Nursing Councils Report for June

Nursing Councils Report for June

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

-The July 2015 Journal Club was led by Catherine (CJ)  Rovaldi , MS, MBA, BSN, RN, CNOR.  CJ presented an article she co-authored titled, “The Effect of an Interdisciplinary QI Project to Reduce OR Foot Traffic.”  The Journal Club meets on the third Monday of every month from 12-1 PM in the second floor South Tower Conference Room. Please bring your lunch and join us to explore how to incorporate research evidence into practice.
-MSU has been selected to participate in the READI (Readiness Evaluation and Discharge Intervention) study in order to advance our understanding of the impact of a discharge readiness assessment on readmission and post-discharge ED visits. This is a multi-site study of 32 Magnet hospitals, including two hospitals in Saudi Arabia. Cathaleen Ley is the site coordinator for this study. Nurses on MSU completed Phase I training in May 2015.
-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

  • Falls Committee
    • Based on feedback the Falls Committee has received from nursing staff, both the post-fall checklist and post-fall huddle forms have been revised for clarity.  While most of the revisions are related to increasing the clarity of the forms, there are a few additions. The revised Post-Fall Checklist includes a reminder about documentation of a progress note and the Post-Fall Huddle includes additional contributing factors and an area to provide a brief description of the fall event.
  • CAUTI Committee
    • CAUTI unit champions are developing an additional auditing tool to support the regular evaluation for necessity of the Foley catheter and early removal of the device. Policy work continues to include changes made by the team, including the use of an insertion checklist and emphasis on two person insertion to promote best practices.
    • Laminated Foley Catheter Use/Removal algorithms have been distributed to all units house wide for easy reference.
  • Insulin Pens
    • Journal Club presentation on the topic of biological contamination of insulin pens (due to one pen being used for multiple patients) triggered a discussion on the need to educate our nurses on the importance of using one insulin pen per patient.
    • Actions that will be put in place to prevent biological contamination of insulin pens include: (1) education added to new hire nursing service orientation, (2) Diabetic Unit Champions will be deployed to assist in educating nurses, (3) task force to develop whole house education, and (4) revision of policy to address steps to take if pens has been used on multiple patients.
  • Bedside Shift Report
    • Scanners have been ordered for all units. Once scanners have been received, bedside report will be rolled-out.
    • A prevalence study will be conducted on frequency of bedside shift report prior to roll-out.
    • Coffee Cart Rounds will be used to promote roll-out of Bedside Shift Report.

Professional Nurse Council
Chair: Carrie Jackson, MSN, RN
Co-Chair: Daniel Shields, RN

Initiatives: SNAC, Diversity/Advocacy, Community, COPE

-Workforce Data Survey began July 1. PNC Reps are to champion 100% participation from nurses this year. This survey also helps the organization look at where resources are needed to encourage professional development.
-Professional Practice is seeking professional evidence-based knowledge on the use of staff’s first and last names on identification badges.
-DAISY award nominations are being finalized and the next celebration is being planned.
-PNC expectations were reviewed with the present PNC members and an expectation list for directors is to be completed and presented in August.
-Community Initiative is gearing up for their annual Back to School Backpack Drive. Request is for each unit to donate two backpacks with supplies.
-COPE Initiative has added additional members and training is being finalized. A mock COPE session was held recently at a nursing education hour.

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

Initiatives: Professional Development

-CPM optimization phase closed out the end of June. Requests for Epic changes will go back through normal channels (i.e. IIC).
-New AAMC Intranet will go-live mid-July.
-Over 700 staff attended annual house-wide skills day.
-PCT survey – done so educators are able to better orient/educate techs. Looking at the possibility of a monthly skill session in the SAIL center for techs.
-AAMC nurse residency ranked #1 in the nation; 96% retention rate of new grads. We have 24 new grads starting in September.
-Joint Commission tracers beginning on each unit for Joint Commission preparedness.

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

-New internet/intranet is coming mid-July 2015. Log onto the current intranet to see a preview of new site.
-New MAR icons for Chemo drugs, pregnant healthcare provider precautions, and for Hazardous drugs. They are displayed on expanded MAR view and on Admin screens.
-Two questions will be added to the blood administration screen related to Irradiated Blood products. Changes coming soon. Tip sheet will be sent out.

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):

-*NEW* Sexual Assault Forensic Exam- new policy to establish written procedures for management of sexual assault victims in the ED
-IVT 18.2.02 Non-Tunneled Central Line Insertion- revised to state that femoral lines placed in emergent situations must move to a non-femoral location ASAP after the patient is stable
-MED16.1.34 Medication Samples- policy changed to comply with JC standards around med samples in clinics
-SNP 15.3.09 Breastmilk feeding discrepancy- 3 year review
-SNP 15.3.42 Umbilical Venous Catheter (UVC) insertion, maintenance, and removal- to reduce CLABSI incidence, central line practice has changed significantly in the NICU over the past 2 years; policy updated to reflect current practice
-SNP 15.3.04 Arterial Lines: Umbilical Artery Catheter (UAC) and PAL– policy updated to reflect current practice
-SNP15.3.58 Peripherally inserted central catheter – policy updated to reflect current practice and include PICCs in NICU and Peds
-SNP15.3.59 Peripheral Intravenous therapy– policy updated to reflect current practice

Charge Nurse Council
Chair: Marianne McKiernan, RN
Co-Chair: Barbara Buckley, BSN, RN

-Council reviewed goals and results from FY’15 and final approval of council goals FY’16.
-Lunch coverage on the units:  GSU PCTs using the buddy system to cover lunches for a “full and uninterrupted lunch.”
-Michelle Lusby provided updates about PACU temporary move and throughput.
-Devra Cockerille showed the new patient/med scanners coming to the units.
-Tracey Nolte discussed the new “after hours hospitalist coverage.”

Nursing Operations Council
Chair:  Irma Holland, MSN, RN

-David Michaels updated council on Hackerman-Patz house online reservations and asked for Directors help to promote.
-Directors agreed to discontinue the director on-call program and to cover their own units on weekends and manage downtime as appropriate.
-Joint Commission readiness plans discussed. Each unit will provide champions to facilitate tracer activity on the unit.
-NOPs reviewed Nursing Workforce Data Survey and made a request to add years of experience for other data collection needs
-Council goals distributed, volunteer solicited to form workgroups to be responsible for achieving the goals.
-Council advised on revisions to a Nursing Director orientation checklist being developed for onboarding of new nursing directors.
-A new registration process was reviewed with directors. Changes to be made in facesheet and printing process.
-Council reviewed revisions to post Fall Huddle and checklist.

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