Nursing Councils Report for April/May/June

Nursing Councils Report for April/May/June

Nursing Research Evidence-Based Practice Council
Chair: Cathaleen Ley, PhD, RN
Co-Chair: Cheryl Briggs, BSN, RN

Journal Club:

April- “Identifying Pediatric Emergence Delirium by Using the PAED Scale” presented by Jennifer King, MSN, RN and Michelle Lusby, BSN, RN

May- “Religious Values and Healthcare Accommodations Voices from the American Muslim Community” presented by Lashawn Sanchez, RN

June- “Are Nurses Recognizing Delirium?” presented by Danette Reading, BSN, RN and Sharolyn Bush, MSN, RN

Bedside Scientist Awards – Fiscal Year 2017:

The Nursing Research and Evidence Based Practice Council is very pleased to announce the newest Bedside Scientist. Each of the principle investigators and their team were awarded a $1,000 to complete a nursing evidence-based quality improvement project or a nursing research study to be conducted in FY2017. Bedside Scientist grants are awarded to clinical nurses and clinical support staff to conduct studies to improve the quality of patient care, especially to reduce patient harm. All grants are reviewed and approved by the Nursing Research and Evidence Based Practice Council for scientific metric and feasibility. For questions regarding Bedside Scientist Grants please contact Cathaleen Ley at cley@aahs.orgFY2017-Bedside-Scientist-Grants2
















Nursing Quality Council
Chair: Cathaleen Ley, PhD, RN
Co-Chair: Lauren Stylc, RN

  • Benchmark of Nurse Sensitive Indicators:
    • The majority of the inpatient units outperformed their NDNQI benchmark on falls with injury (10 of 12 units), hospital acquired pressure ulcers (HAPU) (10 of 12 units), central line associated blood stream infections (CLABSI) (10 of 12 units), and catheter  associated urinary tract infections (CAUTI) (7 of 11 units).
    • The majority of the ambulatory departments/units outperformed their NDNQI benchmark on total falls (11 out of 16 departments/units) and on injury falls (12 out of 16 departments/units).
    • AAMC exceeded the Core Measure national mean for Venous Thromboembolism (VTE-1) – patients receive VTE prophylaxis the day of/after hospital admission or the surgery end date.
  • Catheter  Associated Urinary Tract Infections  (CAUTI):
    • CAUTI Best Practice training was conducted in May for CAUTI Champions.
    • Nurse driven Foley removal protocol added to Urinary Catheter (Foley) Use and Removal policy. Please refer to Attachment C.
  • Falls Committee

DeRoyal sensor chair pads and fall alarms

    • A pilot study of the DeRoyal sensor chair pads and fall alarms was conducted on the Special Care Unit in April for the purpose of evaluating staff satisfaction with the quality of the fall alarm, sensory chair pad sensor, and staff satisfaction with the connection of the fall alarms to the nurse call system. Using a 5 point Likert scale investigator developed survey tool nursing staff satisfaction was determined to be high to all components evaluated.  As a result of this study, the decision was made to purchase the DeRoyal sensory pads and chair alarms.
    • The chair pads and alarms will be used on all adult inpatient units, including the Adult ED and the Observation Unit. The fall alarms will be mounted to the walls on all adult inpatient units, Adult ED, and Observation unit. The alarms will not be mounted on the walls on Labor and Delivery, Mother Baby, and WSU but will be available on the unit for use as needed.
    • On August 1, 2016, training of nursing, physical therapy, and transport staff will be conducted. Once unit staffs are trained, the Posey alarms will be removed and replaced with DeRoyal Sensor Pads.

Modification to Fall Policy:

    • The Fall Policy was modified following an event during which a patient fell.
      • Current policy is that high risk patient cannot be alone when toileting  (toilet, bedside commode)– change wording to include bedpan
      • Addition to  policy that nurse must be notified by transporter when  high risk patients return to the unit following transport so that bed and fall alarms are plugged in.

Post Fall Education:

    • Post fall education has been added to EPIC for patients who have fallen in the hospital and could have a potential head injury.
    • When a patient has a fall during admission and the high fall risk education topic is triggered, post fall educational resource material handout can be accessed for post-fall educational purposes. This handout can also be printed and given to patient/family.


Professional Nurse Council
Chair: Daniel Shields, RN
Co-Chair: Shahde Graham-Coker, MSN, RN
Initiatives: SNAC, Diversity/Advocacy, Community, COPE

  • Poster for the Nurse’s Fair focused on workplace violence/bullying.
  • Nurse Satisfaction Survey advocates were PNC members among others – 92% average unit participation this year.
  • PNC is advocating the Workforce Survey for impending Magnet data submissions in the coming months.
  • PNC is advocating to help with unit readiness for the Joint Commission visit this year.
  • Escort spoke at the last meeting regarding changes in medication transfer process with patient throughput – more information to be distributed to nursing staff.


Clinical Education Council
Chair:  Robin Colchagoff, MSN, RNC, CCE
Co-Chair: Mary Cohn, MSN, RN
Initiatives: Professional Development

  • Reviewed nurse clinical ladder changes and the new PCT clinical ladder.
  • Approved CEC FY17 Goals- includes goal for the new PCT Clinical ladder and goals for patient throughput and patient satisfaction.
  • Reviewed plan for Epic upgrade on 7/16/16.
  • Continue to evaluate and modify the orientation for new grads at AAMC- each area looking at individual unit orientation for opportunities to streamline, increase efficiency and retain relevance while maintaining quality and preparing nurses appropriately for independence; changes began with July new grad group.


Interdisciplinary Informatics Council
Chair: Jennifer Dupre, MSN, RN
Co-Chair: Lindsey Alexander, BSN, RN

  • A prompt will display under the allergy tab when “Mark as Reviewed” is chosen and the section has not been filled out.  A tip sheet on this change will be sent out soon.
  • The Joint Commission is focusing on range orders this go around.  Please familiarize yourself with our policy regarding range dose orders.  There is an electronic tip sheet available.
  • COMING SOON!!  An LDA for insulin pumps.  You will be hearing more information regarding this change in documentation in the coming weeks. Please be on the lookout for it.
  • Congratulations to everyone on the EPIC upgrade. It was very successful and seamless. If anyone has any concerns or issues regarding EPIC or the changes made please contact the help desk at x 5202.


Clinical Practice Council
Co-Chair: Denise Matteson, BSN, RN, CAPA

CPC approved the following policies to move on to the Hospital Policy Review Committee (HPRC):

  • MED 16.1.16 Patient Controlled Analgesia, The POSS score definition has been added along with new policy statements, and Pediatric definition along with reference updates.
  • MED 16.2.08 Hydromorphone Parenteral Administration, The purpose of this policy is to restrict where it is used (when, where, how). References updated
  • MED 16.2.04 Adult Inpatient Continuous Intravenous Controlled Substance Infusions, Content unchanged added RN double check I process and references updated.
  • GNP 14.3.04 Hypoglycemia & Hyperglycemia in 14 years and older, This policy was updated to reflect the order set.
  • GNP 14.3.05 Hypoglycemia & Hyperglycemia in the Pediatric Patient <14 years of age, This policy was updated to reflect the order set.
  • IC 5.1.04 Hand Hygiene, This policy is 3 year review added section on what to do if the worker has upper extremity support device such as cast.
  • SNP 15.2.06 Circulating for Vaginal Delivery, This policy is a 3 year review, nothing left behind criteria has been added.
  • GNP 14.6.02 Safe Haven Hospital Process, Policy updated with the required revisions for laws regarding Safe Haven.
  • NAP 12.2.02 Nutrition Care Process, This policy is a 3 year review, references have been updated, definitions added, and key terms clarified.
  • NAP 12.1.17 Assessment & Reassessment of Nutrition Care, This policy is a 3 year review, references have been updated, and key terms clarified.
  • GNP 14.2.07 Blood Culture Collection, This policy is a 3 year review, specific information added to timing and numbering of sets and sites added no content change.
  • SNP 15.4.47 Post Anesthesia Care Phase I Nursing Standards of Care, This is a revised policy from the Mock Joint Commission survey.  The policy speaks to the specific practice of nursing standards of care in the Phase I recovery of the patient.
  • SNP 15.4.48 Phase II Standard of Care, This is a revised policy from the Mock Joint Commission survey.  The policy speaks to the specific practice of nursing standards of care in the Phase II recovery of the patient. The Post-Anesthetic Discharge Scoring System (PADSS) has been added as an attachment.
  • NAP 12.1.14 Patient Care Assessment Documentation, This policy revised to include recommendations from the Mock Joint Commission survey.  The policy now includes both adult and pediatric populations to reflect CPM changes.
  • NAP 12.1.01 Admission Assessment, It was recommended that this policy be combined with the Patient Care Assessment Documentation policy.
  • ADM 1.1.84 Critical Incident Stress Management Response-COPE, This policy is revised to update correct format and current practice.
  • MED Range Orders, Three year revision of this policy.  Simplified the wording and formatting.
  • NAP 12.1.18 Pain Assessment & Resources, Three year revision of this policy.  Appendix C added for pain assessment and management algorithm, N-PASS scale added as attachment.
  • MED 16.1.29 Opioid & Non-Opioid Pain Management, Policy updated to reflect current practice and be compliant with current Joint Commission standards.
  • SNP 15.2.13 Utilization criteria for occupying the third operating room in L & D, This policy is a 3 year revision with no changes.
  • SNP 15.2.155 Labor, delivery, recovery postpartum, This policy is 3 year revision.  Process is now more defined.
  • SNP 15.2.155 Maternal transport process, This policy is 3 year revision.  It was suggested that after Joint Commission all Transport policies be combined if possible.
  • #TBD Emergency Department Advance Order Protocol, This policy gives the Pediatric Charge nurse/Triage nurse ability to treat pain, fever, nausea/vomiting or laceration by advance order.
  • #TBD Drug Shortages, New policy states our process as a facility to alert and handle drug shortages when they occur.
  • #TBD Concentrated Electrolytes Storage, This is a new medication safety policy for proper storage and handling of concentrated drugs.
  • GNP 14.1.16 Diet Preparation for PET Scan, Three year review with updates from Pharmacy.
  • SNP 15.5.075 Immediate-use stream sterilization in the operating room, Three year review. Policy updated references, and reformatted.
  • SNP 15.4.074 Daily quality assurance testing of steam sterilizers in the operating rooms, Purpose of this policy is to test the sterilizers daily, report to leadership if not meeting standards.
  • #TBD Definition of the critically ill patient for Point of Care Glucose Meter Testing, State mandate that facilities using Glucose Meter testing have definition of the critically ill patient in regards to Point of Care testing.
  • GNP 14.2.02 Administration of Blood and Blood products: Adult population, Three year review no content changes.
  • SNP 15.3.05 Blood Product Administration NICU Population, Three year review no content changes.
  • SNP 15.2.67 Blood Product Administration Pediatric Population, Three year review no content changes.
  • SNP 15.4.34 IV and Irrigation Fluid Warming, Three year review added process to time and date when product is pulled from warming devices.
  • SNP 15.4.12 Medication labeling and administration in the operating room/procedural area, Three year review added more defined handling of single use medications, updated references

CPC retired the following policies:

  • NAP 12.1.03 Admission of Cesarean Section, The elements of this policy are contained in other policies.
  • NAP 12.1.02 Admission of the Laboring Patient, The elements of this policy are contained in other policies.

CPC did not approve and must return:

  • #TBD Blood borne Pathogen Exposure Control Plan, This is a new policy required by OSHA and Joint Commission.

CPC updated goals and charter to be reviewed at next Nurse Executive Meeting.  Minimal changes were made.


Charge Nurse Council
Chair: Lisa Davis, RN
Co-Chair: Devra Cockerille, RN

  • No May meeting- Charge nurses attended HR open house, Devra Cockerille reported 85 attendees, 45 interviews arranged, 5 onsite interviews and offers and to date 21 hires from the event.
  • Charge nurse title update discussed. Lisa Davis, Devra Cockerille and Lil Banchero meeting with HR to align positions and charge nurses duties.
  • Lisa Laking from Informatics presented Epic Go Live and reviewed Healthstream/E-learnings and Superusers encouraged to be used for all units.
  • Lisa Davis discussed the Charge Nurse workshop planned October 11th to target prn charge nurses.
  • Beth Christy from Infection Prevention discussed urine specimen cups, single pill cutter/crushers, CHG baths for central line patients and answered infection prevention related questions and networking.

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