Earth Week (Should be Every Week!)

Visit the Earth Day Canada website at http://www.earthday.ca/pub/index.php for a list of Earth Week events in your area that you and your family can participate in.

~Bring a ‘litter-less’ lunch to work all week (no plastic or foil wrap). Continue this practice beyond Earth Week. This includes bringing reusable mugs when buying coffee and other refreshments at the coffee counters. Tim Horton’s and Second Cup offer discounts to those using their own mugs!

Impact
· Reduce your waste – In a lifetime, the average North American throws away 600 times his/her adult weight in garbage.

~ Always turn taps off tightly at work and at home.
~ At home and at work, develop the habit of defrosting frozen food in the fridge overnight instead of running water.

Impact
· Conserve water –A faucet that drips one drop per second wastes nearly 12,000 litres of water per year.
· Check for leaks in your toilets at home – a leaking toilet can waste up to 400,000 litres of water or about $730 per year.

~Avoid printing paper – try to use email instead of paper copies whenever possible. If necessary, use double-sided photocopying or printing.
~Install low-flow aerators on your faucets at home. (Aerators are small fixtures added to the water stream, reducing water flow while keeping the same pressure. Very easy to install and cost is under $10)

Impact
· Approximately 80% of office waste is paper and of that, 70% is not recycled.
· Low-flow aerators can reduce the water usage of faucets by as much as 40% from 4 gallons per minute to 2.5.

~Take public transit, ride a bike, walk or carpool with friends and co-workers to work
Install energy efficient compact fluorescent lights (CFL) at home.
~Recycle old computers and computer equipment for FREE (during Earth Week) by dropping it off at Computation – located at 280 Jane Street, between the hours of 10am and 7pm.
http://www.computation.to/recyclingEvent.html

Impact
· One city bus eliminates the emissions of 40 cars.
· Save money and use less energy - A single 18 watt CFL used instead of a 75 watt incandescent
will save about 570 kWh over its lifetime – that’s $45 in savings (at 8 cents per kWh).

~At home and at work, always turn off lights, printers, faxes, computers, etc. when they aren’t in use. At home? Unplug all electronic devices when not in use (e.g. toaster, kettle, blender, coffeemaker, battery charger, etc.). OR: You can plug your electronics into a power bar that can easily be switched off.

Impact
· Electronic devices still draw power even when they are turned off. This is called standby power.
· Over a year, electronic devices at home can draw enough standby power to run a refrigerator for a month. (who knew?!)

~In the GTA? Bring your family and friends to the Annual Trees across Toronto city-wide planting event from 10am – 12pm. Locations can be found at this website: http://www.toronto.ca/parks/treeadvocacy.htm

Impact
· Trees help reduce the effects of global warming by absorbing carbon dioxide.
· A single mature tree can absorb 48 lbs of carbon dioxide per year and release enough oxygen to support two human beings.

Dipute Regarding Medical Care Plans

This policy was forwarded to me today, and I thought it might be useful to know where to find it. It might come in handy when working shift or weekends?!

Just to let everyone know that the attached policy was uploaded to the intranet on March 18, 2008.
Policy #: I-D-2550 can be found in the Patient Care manual, under Section I: Policies and under the sub-heading “Disputes” (Please note, that Sunnybrook P&P's can only be accessed on Sunnybrook computers.)

ICP Waveform

Question: On the ICP waveform, what exactly do P1,P2 and P3 waveforms represent?
Answer:

This is what a normal ICP waveform looks like:

The ICP waveform results from transmission of arterial and venous pressure through CSF and parenchyma.
The ICP waves correlate with each cardiac systole and diastole, and therefore mimics an arterial waveform. Each individual wave has three peaks. They are fairly flat with little variation in amplitude when the ICP is low.

There are 3 distinct pressure oscillations:

P1 (percussion wave) and reflects cardiac systole
P2 (tidal wave) reflects cardiac diastole
P3 (dicrotic wave) is located immediately after the dicrotic notch and sloped into the diastolic baseline portion

Analysis of the ICP waveform should include an assessment of the wave amplitude and the configuration of the wave (P1, P2, P3,).
As the ICP rises, so does the amplitude of the three wave components. Persistent elevations usually cause P2 to increase more than the P1 or P3 components, resulting in a rounded appearance of the pressure wave.

See how P2 is higher than the other waves? P1 is supposed to be the highest. Not a good thing – this means that overall the ICP is rising – higher wave, higher pressure.
the elevated P2 means that the intracranial compliance is probably decreasing, as the pressure is rising. Makes sense – pressure rises, things get less compliant, more rigid.
Monroe-Kellie Hypothesis!

Hopes this helps clarify the question, Sandi. Thanks for asking!

Xray Safety

There has been some concern about nurse and patient radiation exposure from xrays taken post operatively in the PACU.
Last week, Henry Sinn, Director of Medical Imaging spoke to a few of the nurses working on MGround. To make a long story short, he was adamant that xrays were of negligible safety concern for nurses and patients in a common room where xrays were being taken. Basically, the cassette that the xray is placed in absorbs 85% of the rays. Safe xray practice includes keeping minimally 3 feet away from the patient during xray, and keeping out of direct line of the xray shot. The xray tech also centres the picture on the patient area to be xrayed so that as many of the radiation rays are absorbed on the cassette. Henry said that the techs and RN's actually do receive scattered radiation from the patient after the xray has been taken as the patient naturally absorbs some of the radiation. For portable xrays, the cardinal time is 0.1 seconds of exposure.
There was a research test done in CrCU in 2005 where volunteer nurses offered to wear radiation tags for 6 months, with readings taken after each 3 months. The amount of radiation exposure was negligible. (The research was done there because daily CXR are done on all patients every morning and the RN's were concerned about their exposure.) A millisevert is a measure of radiation dose. The radiation dose from one chest x-ray is approximately one-tenth of a millisevert. (It is to be noted that the RN or xray tech would not receive this one-tenth millisevert because they are not the ones receiving the xray.) 5 milliseverts is the limit for non-radiation workers ie nurses. The xray techs' limit is 50. Henry noted that the xray techs all wear the radiation tags and every three months they get turned in to Health Canada to have their values checked. All have been reported with negligible results.
Interesting to note, that there is a certain amount of environmental exposure to background radiation that we all normally absorb from everyday things such as TV, computer, cell phones, microwaves etc.
For more information, and to find out what your background radiation level is, check this out:

Xray Safety Theory and Practice Medical Site

A little Trivia Pursuit:
1 CT scan can generate as much radiation as 100-300 xrays
1.5 hours on a plane is equivalent to 1 CXR (from cosmic rays!)

Since this was a post about safety, I thought I'd use this opportunity to point you in another safety direction. When you are at a Sunnybrook computer, check out the Occupational Health & Safety bulletin for some FYI.

SPANC Meeting Minutes

SPANC Meeting Minutes
Thursday April 3, 2008

In Attendance
Carol Deriet, PCM
Ramona Hackett, CE
Betty Mannino, RN PACU
Sandi Weir, RN PACU
Pam Giroux, RN PAC
Seema Ratanshi, RN SSSU

Meeting Commenced at 18:10

Minutes from Jan 31, 2008 amended. Staff representation at S.P.A.N.C. to include only RN’s from the Peri-Anesthesia group for now.

Meeting Times: the group agreed that lunch times work best as it is difficult to commit to after work hours for meetings. Also, with having meeting over lunch hours, more RN’s may be willing to attend SPANC. Agreed that the first Wednesday of each month (after Nursing Council) a SPANC meeting will be held between 11:30-13:30. Carol and Ramona will be unavailable for the first Wed in May; however on May 14, 2008 room MB206 has been booked for our meeting. June 4, 2008 room MB206 has also been booked.
These lunch sessions can be more of a drop in to facilitate more input from more RN’s across the peri-anesthesia group.

Nursing Council Structure
We need to consider how we want to structure out group. Do we want a Primary leader, co-chairs, representative from each sub-group?
For now, the group has decided that Betty Mannino will be SPANC’s representative at Corporate Nursing Council meetings which are held on the last Wednesday of each month.
It was also suggested that one person from each sub-group could attend every month so everyone can have an opportunity to see what council is all about.

Update from Betty on Nursing Council Meeting Agenda for March 2008

*Recertification for WHIMIS
*Nurse Externs (STUDENT NURSES) to work at SHCS during the summer months (not in Peri-anesthesia) to ease the transition from student RN to Graduate RN.
*Nursing Nomination Forms: RN Research, Education, and Best Practice. Can nominate individuals, or a group. Review Nurses week web page for further details. Nominations are due April 18, 2008. Submit to Dawn Ashman or to Frances Flint.
*The Allergy Documentation Record expected by the end of April.
*The Double Check Policy’ Implemented for high-risk drugs. The goal is a systematic approach to double checking drugs. Target date is June 2008. It will be a standard for accreditation for 2009.
*Look for the DNR Documentation Record Sheet in the FRONT of the chart by the end of April *The DNR Confirmation Form” mandated by the Ministry of Health by the EMS.
Braden Scale documentation record. revised. A more objective format due end of April.
*Nursing Voice wants your written articles. Submission of articles to nursing council can be done online or given to Betty .
*All nurses are reminded to watch the VTE Web Video http://mysb/data/dre/vte/player.html

Blog Feedback: Not everyone is familiar with the concept of a Blog, but those who have looked at it seem to like the idea. Sandi suggested weekly trivia quizzes/ case studies. Ramona has also been interviewing nurses and will post the interviews on the blog. The idea is to continue getting to know each other amongst our varying subgroups. A Journal Club has been suggested to keep our nurses current, or give them ‘Food for Thought’

Nursing Week is May 12-18
Betty has poster ideas; they will be forwarded to Frances Flint. All members of SPANC agreed that we need to have representation this year. We will work on posters, and also design a tour so that other staff from around Sunnybrook will have an idea of who we are, where we work, and what we do.
Projects:
Subgroups can start working on Revision of unit pamphlets
Best Practice: Airway Management, throughout all the areas. Ie: Home CPAP, Extubation etc.
Policy & Procedures. There has been a discharge policy draft for review in PACU. So Far, no RN has commented on it. Input is requested so that changes can be made while the policy is still in draft form.
There will be more Policies and Procedures that need to be implemented across all groups
Ultimate goal is to work together andpresent at an OPANA meeting.

Meeting Adjourned 19:55

Question & Answer/ Laparoscopic Chole

Hi Dr. F,
I am wondering if you could help me answer a question for one of the RN's in PACU. Tuesday April 8th a laparoscopic cholecystectomy was performed on nightshift, the pt's name was TB, HF 2****24. In speaking with Carol PCM of PACU it was agreed that this procedure was deemed Emergent Type A. Alex PCM OR also agreed, stating that research has suggested that these types of patients need to be treated acutely and recover quickly. I am wondering if you have access to this research that I can pass on to the RN's in PACU to clarify questions that they have regarding the emergent nature of this procedure.
Thank you so much,
Ramona

Were the nurses in the recovery room unhappy with a patient with acute cholecystitis being done in the evening?

darlene

A question did arise as to how emergent it was, and so I'm trying to clarify it. The PCM's are satisfied that it was an A2 case, and I'd like to be able to get back to the RN's with the correct information so that there is no future confusion or questions regarding chole patients being operated on after hours.
Other than sepsis, what might be some of the critical diseases that might warrent the gallbladder to be removed sooner than later? Extra-large stones? Intractable pain? Multiple gallbladder attacks?
I'd like to give the RN's a clear understanding as to the importance of this procedure being done emergently.
Thanks again!
Ramona

Hi,

No problem. I will do my best to help clarify.

Stones in the CBD - choledocolithiasis (which this patient had)
Acute cholecystitis (which she also had) which includes patients with normal WBC who have had pain longer than 6 hours.
GS pancreatitis.

Ascending cholangitis.

In acute cholecystitis, it is better for the patient, fewer hospital visits, pain, and fewer complications to have the GB removed within 72 hour of the onset of pain. I would have to double check the chart, but this woman's pain started at noon on Sunday I believe. So, the GB should be removed within 72 hour of the onset of pain. It can wait until the morning or the following night...but it can't wait on the B list because it is unlikely to get done at night and then would be done at 48 hours which would be too late. Not to mention the fact that she had evidence of biochemical choledocolithiasis and would still be waiting on the ward today with more cases being cancelled and instead she will go home today or tomorrow.

I am happy to discuss this with Andy or Alexandra. I am sure this has been reviewed in the past but maybe I am not aware of the history.

I believe I followed all of the rules and did my best to give the patient the best care possible.

I hope this helps.

darlene

An excerpt From Dr. S's email:
1. Dr. F should be congratulated on her decision making and judgement re the medical management and logistics of this case.
2. We feel that in the era of ACCESS service logistics will be easier.
3. We are in fact critical of surgeons who, if operation is possible, pursue a non-operative course in such cases as this approach is outmoded, associated with longer LOS and impaired patient flow.
Dr. B pursued this in a evidence based manner with OR management some time ago.

I am happy to discuss as you see fit-

ajs
And my Response:
I would be happy to share Dr. B's information with the PACU staff. It is my sincere hope that by sharing knowledge with the nurses, and providing updates regularly, we can all work together more effectively as a team and provide the best care for our patients.

FYI:
The OR Booking Policy, with Appendix II (Emergent Type A Cases) can be found here. Please look under Sepsis.
http://mysb/data/1/rec_docs/630_I_O_1300.pdf

Also, I did a little Google search, and found multiple abstracts with the following conclusion:
The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute cholecystitis

Conclusions: In acute cholecystitis, patient delay is associated with a high conversion rate. Early timing of laparoscopic cholecystectomy tends to reduce the conversion rate, as well as the total and the infectious complication rates. Male gender, a history of biliary disease, and advanced cholecystitis are associated with conversion. Male and older patients are associated with a high total and infectious complication rates.

If I should get a response from Dr. B, I will let you know!

New Staff Members

Seema Ratanshi is our latest peri-anesthesia member. She has joined the SSSU team and comes to us from D6. Seema actually has already finished her orientation, and I forgot to include her name in the lengthy list I posted a while ago. To make up for my little slip, I'll include a picture of her so that you will all recognize her and welcome her to our group.

Seema is on the left ;)

Toronto Breast Cancer Symposium

The Toronto Breast Cancer Symposium

This might be of interest to some of you! Check out the information HERE

Question & Answer

Question:
Hi Barb
PACU is trying to be part of a Greener World!
One of the RN's in PACU is wondering if it is at all possible to recycle plastic face masks, nasal prongs, iv tubings/bags. (Not for patient reuse, but blue-bin type recycling.) I know it's a long-shot, but I just thought I'd pass her question along. Thanks!
Answer:
Ramona
I agree that we all need to think greener, which is one of the reasons for protective eyewear to be recycled/reprocessed. However, when it comes to contaminated articles, it becomes a safety issue and/or potential health hazard.
thanks
Barb (Wilson) Catt
IP&C