Recently Updated Nursing Practice Manual

The standard times of administration have been changed to consolidate the medication passing times for nursing:

TID: 9am / 1pm / 5pm

QID: 9am / 1pm / 5pm / 9pm

The Blood Bank  will soon not be dispensing any filters with platelets, cryoprecipitate or granulocytes.  The blood administration sets which are stocked on the floors, are to be used for these transfusions, as well as red cell and plasma transfusions.  This procedure has been revised to reflect this change.

Calamine lotion has been deleted from use. 

Item #1 was changed to reflect new temperature maximum standards of 130˚ for blankets and 110˚ for solutions.  Corresponding daily log was also modified to reflect this.

Please review all of the following protocols related to pain:

Protocol: Pain: Care of the Adult Patient with (and Use of Pain Scales)

Protocol: Pain (Acute): Care of the Patient Receiving Continuous Narcotic Infusion

Protocol: Pain (Acute): Care of the Patient Receiving IV or SC Narcotics via PCA Pump

Protocol: Pain: Epidural Infusion and Patient Controlled Epidural Anesthesia: Care of the Patient Receiving

Please review for addition of "Ticket to Ride" procedure.

This is a new procedure.  Please review entire document.

Clinical Assessment and Care:

#4: Assess pain level at least every four hours or more frequently with uncontrolled pain.

#5: Monitor and document drainage from the Heimlich Valve at least once every shift if it is attached to a collection device.

All seven of the Central Line documents have been revised to reflect our current standard of practice. 

Clinical Procedure: Central Lines: Alteplase (Cathflo Activase®) Instillation for Catheter Clearance

Clinical Procedure: Central Lines: Blood Drawing

Clinical Procedure: Central Lines: Dressing/Catheter Site Care

Clinical Procedure: Central Lines: Implanted Port: Accessing Port with Huber Needle

Clinical Procedure: Central Lines: Patient Care

Clinical Procedure: Central Lines (and Implanted Ports): Intravenous Fluid Administration

Clinical Procedure: Central Lines and Implanted Ports: Heparin/Normal Saline Flush

All documents will reflect that:

1. Handwashing immediately before accessing any central line is mandatory.
2. Chlorhexidine gluconate (CHG) in swab or pad form is to be used for:
   1. skin disinfection (IV insertion, phlebotomy, blood cultures, accessing infusa ports)
   2. obtaining blood cultures from a central line or a-line
   3. accessing a line for TPN, lipids and/or propofol
3. The standard cleansing requires:
   1. a 15 second vigorous scrub of the skin or port.  Then allowing it to completely dry.
4. General access of IV lines (peripheral or central) requires a 15 second alcohol or CHG scrub.
5. Needleless ports are to be changed every seven days, regardless of whether a clear or gauze dressing is in place.  It is to be coordinated with dressing changes.
6. Needleless port dressing changes require sterile technique including sterile gloves and mask.  Wipe entire line and ports and hub ends prior to reconnect.
7. There is no need to use nonsterile gloves with central line access for medications and IV tubing unless there is no needleless port on the line.  It is critical, however, to maintain sterility of the needleless port between the time cleaned and access.
8. Universal precautions would require gloves to be worn if there was:
   1. no needleless port on the line
   2. blood in the tubing
   3. blood drawing
   4. handling of blood tubes (even if using a needleless closed system)

Please review all seven of the central line documents to acquaint yourself with all of these revisions.

Procedure:

#1 (Point of Emphasis): Those patients who may benefit from a calorie count include, but are not limited to, patients with:

• Poor intakes/appetite associated with certain diagnosis (i.e., dysphagia/mental status changes, certain cancers and treatment-related issues)
• Nutrition support: supportive documentation for initiating or transitional feeding
• Further appetite/intake documentation needed to fully assess nutrition adequacy
• Significant weight loss (>5% within one month or >10% within 6 months) with continued poor appetite/intake and/or failure to thrive (FTT)

Policy:

#2: Patients on admission with an assigned risk score of 0-2 are classified into the universal fall risk and universal falls strategies are to be instituted.  No further assessment is warranted until the time of discharge unless there is a change in patient condition or treatment, a fall, or the patient is transferred.

Procedure:

#2 (Point of Emphasis): The patient's ID bracelet is to be left in place in the event of death.

Policy:

#3: Notify Facilities Management when the warmer temperature is outside the recommended range. 

#6: Irrigation solutions placed in the warmer must be dated and timed and removed after 72 hours.

#7: Povidone Iodine (Betadine) can not be placed in the warmer. 

#8: Contrast medium should be stored in a dedicated warmer.  Refer to manufacturer's guidelines for the proper temperature range.

#9: Pour irrigation fluids removed from the warmer after 72 hours may be updated with a 60 day expiration date for use at room temperature.   

Policy:

#4: The physician/LIP must write an order to allow use of the patient's own medications.

Points of Emphasis:

#4: After being notified of the patient's impending discharge, the central pharmacist will remove the patient's medication from safe.  The medication will then be delivered to the nursing unit by a pharmacy runner or a licensed member of the nursing staff may also pick up the patient's meds.  Any medication that is not claimed 30 days after discharge will be removed from the pharmacy safe and destroyed.   

Policy:

#5: Lipid infusions should hang no longer than 12 hours.

Appendix A:

A category for Midline Catheter was added to the Appendix: Flushes for Central IV Access Devices.

Policy:

#1: Regarding antagonist for anticoagulants: "There is no reversal agent for Fondaparinux (Arixtra)."

Clinical Assessment and Care:

#6: There are now 4 standard order sets for Intravenous Heparin Therapy.

Patient Teaching:

Information has been added regarding rationale for anticoagulation therapy.  Please review.

References:

Website link is now available to review Hospital Anticoagulation References.

http://nursing.uchc.edu/Pharmacy/index.html

Appendix A:

Several categories of individuals were added to the list of "High Risk Categories with a Reasonable Expectation of Need for Post-Hospital Support or Services".  See pages 5 and 6 of the document.

Policy:

#3, b: "In CPOE, the preprinted MAR can accommodate approximately 20 allergies or 80 character limit.  If allergies exceed this limit the MAR will state 'see chart'". 

#7: In CPOE, discontinuation of allergy alert precautions will occur only as the result of an electronic data entry, inactivation or marking of erroneous by a physician, nurse or pharmacist and the name of that individual will be stored along with the date and time of revision."

Desired Patient Outcomes:

#2, e: The word "drug" was taken out and replaced by "herbal remedies/other prescription medications/OTC meds."

Educational Content:

#4, d: Statement "d" was added: "Maintain a current list of medications for medication reconciliation for future healthcare visits."

Appendix A:

High Risk Categories with a Reasonable Expectation of Need for Post-Hospital Support or Services

Several new categories have been added (listed below) and others have been reorganized:

• Unsafe home environment (e.g., fall risk)
• All patients with developmental/ intellectual disabilities
• Family conflict
• Organic brain disorders

Policy:

#5: This statement was changed to incorporate prn medications.  It now reads: "Scheduled and PRN medications will be administered within 1 hour before or after the dosing interval or scheduled time."

Policy:

Reordering Medications

#1: A decision to change the duration of CPOE for pharmacy orders from 14 to 30 days on medications with the exceptions noted in the policy was made based upon a review of the state regulations.

Clinical Advancement and Care:

#6: "Care Line" is now called "Child Abuse Hot Line"

Documentation:

#1: The form 136 (Appendix A) is no longer in duplicate form.  When completed, a copy must be made and forwarded to Social Work.

Clinical Assessment and Care:

#7: "Report elder abuse, neglect, exploitation or abandonment to Protective Services for the Elderly at the Department of Social Service, State of Connecticut (1-888-385-4225). 

Documentation:

#2: "Document any contact with the  Protective Services for the Elderly at the Department of Social Service, State of Connecticut."