Week End Wrap Up

1. Week End Wrap Up May 24, 2010

2. Staff Meetings • Tuesday, June 1, 2010 • BB667 (OB Conference Rooms) • 1500-1930 & 1900-2300 • Monday, June 7, 2010 • Two locations • SCC 252 • 1100-1530 & 1500-1930 • BB667 • 1900-2300

3. Staff Meeting Agenda • Announcements • Practice changes/timelines • Mother Baby Updates (Purple Crying, Documentation) • Holidays (8-hours versus 12-hours) • Scheduling issues • MIC Idea Summit presentation • Mandatories/LMS demo

4. Referral Process Changes • Improved referral intake process completed today • Team created streamlined process which reduces number of activities for each role, eliminates rework, and improves communication among team, and with referring providers—wow! • CHARGE NURSE ROLE IN REFERRAL PROCESS • Twice/day TEAM STEPPS – Identify L&D status by assigning color • Charge RN responsible for keeping color code tool up to date

5. Referral Process Changes (cont.) • GREEN – Attending will accept all referrals  • YELLOW – Attending needs to call/talk with Charge RN before accepting referrals; Action: Chief & Charge RN trouble shoot patient flow issues with goal of returning to GREEN  • RED – Attending comes to L&D and runs board with Chief, Charge RN; contact Nurse Manager or Flow Supervisor prn • BLACK – No referrals can be accepted; assemble management team Gigi or Debi, Karen Odle (Director of Perinatal Services), Flow Supervisor and Medical Director (if needed)

6. Referral Process Changes (cont.) • Charge RN responsible for alerting Attending and Chief of changes in unit status by sending text message – only text color (your phone # is on their card) • Attending will accept all transfers if Green was status indicated at TEAM STEPPS unless Charge RN texted change • Attending will call Charge RN to notify transfer is coming and ETA • Charge RN responsible for texting Chief Resident and Generalist of new transfer (no longer responsibility of Attending to notify Chief) Include in text: G/P, GA, diagnosis and ETA

7. Referral Process Changes (cont.) • Circulating RN in OR monitoring Med-Con pager in OR; she will call Med-Con to alert that Attending can call after C-Section; if call an emergency, will transfer to Charge RN to take info • Referring Provider is transferred to front desk person (PSS/Float/RN/Tech) after Attending has accepted patient • Front desk now collects all info on referral patient

8. EFM Alert Acknowledgment • RN acknowledging EFM alert needs to call RN caring for patient to make sure they can follow up • SITUATIONS • Acknowledging paper end alert and not letting RN know; paper missing for 1-2 hours at night. • Baby off monitor and alert acknowledged; RN not notified; patient off monitor too long • Especially important in busy shifts at higher census when "juggling many patients" • Teri

9. 34 to 34.6 wk late preterm newborn • 34 to 34.6 week newborns need to transfer to the PCN within 30-60 minutes after birth • These infants require close observation due to increased risk of respiratory, thermo and nutritional instability • Babies 35 to 37 weeks may stay with Mom in L&D if RN remains in room until Mom's transfer • RN may transfer 35-37 week infant to PCN before Mom's transfer if she feels it's necessary . • When PCN is closed, charge RNs trouble shoot newborn placement as they have been—NICU, PCN RN able to be in the room, open PCN, etc • Any questions, let us know

10. Bedside Safety Checks Make a Difference •  Hospital wide evaluation of value of checks reported via PSN:       • During safety checks, noted patient did not have ID band.  Ordered FFP not infused until ID verified • Patient on protonix gtt .  Found levophed gtt running.  Pt previously on levo gtt but titrated off last night, or so everyone thought.  RN recommendation – “Double check gtts including before end of shift”  • During bedside safety check, noted ketamine gtt connected to wrong IV fluids and no name band • An hour after shift change patient found to have bag of heparin infusing in place of NS.  Resulting PTT >200.  RN recommendation -  “Observe closely 5R of drug admin.  Do bedside safety checks religiously”  • Patients and families also like safety check as evidenced by a complimentary letter:      "I wanted to share some feedback from recent hospitalization of my sister-in-law…..…(my brother) and his wife, were extremely impressed with the nursing care. The nurses were fun, responsive, informative, caring, attentive……... use of the white board is flawless. We always knew the names of folks… …my brother and his wife really liked the bedside shift reports. They said it happened all the time. …My brother was also impressed with how everyone checked the name band the first time they came in.  • Bedside Safety checks are expectation at shift change.   To do them correctly both on-coming and off-going RN enter room and review:  ID, Medications, PCA (Epidurals, Lines) Allergies, Check O2 and Thank you.  (IMPACT)   • On-coming RN should be doing the patient check “fresh eyes”.  Off-going RN should be doing verification in ORCA “tired eyes” • Thank you for your continued work to keep our patients safe--Neil Francoeur, RN.  Patient Safety Officer

11. Heparin IV bags • Pharmacy currently unable to obtain premixed bags of heparin 25,000unit/250ml used for heparin protocol • Until manufacturer able to re-supply, have taken following steps: • Removed premixed heparin bags from Pyxis • Make heparin 25,000unit/D5W 250ml in pharmacy • Done in "batches" with multiple check points to assure appropriate compounding • Labeled with "Heparin, High Alert" Stickers (stop-sign like) to call-out they are heparin bags

12. Low Molecular Weight Heparin • UW Medicine Pharmacy & Therapeutics Committee in consultation with experts in thrombosis and anticoagulation reviewed data with Low Molecular Weight Heparin (LMWH), and determined dalteparin (Fragmin) was most cost effective agent for institutions • To achieve desired patient and financial outcomes following steps will be implemented June 1, 2010: • 1. Pharmacy will auto-substitute dalteparin 5000 units daily for VTE prophylaxis orders for enoxaparin 30mg daily, 30 mg every 12 hours, and 40 mg daily • 2. A new LMWH order form (UH2933) has been developed for use in VTE treatment, bridge therapy and acute coronary syndromes • Please order form UH2933 from Materials Management in anticipation of June 1st implementation date. • Form is in PMM system and can be added to order template • Please allow 5-7 days as it is a non stocked item • Contact your clinical pharmacist if you have questions or would like additional information

13. New Warfarin Order Form • To improve safety using anticoagulants, new warfarin order form implemented • Form introduced at HMC and now required at UWMC to standardize prescribing of warfarin across institutions   • Order form is UH2924 • Order form required for: • New start warfarin • Continuation of home warfarin • Change in warfarin dose • Hold or discontinuation of warfarin • Filed in heparin section of patient chart—charts coming when we go online with ORCA; for now will remain in orders section of chart • Thank you for supporting use of order form to improve safety of warfarin therapy • Jackie Biery, Pharm.D. Medication Safety Pharmacist

14. May 2010 Pain Reassessment Audits • Of charts audited in May • 172 dose of narcotics given • 138 documented reassessment in 1 hour • 80% reassessment work—right direction • Of charts audited week of May 17 • 35 doses of narcotic given • 33 had reassessment within 1 hour • 94% • GREAT WORK this week (despite being very busy!)

15. Fiscal Year 10 Pain Reassessment Audits (cont.) • Best Practice post narcotic administration assessment/documentation of patient response within 60 minutes • Documentation of reassessment noted in new column on flowsheet (separate from documentation at time of administration • UWMC minimum standard for pain reassessment—90 % • Best MIC compliance fiscal year 2010—82% • Problem times: night shift & shift changes

16. Interpreter News • Interpreter sheet used to sign in and out is interpreter’s worksheet • Needs to remain with interpreter • Interpreters are spread thinly with frequent, overlapping work • Communication with individual interpreters re unit needs, please take time to clarify unit needs and interpreter availability

17. Closet Locks on Mother Baby • First stage toward redesigning supply placement has begun • Several rooms now outfitted with shelves and “invisible locks” • Will trial what to stock and process to obtain supplies once several more rooms ready • Will largely be PCT function and responsibility • Stay tuned!

18. Compensatory Time • Unused overtime compensatory time paid off by June 30, 2010 • Accrued holiday compensatory time may remain unpaid until September 30, 2010 • Please refer to the University website for more information about comp time:  http://www.washington.edu/admin/hr/ocpsp/flsa-ot/ot.html • Questions may be directed to Department Human Resources Consultant

19. Babies need your help • GBS Status • document GBS status on triage form AND newborn resuscitation record • mom GBS+, include antibiotic type, # of doses and time of last dose • Medication History • Document on triage form—include methadone dosage • Blood Type accurate documentation

20. Glycomark • New lab test ordered to evaluate patient's diabetic control • Called GLYCOMARK • Lab reports it: 1,5 Anhydroglucitol. • CBGs give immediate information, • Hemoglobin A1C gives average of patient's glucose level over last 60 to 90 days • GlycoMark level provides estimate of patient's post meal glucose levels over past 1-2 weeks • Evidence that up to 40% of patients whose blood glucose levels appear well controlled experience postprandial hyperglycemia • Studies show oscillating hyperglycemia leads to more damaging complications than constant high glucose levels

21. Blood Services Tube Labeling • Issue: ongoing problems with correct labeling PSBC specimens and requisitions • Consequence: PSN reports, cancelled specimens and mother and baby blood redraws • PROCESS • ENSURE that U # and name not cut off on label • Generally Primary nurse completes PSBC requisition and specimen label: date, time of blood draw & signatur • Then 2nd RN comes to patient room & verifies pt's name, U #, DOB, AND that date and time on label and requisition match and primary RN signature on both • Then, second RN signs both

22. Blood Services Tube Labeling (cont.) • In emergency if primary nurse unable, second nurse fills out label, requisition and signs both • Then primary nurse does double check of correct/matching date and time on both tube label and requisition and 2nd RN signature on both • Then, primary nurse signs both • "STOP" sign posted by tube stop requiring triple check: • U# clear and complete on label • Date and time the same and on specimen label and requisition • Same two signatures on specimen label and requisition • Do this triple check prior to tubing sample to TSS—it could save patient another poke and you another blood draw! • Other ideas welcome—let us know!

23. Blood Services Tube Labeling (cont.) • Have you checked that all required info on your blood bank tube label and paperwork are correct, complete and legible?

24. Back in the 1500s: • Baths consisted of big tub filled with hot water • Man of house had privilege of nice clean water, then sons and other men, then women and children • Last of all, babies • By then water was so dirty you could actually lose someone in it • Hence the saying, "Don't throw the baby out with the Bath water!"