Week End Wrap Up

May 24, 2010

Staff Meetings

Tuesday, June 1, 2010 BB667 (OB Conference Rooms) 1500-1930 & 1900-2300

Monday, June 7, 2010 Two locations

SCC 252 1100-1530 & 1500-1930 BB667 1900-2300

Staff Meeting Agenda

Announcements Practice changes/timelines Mother Baby Updates (Purple

Crying, Documentation) Holidays (8-hours versus 12-hours) Scheduling issues MIC Idea Summit presentation Mandatories/LMS demo

Referral Process Changes

Improved referral intake process completed today

Team created streamlined process which reduces number of activities for each role, eliminates rework, and improves communication among team, and with referring providers—wow!

CHARGE NURSE ROLE IN REFERRAL PROCESS Twice/day TEAM STEPPS – Identify L&D status by

assigning color Charge RN responsible for keeping color code tool up

to date

Referral Process Changes (cont.)

GREEN – Attending will accept all referrals

YELLOW – Attending needs to call/talk with Charge RN before accepting referrals; Action: Chief & Charge RN trouble shoot patient flow issues with goal of returning to GREEN

RED – Attending comes to L&D and runs board with Chief, Charge RN; contact Nurse Manager or Flow Supervisor prn

BLACK – No referrals can be accepted; assemble management team Gigi or Debi, Karen Odle (Director of Perinatal Services), Flow Supervisor and Medical Director (if needed)

Referral Process Changes (cont.)

Charge RN responsible for alerting Attending and Chief of changes in unit status by sending text message – only text color (your phone # is on their card)

Attending will accept all transfers if Green was status indicated at TEAM STEPPS unless Charge RN texted change

Attending will call Charge RN to notify transfer is coming and ETA

Charge RN responsible for texting Chief Resident and Generalist of new transfer (no longer responsibility of Attending to notify Chief) Include in text: G/P, GA, diagnosis and ETA

Referral Process Changes (cont.)

Circulating RN in OR monitoring Med-Con pager in OR; she will call Med-Con to alert that Attending can call after C-Section; if call an emergency, will transfer to Charge RN to take info

Referring Provider is transferred to front desk person (PSS/Float/RN/Tech) after Attending has accepted patient

Front desk now collects all info on referral patient

EFM Alert Acknowledgment

RN acknowledging EFM alert needs to call RN caring for patient to make sure they can follow up

SITUATIONS Acknowledging paper end alert and not letting RN

know; paper missing for 1-2 hours at night. Baby off monitor and alert acknowledged; RN not

notified; patient off monitor too long

Especially important in busy shifts at higher census when "juggling many patients"

Teri

34 to 34.6 wk late preterm newborn

34 to 34.6 week newborns need to transfer to the PCN within 30-60 minutes after birth

These infants require close observation due to increased risk of respiratory, thermo and nutritional instability

Babies 35 to 37 weeks may stay with Mom in L&D if RN remains in room until Mom's transfer

RN may transfer 35-37 week infant to PCN before Mom's transfer if she feels it's necessary .

When PCN is closed, charge RNs trouble shoot newborn placement as they have been—NICU, PCN RN able to be in the room, open PCN, etc

Any questions, let us know

Bedside Safety Checks Make a Difference

     Hospital wide evaluation of value of checks reported via PSN:      

During safety checks, noted patient did not have ID band.  Ordered FFP not infused until ID verified  Patient on protonix gtt .  Found levophed gtt running.  Pt previously on levo gtt but titrated off last night, or

so everyone thought.  RN recommendation – “Double check gtts including before end of shift”  During bedside safety check, noted ketamine gtt connected to wrong IV fluids and no name band

An hour after shift change patient found to have bag of heparin infusing in place of NS.  Resulting PTT >200.  RN recommendation -  “Observe closely 5R of drug admin.  Do bedside safety checks religiously” 

Patients and families also like safety check as evidenced by a complimentary letter:      "I wanted to share some feedback from recent hospitalization of my sister-in-law…..…(my brother) and his wife, were extremely impressed with the nursing care. The nurses were fun, responsive, informative, caring, attentive……... use of the white board is flawless. We always knew the names of folks… …my brother and his wife really liked the bedside shift reports. They said it happened all the time. …My brother was also impressed with how everyone checked the name band the first time they came in. 

Bedside Safety checks are expectation at shift change.   To do them correctly both on-coming and off-going RN enter room and review:  ID, Medications, PCA (Epidurals, Lines) Allergies, Check O2 and Thank you.  (IMPACT)  

On-coming RN should be doing the patient check “fresh eyes”.  Off-going RN should be doing verification in ORCA “tired eyes”

  Thank you for your continued work to keep our patients safe--Neil Francoeur, RN.  Patient Safety Officer

Heparin IV bags

Pharmacy currently unable to obtain premixed bags of heparin 25,000unit/250ml used for heparin protocol

Until manufacturer able to re-supply, have taken following steps: Removed premixed heparin bags from Pyxis Make heparin 25,000unit/D5W 250ml in

pharmacy Done in "batches" with multiple check points to

assure appropriate compounding Labeled with "Heparin, High Alert" Stickers (stop-

sign like) to call-out they are heparin bags

Low Molecular Weight Heparin

UW Medicine Pharmacy & Therapeutics Committee in consultation with experts in thrombosis and anticoagulation reviewed data with Low Molecular Weight Heparin (LMWH), and determined dalteparin (Fragmin) was most cost effective agent for institutions

To achieve desired patient and financial outcomes following steps will be implemented June 1, 2010:

1. Pharmacy will auto-substitute dalteparin 5000 units daily for VTE prophylaxis orders for enoxaparin 30mg daily, 30 mg every 12 hours, and 40 mg daily

2. A new LMWH order form (UH2933) has been developed for use in VTE treatment, bridge therapy and acute coronary syndromes

Please order form UH2933 from Materials Management in anticipation of June 1st implementation date.

Form is in PMM system and can be added to order template Please allow 5-7 days as it is a non stocked item Contact your clinical pharmacist if you have questions or

would like additional information

New Warfarin Order Form

To improve safety using anticoagulants, new warfarin order form implemented

Form introduced at HMC and now required at UWMC to standardize prescribing of warfarin across institutions  

Order form is UH2924   Order form required for:

New start warfarin Continuation of home warfarin Change in warfarin dose Hold or discontinuation of warfarin Filed in heparin section of patient chart—charts coming when we go

online with ORCA; for now will remain in orders section of chart

Thank you for supporting use of order form to improve safety of warfarin therapy

  Jackie Biery, Pharm.D. Medication Safety Pharmacist

May 2010 Pain Reassessment Audits

Of charts audited in May 172 dose of narcotics given 138 documented reassessment in 1 hour 80% reassessment work—right direction

Of charts audited week of May 17 35 doses of narcotic given 33 had reassessment within 1 hour 94% GREAT WORK this week (despite being very

busy!)

Fiscal Year 10 Pain Reassessment Audits (cont.)

Best Practice post narcotic administration assessment/documentation of patient response within 60 minutes

Documentation of reassessment noted in new column on flowsheet (separate from documentation at time of administration

UWMC minimum standard for pain reassessment—90 %

Best MIC compliance fiscal year 2010—82%

Problem times: night shift & shift changes

Interpreter News

Interpreter sheet used to sign in and out is interpreter’s worksheet

Needs to remain with interpreter Interpreters are spread thinly with

frequent, overlapping work Communication with individual

interpreters re unit needs, please take time to clarify unit needs and interpreter availability

Closet Locks on Mother Baby

First stage toward redesigning supply placement has begun

Several rooms now outfitted with shelves and “invisible locks”

Will trial what to stock and process to obtain supplies once several more rooms ready

Will largely be PCT function and responsibility

Stay tuned!

Compensatory Time

Unused overtime compensatory time paid off by June 30, 2010

Accrued holiday compensatory time may remain unpaid until September 30, 2010

  Please refer to the University website for more

information about comp time:  

http://www.washington.edu/admin/hr/ocpsp/flsa-ot/ot.html

  Questions may be directed to Department

Human Resources Consultant

Babies need your help

GBS Status document GBS status on triage form

AND newborn resuscitation record mom GBS+, include antibiotic type, #

of doses and time of last dose Medication History

Document on triage form—include methadone dosage

Blood Type accurate documentation

Glycomark

New lab test ordered to evaluate patient's diabetic control

Called GLYCOMARK Lab reports it: 1,5 Anhydroglucitol. CBGs give immediate information, Hemoglobin A1C gives average of patient's glucose

level over last 60 to 90 days GlycoMark level provides estimate of patient's post

meal glucose levels over past 1-2 weeks Evidence that up to 40% of patients whose blood

glucose levels appear well controlled experience postprandial hyperglycemia

Studies show oscillating hyperglycemia leads to more damaging complications than constant high glucose levels

Blood Services Tube Labeling

Issue: ongoing problems with correct labeling PSBC specimens and requisitions

Consequence: PSN reports, cancelled specimens and mother and baby blood redraws

PROCESS ENSURE that U # and name not cut off on label Generally Primary nurse completes PSBC requisition

and specimen label: date, time of blood draw & signatur

Then 2nd RN comes to patient room & verifies pt's name, U #, DOB, AND that date and time on label and requisition match and primary RN signature on both

Then, second RN signs both

Blood Services Tube Labeling (cont.)

In emergency if primary nurse unable, second nurse fills out label, requisition and signs both

Then primary nurse does double check of correct/matching date and time on both tube label and requisition and 2nd RN signature on both

Then, primary nurse signs both

"STOP" sign posted by tube stop requiring triple check: U# clear and complete on label Date and time the same and on specimen label and requisition Same two signatures on specimen label and requisition

Do this triple check prior to tubing sample to TSS—it could save patient another poke and you another blood draw!

Other ideas welcome—let us know!

Blood Services Tube Labeling (cont.)

Have you checked that all required info on your blood bank tube label and paperwork are correct, complete and legible?

Back in the 1500s:

Baths consisted of big tub filled with hot water

Man of house had privilege of nice clean water, then sons and other men, then women and children

Last of all, babies

By then water was so dirty you could actually lose someone in it

Hence the saying, "Don't throw the baby out with the Bath water!"