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SPECIAL SUPPLEMENT: REGULATORY READINESS

July 2014

As you know…..

The clock is ticking on our upcoming JC survey. This Special Supplement Newsletter is designed to pull together communications, practice changes, and helpful hints that have been distributed.

BUT FIRST…. BREATHE!!!

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Equipment Cleaning Contact time: Dispatch (5 minutes) & Oxivir (1 minute) All surfaces need to remain wet for the contact time to ensure effectiveness. Reapply &

continue wiping to ensure adequate coverage to keep wet for the contact time. Unit-owned equipment such as bladder scanners, scales & ultrasound devices should be

cleaned after each use before they leave the patient room and then should be stored in a clean area.

All equipment not in a patient room must be tagged: The only exceptions to tagging are: BP machines, glucometers and walkers used by PT.

Tagging is essential: Red (soiled) Green (clean) Brown (soiled—enhanced contact precautions)

CAUTI Prevention Nurse Initiated Catheter Removal Protocol

Remove catheters as soon as possible when patient no longer meets criteria Use the Bladder Scanning Algorithm per COP-046 to determine if a catheter needs to be reinserted—avoid

reinsertion if possible Maintain urinary catheters carefully

Do not break the seal on the all-in-one catheter sets Keep catheter area/perineal area clean and dry– wash daily

Remind providers to use the Urinalysis Reflex Testing order to prevent unnecessary testing - maintain sterility when obtaining urinalysis and culture samples

Hand Hygiene Upon entry and exit of each patient's room/area regardless of glove use Remember that you pick up transient bacteria on your hands every time you touch surfaces or place your

hands in your pockets etc. Hand hygiene protects patients from these hitchhikers. When rounding, hand hygiene on room exit counts for the entry action only if you are immediately going

from one room to another without touching anything.

Isolation Patients - Transmission-based Precautions Isolation signs should be visible to all those entering the room. All staff and visitors are expected to comply with sign instructions. After discharge, isolation signs should remain in place until the room has been cleaned. Hand hygiene should always be performed before donning Personal Protective Equipment (PPE). Gowns should be properly tied in the back and masks should be worn over the nose. All PPE is to be removed and discarded upon exiting the room. If traveling with a patient on Isolation, upon arrival to destination, remove PPE and perform hand hygiene.

Additional Important Points Specific to Airborne Isolation When entering a patient's room on Airborne Isolation, all staff, students, and providers need

to don the reusable or disposable particulate respirator for which they have been fit tested within the past year -or- must use the PAPR equipment supplied in the clinical area.

All patients requiring Airborne Isolation must be placed in a negative pressure room. If TB is suspected and AFB sputum sample has been ordered, ID must be consulted and

patient must be placed on presumptive Airborne isolation until 3 samples are confirmed to be negative.

Infection Prevention Reminders

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Oxygen Safety

Management of Oxygen E-Cylinders Key points to remember: Oxygen e-cylinders must always be secured in a rack, stretcher or caddy.

O2 storage racks Must be labeled FULL or PARTIAL/EMPTY Store only Full – Unopened Cylinders in the FULL rack Store other cylinders in the PARTIAL/EMPTY rack Cylinders should NEVER be stored on the floor!!

Use only Full-Unopened Cylinders when transporting mechanically ventilated or oxygen dependent patients No more than 12 E-cylinders may be stored in an area

You will see these new signs in your storage rooms!

Medical Gas Shutoffs Know where your area’s O2 shutoff valves are in an emergency!

Only the charge nurse, NM, or a chief technologist in a procedure area should authorize O2 to be turned off. Call SOSC 8-5174 if you turn off any medical gas.

Slide the door to the right or simply pull the cover off

Turn each valve ¼ turn so that the handle protrudes from the box to stop the flow of gas.

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Non-Violent Restraint Requirements

For additional information: See COP-029- The Use of Restraints on Non-violent Patients for Medical Reasons

If restraints are continued from a previous day, you may add date/time of initial application— under “Comments”

Please label it “initiated on___________”.

Remember - If you use restraints, the problem MUST be added to the Plan of Care

Restraint problem is found under Safety Prevention Measures on the POC Include restraints in the Patient and Family Education as well Once restraints are removed, complete the Date Problem Resolved field

Nursing Documentation

If restraints are continued from a previous day, you may add date/time of initial application— under Comments

Please label it “Initiated on________@_______”.

Start a new form each day when you begin a new flowsheet.

Continuous Initiated on xx/xx/xxxx

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Medication Management Issues Control of Access to Medications

We have a responsibility to control the access to medications by unlicensed staff in medication storage areas including, but not limited to, materials distribution area, clean utility rooms, procedural areas and medication rooms. 1. New addendum to MM-005 Medication Management policy includes a table that defines

staff responsibilities: Staff whose job responsibilities require them to access medication supply and

storage areas for the purposes of transporting, stocking, cleaning, and service/repair will have access established by their supervisor.

Any staff who do not have access to those areas through their own badge access/keypad must obtain access from someone who has authorized access.

2. Crash Cart delivery and pick up Crash cart medication contents are managed by pharmacy during the initial Stocking, then locked. The restocking process occurs in conjunction with

Equipment Distribution (EQD) staff, therefore, medications must be re-locked prior to cart pickup by EQD staff.

There will be an additional lock with the crash carts so that after a cart has been opened, the RN caring for the patient will replace the drug trays in the cart and secure the cart with a new lock. There is no need for RN to document new lock #.

For questions, please contact pharmacy

Medication Safety: Did You Know?

Pharmacy has an established system to maintain lists of Sound-Alike, Look-Alike (SALA) medications to prevent medication errors (see MM-012 for the lists)

Drugs that are similar in physical appearance, have similar names, or similar packaging are stored separately in pharmacy.

Drugs that have similar names use enhanced TALLman lettering to help distinguish them from each other on your E-MAR.

(eg: cefTRIAXone and ceFAZolin, traZODone and traMADol, predniSONE and prednisoLONE) “SALA alert” stickers are on the bins in the pharmacy to help prevent dispensing errors.

Certain Multi-dose Drugs Can Be Sent Home at Discharge

Verify that the drug, dose, strength, route and directions are the same as prescribed for home.

Make sure the drug has the original pharmacy label with the required information

Please ensure that the lock boxes in patient rooms are emptied at discharge!

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GLUCOMETER MANAGEMENT ACCU-CHEK® Inform II Glucometer

The glucometer reports glucose ranges from 10 to 600 (Results <10 read “LO” Results > 600 read “HI”)

If test result is a critical value - an “Out of Critical Range” message will appear

When Do Test Strips and Control Solutions Expire?

Test Strips are good until the expiration date printed on the label

Control Solutions

good for 3 months after opening

Control Solutions must have both

Opened Date: ______

Discard Date: ________

Clearly written on the label

Quick tip: place a piece of tape

over the date once it is written on the

vial to prevent smearing

REMEMBER :

Dock the meter after use so results

can be uploaded to medical record

Safe Medication Use Reminders

Always Use 2 patient identifiers

Adhere to “do not use abbreviations” list (See MM-006A)

Review all look-a-like and sound-a-like drugs

Label all drugs – including those placed on a sterile field

Medication reconciliation should occur upon admission,

discharge, and all transfers of care

Be extra careful with high risk drugs or PINCH meds PINCH meds

P - Potassium

I – Insulin

N – Narcotics (Opiods)

C – Chemotherapy (& Biotherapy)

H – Heparin (& other anticoagulants)

Remember to do independent double checks for Insulin, Narcotics, Chemo &

biotherapy, Heparin & other anticoagulants, & TPN

Provide patient education with all new drugs started, especially the adverse

side effects prior to administration to first dose!

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Medication Management NEW! Adult Titration Dose Protocols

In order to avoid nursing scope of practice issues, a

TITRATION DOSE PROTOCOL has been established

to guide the use of medication infusions.

See MM-003 C for full table and additional instructions

IMPORTANT FACTS FOR NURSES REGARDING THE TITRATION PROTOCOL: 1. Titration protocol MUST be ordered and must be followed unless otherwise specified in provider orders.

2. A copy must be placed in the patient’s medical record (under the orders section) including patient

identifiers or patient sticker.

3. If the prescribed therapeutic endpoint cannot be reached while remaining within the protocol limits,

contact the provider for new orders.

SINGLE VS MULTI-DOSE MEDICATION VIALS Single-use vials: These should never be used for more than one dose. These

vials do not contain preservative and can pose an infection risk since they can

be easily contaminated.

Multi-dose vials: There should always be an expiration date/time on every

multi-dose vial . All are good for 28 days, and then must be discarded.

Insulin Pens: Should be used only on a single patient, should be labeled

with patient name and DOB (or MRN) and are good for 28 days.

Vaccines: These are good until the manufacturer’s expiration date as long as they are

stored according to manufacturer’s specifications.

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What is the change? Where can I find it? Why was it changed?

New Indications for PRN pain medicine

Orders for Analgesics To distinguish mild, moderate, and severe pain indications per regulatory requirements To reduce “therapeutic duplication” and improve pain management

New Order Risperidone added to Adult ICU Sedation PowerPlan

Adult ICU Sedation PowerPlan

Promote safer patient care

Inactivate STC MET PROFILE lab or-der and replace with CMP (Comprehensive Metabolic Profile)

Order Catalog Provide standardization in ordering and lab practices

Clinical Informatics - TJC Tips: Order Review

A surveyor for TJC may ask to see an order on a patient that has had a lengthy hospital stay .

You may have to find that order.

Cerner is designed to display only a select number of orders at one time to maximize the speed

of the system. Your “older order” is still there, just not displayed.

To view, you must select the “Show More Orders” button in the lower right corner.

This selects the next group of

orders for review. This can be

repeated until the target order is

located or all orders have been

displayed.

You will know that all orders

have been displayed when

Show More Orders box turns

For more information, contact

clinicalinformatics@umm.edu

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July Cerner Changes

JC SURVEYOR TIP: CREDENTIALING OF PROVIDERS If a surveyor asks you “How you know that a provider is credentialed to perform a procedure?” The correct response is “The LIP is responsible for being properly credentialed to perform the procedure independently”. If I am concerned:

I may contact next level of provider to assist with the procedure or Verify credentialing privileges in E-value for residents/Fellows & MIDAS for Attendings & NPs by

searching MIDAS @ http://intra.umms.org/ummc/nursing/cppd/clinpractice/clinresources/midas or E-VALUE @ http://intra.umms.org/ummc/nursing/advpractice/education-and-training/onboarding/evalue

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New!!! Disposable CO2 Detectors: Color Change

Accessing the Complete Anesthesia Record

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Regulatory Readiness Intranet page

http://intra.umms.org/ummc/nursing/cppd/clinpractice/

clinresources/regulatory-resources

or SEARCH: “Regulatory Resources” on the intranet home page