Here are some of the Things You Need to Know
Time Outs
A time out is required for all procedures, including bedside procedures, for which a permit is asked. It is important to identify the patient by two means, such as name and medical record number, and to identify the procedure, the site, the position, correct implants and the fact that all records have been reviewed, including the consent. The time out must be done in the location where the procedure will be done and must be documented.
(Any differences must be reconciled prior to the procedure)
Hand-Off Communication
The primary objective of a “hand-off is to provide accurate information about a patient’s care, treatment and services, current condition and any recent or anticipated changes. There must be an opportunity for questions and answers, with limited interruptions.
Read Back
For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and “read-back” the complete order or test result.
Note: The receiver writes the information down or enters results in the computer, and then the receiver reads what was actually recorded.
Abbreviations
These are the abbreviations you should never use, because they can be confused.
Do not use them.
● U,u
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● IU
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● Q.D., QD, q.d., qd
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● Q.O.D., QOD, q.o.d, qod
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● Trailing zero (X.0 mg)†
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● Lack of leading zero (.X mg)
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● MS
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● MSO4
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● MgSO4
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Medication Reconciliation
This process has four steps, and each must be done carefully. (1) The list of medicines taken at home is entered in Impact by nursing and should be reviewed for accuracy. You should refer back to the home meds as the patient progresses through the organization. (2) When discharging a patient in Impact, be sure that the list of medications on discharge is the complete list of what you want the patient to take at home. (3) Then be sure that the list of discharge medications in the discharge summary is the same as the list given to the patient at discharge. (4) Be sure that you designate a discharge summary be sent to the next provider of care and name that provider.
Hand Hygiene and Contact Precautions
We must be in the habit of washing our hands (when hands are visibly soiled) or using the alcohol based hand cleaner (when hands are not visibly soiled) when entering and leaving a patient’s room. Also, we have to obey the requirements for contact precautions (generally a gown and gloves and leaving lab coats at the nursing station).
Fire
Remember that we move patients laterally to a place behind fire doors if there is a fire. Look around the unit for the fire alarm and for the shut-off valve for oxygen. In case of fire, pull the alarm and shut off the oxygen valve, being mindful of patient’s needs as well.
If you do not know the answer to a question, say, “I do not know, but I know that I can ask … the unit manager or … the medical director for the answer.”
Important Aspects of Core Measures
We need your help with each of these.
Surgical Care Improvement Project (SCIP)
- Prophylactic antibiotics are to be given within one hour of incision time.
- Prophylactic antibiotics are given for no more than 24 hours after surgery end time (48 hours for cardiovascular surgery), regardless of drains or appliances. For UAB, the easiest way to comply is to have one dose given in PACU.
- Cardiac patients must have a 6 a.m. glucose. If the glucose is >200 on post-op day one, a repeat glucose level is to be drawn on post-op day two at 6 a.m.
- Patients who have colon surgery should have a temperature of =>96.8 degrees on arrival in PACU.
Acute Myocardial Infarction
- Patients with ST elevation MI should have an admission time to balloon inflation time of ninety minutes or less during a Percutaneous Coronary Intervention (PCI).
- Patients should get aspirin on admission and on discharge. If there is a reason for not receiving aspirin at admission or at discharge, the reason MUST specifically be documented in the chart.
- Patients should be prescribed a beta blocker within 24 hours of admission and be discharged from the hospital on a beta blocker. If there is a reason for not receiving a beta blocker at admission or at discharge, the reason MUST be specifically documented in the chart.
- Patients with LVEF <40% should be prescribed and discharged from the hospital on an ACE or an ARB unless contraindicated. If neither class of drug is prescribed, there MUST be a specific reason documented for each class. Only these 5 conditions suffice as documentation for both classes of drugs: angioedema, hyperkalemia, hypotension, renal artery stenosis, worsening renal function/renal disease/dysfunction.
- Patients who have smoked in the last year should be counseled on smoking cessation. We accomplish this with a printout in every discharge instruction sheet from Impact.
Congestive Heart Failure (CHF)
- Patients with CHF should be prescribed and be discharged from the hospital on an ACE or ARB if LVEF <40%. If neither class of drug is prescribed, there MUST be a specific reason documented for each class. Only these 5 conditions suffice as documentation for both classes of drugs: angioedema, hyperkalemia, hypotension, renal artery stenosis, worsening renal function/renal disease/dysfunction.
- LVEF should be measured by Echocardiogram, if no previous Echo on record.
- Discharge instructions should include (a) activity, (b) diet, (c) follow-up, (d) weight monitoring (e) what to do for weight or symptom change (f) what home medicines to continue, what to stop, what new medicines to take, and signed by the physian (note: if the medication reconciliation is done as outlined above, it meets the JCAHO requirements).
- Patients who have smoked in the last year should be counseled on smoking cessation. We accomplish this with a printout in every discharge instruction sheet generated by Impact.
Pneumonia
- Patients should have blood cultures drawn before antibiotics are given in the Emergency Room.
- Patients should receive antibiotics within six hours of admission to the Emergency Room.
- Oxygen saturation should be measured within 24 hours.
- Nursing is responsible for screening and administering pneumococcal and influenza vaccines through their protocol.
- Patients who have smoked in the last year should be counseled on smoking cessation. We accomplish this with a printout in every discharge instruction sheet generated by Impact.