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. patient care.” 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. Revised 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 Behavioral Management 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. 2 Diabetes Update 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. 3 The features of the new PCx strip include: Gold wrap to easily distin- guish it from the current silver wrapped version The test strip requires less blood 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- email@example.com, 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. 5 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 urologists. 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 6 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. 7 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 Newsletter Communications and dependent loops in the tubing as possible. Coordinator Specialist 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 John Nasseff 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, firstname.lastname@example.org 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.
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