SLUHN Nursing Practice Alert- RN February 2015

Nursing Practice Alert - RN

February 2015

Directions for Completion

Due to the educational content being communicated/reviewed, successful completion of the Posttest will award 0.5 CE.

  1. This program is to be completed by RNs; the content primarily impacts nurses in inpatient areas but may be applicable to others.

Review should be completed by March 16, 2015

  1. Before proceeding to the posttest, be sure you have read the following information.
  1. 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.

  1. Comments, question, or suggestions can be directed to your manager or supervisor.

NEW for Your Review:

Intermittent Pneumatic Compression Devices (IPCD) - proper sizing

IPCDs are commonly referred to as SCDs and foot pumps. It is important that the calf sleeve or foot cover is properly sized. This will help with effectiveness of the therapy, comfort and patient compliance in using the IPCD. A sizing chart is available on theNursing Practice Resource Site.

The following sizes are stocked on units:

  • Kendall SCD Express Sleeve (calf, knee length): small, med, large, x-large
  • Kendall A-V Impulse Foot Cover: med, large, x-large

Reminder: the Kendall SCD™ 700 Series Controlleris equipped with alarms, many of which can be easily resolved (“User Resettable”).One such alarm may indicate incorrectly fitting sleeves - Example: High Pressure (Leg Sleeves) = tight fitting leg sleevesaction > check for tight leg sleeve & adjust fit (or size up) and check tubing for occlusion

For manufacturer’s references: MyNet > Tools tab > Nursing Practice Resource Site > Equipment tab > Sequential Compression Device

Vancomycin – Levels, Critical Values, & Reporting

Recent discussions at Infection Control Committee Meetings and other meetings attended by our Pharmacy colleagues have brought to light some inconsistent practices related to vancomycin-related labs to bring to your attention:

  1. For vancomycin critical results, call the ORDERING provider/service, not the Infectious Disease (ID) physician because they are consulted on the patient (only call ID if they ordered the trough).
  1. For vancomycin critical results, check the original trough order and review nursing communication orders to make sure there isn’t a “sliding scale” order already placed for what to do with the level.
  1. Vancomycin random levels should be drawn at the pre-specified time; however, vancomycin troughs should ideally be drawn 30 minutes or less from the next dose. When vancomycin troughs are drawn greater than 30 minutes prior to the dose, they can be significantly higher from a true trough, resulting in a provider inappropriately adjusting the dose if they do not catch the “timing”.
  1. Vancomycin levels should ideally be drawn peripherally in order to avoid falsely high levels due to vancomycin sticking to the catheter it was infused through. Vancomycin levels can be drawn through an IV line/catheter, if it can be ensured that the lumen was not being used recently to infuse the vancomycin. FYI - following a vancomycin infusion, flushing the line/catheter justprior to drawing the level has NOT been shown to correct this issue.
  1. When a vancomycin trough or random level is drawn, do NOT hold the next dose without specific orders from a provider to do so (typically done when the current dosing regimen is expected to be producing supratherapeutic troughs [>20 mcg/mL] based on the patient’s weight and renal function). The risk of treatment failure and development of resistance for holding a dose when the level is therapeutic (10-20 mcg/mL) or low, outweighs the small risk of reversible renal impairment from giving the dose during high levels.

Please make sure to advise assistive personnel who are drawing labs if there are any specific, time-related or technique-related requirements as noted above.

Urinary Catheter Insertion – practice reminders

Event: Female patient required a urinary catheter prior to transfer to another facility. After the patient arrived at the facility and complained of pelvic pain and discomfort, a gynecological exam was performed and a betadine swab was removed from the patient’s vagina.

Follow-up: Although no harm occurred, this patient required antibiotics to avoid a serious injury. Events involving retained objects are considered Joint Commission Sentinel Events and are also known as “NEVER” events. This situation was reported to the Pennsylvania Patient Safety Authority and Department of Health. Additionally, the patient and family were notified in writing.

The following points have been identified to help prevent recurrence and should be incorporated into clinical practice immediately:

  • Landmarks
  • Appropriate positioning of the patient, assistance from a healthcare worker, and adequate lighting should be used to assure visualization of landmarks
  • Under no circumstance should any object be inserted into the vagina to assist with identifying landmarks
  • After cleansing the swabs are considered contaminated and must be discarded
  • Healthcare Worker “Buddy”
  • When inserting urinary catheters the RN should seek the assistance of another healthcare worker to be present during the procedure
  • The additional healthcare worker (buddy) serves as a witness to procedures, ensures assistance is immediately available, and provides an additional set of eyes to ensure high quality sterile technique
  • Count

Following insertion of a urinary catheter, it is the responsibility of the RN to assure the number of swabs discarded at the end of the procedure match the number present at the beginning

Next Steps

  • A mandatory education review program for all RNs who insert urinary catheters – coming soon
  • Identification of unit/department based validators who will be responsible for staff training and validation of urinary catheter insertion techniques – more to follow
  • Documentation procedure to support “Buddy” and “Count” – more to follow

Recently Implemented Clinical Practice Changes:

POSS (Pasero Opioid-Induced Sedation Scale) Score

  • POSS scores are performed and documented pre-intervention and post-intervention with pain scores when opioids are administered
  • See Pain Management [D-23] policy in NPPM for additional details

Port Care Summary

When Accessing a Port

  • An order is needed to access a port
  • If skin is compromised over a permanent venous access device, do not use and notify the physician/AP immediately
  • At the Bethlehem Campus, only specific nursing groups may access and deaccess ports - see “Port Access Call Schedule” on Nursing Practice Resource Site (under Clinical Practice or Equipment tabs)

Ongoing Care

  • Ensure there is an order for flushing the port
  • Flush port per SLUHN flush protocol:

◦accessed port- flushbefore use with normal saline 5 mL and flushafter each use with normal saline solution 5mL followed by 3mL heparin (100 units/mL)

◦not accessed(port not in use)- obtain physician order for flush frequency, typically every 4-6 weeks

  • If port is accessed, ensure port is reaccessed every 7 days with a new needle
  • Assess site upon first contact with patient on your shift and thereafter at frequent intervals, normally not greater than 2 hours
  • Report any breaks in the skin, redness, swelling, warmth, drainage, etc. to the physician/AP immediately
  • No ointments are to be used on the port site
  • Provide patient education during hospitalization and upon discharge; reinforce previous two bullets (above)
  • An order is needed to deaccess a port

Med Infusion Time Out-Accountability of 2nd RN

  • Review of recent medication errors identified the 2nd RN failed to recognize a misprogrammed infusion pump during the Med Infusion Time Outs; therefore the errors were not intercepted and it reached the patient
  • It is important for the 2nd RN to follow all steps of the Med Infusion Time Out independently
  • Remember, the 2nd RN who checks the infusion is as responsible, if not more so than the first RN
  • It is very unlikely that two nurses would commit the same error if theMed Infusion Time Out process is performed independently, thoroughly and carefully
  • Please note, if two nurses set up a med infusion together, a third nurse must perform an independentMed InfusionTime Out

V.A.C. Labels (Vacuum Assisted Closure)

The person placing the V.A.C dressing on the patient is responsible for:

  • completing the 2 dressing labels contained in the V.A.C. dressing kit including date, time and number of pieces
  • placing the first label on the wound dressing covered with an additional piece of clear film to ensure label stays in place and remains legible
  • placing the second label in the paper progress notes of the patient’s chart
  • detailing on the paper progress note a description of the type and number of sponges and other dressing pieces placed in the wound (e.g. 2 black sponges and 1 white sponge and 1 Adaptic)

IV Infusions

Rate/Dose Changes

When a rate or dose change to any infusion is made, always ensure RUN is pressed within4seconds of changing the rate/dose. If this is not done, the new rate/dose is cancelled and the pump continues to infuse at the old rate/dose (this is NOT NEW). In addition, a message appears on the pump screen “Rate change aborted” and an intermittent alarm will continue to sound to notify the nurse that a rate change was attempted and aborted (the visual message is NEW).

RateGuard™ & DoseGuard™

RateGuard™is used for rate-based primary and secondary infusions (e.g. Fluids, IV antibiotics, Blood products).

DoseGuard™ is a hospital-defined, custom drug library,used for soft and hard dose limits on medicated infusions.

All infusions, with FEW exceptions, should be programmed in DoseGuard™ or RateGuard™NOT in Basic Infusion.

Look for a LABEL – if there is not label, it is not programmed in the correct mode.

After programming and before walking away from the pump, always ensure the following:

  • A bar is visible on the view screen
  • The pump is labeled
  • The green run light is on

Central Line Practice Reminders

  • Administering IV push medications via a Central Line:

A 10 mL syringe should be used when assessing patency and flushing central venous access devices. Once patency is assured, medication administration in a smaller diameter syringe is acceptable. This eliminates the need to transfer small quantities of medications to a 10 mL syringe thusincreasing accuracy and decreasing risk of error.

  • Catheter Occlusion Algorithm:

Algorithm is now attached to Central Venous (Vascular) Access Device [D-04] policy. Additional information on administering Cathflo® can be found in the policy attachment, on the Nursing Practice Resource Site(under Medications or Equipment tabs), and in the package insert.

Practice Expectations:

  • Remember to label the line “DO NOT USE” while Cathflo® is dwelling
  • Please Note: After Cathflo® dwell, catheter patency is assessed by aspirating blood. If patency has been restored, aspirate to remove Cathflo® and residual clot (as per Cathflo® packet instructions). Change needle-free valve prior to the final irrigation with normal saline solution.Changing the valve is necessary to prevent clot debris in original valve from being reintroduced into the line/patient.
  • Flush Protocol – recent changes:
  • All inactive central lines (PICCs and temporary/non-tunneled catheters (e.g. triple lumens)) are flushed every 12 hours per each lumen at 0900 and 2100.
  • Detailed description of flush process (note: this applies to central and peripheral IV access) - FLUSH PROCESS (performed before med or IV fluid administration & when flushing inactive lumens/lines): Perform hand hygiene, scrub the hub, attach saline syringe, aspirate gently to visualize a free flowing blood return (i.e. blood pulls back without resistance), inject normal saline. If blood mixes with saline, remove syringe & discard, perform hand hygiene, scrub the hub, and flush with new saline syringe. If small gauge peripheral IV does not show blood return, monitor site carefully. If other lines do not show blood return, additional interventions and investigation is required (e.g. follow Catheter Occlusion Algorithm, Central Venous Access Device).

Other General Reminders:

Blood Glucose Correction

The nurse covering a blood glucose obtained by Glucometry must use the downloaded result, unless she/he obtained the result personally. It is not acceptable or safe practice to cover blood sugars with information from verbal or handwritten communications.

Heparin Infusions – failure to restart at new rate

When stopping Heparin infusion due to high aPTT, be sure to restart drip at the new, lower rate. Several instances have been reported where drip was held for an hour as per order set/protocol, but then restarted at the old rate.

Anticoagulation Medication Duplications

Recently there has been an increase in anticoagulant duplication errors. Prescribers, pharmacists and nurses allplay an important role in helping to prevent this type of error. Prescribers and pharmacists are receiving information related to the procedures they are expected to follow to prevent duplication errors.

From the nursing perspective:

  • Nurses must clarify with the prescriber when more than one anticoagulant has been ordered. It is possible that more than one anticoagulant is intended, but because this is typically not the case, clarification must be obtained and documented.
  • Nurses need to be knowledgeable of newer anticoagulants to be able to identify therapeutic duplication. Some examples of newer anticoagulants include:

Dabigatran (Pradaxa)

Rivaroxaban (Xarelto)

Apixaban (Eliquis) –involved in most of the recent events

Micromedex is a quick, excellent resource. There is a new Antithrombic Agent Chart on the Nursing Practice Resource Site under MedicationsAntithrombic Agents

Blood Product Transfusion Practice Reminders

  • RNs assess the patient for signs/symptoms of transfusion reaction throughout the duration of the transfusion, generally at 5 minutes after the start of the transfusion, then in 15, 30, 60 minutes and every 60 minutes thereafter until transfusion complete and documents assessment findings that are abnormal.
  • For routine blood product transfusions, the 3 sets of vital signs are documented on the transfusion record.
  • Intra-operatively, after the two person verification is documented, remaining documentation may be recorded on the Anesthesia Record. Check the box on the Transfusion Record form to indicate this.
  • If blood products are released from the Blood Bank in a cooler and blood products are administered, a reconciled copy of the Laboratory blood product log (e.g. Surgical Procedure Blood Products log) will be sent to the patient care area and placed in the patient’s medical record.

Transfers to Other Hospitals and SNFs

The RN completes the following for all patients transferred to another hospital or SNF:

  • Complete and print Med Rec
  • Complete and print Nursing D/C Instructions
  • Complete and print Transfer Summary & Transition of Care Summary
  • Ensure chart is copied
  • Fax to facility
  • Med Rec
  • D/C Instructions
  • Transfer Summary
  • Transition of Care Summary

Place all of the above in the transfer folder

  • Call report to facility/receiving unit
  • Remove all IVs, telemetry, indwelling urinary catheters, central line per MD order
  • Ensure patient has all belongings and that checklist is signed

**Note: for all transfers within the hospital (i.e. Behavioral Health, Acute Rehab), the inpatient chart accompanies patient.

Documentation Reminders

Perineal care is documented under “Gastrointestinal” > Intervention > select Perineal care from dropdown box

Indwelling urinary catheter removal (Foley removal) is documented under “Renal” > Urinary > Foley present > Intervention > select Discontinue from drop down box.

Chart Checks

Chart checks are not being completed consistently and paper orders have been missed.

In November 2013, there was a communication related to the importance of conducting chart checks due to several order omissions that impacted and/or had the potential to adversely affect our patients. This message was repeated in the March 2014 Practice Alert.

In order to avoid missing written/paper orders, the following practice was put in place:

  • Review written/paper orders* in the medical record/chart since the previous Chart Check.
  • Chart Checks are performed at least once prior to the end the worked shift.
  • Assure all orders are accurately transcribed and profiled.
  • Document Chart Check completion in the medical record/chart on a standard Physician’s Order form.

Example: 02/15/15 @ 06:45 Chart Check------Nice Nurse RN

Examples of written/paper* orders in the medical record include:

*Heparin Orders

*Restraint Orders

*Insulin Orders (several sets)

These order sets need to be signed off by the RN!