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Warren Campus Nursing Practice Alert

June 2015

Directions for Completion

1. This program is to be completed by RNs & nursing staff and Unit Secretaries

Review should be completed by June 27, 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 – June 2015

COUMADIN Teaching

Core Measures have not gone away!

Measures that SLW had chosen in prior years as our Core Measures were retired on Jan 1st, 2015. SLW had to choose “new” measure sets for data submission. Our current measures include Venous Thromboembolism (VTE), Stroke (STK), Global Immunization (GLB), Outpatient Throughput (which includes pain management - long bone fractures, Stroke - CT Scan in 45 minutes and AMI / Chest Pain), Inpatient Throughput (IED) and Tobacco Use (TOB)

In 2014, our performance related to VTE Discharge Instructions, which includes Coumadin teaching, achieved 93.9%. However, currently for 2015 this rate has declined to 83.3%. SLW needs to strive and achieve 100%.

What does this mean?

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CY 2014 Summary for SLW” | | | |CY 2015 YTD Summary for SLW: | | | | |Measure: | | |Rate % |Measure | | |Rate % | |VTE Prophylaxis |514 |528 |97.3 |VTE Prophylaxis |178 |187 |95.2 | |ICU VTE Prophlaxis |94 |95 |98.9 |ICU VTE Prophlaxis |41 |43 |95.3 | |VTE Discharge Instructions – Coumadin Teaching |31 |33 |93.9 |VTE Discharge Instructions – Coumadin Teaching |5 |6 |83.3 | |

What do we know?

The data in the table above for warfarin teaching is a documentation issue. Our current documentation of teaching occurs on paper and just listing warfarin under “prescribed medication” is NOT enough. To meet this measure there are 8 elements that must be reviewed for warfarin and documented. 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? Are we doing anything specific for SLW?????

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 Core Measure checklist for each discharged patient

• Clinical Coordinators will be responsible for checking warfarin patients on their unit and reviewing with bedside RN that teaching was completed

Documentation Reminders for Coumadin/warfarin:

1. Whenever warfarin is prescribed and administered print out the education from LexiComp and perform and document teaching - If only Food & Drug Interaction teaching is addressed, it does not meet all the other required Core Measure components!

2. If warfarin appears on any Med Rec (admission, transfer, or discharge), perform and document teaching even if the order is not active (Teaching record)

3. The RN can document warfarin teaching in the teaching record at any time during the admission. Unless you want to write all the required elements…..Just CHECK THE BOX:

Page 2 of the Teaching Record: Resources & Materials Given

( Lexi-Comp: Warfarin (which includes: importance of the following: taking as instructed, monitoring scheduled PT/INR; consistent amount of foods with Vitamin K intake; Avoiding major changes in dietary habits or notify health professional before changing habits; diet & medications can affect the PT/INR level, don’t take or discontinue any medications or OTC medications except on the advice of the physician or pharmacist, and Warfarin increases the risk of bleeding

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 must ensure a “Service/Attending” and “Status” are ordered for all patients when confirming initial orders

2) Unit secretaries: ensure both a “service/attending” and “status” is ordered.

Common mistake we make at Warren Campus:

Follow up… Most mistakes come from O.R where order status is either incorrect or missed.

Follow up to obtain appropriate orders is required.

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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- Looking to merge at Warren).

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 Nurse manager/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 Nurse Manager/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 Guidelines located in SoftMed

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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.

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PROTONIX® & PEPCID® Practice Change for the Network Pharmacies: (Warren Campus is currently doing this and will continue the same practice)

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.

• Pharmacy will continue to mix 80mg dose at Warren Campus

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

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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 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, dialysis, and E.R units, 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:

o RNs will remove the gauze, assess the site, perform central line care, apply a regular 3M central line dressing and document. Rationale: Gauze dressings are a medium for bacterial growth placing patients at a higher risk for central line infections while hospitalized. Making this practice change, for all patients with dialysis catheters, will help to protect the patients while hospitalized.

o 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

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Coming Soon:

• Code Status/Resuscitation Level policy education (June – implementation July 1)

• VTE Prevention Annual Education [pic]

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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!

3M CHG dressings remain in place for 7 days like the regular 3M central line dressings!

CHG impregnated portion of the 3M CHG dressing

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