heme / onc nursing updatesarah taylor –amador bsn, rn, cpon. standard requirements...
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Heme / OncNursing Update
Michelle Burke MSN, ARNP, CPN, CPON
Sarah Taylor – Amador BSN, RN, CPON
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Standard Requirements Non-Violent/Medical
Restraints
Violent Restraint/Seclusion for Behavior
Management
Initial Physician verbal or written
order
Within 1 hour of restraint As soon as safely possible; verbal order signed
within 24 hours of initiation
Modification of Plan of Care Yes Yes
Notification of Nursing Leadership
(OA/Director)
Yes Yes
Documentation of observations and
vital signs
At initiation and every 2 hours At initiation and every 15 minutes
Monitoring: all patients
mechanically restrained on a floor
outside of ICU/ED require 1:1
observation
Every 2 hours Continuous observation
Re-written physician order Each calendar day and each
time patient comes out of
restraint and restraint must be
reapplied
Within 1 hour of need for next episode of
restraint/seclusion
Notification of guardian of the
initiation of restrained/seclusion
Yes Yes- Promptly
Notification of treating/attending
physician if orders and face-to-face
assessment performed by other
Within 24 hours Yes- As soon as possible
Face to Face Assessment Within 24 hours of initiation by
physician or resident
Within 1 hour of restraint by physician, resident or
trained RN, ARNP, PA
Debriefing N/A Immediately- within 24 hours max.
RN Evaluation Every 2 hours Every 60 minutes
Education Documentation Yes Yes
Alternatives Documented Yes Yes
Dec
isio
n M
atri
x
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Medication Safety
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Please note that these new clear syringes with an amber colored plunger will be replacing the syringes we currently receive from pharmacy with the white
plunger. They will be used to administer oral medications, just as the color of the ones we use on the units/floors.
(0.5ml & 20ml syringes are not available at this time)
Old
New Amber Colored Oral Syringes coming from Pharmacy
Syringes
Old
Clinical Education Team
NLK July 2016
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MannitolGiven with or before Cisplatin
FILTER REQUIRED (RN responsibility if pharmacy did not put filter on tubing during drug preparation)
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MannitolMost COG protocols state“per institution guidelines”
• The role of mannitol as a nephroprotectant in patients receiving cisplatin therapy. (2012 abstract on PubMed)•University of North Carolina, Chapel Hill, USA.•Abstract• To review the efficacy and safety of concomitant mannitol
administration with cisplatin therapy to reduce the incidence of nephrotoxicity.
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Mannitol• DATA SYNTHESIS: • Cisplatin therapy can lead to transient and permanent renal impairment. Molecular
and histologic changes occur in the renal tubules, which contribute to nephrotoxicity. The adverse effect profile of cisplatin is well documented, but the prevention strategies to alleviate renal impairment due to treatment are less understood. Mannitol plus hydration has been used for several years to alleviate toxicity associated with cisplatin therapy. However, the data for mannitol administration have not been convincing. When the use of mannitol and hydration is compared directly to hydration alone, mannitol shows no benefit. In some patients, not only was mannitolnot protective, its administration was associated with worsening renal function.
• CONCLUSIONS: • Although mannitol plus hydration is used to decrease cisplatin-induced
nephrotoxicity, there are no compelling data that the addition of mannitol is more nephroprotective than the use of hydration alone. Appropriate hydration remains the most reasonable strategy to reduce the incidence of cisplatin-induced nephrotoxicity
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Inhibits the activation and proliferation of T-lymphocytes thus preventing GvHD
IV Dosage: Initially started at 0.02 mg/kg/day and titrated depending on levelsoDose dependent on achieving and sustaining therapeutic blood levels
oLevels should be drawn from LARGE lumen
IV to PO conversion is approximately 1:3
Therapeutic Levels range between 5 – 15 (dependent on diagnosis)o Increased absorption with “azoles”
oDecreased absorption with food
Tacrolimus (FK-506, Prograf)
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Must be given on dedicated line with either NS or D5WoCompatible with several medications
Levels usually obtained Mondays and Thursdays from LARGE lumenoContinuous IV: stop Tacrolimus infusion, clamp line, and draw from opposite lumenoOral: Draw from lumen that never received Tacrolimus
Sign should be placed at bedside indicating to draw Levels from Large lumen
Take on empty stomach
Instruct patient/caregiver on importance of strict adherence to administration schedule (9AM / 9PM)
Side effects: hypomagnesemia, tremors, headaches, hypertension, and nausea
Tacrolimus Nursing Implications
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Pneumocystis carinii pneumoniaClinical features
• Tachypnea• Dry cough• Fever• Dyspnea• Rapid respiratory deterioration
•Diagnosis•Chest x-ray
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Pneumocystis carinii pneumonia•Treatment•Prophylaxis•Trimethoprim-sulfamethoxazole (TMP-SMX)•Dapsone•Pentamidine• Inhaled • Intravenous
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PentamidineInhaled pentamidine
-Picked up by RT from pharmacy
- Usually for 5 years and older
- For specifics, see administration procedures from Respiratory
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PentamidineIntravenous pentamidine-Potential for anaphylaxis- Monitor vitals - Hypotension / cardiac arrest with rapid infusion
-High alert / second witness
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This includes (but not limited to) :
• Pentamidine• IV Electrolyte Boluses
- Potassium, Magnesium, Phosphorous, Calcium
• Bleomycin• Vancomycin• Gentamicin• Cyclosporine• Tacrolimus
BE Alert Medication Safety Update:Small Volume Infusions (dispensed in a syringe) with Specific Rates should ALWAYS be given on
a Syringe Pump
Remember to run the flush at the same rate as the medication infused
Contact your Clinical Education team for questions
Clinical Education Team 6/2016Nicklaus Children’s Hospital (2014). IV Policies- General Retrieved from: http://policies/dotNet/documents/?docid=4835&mode=view
ALL medications dispensed in a volume of less than 10ml should be on a syringe pump
• Azithromycin• Tobramycin• Amikacin• Ciprofloxacin• Levofloxacin
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High Alert Table of Drugs
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New Epinephrine Labeling
Labeling will be in mg/mL
Previously: Epinephrine 1:10,000 new Labeling 0.1mg/mL
Epinephrine 1:1,000 new Labeling 1mg/mL
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New Epinephrine Labeling
Labeling will be in mg/mL
Previously: Epinephrine 1:10,000 new Labeling 0.1mg/mL
Epinephrine 1:1,000 new Labeling 1mg/mL
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Mesna•Protects from cystitis caused by Ifosfamide or Cyclophosphamide
•Prevents adherence of acroleinmetabolities to bladder wall
•Causes false positive ketones in urine dipstick
•HIGH ALERT / MUST BE GIVEN ON TIME
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Leucovorin
• Given for MTX clearance / rescue
•HIGH ALERT / MUST BE GIVEN ON TIME
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PCA documentation -Always remember handoff documentation
-Always remember second witness with NEW VIAL and DOSE CHANGE
-WATCH your I & Os- Especially if not 1mg / 1 ml
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Patient Safety
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Patient FALLS
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Monthly audits in progressHIGH RISK must have:
• Humpty sign at bedside• Humpty ID band on• White board updated• Magnet on the census
board• Teaching documented • IPOC updated
FALLS FACTS
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CLABSI
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Top 5 Places for germs in your area
•Cell Phone
•Door handle
•Computer keyboard
•Keys
•TV remote/Call bells
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Survival Times of Microbes on SurfacesSurvival Times of Microbes on Surfaces
Microbe Survival Time
Acinetobacter 3 days to 5 months
C. difficile 5 months
E. Coli 1.5 hrs to 16 months
Enterococcus (VRE) 5 days to 4 months
CRE weeks to months
Pseudomonas 6 hours to 16 months
S. Aureus 7 days to 7 months
HIV </= 7 days
HBV > 1 week
Influenza 1 to 2 days
Norovirus 8 hours to 7 days
Candita Albicans up to 4 months
Mycobacterium Tuberculosis undetermined months
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Blood-related Infections• Intravenous sites can become seeded when organisms from
distant infection sites are transported to the access port or adhere to the catheters
•When attempting to determine if the patient has a catheter-associated infection staff should be suspicious of an IV catheter-related infection if the blood drawn from the central line culture has five times the organism growth compared to blood obtained from a peripheral vein.
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Blood-related InfectionsPrevention:
When infection is suspected, best practice is to get two blood cultures. One peripheral culture and one central line culture. Gold standard are peripheral blood cultures.
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Infection Prevention Basics
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Hub Care •Clean needleless connector/hub with prevantics CHG wipes before opening the line•When to Replace Needleless Connectors •With dressing change•As needed if occluded or if visible blood or debris is seen in or on connector •Prior to drawing blood cultures•After giving Blood Products
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Wipes versus Curos CapsPrevantics Wipes Curos Caps
One time use One time use
Disinfects in 30 sec and dries in 30 sec
Minimum duration is 3 min
Use when port is frequently used Protects port protected from environmental contamination
CHG and Alcohol Just alcohol
Can be used for 7 days
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Chloraprep Skin Cleansing
•ChloraPrep is 2% chlorhexidine and 70% alcohol product:
• The skin should be scrubbed in a back to forth motion for 30 sec and allowed to dry for 30 sec. When used in moist areas(inguinal fold scrub for 2 minutes and allow to dry for 1 minute.
One 3ml applicator covers
4 in. x 5 in.
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Proper Insertion Practices• Ensure utilization of insertion bundle•Chlorhexidine for skin antisepsis•Maximal sterile barrier precautions (e.g., mask, hair
cap, sterile gown, sterile gloves, and large sterile drape)•Hand hygiene•All people in the room not performing the procedure
need to wear a hair cap, mask, and clean gloves•Primary RN for the patient at the time of the procedure
is responsible for documenting timeout in the EMR
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Flushing CVL• Use aseptic non touch technique• All Central lines need to be flushed once a shift using the
power flush method unless the patient is receiving pressors or TPN through the line. In these situations, the lumen should be power flushed when the lines are being changed.
• Follow SASH• S: Saline 8-10ml saline flush (3ml for NICU)• A: Administer medication • S: Saline 8-10ml saline flush (3ml for NICU)• H: Heparin (10units/ml) Length of lumen heparin flush
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Lab draws using Stopcock method
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Important to know!
•DO NOT reconnect any previously used Peripheral IV tubing or IVF’s to a central line
Remember: The 3 main sources of bacteria responsible for IV-associated infections are:
• Air/Environment • Skin • Blood
Clinical Education Team L.S. 06/2016
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C. L. A. B. S. I
Let’s be CLABSI Free!
Chlorohexidine
Wipes
Curos Caps/TIPS
Discuss line necessity
with Physician
Daily linen changes
Air Dry your port
Scrub your Hub Bedside Cleanliness
Wipe it down & document
Survey and
assess your
site! Make
sure it is
clean, dry and
intact. Date
should be
visible!
Clinical Education Team L.S. 06/2016
Be mindful of
Isolation Precautions
Keep an “I” out!
Be CLABSI
FREE!!
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Major Changes•MUST CHART AND COMPLETE DAILY BATH and twice a day CHG to CVL
•Daily wipe down of leads, bed rails, TV remote, and bedside table. QSHIFT wipe down of CVL tubing
•Powerflushes !!!! Twice a day
•Clean gloves SHOULD be worn ANY time staff come into contact with the patient, IV catheters, IV pumps, Medications, or IV tubing
•Flushing guidelines for CVAD’s
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Skin care / Oral care
ONC care bundle review
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Documentation for Bathing and Oral Care
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NEW IMPROVED PROCESS- Changes from DNV site
recommendation - Remember the system will
generate a order and TASK, work off the TASK
- If patient needs dressing change earlie, RN to place a PRN change order
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Daily Line Necessity Documention:
PICC – “YES” must be charted;
Broviacs – N/A must be charted since they are surgically placed for long-term use.
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Cover with CUROS
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Pain re-assessment / comfort
•All patients with a pain score of 4 or greater need an intervention and
RE-ASSESSMENT within 60 minutes
•Also, any intervention also needs a
RE-ASSESSMENT
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9/29/2017
During, patient report, verify last weight on
hand-off tool in PEDS
Assessment sheet.
Patient must always be weighed upon
admission or transfer to the unit.
Patient height & weights
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Document & Post ISOLATION PRECAUTIONS
Document in PEDS Post Signage
Must Document Isolation type every 12 hours under treatments and care section
Please see your Clinical Educator/Specialist and Infection Prevention Team for any questions
Clinical Educati
on Team
Nicklaus Children’s Hospital (2013). Isolation Precaution. Retrieved from: http://policies/dotNet/documents/?docid=3819&mode=view
Isolation guidelines are located in the Isolation Precaution policy
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Gastrostomy site care• Gently lift plastic ring on GT and clean around stoma site. • Use cotton tipped applicators to cleanse area around tube
with soap and water ONCE A DAY and as needed. • Spandex should always be on when patient has a MIC -gtube
• A soft wick can be used, only use one at a time. • Document G-tube site care in EHR (PEDS) MIC g-tube
If you didn’t document, it wasn’t done.
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Waste Streams of NCHWastes saturated
with blood or
other bodily
fluids
Non-Hazardous Trace
Chemotherapy (< 3 % ) or any used
PPE’s
Hazardous Bulk
Chemotherapy
(Partial Chemo Items)
Needles and
empty sharps
(syringes w/needle,
vials, ampules)
Maintenance IV
solutions
without
additives
Controlled
substances
(witness waste in
sink)
Pharmaceutical Wastes
BKC
• Syringe w/ meds• Ampules w/ meds• Glass vials w/meds
* NO empty items, NOtrash, NO controlled substances, NO plain IV solutions *
Medications left in a non-sharp format
For medications left in a SHARP
• Partial IV bags• Pills/Capsules• Medicated ointments &
creams (capped)* NO trash, gloves, etc., NOcontrolled substances, NOSHARPS
Items to send to pharmacy in a medication
ziploc bag
• Items that have a BLACK DOT
• Aerosols/Inhalers• Corrosives/Oxidizers
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IMPORTANTBMT labs for chimerism
Always verify MD order for “source” of lab.
Ex- source is
Bone Marrow Specimen
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Chemotherapy Updates
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Chemo worksheet
ALL admissions for chemo MUST have a chemo worksheet completed on admission when orders are inititated.
Discussion- When chemo is moved up daily?
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Chemo Documentation
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Chemo Documentation
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Chemo Documentation
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Oncology Flowsheet
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Oncology Flowsheet
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Childrens Oncology Group
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Sample MTX orders set
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Blood updates
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Collection of sample for Type and
Screen/ Crossmatch
• Two people must go to the
bedside to ID patient and
SCAN and label specimen tubes at
PATIENT BEDSIDE
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Type and Screen
• Was the patient identified by collector AND witness by comparing the first and last name, DOB and MR # on the request with the info on the patients wristband
• Ask patient (or parent) to “state name and date of birth”
The collector and witness must write their employee numbers, date, time obtained on specimen tube
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If blood is drawn from a central line, specimen should be obtained after appropriate amount of waste blood is discarded.
WASTE BLOOD MUST NOT BE USED AS SAMPLE FOR T & S
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Cerner Bridge Transfusion
Administration• Enables providers to positively identify the patient and verify the
administration of blood products using bar-code technology.
• Bridge Transfusion solution is used to:
• Start a Transfusion
• Hold a Transfusion
• End a Transfusion
• Consents and Orders will continue to be reviewed in PEDS
PowerChart
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Bridge Transfusion Chart Overview
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Bridge Transfusion Workflow
Start a Transfusion
1. Click on the Bridge button from the
PEDS menu toolbar
2. Scan the Patient’s Wristband
3. Select the Start Transfusion button
4. Complete the Pre-Checks
5. Scan the Recipient Label
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Bridge Transfusion Workflow Cont’d6. Scan the Blood Bag (4 Scans)
7. Document Start Vital Signs
8. Document IV Line and Initial
Rate
9. Click the Start button
10.Document first 15 minutes and
hourly vital signs in PEDS
PowerChart (IView)
❹❶
❷❸
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Starting the Transfusion
• Start infusion slowly (5% of total
volume) infusing this amount for
the first 15 minutes.
• Review what to do for platelets
• Nurse (or designee) must remain
with patient for the first 15
minutes!
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During the Transfusion
• Calculating Rate (After the 15 minutes)
• Do not infuse other IV solutions simultaneously with blood through the same IV.
• Do not add medications to blood.
• Vital signs must be obtained before, 15 minutes, and every hour during the infusion.
After the TransfusionMust save bag for at least one hour after
transfusion has ended.
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Possible signs and symptoms of a transfusion reaction:
Urticaria Hypotension
Fever Tachycardia
Chills Respiratory distress
Myalgias Bleeding
Nausea Shock
Vomiting Back pain
Diarrhea Abdominal pain
Pain at infusion site Chest pain
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Action Steps for Reactions1. STOP transfusion and disconnect tubing and
cover with a sterile cap
2. Flush IV with normal saline
3. Notify physician immediately and document
“Clinician Notification” in EHR
4. Recheck all identifying labels
5. Treat symptoms per MD order(s)
6. Monitor vital signs Q 15 min or per MD orders
until stable
7. Follow MD orders to either “End” or “Hold”
transfusion
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Placing Transfusion on HOLD:
Mild Reactions
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To Restart Transfusion: Symptoms
Resolved
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END Transfusion:
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Transfusion Discontinued:
Moderate/Severe Reaction• Complete the transfusion reaction section
in Bridge
• Report the suspected reaction to blood
bank personnel and determine what lab
specimens are required
• Return remaining blood with ALL attached
tubing to blood bank• NOTE: if reaction occurs AFTER product is completed or during
downtime a PAPER “Transfusion Reaction Form” will need to be
completed.
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Transfusion Reaction Documentation
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Transfusion Reaction
• Transfusion Reaction
Investigation Report will be
completed based off the
bridge documentation on all
actual and suspected blood
reactions.
• REMEMBER TO NOTIFY
ATTENDING MD
• Also complete incident report
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When do I do a Huddle Form?
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Quality Indicators
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Patient Falls
CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE ED PACU Psych
NDNQI Mean:Total patient falls per 1,000patient days
(Magnet Facility Comparison)0.43% 0.43% 0.01% 1.62% 1.62% 1.62% 1.62% 1.24% 1.54% 0.37% 0.04% 1.58%
Nicklaus Children's Hospital Mean: Totalpatient falls per 1,000 patient days
0.00% 0.00% 0.00% 0.56% 0.77% 1.01% 0.00% 1.37% 0.00% 0.12% 0.00% 0.64%
0.00%
0.40%
0.80%
1.20%
1.60%
2.00%
Falls
rat
e p
er 1
,00
0 p
atie
nt
day
s
Patient Fall Rates per Unit1st Quarter 2016
NDNQI® Benchmark Comparison
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Patient Falls with Injury
CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE ED PACU Psych
NDNQI Mean:Total patient falls per 1,000 patientdays
(Magnet Facility Comparison)0.09% 0.09% 0.00% 0.64% 0.64% 0.64% 0.64% 0.23% 0.34% 0.08% 0.02% 0.52%
Nicklaus Childrens Hospital Mean: Total patientfalls with Injury per 1,000 patient days
0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.68% 0.00% 0.00% 0.00% 0.64%
0.00%
0.10%
0.20%
0.30%
0.40%
0.50%
0.60%
0.70%
0.80%
Falls
Rat
e w
ith
Inju
ry p
er
1,0
00
pat
ien
ts d
ays
Patient Fall Rates with Injury per Unit1st Quarter 2016
NDNQI® Benchmark Comparison
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Pain AIR Cycles
CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE
NDNQI Mean: % Pain AIR cycles completed(Magnet Facility Comparison)
97.35% 97.35% 96.8% 96.9% 96.9% 96.9% 96.9% 96.3% 96.6%
Nicklaus Children's Hospital Mean: % Pain AIRcycles completed
90.0% 100.0% 100.0% 100.0% 88.5% 100.0% 100.0% 86.7% 100.0%
80.00%
82.00%
84.00%
86.00%
88.00%
90.00%
92.00%
94.00%
96.00%
98.00%
100.00%
% c
om
ple
te P
ain
AIR
cyc
les
Pain Assessment-Intervention-Reassessment (AIR) Cycle Completion1st Quarter 2016
NDNQI® Benchmark Comparison
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Hospital Acquired Pressure Ulcer (HAPU)Stage II and above
CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE
NDNQI Mean: Hospital Acquired PressureUlcer (HAPU) Stage II and above
(Magnet Facility Comparison)3.5% 3.5% 0.23% 0.14% 0.14% 0.14% 0.14% 0.43% 0.25%
Nicklaus Children's Hospital Mean: HospitalAcquired Pressure Ulcer (HAPU) Stage II and
above0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
-0.5%
0.5%
1.5%
2.5%
3.5%
4.5%
5.5%
6.5%
7.5%
% o
f su
rve
yed
pat
ien
ts w
ith
H
AP
U S
tage
II a
nd
ab
ove
Hospital Acquired Pressure Ulcer (HAPU) ≥ Stage II 1st Quarter 2016
NDNQI® Benchmark Prevelance Comparison
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RN Education
CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE Psych ED OR PACU
NDNQI Mean: %BSN or higher education(Magnet Facility Comparison)
83.68% 83.68% 71.00% 79.1% 79.1% 79.1% 79.1% 80.2% 68.9% 59.2% 63.9% 61.6% 63.8%
Nicklaus Children's Hospital Mean: % BSN orhigher education
73% 73% 69.4% 69.7% 87% 56.8% 71.1% 91% 63.6% 69.23% 49.1% 59.3% 50.0%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
% B
SN d
egre
e o
r h
igh
er
BSN or higher prepared nurses per unit1st Quarter 2016
NDNQI® Benchmark Comparison
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RN Certification
CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE Psych ED OR PACU
NDNQI Mean: % Nationally Certified RNs(Magnet Facility Comparison)
31.4% 31.4% 32.1% 33.4% 33.4% 33.4% 33.4% 35.7% 36.8% 18.3% 20.0% 33.5% 33.9%
Nicklaus Children's Hospital Mean: %Nationally Certified RNs
43.3% 41.8% 49.4% 15.2% 33.3% 37.8% 47.37% 46.9% 36.4% 23.1% 36.2% 33.3% 50.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
% o
f D
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Certified Nurses per Unit1st Quarter 2016
NDNQI® Benchmark Comparison
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Catheter Associated Urinary Tract Infections
CICU PICU 3 E 3 N 3 S 3 NE 2 E 2 NE
NDNQI Mean:CAUTIs per 1000 Catheter Days(Magnet Facility Comparison)
1.98% 1.98% 0.5% 0.5% 0.5% 0.5% 0.87% 0.5%
Nicklaus Children's Hospital Mean: CAUTIs per1000 Catheter Days
16.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
18.00%
CA
UTI
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Catheter Associated Urinary Tract Infections1st Quarter 2016
NDNQI® Benchmark Comparison
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Central Line Associated Blood Stream Infections (CLABSI)
CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE
NDNQI Mean: CLABSI per 1000 Central linedays (Magnet Facilty Comparison)
1.05% 1.05% 0.90% 1.15% 1.15% 1.15% 1.15% 1.05% 1.3%
Nicklaus Children's Hospital Mean: CLABSI per1000 Central line days
3.57% 0.00% 0.00% 0.00% 1.24% 0.00% 0.00% 12.35% 0.00%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
CLA
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Central Line Associated Blood Stream Infections (CLABSI)1st Quarter 2016
NDNQI® Benchmark Comparison
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Code Blue
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Code Blue
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Code RolesWhat is my role in a code?
• 1 person-Team Lead
• 1 person-Airway
• 1 person-Compressions
• 1 person-get cart/call code
• 1-2 person(s)-Meds/calculations
• 1-2 person(s)-documentation
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Code Blue Basics
• Call a code (555)
• HOB DOWN
• Lower bed in order to perform adequate chest compressions
• Place patient on backboard
• Airway person should be at HOB
• Check pulse• Infant: brachial
• Child: Carotid What is wrong with this picture?• Bed in high position• 2 people performing airway• No chest rise
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AIRWAY• Airway person: at HOB
• Face mask: minimum 5L O2 (otherwise pt breathing in own CO2)
• AMBU: hook up to O2.
• Always assess for CHEST RISE
• MRSOPA• M= mask (size, seal, position)• R=reposition (head tilt chin lift, nostrils
toward sky)• S= suction• O= open mouth• P=pressure (squeeze ambu harder)• A= advanced airway (consider
intubation)
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Code CartWhat drawers do I use?
Only 3 drawers are opened in a code
• 1. Top drawer-MEDICATIONS
• 2. Color drawer by weight (braslow tape)-SUPPLIES, FLUIDS
• 3. Bottom drawer-additional supplies (drawing up meds, saline flushes, intubation, etc)
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Restraints and Seclusions
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RESTRAINT AND SECULSION
A restraint is any manual method, physical or mechanical device,
material or equipment that immobilizes or reduces the ability of a
patient to move his or her arms, legs, body, or head freely; or a drug
or medication when it is used as a restriction to manage the patient’s
behavior or restrict the patient’s freedom of movement and is not a
standard treatment or dosage for the patient’s condition.
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RESTRAINT AND SECULSION
A restraint DOES NOT include devices such a orthopedically prescribed
devices, surgical dressings or bandages, protective helmets, or other
methods that involve the physical holding of a patient for the purpose
of conducting routine physical examinations or tests, or to protect the
patient from falling out of bed, or to permit the patient to participate
in activities without the risk of physical harm (this does not include a
physical escort).
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RESTRAINT AND SECULSION
Seclusion can only be used in emergency situations, if
needed, to ensure the immediate safety of the patient
exhibiting violent or self-destructive behavior (and others)
and less restrictive interventions have been determined
to be ineffective.
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Quick Guide on what to do, First Try before using restraints
Less intrusive measure:•1:1 patient to staff
observation•Verbal intervention •Child life
involvement •Distraction•Verbal redirection
Less intrusive measure:• Positioning• Positive reinforcement• Music• Family involvement • Mittens or gloves• Securing/covering site
or area
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Quick Guide on what to do if in medical restraintsEvery 2 hours, observation includes:
Behaviors
Restraints removed/ROM
Circulation/Skin checks
Toilet/hygiene offered
Fluids offered hourly, if applicable
Meals/snacks are offered at least three times a
day, if applicable
Vital signs are documented at least every 4 hours
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Quick Guide on what to do for medical restraints
Orders are limited to:
• 4 hours for adults 18 years of age or older
• 2 hours for children and adolescents 9-17 years of age
• 1 hour for children under 9 years old
NOTE: These are guidelines for MEDICAL RESTRAINTS ONLY, BEHAVIORAL RESTRAINTS HAVE DIFFERENT CRITERIA FOR PATIENT SAFETY
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Quick Guide on what to do• The restraint or seclusion order may only be renewed in
accordance with these limits for up to 24 hours unless superseded by state law that is more restrictive
• After 24 hours, and before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a physician or other Qualified License Personnel (if allowed by state) must see and assess the patient.
• Physical holding of a patient for the purpose of conducting physical examination or tests is permitted. However, patients do have the right to refuse.
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What not to do
DO NOT:
• Tuck a patient’s sheets in so tightly that he/she cannot move.
• Use wrist holders/highly padded mitts or other types of devices.
• Use a side rail to prevent a patient from voluntarily getting out of bed.
• Place hand mitts and attach them to bedding.
• The use of PRN orders is prohibited for drugs or medications that are being used as restraints.
• Staff cannot discontinue an order and then restart it because that would constitute a PRN order.
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What NOT to do
Example: When a trial period of observation out of restraints is initiated and
the patient again exhibits the symptoms that prompted the prior use of
restraints, and the patient is placed in restraints again, a new order would be
required. This episode cannot be considered as part of the original
episode/order as it would be considered a PRN order which is not permitted.
A temporary release they occurs for the purpose of caring for a patient’s needs, for example toileting, feeding, ROM, is not considered a discontinuation of the intervention.
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Quality Monitoring
Evidence of prolonged restraints, as defined by the
organization, and, if possible, actions taken to reduce or
eliminate the use of restraints must be analyzed by the
treatment team and presented for management review.
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Staff Training and Competence
All staff involved in restraints and seclusions are provided with
ongoing education and training to ensure patients are cared for in
a safe and therapeutic manner. Training is provided before
providing any restart and seclusion care as part of orientation and
subsequently on an annual basis. Due to the different skill levels
(Level I-IV) and responsibilities of those involved, there are
different levels of education and training.