Nursing Councils Report for September

Nursing Councils Report for September

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

  • The September 2014 Journal Club was led by Claudia Burgett, RN, and DawnMarie Lombardo, RN, both staff nurses on Mother Baby Unit, who presented, “Multimodal approaches to VTE prophylaxis.” The Journal Club meets on the third Monday of every month from 12-1pm in the second floor South Tower Conference Room. Please bring your lunch and join us to explore how to incorporate research evidence into practice.
  • Katie Ernst, a former patient-family advisor at AAMC, presented findings of her Master’s thesis study on bedside shift report, conducted at AAMC. The study found that teamwork and shared understanding of the patient’s condition were critical to a successful shift report.
  • Bedside Scientist grants are funded throughout the year. Please contact Cathaleen Ley at for more information.

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

  • National Database of Nursing Quality Indicators (NDNQI)
    • For Calendar Quarter 2 (April-June 2015), AAMC outperformed its benchmark on injury falls, hospital acquired pressure ulcers, catheter associated urinary tract infections (CAUTI), and central line associated blood stream infections (CLABSI) hospital-wide. While AAMC’s overall performance is good, units that did not outperform their benchmark on these indicators are completing actions plans to address.
  • Nursing Documentation
    • Need for improvement in pain reassessment documentation: pain must be assessed every shift or more often if the patient’s condition warrants and within one hour of a “PRN” opioid analgesic administration. Documentation of POSS score must be completed at the time of medication administration and one hour later.
    • Documentation of physician’s ID for telephone orders is required. Nurses must ask for physician badge numbers for telephone look up.
    • Committee membership has been expanded to include two physician champions – Dr. Amy Yu and Dr. Wids Romeus.
    • New urine clean catch cups have been approved by Materiel Management. Education will began in the Emergency Department in September, with the rest of the hospital following.
    • Clinical Education is currently developing a checklist for Foley insertion for new hires.
    • A root cause analysis is conducted on all CAUTIs at the monthly CAUTI committees in order to have a better understanding of system issues contributing to CAUTI.
  • HAPU
    • The calendar quarter three HAPU prevalence study was conducted in September 2015.

Professional Nurse Council
Chair: Carrie Jackson, MSN, RN
Co-Chair: Daniel Shields, RN
Initiatives: SNAC, Diversity/Advocacy, Community, COPE

  • Professional Practice Model: Approval of new pictorial representation of the PPM will be phased in over next few months — PNC reviewed and made recommendations.
  • Nurse Excellence Awards:  A patient care technician award is being developed for each unit, edits/revisions were made based on feedback. PNC gave feedback on current Nurse Excellence Awards, look for upcoming nurse excellence award review dates and sign-up sheets.
  • CAUTI: Percentages have been increasing. Practice good hand hygiene and ways to decrease CAUTI rates by reviewing proper technique for catheter insertion and foley care with your colleagues.
  • COPE: Four new members have joined. Working on mock sessions. Four COPE sessions were held during the month of August.
  • Cultural Diversity: Working on lunch and learn sessions. Planning Martin Luther King, Jr. Day and planning for Cultural Diversity Week on June 20-25, 2016.

Clinical Education Council
Chair:  Melody Kennedy, BSN, RN
Co-Chair: Gena Kosmides, BSN, RN
Initiatives: Professional Development

  • New pediatric sedation tool going live in EPIC. The UMSS (University of Michigan Sedation Scale) is a valid, reliable tool used to assess sedation in pediatric patients undergoing procedures.  This scale is being adopted by units approved to administer and/or monitor sedation medication according to policy SNP 15.2.70 Pediatric Sedation. This scale will only be visible on pediatric charts for patients < 17 years old.8TT1
  • EPIC Upgrade optimization options presented to the group. Each was prioritized by the educator group. More information will be disseminated when finalized.

Interdisciplinary Informatics Council
Chair: Bill Moore, BSN, RN
Co-Chair: Jennifer Dupre, MSN, RN

  • Influenza vaccine Best Practice Alert (BPA) went live on 9/25/15. If you get the BPA, please enter the flu vaccine order per “standard order mode” in order entry.
  • EPIC 2015 upgrade is coming soon. Go-live will be summer 2016. Look for updates.
  • Revisions to the down time forms are coming, the following will be on the unit soon:
      • Pain/PCA Flowsheet
      • Health Data Base
      • Advanced Directive Inquiry
      • Patient Care Services Admission Screening

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

  • CPC approved the following policies to move on to the Hospital Policy Review Committee (HPRC):
    • #TBD Newborn and Infant Fall Prevention and Management- New policy to address fall prevention needs specific to newborns
    • SNP 15.2.361  Bilirubin assessment in the healthy neonate– 2 changes made r/t bilirubin levels
    • SNP 15.2.40 Assisting with a blood patch– 3 year review; formerly a L&D only policy, however process is followed in ED and PACU, so these 2 units were added to scope
    • SNP 15.2.051 Chlorhexidine gluconate cloths used for skin preparation prior to cesarean section surgery- 3 year review
    • SNP 15.2.35 Spiritual care for infant death– 3 year review
    • SNP 15.2.161 Antepartum patient, care of- 3 year review
    • SNP 15.2.57 Birth certificate information- 3 year review
    • SNP 15.2.10 NICU team attendance at deliveries- 3 year review
  • CPC approved to RETIRE the following policy:
    • GNP 14.7.11 Cleaning the Fiberoptic Bronchoscope– New cleaning process for fiberoptic scopes is included in the Infection Control policy (IC5.1.05 – High-level disinfection of medical devices).

Please note: Policies are not finalized or posted online until signed by Barbara Jacobs or designated VP.

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

  • New Leadership:  Lisa Davis has taken over as chair, Devra Cockerille has taken over as co-chair.
  • Alicia Baines presented on changes to the Verge System.
  • Linda Williams presented on the new Evaluation process and the TEDS system.
  • Peggy Rabuck discussed the benefits of Reiki therapy for patients and staff.  Contact Peggy for more information.
  • Lighthouse Shelter:  Always in need of volunteers to teach classes and assist with clinics.  Mary Perzanowski reviewed how to sign up.  For more information contact Mary.
  • Transporters requesting that staff have patients ready to go when they arrive to avoid delays in their flow.

Nursing Operations Council
Chair:  Irma Holland, MSN, RN

  • Weekend shift voting sheets passed out for NOPs clinical directors to vote.
  • Directors were reminded to complete Intra-cycle monitoring information for Joint Commission.
  • Linda Williams and Lisa Walker presented information on TEDS Performance Evaluation system, the directors discussed issues and concerns and asked for a tip sheet to be distributed.
  • Holly Greever outlined guidelines for Peer Feedback during the performance appraisal process. Holly stressed the importance of correctly defining peers for each nurse for compliance with Magnet.
  • There was a discussion on Room Prep requirements as a result of an RIE conducted with Environmental Services. Inar Maharaj will be asked to attend NOPs for clarification of nursing requirements.
  • Pharmacy Updates – Karen Cash attended to share pharmacy updates, including:

Oncology is facilitating a med-pass project
Med Safety pharmacist is reviewing all diphenhydramine administration to ensure all patient profiles/allergy information is updated
Influenza vaccine screening begins 9/27/15
Staff flu vaccinations scheduled October 15 – Nov. 20.
Clint Welch Announced the new PLUM  300 IV pumps are onsite and being prepped for go-live.

Post your comment