Care
Unit
THE INTENSIVE CARE JOURNAL /
August 2008
WHAT’S NEWS
Is it August already? It seems like just yesterday that it was getting dark at 5PM and you couldn’t wait for some sunshine. It’s been a strange summer however, with the fires, smoke, fog, and intermittent sunshine. If we just had one big rainstorm everything would be just fine.
The Storks hosted a Pot Luck at their home at the end of July. From all accounts it was a fabulous time for all who attended. If only we had at least one compromising photo to paste on the ICU Website. Thanks Brian and Kim for your kind hospitality. Paul Castaneda was passing around a photo of the Storks (it looked like a Harvey Heningson portrait) but it also looked like an archival photo. We all knew it was archival when Paul passed around the second photo which depicted Brian at work. We all know that hasn’t happened lately. Hah!
The Generic softball team fought hard but lost last Monday. Apparently the team scored 10 runs in one or two innings and seemed to finally come into their own.
The friendly beginners bicycle ride has grown into quite a happening. Sharon Brookhouse and Helen Hammer are still leading the rides and many newcomers have joined. Please contact either of them to learn when and where the next ride will commence. Remember it’s just for fun and nobody is left behind.
The regional review team was here three weeks ago to do a mock JCAHO survey. The teams were comprised of Mgmt. and administration from with the Northern Kaiser Region. We as a hospital reviewed well. The ICU in particular reviewed very well. This was in spite of the overhead PA system announcing the “Regional Survey Team is here” repeatedly. That was only a little embarrassing at first and then became quite funny as the review team bowed and curtsied each time it was announced. Thanks to all who weathered the questions and had fun with the reviewers.
DOCTOR’S PULSE
Monica and Mindy have offered Dr. Dichter a position here at Kaiser SRO. He is actually entertaining the possibility. Dr. Dichter has a strong background in developing Hospital Based Services (HBS) and could work both in the ICU and as an HBS physician. The problem for Monica and Mindy is that Dr. Dichter is not a Pulmonologist. One of the criteria (Kaiser Criteria) for hire as an Intensivist is the ability and qualification to do Bronchoscopies. In the meantime Dr. Dichter will be with us throughout the fall season and Dr. Shragg will also begin to do more days per month come this fall. Monica and Mindy will continue to cover the ICU, Clinic, along with their other administrative responsibilities. Thank you all for working so hard for us and our patients.
KRISTINA’S CORNER
I would like to say a special "Thank You" for the wonderful job you all did during the recent Regional Mock JCAHO Survey on July 16 and 17th. I was so impressed with everyone’s composure, knowledge and presentation. It was beautiful to see us working in unison to demonstrate to our visitors how we all participate in creating a center of excellence for our patients and ourselves.
Nursing grand rounds will be starting in September. We will kick off with a presentation by Edith McMillan NP on Lateral Hostility in the Workplace. This will not be paid time. CEU's will be given.
Magnet conference- Coming up OCT 15-17. I would like for 2 ICU staff to attend. Please come see me if you are interested.
GRASP- We will be one of three REGIONAL pilot sites for developing the Regional ICU GRASP tool. Please see
Jennifer or myself if you are interested in participating in the development group.
Leadership Team- I met with Anita Catlin on the AACN Standards for Establishing and Sustaining a Healthy Work Environment. We are currently working with the leadership group on Standard 4, Appropriate Staffing.
PYXIS project- we will begin the PYXIS renovation in early Sept. This will mean the nursing core will be affected for a 2 week period. They will block off half of the station at a time. During this period we will need to take Patient proximity and visibility into consideration when making assignments. Thanks for your flexibility during construction. The end result will be great.
Kaiser Annual Mandatory Offsite - Scheduled for Sept/ 8,10.12,15,17,19,22,26 and Oct/ 1,3,6,8,. All classes will be held at the RESIG building (Redwood Empire School Insurance Group). Flyers and sign up should be coming out next week.
Have a wonderful day
Kristina Smith
HEROES
Congratulations on the ongoing prevention of HAPU's. As a facility, we are now at day 96 without a HAPU (July 31st). The ICU is at day 107.
As a facility, we are at day 12 without a patient fall. The ICU is at day 115. RRT, we are almost meeting the regional goal of 7 RRT calls per 1,000 patient discharges. The RRT form has been revised to include a trigger for a debriefing to be conducting and to identify any educational opportunities. The process has also been changed to require the floor staff RN to complete this form to allow the ICU nurse and RT to perform the hands-on care and coordination required in these situations. Keep up the great work!
ANNOUNCEMENTS
Please join me in welcoming Susan Cowderoy, RN, MSN, CCRN who will be starting on August 5th in the role of ICU
Clinical Nurse Specialist here at Santa Rosa. Susan is not a stranger to Santa Rosa. She
worked in the ICU as a staff nurse intermittently from 1996 through 2005. Most recently, Susan has been working per diem in the PACU at Kaiser San Rafael while she attended UCSF. She has completed her course and graduated in June
2008.
Debbie Lindberg is retiring soon and we would like to take a moment the express our gratitude for a job well done. Deb has worked tirelessly on many of the obscure issues and projects that make a facility like ours tick. If it weren’t for people like Deb our lives would be much less fruitful. There is a celebration scheduled for Deb Thursday Sept. 4th from 12-1:30 in conference rooms E4, E5. Please R.S.V.P to Michaela D. Anderson by August 8th.
Thank you Deb and many best wishes for an enjoyable retirement.
Anne Taylor, will be the new RN Quality Coordinator, replacing Debbie Lindberg (Deb really likes her). She will be working with Kristina Smith R.N. and Mindy Shapiro M.D. to facilitate the ICU Committee. She will be reviewing code blues and RRT calls and reporting them to HEROES and to the ICU Committee.
Reminder: the RRT evaluation forms are new. The yellow copy needs to be filled out, folded, stapled and sent to Quality (address already stamped). Please take the time to look at the new forms and familiarize yourself with the changes. The new policy for RRT was developed in the ICU service unit team and is as follows: When responding to an RRT the ICU nurse will provide the primary care nurse the clipboard, with the RRT form. The primary care nurse is responsible for documentation of the RRT and updating responding
practitioners of precipitating factors leading to the RRT call. The ICU nurse will direct the activity during the Rapid Response call. The ICU nurse responding brings critical care experience to the RRT and should not be simply charting upon arrival.
The Annual SALSA Tasting Contest is back!
Attention All Salsa Chefs—Salsa Season is here & we want to taste yours!
The Salsa Contest will take place at The Annual Multicultural Fair
Weds. Sept. 17
11:30 AM to 1:30 PM
Hospital Green
Please respond to: , or phone 707.393.3040
by September 10 to enter your salsa.
CRITICAL NOTIFICATIONS
Recently the Mgmt. team passed a sign in sheet related to the critical notification protocol (in effect since 2004). Since last July we have been aware of the problem of proper documentation of Critical Values. Last July double exclamation marks were taped to all -Computer on Wheels- stations and Mgmt followed up daily on the need for consistent documentation. That was then, this is now. One year later we still do not document critical values properly (as a hospital we documented 59% of critical values properly). This has become a huge issue for Kaiser SRO because our accreditation as a hospital is now on the line. There has been some rumor about this issue but the fact is we must document critical values 100% of the time within one hour’s time of result (as per our protocol). What does it mean if we lose accreditation? It means don’t bother showing up for work (no matter what the contract says) because none of us will have a job. It happens.
STROKE MANAGEMENT
ICU received during our recent mock Joint Commission glowing compliments on the care provided by the nurses and the knowledge of the patients that our nurses verbalized. We have more work to Survey, our Stroke program was reviewed. The complete before we can apply for certification, but we are all on the right track.
POSITION CONTROL
A full-time night shift Assistant Nurse Manager position has been posted, and soon interviews will be scheduled, for the ICU. If you are interested please contact Peggy Vaughan at (510)504-0795.
PEOPLE NEWS
In the July newsletter we reported about the two nurses in Old Shasta who were fighting to save their home. The Motion fire burned out of control until 7/25. Mike Simpson reported a 200 foot wall of fire came within 600 feet of his house. “Dude I almost died” was the only thing he could say after describing his experiences. Apparently, during the mandatory evacuation, while the two CDF engine companies were camped out at Mike’s house, the fire came barreling toward the house. Mike said the house was covered with retardant and the strategy was to let the fire burn over the house and then come out and fight the fires that remained. As the fire got closer to the house 5 Borate bombers (huge Air Force type bombers) suddenly flew in from above, nose to tail, and dropped their payloads on the fire in succession. This slowed the fire for a short time (approx. 10 minutes). Just as the fire began to pick up again the wind shifted direction and the house was saved!! The only thing Mike could say, other than the above remark, was those CDF guys are the”salt of the earth.”
JCAHO 2008
Goal 2- Improve the effectiveness of communication among caregivers.
Implementation Expectations for Requirement 2B:
- Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.
- The list of abbreviations not to be used includes the following:
- U, u, IU
- Q.D., QD, q.d., qd
- Q.O.D., QOD, q.o.d., qod
- Trailing zero (X.0 mg) 2.0 mg
- Lack of leading zero (.X mg) .2 mg
- MS, MSO4, MgSO4
- HS
- T/W
- X_ D
- cc
Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes.
- The organization implements the “do not use” list and applies this list to all orders and all medication-related documentation when handwritten.
- Preprinted forms do not include any abbreviations identified as not to be used.
HEALTH CONNECT
Looking at an Encounter from another Facility or Date
1) Go to Hospital Chart (in the Action menu or on your toolbar)
2) Type MRN and Accept
OR
1) From inside the patient's chart choose Hospital Chart
2) Choose your patient's name from those displayed and Accept
THEN
3) Choose the encounter you wish to review from the list provided and Accept
EDUCATION CORNER
August
CCRN Review Course; part IV of a four part series from 8:30am to 12:30pm in E5 - August 15
Disseminated Intravascular Coagulation from 1:00pm to 2:00pm in E5 - August 15
Rhabdomyolysis from 2:00pm to 3:00pm in E5, also on August 15
September
CCRN Review begins again on September 18th but with a new format. This will be a three part presentation of the Kaiser Videoconference version. The previous series was the AACN version. Exact times and location TBA.
Back by Popular Demand: The "Fall Offsite" begins September 8th. This mandatory training will be offered on multiple dates in September and October. Don't forget to make sure you are signed up. The offsite will be from 8am until 4:30 at the RESIG (Redwood Empire School Insurance Group) location. Look for the flier.
October
Hemodynamic Training with Michael Collins and/or CCRN Review part II of a three part series will be held on October 16
ICU competency assessment will begin in October
Do you have a course you would like to teach? Or a class you wish was offered? If so, please call Diane at x34543. Topics being planned for the future include "Managing Sepsis" and "Managing Trach’s".
INFORMATIONAL
Heroes:
ICU Audits continue to be an issue on the forefront of our regulatory compliance. Below are the responsibilities we as a unit must perform on a regular basis. Most of this information is reportable and will soon (if not already) be public knowledge. Please help us when we ask you to do an audit. Thanks to you it).
Nurse Knowledge Exchange (NKE): 5 Audits/ Unit/ per shift/ Month (Due the second Friday every month).
MedRite:
Central Line: Daily (UA usually documents in CL/VAP bundle book. This is a daily tally of central lines in the unit).
CLV-JCAHO: Daily (E-faxed to Barbara Schlieman).
Skin/Wound Assessment-DPH- POC: 18 per month (E-faxed to Barbara Schlieman).
Care Plan/ Education- JCAHO PPR: 18 per month (E- faxed to Barbara Schlieman).
Procedural Sedation/Picc line audits: Every time procedural sedation is performed or a Picc line is inserted an audit should closely follow. The audit forms will live in the ICU Forms Drawer adjacent to the unit assistant. Give completed copy to ANM.
Central Line Audits- Every time a central line is inserted a central line audit is required. Please fill one out and fax it to the number (infection control) provided. The completed copy will then live in the CL/Vap bundle book in the nursing station.
FINANCIAL HEALTH
Pay period 15 is has come to a close and at this writing PP 16 is in progress. In pay period 15 we performed well but we really suffer during times of low census. The HPPD/CPPD ratios were consistently in the low 70-80th percentile (anything greater than 90% is good). Pay period 14 didn’t look too good either. This is greatly influenced by the ICU census. At periods of low census our numbers look dismal. And conversely, at times of high census, we look good. Please continue to help us be fiscally responsible. The main areas of focus remain: 1) if you are offered a cut and can take it please do so (this usually happens during low census times), 2) if you are in danger of missing a meal or a break please let the lead nurse or ANM know as soon as possible to help problem solve and possibly eliminate the possibility of missing these
breaks (it is state law that you be provided with break and meal time periods. If you are offered a break or meal time and you refuse to take it, missed meal/breaks will be denied), 3) please try to limit incidental overtime. Incidental overtime usually occurs by clocking in too early or too late. Please be responsible to clock in at the correct times (i.e. within the 6 minute window before and after your shift). If you are in danger of working over please let the lead and ANM know so that they can help you problem solve to get you out on time.
PHARMACY
BLACK BOX WARNINGS
In the United States, a black box warning (BBW (also sometimes called a black label warning or boxed warning)) is a type of warning that appears on the package insert for prescription drugs that may cause serious adverse effects. It is so named for the black border that usually surrounds the text of the warning. A black box warning means that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects. The U.S. Food
and Drug Administration (FDA) can require a pharmaceutical company to place a black box warning on the labeling of a prescription drug, or in literature describing it. It is the strongest warning that the FDA requires. Many medications are being
reviewed by the FDA and are receiving BBWs (i.e., fluoroquinolones as noted in the July ICU newsletter).
Two medications with black box warnings that have received greater attention recently at our facility are Fentanyl (Duragesic) transdermal patches and haloperidol (Haldol).