Nursing Practice Alert February 2016 0.5 CE Directions for - - PDF document

1

• St. Luke’s University Health Network

Nursing Practice Alert

February 2016

0.5 CE

Directions for Completion

• 1. This program is to be completed by nurses; it may be applicable to others.

A separate Nursing Assistive Personnel Practice Alert can be found on Tracker Trainer called: PCA Practice Alert Feb. 2016

Review should be completed by March 12, 2016

• 2. Before proceeding to the posttest, be sure you have read the following

information.

• 3. 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.

• 4. Comments, question, or suggestions can be directed to your manager or

supervisor.

2

• St. Luke’s University Health Network

Nursing Practice Alert – February 2016: Epic in Clinical Practice

Congratulations to all members of the patient care teams who have contributed to the successful launch of the Epic electronic health record (EHR) at St. Luke’s. This document is devoted almost exclusively to clinical practice issues which have surfaced since go-live and require immediate attention.

Medications & Infusions

IV Infusions

• GENERAL RULE: ALL IV infusions not only need to be “started” in Epic, they need to be stopped when the bag is

replaced or discontinued.

• Failure to stop infusions properly creates more work!
• Increases lines on the I/O Flowsheet because each new bag is looked at as a new infusion, not a

continuation of the one already running; it can look like multiples of the same infusion solution are hanging concurrently

• Affects provider trending reports and rounding reports, showing incorrect infusions running
• Discharges: if you get a warning (sometimes red and sometimes yellow) which states the patient cannot

be discharged because they have one or more infusions running. While the warning can be over-ridden, it is NOT the right thing to do. Breaking News: Epic Analyst to the rescue!! A new MAR Flag was deployed that alerts the nurse that an infusion “Requires stopped action”. This will populate if the running infusion order is completed, discontinued or expired. See screen shot below. Example #1: Epinephrine was dc’d and was stopped, so there is no flag. Example #2: The Heparin order was dc’d, but the infusion has not been stopped in Epic; the yellow flag indicates “Requires stopped action”

Medication Infusion Timeout

Medication Infusion Timeouts must be done for all continuous medication infusions placed on the pumps in Dose Guard. This terminology may be an easier way to remember to do this. To perform the Medication Infusion Timeout, after verifying correctness of the infusion requirements, the second RN logs into the patient’s record separately under his/her own ID and selects the cosign option when right clicking the rows they wish to cosign. Typing a note* is not acceptable. *EXCEPTION: The ED currently does not have a Med infusion Time Out process built; the build is in progress. The ED follows a temporary process for documenting med infusions timeouts via two separately entered notes. 1 2

3

• St. Luke’s University Health Network

Blood Administration

• Link the line as requested when hanging the blood product; this cannot be skipped.
• Start AND Stop the infusion. Failure to stop the infusion results in the unit(s) appearing to hang for long periods
• f time. Failure the STOP the infusion in Epic in a timely manner results in lack of reimbursement for the blood

administration.

• If you get a warning when scanning the blood - STOP - call the blood bank. Do not assume it is “just a glitch”.

Verify with the Blood Bank before administering.

• Document the fact that you looked for and verified there is a blood consent each time that a blood product is
• hung. If the “paper” consent is not on the chart, you can locate scanned consents in the “Media” tab (see below)
• When completed, do not choose to skip the documentation in the blood administration module. The following

are required:

• the rate must go to “0” and you must also document the volume infused
• assessment of the patient for a reaction or that there was none

The blood bank also needs to report on blood administration information for their accreditation. They maintain strict records on units of blood that are given to patients and our completing the unit is the only way they are notified the unit was actually infused. Location of scanned consents, etc. Step 1: Select “Chart Review” Step 2: Click on “Media” tab Step 3: Scroll for document required & review on-line

4

• St. Luke’s University Health Network

Insulin Infusions

• GENERAL RULE: ALL IV infusions not only need to be “started” in Epic, they need to be stopped when the bag is

replaced or discontinued.

• “Glucose Management” Sidebar Report provides important trending information to help manage titration (same

process outlined in Heparin Sidebar description below). Note: if you get a red alert screen when attempting to

• pen report, click and drag to expand screen and hit “refresh” button
• Always stop an Insulin infusion on the flowsheet if a second Insulin infusion is ordered
• This may happen if moving from a DKA protocol to a regular insulin infusion OR if provider orders a new

infusion after surgery rather than continuing the existing infusion

• If initial infusion is not stopped, the Epic system sees 2 insulin infusions running and cannot populate the

“Glucose Management” Side Bar report

Heparin Infusions

• GENERAL RULE: ALL IV infusions not only need to be “started” in Epic, they need to be stopped when the bag is

replaced or discontinued.

• When a provider initially orders a heparin infusion, the order must be profiled by pharmacy.
• This is a RARE case where a Pharmacy profile occurs in Epic, (because of the special weight- based

component involved in the heparin infusion protocol)

• Until this profile is completed (pharmacy estimates 20 minutes), a “dummy” order occupies the MAR

which says “Once”. If you try to use this order you will get an alert when scanning that tells you MAR and infusion bag do not match. DO NOT initiate the infusion until profile is complete.

• Bolus Doses
• Heparin bolus doses will only appear on the MAR if ordered
• Initial bolus entry will show as a separate one time order, not under main infusion order
• Ongoing boluses will show under the prn section of the MAR, not under main infusion order
• Weights
• The maximum weight for patients on VTE protocol has been reduced from 150 kg to 125 kg.
• The reason for this change was a history of patients weighing > 125 kg becoming over anticoagulated.
• Weight-based Heparin order sets in Epic currently allow prescribers to manipulate doses and weights

(i.e. entering actual patient weight instead of dosing weight); Pharmacy is on the lookout for such order set manipulations and should correct when identified. Nurses should also clarify any unusual orders. Note: The Epic team is working on a fix so providers cannot manipulate standards doses and weights.

“Sidebar” Reports

• Insulin and Heparin infusion trending reports can be viewed from at least 2 different locations providing

important information to help manage titrations. Heparin = Anticoagulation Insulin = Glucose Monitoring

• You will find examples of the location of the trending reports below. Though providing the same information,

the view in example #2 is wider, and staff has reported that it may be easier to use in helping to manage titrations.

5

• St. Luke’s University Health Network

Note: if you get a red alert screen when attempting to open report, click & drag to expand screen then hit “Refresh”

• Ex. 1
• Ex. 2

Summary > Index > desired

6

• St. Luke’s University Health Network

PCA/PCEA

• GENERAL RULE: ALL IV infusions not only need to be “started” in Epic, they need to be stopped when the bag is

replaced or discontinued.  To calculate PCA intake, shift value totals (0600-1400-2200) are entered in mL on Epic flowsheet. Nurse must convert pump total (displayed in mg) into mL. Note: Working with Epic team to add mg shift totals to documentation  Along with shift value totals, the flowsheet has entry areas for # of doses given, # attempts and reservoir

• volume. Although our policy only requires shift totals be documented at this time, documenting the # doses

given and the # of attempts provides valuable clinical information.

Duramorph

A complete Duramorph order set, including monitoring parameters, has been built in Epic and is live as of Friday, February 26! The order set in Epic is called “Duramorph Epidural/Intrathecal Single Dose Analgesia” and can be searched for using “Duramorph”. Reminder: Anesthesiology will be solely responsible for ordering pain medications while a patient is under Epidural Single Dose Analgesia therapy (i.e. first 24 hours post Duramorph administration).

POSS

Reminder: the need to document POSS (Pasero Opioid-induced Sedation Scale) on patients receiving pain medications did not disappear with Epic. Until further notice, you can find POSS located under the Vital Signs tab, under Awakening Trial/Sedation Scales. Performance of POSS is required along with a pain rating for all patients receiving opioid analgesics (i.e. pre-medication administration and with pain reassessments).

Interdisciplinary Care Plans

During our recent visit from Joint Commission for our Quakertown Campus, the surveyors identified an area of improvement needed to be compliant with care planning related to the following standard: STANDARD: PC.01.03.01 EP#: 5(A) The written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals. Reminder: this feature was reviewed in Epic training for all staff participating in the Care Plan Activity. All Goals must have a start date and expected end date. Additionally there is a report to monitor and view how well a patient’s care plan is progressing. The report is called SL IP Care Plan Review. This will help the leadership team make sure all areas are documented on for the patient: Start Date, Expected End Date; Problem/Goals/Interventions/Progress Associated Notes; End Date.

7

• St. Luke’s University Health Network

I & O

Failure to document I & O is problematic if ordered and not done/documented and/or if it is a standard of care and not

• followed. Much of the patient data in Epic is tied together to form a cohesive picture of the patient’s hospitalization.

Small things like failure to document the amount of urine output and/or failure to document I & O in a timely manner affects the overall patient picture, rounding reports, MEWS, etc.

MEWS

MEWS – Modified Early Warning System (Score) With the transition to Epic, St. Luke’s adopted the nationally recognized healthcare tools called MEWS to help nurses to monitor their patients and improve how quickly a patient experiencing a sudden decline receives clinical care. The color coded “bubbles” provide a visual cue related to the current MEWS score.

LABS

• PTTs
• PTTs from weight-based order sets (protocol) must be entered by the RN for the time due based on

changes to the Heparin infusion and previous PTT results – this is NO LONGER a UC function

• PTT protocol information appears under Nursing Orders and does not appear on the work list

MEWS scoring is based on the following parameters:



Respirations



Pulse



Systolic blood pressure



Level of consciousness



Temperature



Urine output RN Role with MEWS: Nurses must minimally address MEWS scores at handoffs during assignment changes, every 8 hours, and with any change in patient condition. On Learning Home Dashboard, review “Understanding MEWS in Epic”. Did you miss the education on MEWS last fall? Search for it via My E- Learning.

8

• St. Luke’s University Health Network
• Lab Specimens:
• Do not print label hours before collection – doing so defeats the purpose of the print label function and

returns us to our old system of lost/missed labels

• The collector MUST enter collection information as part of the Positive Patient ID workflow. This allows

the lab to have an order to receive the specimen against. This may be one of the areas we are seeing an issue with the Rover; we are investigating further with Epic.

• Cultures must have a site entered (i.e. sacral wound)

ANNOUNCEMENTS SUPPLY ISSUE – first announced 11/2015 - Bard Indwelling Urinary Catheter Kits Backorders

CR Bard is having “rolling” backorder issues with production consistency of the normal indwelling catheter “Foley”

• trays. Our buyer is getting what product she can, but this means the product could change with each order she places.

Since our stock ultimately comes from the distribution center which will have the latest product received, clinical areas will have a mix of product. Because supplies in the tray can vary, it places patients at risk for CAUTIs if staff are not vigilant and ensure procedures are flowed for pre-insertion pericare. Why is there an issue?  Trays may have different names (i.e. Advance, SureStep, etc.) and some contents differ

• May or may not contain Castile soap for pre-insertion pericare
• May contain iodine-impregnated swabs or may require user to saturate the swabs with iodine packet
• May or may not contain hand sanitizer for use by the user prior to insertion procedure

 There can be no change in clinical practice or insertion procedure regardless of which tray is available as it may affect our catheter infection rates. What is the answer? Pericare MUST be performed prior to catheter insertion. The RN must anticipate that there will be no Castille soap in the tray and ensure that non-sterile gloves, disposable washcloths, and soap/water are available to provide pericare in the event the tray does not contain it.

PRACTICE CHANGES – first announced 12/2015 Central Venous Access CHG Dressing Kit Coming in MARCH!

• St. Luke’s University Health Network will soon implement a change from non-CHG dressings to CHG dressings for ALL

Central Venous Access catheters (central lines). ALL central venous access catheters will now use a Central Venous Access CHG Dressing and all ports will use a Port CHG

• Dressing. This change is in response to a CDC recommendation and continued issues with CLABSIs.

 The transition to using CHG dressings for hemodialysis catheters only began in May 2015 in response to a CDC recommendation for dialysis catheters and as a proactive measure after dialysis catheter related CLABSIs were identified.  As soon as the new CHG dressings/kits are available, the network will transition to using CHG dressings on all central venous access devices! New dressing kits will be arriving to clean utility rooms soon.  The new CHG dressings will be stocked in the same location as the previous CVP/CL dressings.  The CHG dressing will continue to come in a kit form.  Current CVP/CL dressing kits, newly named as “Invasive Line Kit” will still be stocked and used for invasive lines that are not centrally located (i.e. arterial lines) and which do not need CHG dressings.

• There is no change in the type of dressing for peripheral IVs

9

• St. Luke’s University Health Network

NOTE: When CHG dressings are placed on newly placed PICC lines, the CHG dressing will NOT need to be changed in 24

• hours. All CHG dressings will be changed every 7 days, or as needed.

3M CHG Dressing – Note the rectangular CHG patch over insertion site Look for announcements of inservicing by our 3M representatives at your campuses soon!

CHG impregnated portion

• f the 3M CHG dressing

3M CHG dressings remain in place for 7 days like the regular 3M central line dressings!

POLICY: this change will be reflected in policy as soon as possible but may not be immediate…the change in practice should

• ccur when CHG dressings are available.

10

• St. Luke’s University Health Network

The document below was recently distributed network-wide by Donna Yeaw, RPh, Director of Pharmacy,

• St. Luke’s University Hospital and is included here for your reference.

Narcotic Drip and PCA Scanning Update

What: Standard narcotic drips and PCAs (morphine, hydromorphone, and fentanyl) will be dispensed by pharmacy with a readable barcode. These items will not require patient specific labels and will be stocked in AcuDose cabinets. There will be a different pocket for the PCA and the drip. When: February 22, 2016 Why: Updated barcode labeling process developed to meet barcode scanning compliance and best practice recommendations. Goal was to establish a consistent network practice. Standard narcotic premix bags will be purchased by network pharmacies. The same infusion bag will be used for both continuous drips and PCAs. Different barcodes will differentiate whether the bag is intended for PCA use or to be hung as an infusion. How: For PCA Administration: The nurse will scan the manufacturer barcode on the label. Nursing will affix a patient identification label to bag before hanging. For Drip Administration: The nurse will scan the Epic 2D barcode attached to the bag by pharmacy. (The manufacturer barcode will be covered). Nursing will affix a patient identification label to bag before hanging. Please contact your network pharmacy with any questions or concerns.