Breast Milk Reminders

Everyone's favorite topic...  :)

Please remember that no breast milk should be stored, thawed, or fed to a baby without using the MOMs system.  I have now had everyone added to the MOMs system who did not have access.  If you did not let me know you could not access the system, then you need to email me ASAP with your net ID and I will get you added.  I will be getting a few staff trained as super users so we can be more comfortable using the system.

I have had complaints from the NICU that staff floating over are not using MOMs.  Please ask for help from the charge RN if you are unsure of what to do when floating.  Also, you CANNOT store breast milk bottles in a biohazard bag in the refrigerator or freezer.  The bottles must be labeled, dated, and placed in the bins.

The final reminder is to be sure to gather and send home all of a patient's breast milk when they are discharged.

Please let me know if you have any problems or questions.  This is a very serious patient safety issue and you will not be following policy if you fail to use the MOMs system.

Thanks so much!  Melinda

Clarification: IV bags/tubing

There was some confusion regarding what IV bags we change and when.  The 7C staff meeting minutes were not entirely correct, and have since been updated. 
To clarify- we are to change any bags that come from Pharmacy AND any bags containing DEXTROSE (whether it came from pharmacy or not) every 24 hours.  This includes our IVF that come from the Pyxis and Accudose.  The tubing, however, only needs to be changed every 72 hours. 
Pre-mixed bags that DO NOT contain Dextrose, like 0.9%NS, or the Heparin in our Accudose, are good for 72 hours. 

We are discussing the frequency of bag changes and in an effort to save costs, we may find that only bags prepared in pharmacy expire in 24 hours- but until those results are finalized, we have to follow the policy.  Any questions, let me know, thanks.
- Erin 

FIT Testing Deadline: MIDNIGHT, Jan. 31, 2013

Today is January 29th.  You must get FIT tested before midnight, January 31st or you will not be able to work.  Thanks for getting this taken care of ASAP.  I will be pulling a list of anyone left tomorrow.

Melinda

Critical Drug Shortage Update re: D50%

Nursing team,

   We are experiencing a critical shortage of COMMERCIAL AVAILABLE Dextrose 50% 50 mL vials and syringes.  We have been able to produce D 50% 50 mL vials in-house to assist with the short supply of these products but since they are required to be refrigerated they will need to be dispensed from the inpatient pharmacy.   

Therefore, we will need to remove the commercially available D 50% 50mL vials and syringes from virtually all AcuDose cabinets in order to reserve that supply for orange tackle box replenishment.

WE ASK THAT YOU RESERVE THE USE OF COMMERCIALLY AVAILABLE DEXTROSE 50% 50 mL SYRINGES TO TRUE EMERGENCY SITUATIONS AND ACQUIRE THE DEXTROSE 50% 50 mL VIALS FOR THE INPATIENT PHARMACY IN ORDER TO RESERVE THE COMMERCIALLY AVAILABLE PRODUCT FOR OTB. 

Please let me know if you have any questions. 

Christopher R. Fortier, PharmD

Manager, Pharmacy Support & OR Services

Medical University of South Carolina

Adjunct Assistant Professor

South Carolina College of Pharmacy

150 Ashley Avenue, Room 611

Rutledge Tower Annex

Charleston, SC 29425

Phone: (843) 792-7354

Email: Fortier@musc.edu

Meeting Minutes have been posted!

Hello -

The meeting minutes have been posted for January 2013 for staff meetings - 7C and PICU.  Please make sure to read the meeting minutes and comment that you have read them.  You can comment as an anonymous user, just don't forget to sign your name.

The link to the minutes is on the right side of the blog under the "Pages" heading.
Next staff meetings for PICU are: April 15 and 17 and for 7C are: April 22 and 24.

Amanda

Therapeutic Hypothermia

Hi there- I posted an article in the PICU breakroom from the Journal of Emergenices, Trauma, and Shock on inducing hypothermia in pediatric patients after cardiac arrest.  The study of this therapy is ongiong as more and more data is collected.  This article is a quick overview of how and why we cool patients after cardiac arrest, but if you want more information about the ongoing study, check out www.thapca.org/
-Erin 

Friendly Reminder re: A.M. Chest Xrays

Hey guys, please remember to allow the radiology technicians to perform the a.m. chest xrays as ordered.  We should not be sending them away because the patient is sleeping.  If you think we don't really need to be following morning films, then please consult with the physician team ahead of time and have the order discontinued.

Thanks so much!  Melinda

Education Tip: Insulin Infusions

Hi there,
Just a reminder- When initiating an insulin infusion, or changing the tubing of an insulin infusion, please be sure to flush and waste the first 20cc.  This allows the insulin particles to become saturated into the polyvinal tubing and ensures the insulin delivered is at maximum potency.  Failure to flush the first 20cc could delay the desired effects of treatment.  This does not have to be done when changing the bag only, just when initiating the infusion and when the tubing is changed.  If you have any questions about this, please see me, or refer to the CATTS module "Nursing Orientation: Diabetes Part Two".  Thanks Everyone! 
-Erin 

PICU Staff Meeting Minutes

PICU staff meeting minutes have been posted.  You can find the minutes by looking on the right side of the blog page, under "staff meetings." Please read over the minutes, and then remember to comment on the minutes with your name.  This will take the place of the "read & sign" meetings notebook, and will count as participation for attending a staff meeting.

Thank you.

January Competency: FIT Testing (updated list)

If your name is on the list below, please make a plan to get Fit tested as soon as possible.  Remember, this is MANDATORY for all clinical staff.  If you do not meet the deadline of January 31, 2013, you will be suspended.  Please also note that this is the year of personal accountability, so we will not be running you down to get this done.  The unit Fit testers include:  (7C)- Lauren Mercede, Amy Russell, Lisa McCormick; (PICU) Jennifer Larkins, Patricia Prause and for everyone- Amelia Little and Amanda Weatherford.  If you cannot wear an N-95 mask for medical reasons, allergies, or facial hair (hopefully just a problem for our male staff), you will have to get a PAPR hood.

PICU

Katherine Baldwin

Marilyn Julian

Jennifer Larkins

Jayme Mason

Alicia Piede

Reames Rinehart

Julie Taylor

Linette Turbeville

Tammy Major

Bobby Morrow

Madeline Ward

7C

Lindsay Amerman

Shane Crawford

Amy Russell

Philip Schlabs

Amanda Smith

Amanda Taylor

Competencies Worksheet:

PICU Staff:

You will find a "Worksheet for Identifying Ongoing Competencies" in your mailbox. This worksheet coincides with MUSC's move to a different competency system. From now on, we will complete our annual competencies during the fiscal year, or from July to the following June (the same as CATTS). This will start in July of 2013.

In this new model, we will base competencies off of YOUR ideas. Please complete the worksheet with your ideas about new, changing, high-risk, or problematic areas that could be turned into an educational competency. Once you have listed your ideas, rank their priority or level of importance. This will make it easier when deciding which items will be the most valuable to develop into competencies.

We want everyone's input this year on what you think our educational and competencies needs are. Please complete this worksheet no later than February 15th and turn it into Melinda/Amelia's box in the breakroom. This worksheet needs to be completed by both RNs and PCTs.

Please let Melinda or Amelia know if you have any questions!


7C Staff:

We will discuss this worksheet and competency model at our staff meetings next week. 7C will start the worksheet next week. More details to come!

Emergency Operations (Disaster) Manual

The Emergency Operations (Disaster) Manuals have been updated for both PICU and 7C.  Please make yourself familiar with the manual and sign the new 2013 attestation sheet located in the front of each manual.

If you are not sure where the disaster manual is located, please ask a Charge Nurse to show you where the manual is located. 

Please sign the attestation sheet no later than January 31, 2013.

Biggest Loser

7C & PICU:

MUSC Children's Hospital has parterned up with the Lean Team and Children's Hospital Wellness to have our very own Biggest Loser competition!  Participants will be broken up into teams, based on the unit that you are from! 

You can weigh in tomorrow, January 18, from 11:30a - 12:30p, and if you miss going tomorrow, you can also go the next two Thursdays and Fridays to join in on the competition.

See this link for more information: http://academicdepartments.musc.edu/lean_team/chwellness/documents/biggestloserrules.pdf

January Competency - FIT Testing

If your name is on the list below, please make a plan to get Fit tested as soon as possible.  Remember, this is MANDATORY for all clinical staff.  If you do not meet the deadline of January 31, 2013, you will be suspended.  Please also note that this is the year of personal accountability, so we will not be running you down to get this done.  The unit Fit testers include:  (7C)- Lauren Mercede, Amy Russell, Lisa McCormick; (PICU) Jennifer Larkins, Patricia Prause and for everyone- Amelia Little and Amanda Weatherford.  If you cannot wear an N-95 mask for medical reasons, allergies, or facial hair (hopefully just a problem for our male staff), you will have to get a PAPR hood.

Thanks so much!

7C

Lindsay Amerman

Shane Crawford

Karen Loury

Lauren Mercede

Amy Russell

Philip Schlabs

Amanda Smith

Sara Smith

Amanda Taylor

Kylie Weddington

PICU

Katherine Baldwin

Natalie Ball

Jennifer Bussey

Ryan Crittenden

Nicole Daigle

Anna Durstine

Karen Gilbert

Marilyn Julian

Jennifer Larkins

Donna Lee

Tammy Major

Jayme Mason

Bobby Morrow

Tiffany Mullins

Brooke Nitterhouse

Alicia Piede

Patricia Prause

Reames Rinehart

Kelcy Scott

Jen Shaw

Laura Smith

Sandy Smith

Julie Taylor

Linette Turbeville

Madeline Ward

Jason Williams

Melinda

Mid Year High-Solid-Low Peer Reviews

7C & PICU Staff,

It is that time of year to send out peer evaluation forms and have High-Solid-Low reviews with your nurse manager team.  You will receive an email invitation from Success Factors to participate in peer review on individual staff.  Please know that your input is anonymous.  I will randomly select 5 staff members who you work with most frequently for peer input.  CULs will also have physician input.  7C staff, as a small unit, you are more likely to have several peer reviews to do.  I apologize for this and thank you in advance for your participation.

Thanks!

Melinda

Kudos from Patients and Families

Congratulations and thank you to Karen Gilbert and Brooke Nitterhouse who were recognized by the family of a recent spinal fusion patient.  These great nurses were said to be "AWESOME" and the best thing about the patient's stay. 

Also, Kylie Weddington, PCT and Liza Hoover, RN were recognized by a family from 7C. 

Great job, ladies!

G-Tube Tips from Kiften Caroll, NP

Nurse managers and educators,

As you all may or may not know, my husband and I welcome the arrival of our son, William, on Jan. 3rd.  We are all doing well and couldn't be happier.  I will be out on maternity leave until April 1st.  In my absence, I wanted to share some g tube care tips.  Please disseminate this information among your charge nurses, clinical leaders and/or nursing staff as you see fit.  My hope is for this to be a resource to help the nurses troubleshoot some of the g tube problems while I am gone.  Julie Mansfield, our PA, is extremely knowledgable regarding g tubes, but will be busy in clinic and not readily available for all g tube needs/family education.  Your nursing staff can play a very valuable role in g tube education and problem management, as many of them already do.  Also please let all nurses know that they are welcome to email me with any g tube questions/concerns.

Here are 10 helpful tips:

1. All new balloon button g tubes will have two stay sutures. These sutures need to stay in place for 2 days.  A surgery resident will remove them.  DO NOT let a patient go home with these sutures!

2. All new g tubes should be left to gravity drain for the first 24 hours post op (approximately).  During this time, patient should have nothing by mouth or g tube, expect for essential enteral medications (you should have an order for this)

3. Clean g tube sites daily with mild soap and water and then dry.  We no longer recommend hydrogen peroxide.  Daily cleaning and drying is important.  Get families involved doing this early on.

4. Clear, tan, slightly goopy, and crusty drainage is normal, particularly in the first few weeks.  Clean this drainage off with moist gauze and pat dry.  A moist g tube site will cause skin breakdown, irritation, tract dilation…all of which will  make leaking/drainage worse.

5. Apply "critic-aid" thick moisture barrier paste to any red, moist or leaky g tube site.  The zinc in the cream will help heal the skin and prevent further breakdown.  You can order this from central supply without an physician order (white and purple tube).  In my opinion I would have a tube at the bedside for every patient with a g tube.  If you don't use it…send it home with the patient for future home treatment of g tube site irritation.  Applying critic aid is usually one of my first recommendations when I am called about a "yucky" looking g tube site.  Most red and goopy g tube sites are all a product of moisture and friction…rarely true cellulitis/infection.

6.  If you have a lot of drainage, irritation or a g tube appear to be "loose fitting" you can apply 2 x 2 IV split gauze to protect the skin and "secure" the g tube.  The more the button moves/wiggles around in the tract the more the tract the will become dilated…leading to drainage and irritation.  Split gauze can help "secure" the g tube and reduce movement.  Make sure to change the gauze often to prevent moist gauze from sitting on the skin.

7. It is important to disconnect the extension tubing from the button when you are not using the tube.  Please try to do this!  The extension tubing is an avenue for the g tube to get pulled out.  It also pulls on the button some and cause the button to wiggle around in the tract, promoting tract dilation.  Get families involved doing this early on.

8.  If a new g tube comes out within 6-8 weeks following initial OR placement…call the surgery resident.  They may or may not ask you to put a small red rubber or foley catheter in the tract.  Make sure they know how long ago the tube was placed and ask what they would like you to do.  If a g tube comes out and it has been more than 8 weeks since initial placement, you may replace the tube or place a small catheter in the tract, then call surgery resident to let them know.  After replacing the tube, always aspirate gastric contents to confirm placement in the stomach.  If replacement is difficult or you do not get gastric aspirate a g tube contrast study may be necessary before you use the tube.  A g tube contrast study is always needed when a g tube is dislodged and replaced within 6-8 weeks after initial OR placement.

9. Granulation tissue looks like a moist red blister.  It can have blood tinged or thick yellow goopy discharge.  The treatment of choice is typically silver nitrate or topical steroid cream.  Call ped surgery to take a look at it.  Not an emergency.  Can wait till the morning or weekday to call, etc.

10. Central supply has most of the common g tube button sizes, but not all sizes.  If you need a size that central supply does not have you can check with the main OR (they stock more sizes).

Key teaching points for families

1. Always remove the extension tubing when you are not using the g tube

2. Clean and DRY the site daily with mild soap and water

3. Some drainage and redness at the site is normal.  A lot of drainage or a lot of redness is not…call ped surgery office (843-792-3851)

4. DO NOT attach anything to the balloon port (blue side of the button)

5. If the g tube falls out in the first 2 months after it is placed…go the ER, preferably MUSC peds ER

PLEASE forward this to all the nurse managers in the children's hospital.  I do not have everyone's email addresses…I think I am missing the NICU, 7B, 8D, and 5th floor nursery

I hope this helps!  Thanks,

Kiften

Kiften Carroll, NP
Pediatric Surgery
MUSC Children's Hospital

stephekb@musc.edu

843-792-7127

Clinical Update: Lipid Shortage and Restrictions

An important message from Kathy Chessman, PharmD

We have been notified that some method of Intralipid allocation from the manufacturer could be in place for the next 7 months.  We received only a partial delivery of our “allotment” on Friday.  We do not know when the remainder, or how much of the remainder, will be received.  In order to avoid wasting as much as possible, we have changed some of our procedures.

Based on the amount of Intralipid 20% that we received today, the following restrictions/procedures will be implemented, which represent a less severe restriction in our tiniest neonates/infants:

Lipid ordering restrictions:

No 3-in-1 Adolescent or Pediatric PNs until further notice.  All lipids will be administered as a separate infusion y-sited into PN infusions.  Orders for Intralipids should be written as a separate physician order in the chart.

Rationale:  Prevents the pharmacy from having to spike two lipid bulk bags in one 24-hr period.  All doses of lipids for the day can be drawn from one bag.  Once the bag is spiked, the lipids should be infused for 24 hr.  We have been unable to find any data to support a longer beyond use date.

For all neonates and infants < 6 months of age:  Daily lipid will be provided with no dose restrictions; however, practitioners should limit the amount of lipid to the least amount felt to be clinical necessary.  A dose of 0.5 g / kg / day will prevent essential fatty acid deficiency (EFAD) in most patients.   

Rationale:  These are our patients must vulnerable to the development of essential fatty acid deficiency (EFAD).  Extremely premature neonates are actually born with biochemical EFAD and can begin to show clinical signs as early as 72 hours.

For all patients 6 months of age and older: 

1) High risk patients (those on PN without significant enteral intake for 2 weeks or more, critically ill or severely malnourished) can receive 1.5 g/kg on Mon, Wed, and Fri, a dose sufficient to prevent EFAD, as long as the lipid supply is sufficient to provide this volume.  Additionally, if there is any remaining lipid after all lipid syringes have been prepared for neonates and infants < 6 months of age, then additional lipid may be given, if needed.  Kathy Chessman will coordinate with the pharmacy and other clinicians to allocate any remaining volume of lipids.

2) Low risk patients (those on PN without any enteral intake for < 2 weeks) may receive lipids only from any volume remaining in the bag opened daily (to prevent wasting lipids that will expire in 24 hr).  Kathy Chessman will coordinate with the pharmacy and other clinicians to allocate any remaining volume of lipids.

Rationale for 1 and 2 above:  since there is a critical shortage, we do not want to just throw away lipid remaining after all neonatal / infant doses have been drawn up for the next 24 hours.  We may be able to administer lipids to older patients on various days during the week using the lipid left after preparing the needed syringes for neonates and infants < 6 months of age.

The Blog is here for MUSC's Pediatric Critical Care Team

Welcome to the Pediatric Critical Care Blog!

Please check this blog at least once a week for staffing updates, educational links, meeting minutes, policy changes, and more! This blog is meant to decrease the amount of mass emails that clog your inbox. Any personal or non-unit specific communications will still be sent to your MUSC email address.There will  be an icon added to all work computers for access. You can also access this blog from any computer, tablet, or smart phone at:

http://muscpcc.blogspot.com/

If you have any topics you would like posted on the blog, please let us know. You can interact by writing comments to each individual post.

Thanks,

Melinda, Amelia, & Amanda



Friendly Reminders

As January is half way over, please remember to do the following by January 31, 2013:

1. Fit Testing (even if you are not expiring this month, need to get everyone on the same schedule).
2. Sign up for Disaster Teams A or B.  Please remember someone has to be on Team A. :)
3. Review the Disaster Manual on your unit and sign the attestation sheet.

Thanks so much,

Melinda