and call for assistance. The staff member shall NOT physically attempt to detain the patient from leaving. If a patient with violent or aggressive behavior tries to leave the hospital (patient elopement), move aside & let them go; be sure to notify security ASAP. DO NOT chase after the patient; you may follow at a safe distance with a coworker to keep the patient in your sight until Security arrives (or to update Security with the patient s last known location or direction of travel). DO NOT follow onto elevators, down stairwells, through abandoned corridors/departments, or outside the hospital. *This information was compiled from previous nursing education (Personal Safety in the Hospital Setting Fall 2014) and from BHU education provided by C. Reade Network Director Behavioral Health Inpatient Services Reminder: If patient is also on Continual Observation, RN should also initiate Continual Observation SBAR (blue) -------------------------------------
NEUTROPENIC Precautions: Evidence-based changes were recently piloted on the PPHP6 Oncology Unit at the Bethlehem Campus. Based on a thorough review of the literature and a successful pilot, the following will be implemented network-wide: Standardized Definition of Neutropenia: Condition in which circulating blood contains an abnormally low number of neutrophils (white blood cells) as determined by the absolute neutrophil count (ANC). Neutropenia - now typically defined by an ANC less than1000/mm³ Diet: the Immunosuppressed diet is being eliminated. Well washed fresh fruits and vegetables are safe for patients with neutropenia. Exception: Immunosuppressed transplant patients should be ordered a Transplant diet (new). Masks: health care providers do not need to wear masks. Patients with neutropenia should wear a mask when outside their room, e.g. going to a test. Neutropenic Precaution Doorway Sign (new, to be distributed to each unit) Patient Education: A Neutropenia Patient Education Packet containing 4 patient information sheets is available through the Educational Services - contact Rose Moser. Units will receive several start-up packets. Hand Hygiene: The most important message we can convey to or patients with neutropenia: hand hygiene is the most effective means of preventing transmission of infection! Provide patient with a pump hand sanitizer on their bedside cabinet (storeroom #33103). Some nursing units carry a par stock. It is a great visual reminder and makes it easier for patients to wash their hands frequently, especially prior to eating. ------------------------------------------------ PROTONIX & PEPCID Practice Change: Effective June 15, 2015 the Network Pharmacies will no longer mix Protonix and Pepcid as IVPB. Single dose patient vials will be provided and RNs will reconstitute and administer IV push. With this move, SLUHN will experience less waste of these meds (they have decreased shelf stability when mixed). Procedure: Protonix (Pantoprazole Sodium) Reconstitute the appropriate number of vials with 10 ml of 0.9% sodium chloride injection for each vial to a final concentration of approximately 4 mg/ml; administer total volume IVP over a period of at least 2 minutes Flush IV line before and after administration with NSS. In-line filter not required. Pepcid (Famotidine) Dilute 2 ml of injection (containing 10 mg/ml) with 0.9% sodium chloride injection or other compatible to a total volume of either 5 ml or 10 ml; administer total volume IVP over a period of at least 2 minutes Flush IV line before and after administration with NSS -----------------------------------------------
PRACTICE CHANGE for Dialysis Catheters: 3M CHG (Chlorhexidine Gluconate) Dressing St. Luke s University Health Network is implementing a change to the 3M CHG Dressing (# 1657) for active dialysis catheters. This is in response to a CDC recommendation for exit site care of dialysis catheters. Phase 1 of this change process began on 5/13/15 at the Bethlehem Campus > dialysis catheter dressings (3M CHG) are applied AND changed by hemodialysis RNs & clearly labeled dialysis catheter along with date, time & RN initials. Phase 2 will be implemented network-wide at SLUHN on 6/8/15: ONLY Dialysis RNs & Critical Care RNs performing CRRT in will apply 3M CHG dressings to active dialysis catheters and label them as above. IR will apply 3M CHG dressings to all newly inserted, temporary and permanent dialysis catheter sites. Outside critical care units (where CRRT is performed), dialysis, and IR, if a dialysis catheter dressing becomes compromised, the RN will perform a regular central line dressing change removing the CHG dressing and replacing with a 3M central line dressing (include labeling as above). Dialysis catheters present on admission and covered with a gauze dressing: RNs will remove the gauze, assess the site, perform central line care, apply a regular 3M central line dressing and document. This process, occurring on admission for all patients with dialysis catheters, will help to protect the patient while hospitalized. External dialysis centers will continue to use gauze dressings between treatments; this practice is acceptable in the community but does not provide enough protection in hospitals where patients are subject to bacterial exposure. 3M CHG Dressing - note labeling and rectangular CHG patch over insertion site CHG impregnated portion of the 3M CHG dressing 3M CHG dressings remain in place for 7 days like the regular 3M central line dressings! Please note (not new): The patient & staff members present must be masked during the dressing change of a dialysis catheter. An order from the NEPHROLOGIST is required to access dialysis catheters for non-dialysis uses. Coming soon: an algorithm for who can access dialysis catheters even with an order! -------------------------------------------- Coming Soon: Code Status/Resuscitation Level policy education (June implementation July 1) VTE Prevention Annual Education