U N I T E D H O S P I T A L
October 2005, Vol. 2 (Issue 3)
Tracer Pathways — Improving Service
Barb Knudtson, RN, Education Services
In 2002 JCAHO started a new initiative called “Shared Emergency Department, Interventional Radiology, Cath
Visions-New Pathways.” This initiative resulted in sig- Lab and Blood Bank. Once this review was complete,
nificant changes to the accreditation process that Hoesing went to those identified areas with a set of
“sharpens the focus of the accreditation process on oper- questions related to practice in those areas and tied to
ational systems critical to the safety and quality of the patient she had reviewed on 3400.
Key areas of focus in the tracer are:
A key part of the changed survey process is the intro- Patient safety goals
duction of the tracer methodology — an evaluation Planning patient care
method in which surveyors select a patient and use that Transitions and communication between areas and
individual’s record as a road map to move through the caregiver staff
organization to assess and evaluate the organization’s Pain management
compliance with selected standards.
To prepare United nursing staff for this change, a num-
In June 2005 United Hospital staff and leaders experi- ber of strategies have been implemented:
enced the new tracer method during the mock survey Unit and department tracers will provide individual
visit with Helen Hoesing. Staff and leaders who partici- nurses with an opportunity to practice the new
pated commented on the in-depth look at patient care, method. These will be carried out at first by leaders,
the significant involvement of the bedside nurse and then unit practice councils, and eventually ACMs.
the range of questions that resulted from looking at one Messages of the Week are being provided to leaders
record. to review with staff to be ready for the types of ques-
tions surveyors will ask.
The mock survey started with a patient selected on Key messages are provided for staff every week in
3400. Hoesing, our surveyor, sat with the patient’s nurse Update.
and record. The nurse reviewed the patient’s current Pocket guides and brochures will be released some-
status with Hoesing. Then the nurse and Hoesing time in October as a resource to staff.
looked through the charts “tracing” the care of the A patient safety goals badge has been provided to all
patient through a variety of departments including staff.
PRACTICE CHANGE: PICC Flush after Blood Draw
The Nursing Research Council
The Nursing Research Council was recently asked by the IV Team to review clinical research evidence around
the amount of flush solution to use after a PICC blood draw. Our past policy stated to flush the PICC with 10 cc
of normal saline (NS). Community standards and recommendations from the IV Nurse’s Society are to adequately
flush a PICC with 10-20 cc NS to prevent clot formation. This change is being made to our current
“Intravascular Access and Therapy” policy. Another change you will see on the “Venous Access Device” adden-
dum of this policy is to use a 10 cc syringe (rather than the previously stated 3 cc syringe) when drawing blood to
prevent rupture or fracture of the PICC. When reviewing these practice changes, Nursing Practice Care Delivery
(NPCD) also recommended and will follow-up on working with pharmacy to get these flushes on the MAR to
facilitate documentation. Any questions about this practice change can be directed to any member of the Nursing
Research Council or NPCD.
Policies Being an Excellian® Super-User at ANW
Linda Johnson, Lisa Waytulonis, RN, Clinical Documentation
Patient Care Support Services
Lisa Waytulonis, RN, Clinical The super-user is essential to a success-
Listed below are those documents in the Documentation, worked as a super-user ful Excellian® go-live. Super-users need
United - Patient Care Policy/Procedure for the Abbott Northwestern (ANW) to be highly motivated and interested
category on the Allina Knowledge Excellian® go-live this summer. As a in supporting their peers, physicians
Network (AKN) that have been updat- member of United’s Excellian® Core and others by being out of the count
ed since 6/2/05. Team, Waytulonis gained valuable and working directly with them during
experience she plans to use in helping implementation. They are involved in
You can view these revised policies on plan for United’s go-live (scheduled for reviewing department work flows, act-
the AKN. first quarter 2007). ing as a teacher’s assistant during train-
ing and directly communicating with
Prior to the go-live, Waytulonis pre- staff on the units during go-live.
loaded patient information and med-
Breast Massage & Hand Expression ications into Excellian® . After go-live, Members of United’s Excellian® SWAT
Breast Milk Collection & Storage she worked five shifts as a super-user team participated in the ANW go-live
Chest Suction, Chest Drainage nurse across three cardiovascular and will be going to Mercy and Unity
System telemetry units at ANW. hospitals to assist them. Participating
Eclipsys SCD: Documentation and in these go-lives helps us plan for suc-
Printing In her role, Waytulonis found that cessful implementation at United. We
Eclipsys SCD: Downtime good communication was important to also hope to benefit by having super-
Eclipsys SCD: Routine Hardware a successful go-live. For instance, she users from those sites come here to
Maintenance and Problem Resolution found that meetings between nursing support us during our go-live. United
Eclipsys SCD: User Access shifts to review outstanding issues, will need many more super-users from
Emergency Patient Care problems and to hand-off the issues log all areas for our own go-live. Watch for
Gastrostomy Tube Replacement were essential. Each charge nurse had a more information on super-user
Hypoglycemia, Treatment of digital pager so that urgent information recruitment at United.
Identification Bands — Patients could be communicated housewide as
Identification of Operative Site necessary for leaders to share with
Med — Administration — employees, super users and Excellian®
Transdermal Route staff.
Med — Management of
Extravasation of Peripheral
Intravenous Solutions & Drugs
Pain Management Celebrations
Declotting Central Venous Catheters
Using Alteplase Congratulations to the following Oncology Nursing Certification:
Apheresis, In-Patient nurses who recently achieved Leslie Foreman, RN, Breast Center
Restraint or Seclusion Use: national nursing certification! Nurse Clinician
Food/Drug Interactions Medical-Surgical Nursing Rehab Nursing Certification:
Certification: Maren Nelson, RN, 8940
Brenda Larsen, RN, 2600
Deleted Joyce Grosser, RN, 2600 Gastrointestinal Nursing
Autotransfusion Monica McClelland, RN, 4400 Certification (CGRN):
Breast Pump — Medela® Classic Katie Westman, RN, 4920/40 Lisa Haviland, RN, Endoscopy
Breast Pump — Medela® Lactina Lisa Torres, RN, 4920/40 Other News
Breast Pump — Medela® Manual Shannon McNamara, RN, 4920/40
Margo Halm, RN, CS, PhD, director
Gerontological Nursing of Nursing Research/CNS was
Certification: recently appointed to the American
Barb Murray, RN, 4400 Association of Critical-Care Nurses
Research Grant Review Panel.
by Diabetes Resource Staff: Patti Long, RN, CDE; Marti Rud, RN, CDE; Lisa Schipp, RN, ES; and MJ Lee-Vanhoulton, RN, CDE
Latent Autoimmune Diabetes in Reminder
When you admit a patient with an
Adults (LADA) insulin pump, you MUST get orders for
A growing number of adults have a form controlling blood glucose for years are the basal rates and meal boluses, as
of diabetes that does not seem to fit ini- those that stimulate pancreatic well as for the correction boluses.
tially into the broadly accepted cate- production of insulin, slow digestion of These MUST be written on the MAR.
gories of type 1 or type 2 diabetes. These carbohydrates or reduce excess glucose If the physician orders “per patient,”
patients have a form of diabetes called production. you must ask the patient what his or
latent autoimmune diabetes in adults her rate is and clear it with the physi-
(LADA). They are often not over- Diagnosis of LADA includes measure- cian. Patients need to bring all supplies
weight and have little or no resistance ment of C-peptide levels, which would as we do not have these. Site changes
to insulin. It is not much different from be low to normal (C-peptide levels in are to be charted same as any other site
type 1 diabetes that appears in children type 2s is within normal or elevated). change. Patient must be completely
but strikes later in life and has a slow Depending on these results, a measure- independent in all areas related to the
onset. An estimated 5 percent to 10 ment of antibodies that attack beta cells pump or it is not safe for that patient
percent of all patients with diabetes may (especially antiglutamic acid decarboxy- to wear the pump in the hospital. Run
have it. Because insulin resistance is lase antibodies) may be performed and in the insulin pump custom document as
minimal or nonexistent, the standard the case of LADA would be elevated. soon as possible as this outlines your
medications designed to reduce insulin The treatment of choice for these indi- responsibilities and lists the pump
resistance tend not to be effective. viduals would be insulin as with type 1s. manufacturers’ resource numbers. This
Medications that are often effective in document is found by selecting #5 in
the custom document screen, typing
“insulin” and selecting insulin pump
document. All insulin pump patient
New Product Alert admissions REQUIRE a consult with dia-
betes resource as per the admission
The Opticlick® Lantus® pen is now stocked in the glucometer kits. There screening tool.
available to our patients through the is now an alternative. The purple
diabetes resource staff. If you have a lancets are much kinder to our
patient who you feel may benefit
from this product, please initiate a
patients as they have a smaller gauge
needle. You can order these from
DID YOU KNOW?
diabetes consult. materials management — Lawson About 8.6 million people over 60
number 154665. Lets make our have diabetes! That’s 18.3 percent
We have received many complaints patients as comfortable as possible. of that age group, and the numbers
about pain from the orange lancets Give them a try! are equal among men and women.
We work with two home delivery
companies: Byram Healthcare and
CCS Medical. Both offer home
delivery of diabetes and other sup-
Medication Update plies (i.e., stoma supplies). They
A new medication has just been secretion and regulating gastric empty- both bill insurance companies,
approved for the treatment of diabetes, ing. It may even encourage new beta cell including Medicare, and only charge
called BYETTA™. It will be injected BID formation, and it has been proven to what Medicare allows (less co-pay
up to 60 minutes before meal time. It cause weight loss in many patients. It is for these patients). CCS also has
does not replace insulin but offers delivered by a pen in 5 to 10 mcg and prescription drug delivery, and they
improved glucose control by increasing must be kept in the refrigerator and dis- accept Medicaid and all other types
the production of insulin in response to carded 30 days after the pen is initiated. of insurance. For more information
food, suppressing postprandial glucagons LOOK FOR IT SOON! about these companies, talk with
one of the Diabetes Resource RNs.
The features of the new PCx
Gold wrap to easily distin-
guish it from the current
silver wrapped version
The test strip requires less
The target area for the blood
application on the new strip
is at the end of the strip
rather than the middle.
The strip has a clear plastic
coating that allows you to see
blood wicking into the strip
Look for it this Fall.
Happy glucose testing.
United Hospital Nursing Shines Words from staff:
Why I Returned to
during Magnet Mock Survey United Hospital
by Naomi English, RN, Patient Care Float
Jessie Schwab, RN, is a critical care nurse
Julia Au Coin, PhD, a consultant from As we accompanied Au Coin around on 3940. She started at United in 1999
the American Nurses Association the campus and heard her speak during as a nurse’s assistant, but left in 2004 to
Credentialing Center (ANCC) and a the informal wrap-up session, we all go to a home care agency. She returned
professor at the University of North realized just how special and valuable six months later. This is an interview
Carolina’s School of Nursing, conduct- nursing is at United and how our daily with her on her perspective of returning
ed a mock survey of the nursing depart- efforts impact the excellent delivery of to United.
ment of United Hospital on Aug. 8-9, patient care. This mock survey gave our
2005. A mock survey is part of the magnet process a big boost as it served Q: What were you looking for when you
process to attain ANCC’s Magnet to build momentum and validate what left United?
Hospital award for Nursing Excellence. we as nurses have already accomplished. JS: I wanted to expand my role as
A committee of United nurses has been professional registered nurse and increase
working for more than a year to earn Those of us on the Magnet Steering my clinical expertise. At the time there
this prestigious award. Currently, only Committee feel that the designation is were no open positions at United, so I
3 percent of American hospitals have well within our grasp. We continue to looked elsewhere.
met the stringent requirements to be make progress toward this achievement.
designated a “Magnet Hospital.” United has submitted an application, Q: What persuaded you to return?
and work has begun on the extensive JS: I started at United as an NA and pro-
During her two days at United, amount of written documentation that gressed to an RN. I felt very comfortable
Au Coin met with staff nurses, nursing is part of the process. with the environment here and with my
leaders, pharmacists, respiratory thera- nursing colleagues. I came back to
pists, administrators and physicians. She I am very happy to be a part of this United in the Float Pool knowing that I
asked probing questions about nurses’ endeavor and represent the staff nurse would find a good environment in which
accomplishments, perception of nursing perspective. Feel free to contact me at to practice and opportunities to expand
by other departments and nursing col- firstname.lastname@example.org, or you can my role as an RN. I felt that the educa-
laborate for excellent patient care. contact Julie Sabo (1-8378) or any of tional offerings were excellent and want-
the other committee members. ed to take advantage of them.
Au Coin focused mainly on staff nurses,
touring many of the nursing areas and Magnet Steering Committee Q: What keeps you at United now?
interviewing individual staff nurses. She JS: I feel I am a valuable member of the
asked them why they choose to practice Ruth Darvell, RN 1-8335 health care team; it is a respectful and
at United, if they were certified in their Julia Endres-Spray, RN 1-8095 learning environment. I foresee opportu-
nursing specialty and how United helps Naomi English, RN 1-8030 nities for me in the future as I continue
them attain/maintain certification. She Kathy Forbes, RN 1-8525 to grow professionally. I took the critical
also was interested in staff nurses’ com- Margo Halm, RN, PhD 1-8536 care course, and it was great. I also am
munity involvement, including types of Barb Knudtson, RN 1-8775 supported by my leaders and peers.
volunteer activities, and how we Susan Loushin, RN 1-8240
achieve balance between our personal Ginny Oskey, RN 1-8666 Q: What advice do you have for others seek-
and professional lives. Sue Penque, RN 1-8815 ing nursing opportunities here at United?
Laurie Post, RN 1-8450 JS: Check everything out; there are so
Au Coin spoke with members of Pat Ryan, RN 1-8369 many opportunities for RNs here. You
United’s nursing committees about how Julie Sabo, RN 1-8378 may not think one position is what you
information on research and quality ini- Debbie Sapp 1-8585 are interested in, but check it out any-
tiatives is communicated to other nurs- Karla Sohl, RN 1-2375 how. I networked with lots of people
ing colleagues. Au Coin was impressed Marie Stuewe, RN 1-6335 here, so they all knew I was looking for
with something that most of us take for Rose West, RN 1-8031 more opportunities and kept me informed
granted — the view from and the when such opportunities arose.
design of many of the patient rooms.
Gerontological Nurse Certification
Becoming a Future Oriented RN
By Anna Gryczman RN, MSN, PHN, AHN-BC, United Hospital Staff RN
Did you ever wonder what the future older,” will grow by more than 50 per- you are considering a career in oncology
will bring regarding your nursing career? cent in the next fifteen years. The most nursing, you know that the majority of
rapidly growing demographic group cancer patients are older adults. Or
The future can be predicted by looking among age categories is the “oldest eld- look at how many older patients have
at demographics, technology and other erly” — the population age 75 and over. chronic health care needs requiring
societal forces. Demographic trends in general medical-surgical hospitalization.
the United States clearly point to an Because of this you may want to consid- The same is true for emergency nursing.
increasing number of elderly people er Gerontological Nurse Certification According to Hutchins (1999) and
needing health care services and not today . . . invest in your personal and O’Neill & Barry (2003), older adults
enough nurses prepared in geriatric professional growth as a registered make up 60 percent of visits to
nursing to manage their care. nurse. cardiologists and 53 percent of visits to
But what does it mean for YOU? Will The American Nurses Credentialing
you be prepared to provide the best care Center (ANCC) offers a gerontological So consider Gerontological Nurse
for your older patients? certification exam for entry-level RNs. Certification today . . . your expert
To prepare for the ANCC knowledge will positively impact
To become confident and competent in Gerontological Nursing Certification patient outcomes in more than one way.
your ability to care for geriatric patients, exam, the John A. Hartford Foundation Be proactive.
you will need specialized knowledge, Institute for Geriatric Nursing offers a
including an understanding of normal FREE online review course. Visit For information about gerontological
aging and familiarity with the different www.hartfordign.org for more informa- nurse examination, including the eligi-
ways an older patient may present with tion and www.geronurseonline.org. bility requirements, fees, exam content
subtle clinical manifestations. outline, study references and a sample
Because the majority of patients in most of practice examination questions, visit
Census Bureau (2000) population pro- nursing specialties are over age 65, you www.nursingworld.org.
jections indicate that the number of will need geriatric nursing knowledge in
elderly defined as the “age 65 and almost every specialty. For example, if
Our Journey to Magnet Status: Focus on Force 1
Julie Sabo, RN, MN, CCRN, APRN-BC
Force 1 of the 14 forces of Magnetism board, the Nursing Practice Care Linda Gfrerer and Susan Loushin
speaks to the quality of nursing leader- Delivery Board. Together they lead staff (Education Services) — Members of
ship. Leaders are not defined just as RN leaders and nurses in other roles Minnesota Organization of Leaders
those in traditional leadership roles, from all areas in reviewing and approv- in Nursing
such as nurse managers, directors or ing variable staffing plans, nursing poli- Sue Penque (Administration) —
CNSs, but also the formal and informal cies, nursing outcomes (patient falls, Past president of American
nursing leaders we have in direct pressure ulcers, nursing satisfaction, Association of Critical Care Nurses
patient care roles. Nurse leaders are etc.) and a multitude of other issues Julie Sabo (John Nasseff Heart
described as knowledgeable, strong risk impacting nursing practice. Hospital) — Past president of local
takers. They are the wise nurses who we National Association of Clinical
go to for nursing consultation when Our Low Lift Committee is another Nurse Specialists(NACNS) affiliate
faced with a difficult patient situation, great example of how nurses have Kelly Gannon (Neuro Program
ethical dilemma or management issue. impacted patient care thorough the hos- Leader) — Member of American
pital. The nurses involved were leaders Neuroscience Nurses
Magnet Force 1 is exemplified in in obtaining, training and championing Margo Halm (CNS) — NACNS
Magnet hospitals by a variety of charac- safety equipment to move patients. Nominating Committee member
teristics. First, competency, skill and and fellow of the American Heart
educational advancement are valued, How are United RNs taking a lead in Association’s Council on
role modeled and supported by the the profession of nursing? Look at the Cardiovascular Nursing
institution. The mission, vision, values number of United RNs running for Linda Christinsen-Rengel (Perinatal
and strategic plan of nursing are con- MNA office, delegate or board of direc- Outreach Coordinator) —
gruent with those aspects of the organi- tors — pretty impressive. Other exam- Membership coordinator for
zation. The Chief Nurse Officer ples of leadership are: Minnesota section AWHONN and
(CNO) represents all nurses within the Bunny Engeldorf (Behavioral Health on Planning Committee for
institution at the highest governing Service) — Commission for MNA Minnesota Perinatal Organization
body. The CNO and other nurse Economic and General Welfare Cheryl Kirchner (Birth Center) —
administrators secure adequate financial Program Member of the Education
and human resources to support nursing Linda White (Medicine) and Julia Committee for Minnesota Section
practice throughout the hospital. Endres-Spray (Oncology) — Both AWHONN.
Nursing input is valued, and decision directors for MNA
making and nursing satisfaction are Anna Grcyzman (Float Pool) — This list is by no means complete and it
measured. Nurses from many roles are Commission for Education could go on and on!
included in decisions and are involved Larry Himebaugh, Bette Sisler, Dan
in governing bodies. Nurses at all levels Halbakken, Denise Elling, among What examples can you think of on
lead and participate in professional others (ED) — All are members of your unit or in your life that exemplify
nursing organizations at all levels. the Emergency Nurses Association and amplify the leadership that nursing
Polly Groshens (ED) — Past presi- takes on at United and in the nursing
Whew! Those are big statements. So dent of Minnesota Emergency community each day? It is there every
how do we at United exemplify this Nurses Association day and the results of that leadership
force? Sue Penque RN, MSN, APRN- Diane Lemay (3300) — A member are evident at the patient’s side.
BC, is our CNO; she is part of the of the MNA Foundation
Senior Management Team, which is Rosanne Ferguson (Sister Kenny
the highest governing body at United. Rehabilitation Institute) — Board Correction:
Her role is integral to all issues affecting member for the Minnesota Stroke In the summer 2005 issue of Nursing
nursing, and she actively advocates for Association Notes, the author of “Staff Nurses
nursing practice. The CNO and our Mary Goering (Birth Center) — Attend Magnet Conference in St.
Minnesota Nursing Association Secretary for MN Association of Cloud,” was listed incorrectly. The
(MNA) leader, Linda Slattengren, co- Women’s Health, Obstetric and author is Naomi English, RN, Patient
chair our highest nursing governing Neonatal Nurses (AWHONN) Care Float.
Practice Change: Foley Catheter Care
The Nursing Research Council
The Nursing Research Council recently 4. Pre-testing of silicone catheter bal- should be avoided to prevent back-
recommended practice changes related loons is not recommended since the flow of urine into bladder.
to Foley catheter management as based silicone can form a crease at the
on evidence in the current research lit- balloon area, causing trauma to the 8. Catheters may leak from a variety of
erature. These changes are discussed in urethra during insertion. causes, including kinked catheters or
the fourth quarter self-study packet. drainage tubing, constipation or fecal
Highlights include: 5. Secure catheters or tubing to the impaction, bladder spasms, infection,
thigh in both males and females to occluded lumens or encrustration.
1. Use alternatives whenever possible, prevent movement and traction. If Refer to the self-study packet for an
such as condom catheters, in men using tape to secure, remove any evidence-based protocol for manag-
when short-term catheterization is sticky biofilm that accumulates on ing each of these problems.
necessary. the catheter since microbes can
ascend into the bladder from this 9. Irrigation of catheters should be
2. For insertion, a single-use packet of residue, setting the patient up for a avoided unless obstruction is suspect-
lubricant and/or 2 percent lidocaine catheter-associated urinary tract ed. Remember a physician’s order is
jelly is recommended for comfort. In infection (UTI). A nonadhesive needed for intermittent irrigation.
men, the lubricant should be gently catheter holder, such as the elastic
injected directly into urethra. If using Cath-Mate™ or multipurpose tube 10. Cleaning urinary equipment is no
lidocaine jelly, wait 2-5 minutes holder, should be considered to longer recommended during hospital
before continuing. eliminate the presence of biofilm, stays to ensure a closed system is
especially if longer-term catheteriza- maintained to prevent catheter-
3. Use the smallest catheter (14-18 Fr) tion is anticipated. associated UTIs. Therefore, leg bags
and balloon size (5 cc) possible. should not be changed to night bags
Inflate the balloon with 5-10 cc 6. Empty collecting bag every 4-6 hours while patients are hospitalized.
sterile water. NEVER use more than to prevent bacteria from migrating
10 cc. up the catheter lumen. 11. There remains no definitive guide-
line on when Foley catheters should
Nursing Notes Editorial Board 7. Collection bags should always be be changed. As a general rule,
kept below the level of the bladder catheters should be removed as soon
Margo Halm, RN, CS Michele G. Scheid
and dependent loops in the tubing as possible.
Sue Penque, RN, CS Elaine Tuhy
Vice President Administrative
The Nursing Research Council:
Patient Care Assistant Miriam Blalock, RN Barb Jacobs, RN Bette Sisler, RN
Becky Braden, RN Katie Krisko-Hagel, RN Patti Soll, RN
Julie Sabo, RN, CS Heart Hospital
John Nasseff Minda Demira, RN Dave Larson, RN Deb Steele, RN
Heart Hospital Glenda Cartney, RN Norbert Erben, RN Stephanie Leininger, RN Linda Strom, RN
ACM, 3940 Mary Goering, RN Diane Lemay, RN Jen Wells, RN
Anna Gryczman, RN Anna McFarlane, RN Molly Zignego, RN
Margo Halm, RN Julie Sabo, RN
Nursing Notes is the official newsletter of United Hospital nurses. Nursing Notes is published quarterly by
the United Hospital Nursing Care Delivery Board. The Nursing Notes editorial board reserves the right to
edit material based on content and space and the right to change this policy at any time. If you are inter-
ested in serving voluntarily on the editorial board, please contact Margo Halm at 651-241-8536.
Submissions for Nursing Notes are preferred in writing (electronic) and can be sent to: Margo Halm, RN,
newsletter coordinator, email@example.com or United Hospital, 333 No. Smith Ave., Mail Route
60231, St. Paul, MN 55102, 651-241-8536. Please include your name, department and phone number.