OPANA/NAPANc

I am working on an in service for this Friday that will highlight the 2008 1st Edition of the NAPAN Standards. FYI, membership with OPANA automatically entitles you to membership with NAPANc (National Association of PeriAnesthsia Nurses of Canada.)
"NAPAN(c) is a growing volunteer organization of over 800 R.N.'s in 8 jurisdictions with contacts in the remaining provinces and territories. JOIN US as we work together for the bright future of PeriAnesthesia Nursing. Membership in your jurisdiction entitles you to NAPAN(c) membership."

"OntarioOPANA- OPANA's Standards Committee is currently working on a 6th version of their Provincial Standards, which will be in print by the end of 2008! Please watch for this new publication on our website.
Please visit OPANA for more information on upcoming events. The Ontarion rep for NAPAN(c) is Virginia Casey. For those of you who aren’t familiar with OPANA, they are a vast group of nurses spread across a very large province. Their executive consists of their President, President-elect, and Past President as well as their secretary and treasurer. As well there are eight provincial area directors and Advisory Council.
OPANA hosted their 22nd annual conference in Toronto last October 20-21. Our largest conference ever, with an outstanding attendance of 370 PeriAnesthesia Nurses from all over Ontario and as far away as Alberta and Manitoba! Topics included Pandemic Preparation, Anesthesia Care Team and Nursing in the Year 2020.
The conference planning committee is well under way planning another exciting conference for October 18-19, 2008. Watch for the conference updates on our website.
Also, please visit our OPANA Blog and blog on. PeriAnesthesia nurses from across the province have already started to discuss topics, share ideas, policies and practises. JOIN IN !!"

Odds & Ends

Want to practice your cardiac rhythms? A recommended site from Delia in PACU.

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Cathy PACU/SDS also wanted to remind staff that if at all possible to please hide the little round blue wheeled chairs. Last week, we had a near-miss with a visitor who tried to sit down on one and it wheeled away on her. Luckily, she wasn't hurt.

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Same Day Surgery, Cardiac Pre-Op Patients

The following information pertains to the CV Surgery Improvement Task Force. Their goal is to drastically reduce the incidence of Surgical Site Infection, most notably Deep Sternal SSI’s, and CABG SSI’s. FYI: Deep Sternal SSI rates for Jan/Feb 2008 was 2.09% (the benchmark is 0.76%) Surgeries are followed up to one year, post-procedure.

FOLLOW UP TO LAST WEEK’S IN SERVICE IN THE NEW CARDIAC SURGERY PRE-OP PROTOCOL

1. The PSP’s are to find out from the RN’s exactly which area to clip. Only patients who are have CABG (Bypass surgery) are required to have their legs and forearms clipped. (They still require that their chest and groins are clipped.) In the new orders, the surgeon will mark specifically which areas he wants clipped.
2. All other CV surgery patients only need their chest and groins clipped.
3. Chests are to be clipped from nipple to nipple, and neck to navel.
4. Position the clipper at a flat to 15 - 30 degree angle on the patient’s skin
5. Stretch the skin taut
6. Clip hair using short strokes against the direction of hair growth
Final skin prep
7. Use medical tape (paper tape) to remove hair clippings from surface of skin
8. Thoroughly cleanse clipped area using appropriate available products
9. Instruct patient to wash the chest area with one or two cloths to get all the hair off, and the groins areas with separate cloths, the legs with separate cloths, and the forearms with separate cloths (if legs and forearms have been clipped.) o
10. These disposable cloths have antiseptic solution on them. Patient is to allow solution to air dry.

PREOPERATIVE HAIR REMOVAL (CLIPPING) CHECKLIST
(From the 3M Learning Package)

REQUIRED SUPPLIES

¨ Charged clipper body
¨ Packaged clipper blade(s)
¨ Gloves
¨ Waste bag
¨ Under pads
¨ Medical tape


PRE-PROCEDURE CHECK

¨ Verify clipping area(s) with nurse
¨ Identify patient
¨ Ensure adequate light and privacy
¨ Uncover only the area to be clipped
¨ Protect bedding with under pads
¨ Put on gloves

CLIPPING PROCEDURE

Prior to clipping
¨ Make sure ON/OFF switch is in OFF position
¨ Attach disposable blade

Clipping process
¨ Switch to ON position
¨ Position the clipper at a flat to 15 - 30 degree angle on the patient’s skin
¨ Stretch the skin taut
¨ Clip hair using short strokes against the direction of hair growth

End of procedure
¨ Turn clipper to OFF position
¨ Remove clipper blade according to manufacturer’s instructions
¨ Clean clipper body and return to charger

Final skin prep
¨ Use medical tape to remove hair clippings from surface of skin
¨ Thoroughly cleanse clipped area using appropriate available products

ADMISSION ORDERS FOR CARDIAC SURGERY PATIENTS

1. These orders are going through their final look at the document committee and it is hoped that they will be passed, and in print by next month. Most of the orders refer to Inpatients from CCU and D6 who are going to surgery, but there are orders that will affect SDS.

2. If patients go through PAC, they will get their usual pre-op blood work and ECG and whatever other tests have been ordered by anesthesia.

3. The new orders for SDS indicated that patients are to rinse and spit with Chlorhexidine gluconate mouthwash 0.12% 10 ml pre-op. It was decided that SDS patients will not be asked to rinse and spit with this mouthwash at home, as they might get it mixed up with their chlorhexidine body wash. Patients are to swish the mouthwash for 20 seconds.

4. It was brought to the attention of the CV Task group that many patients are so strict with their NPO status that they do not even brush their teeth! The group was very surprised, and I think that this is something that we should include with our redesign PAC Patient Education.

5. Please remember that RN’s are responsible for ensuring that pre-op clipping sites are double checked. Two incident reports have been filed from patients having been clipped in the OR. NOTE: The incident report did not indicate where the patient came from pre-operatively.

Great Work!

It's never too late to post a letter of appreciation! This one was sent to Dr. Barry McClellan and is dated April 9, 2008.

"Dear Dr. McClellan,

I would like to take this opportunity to share my very positive experience that I recently had with Sunnybrook and Dr. Marks in connection with my ACL replacement surgery. It was my first time to have surgery or any medical porcedure for that matter and I must say the whole operation was very professional and efficient. While it is not possible for me to remember all of the names of those that were involved in my surgery I would like to say that the medical and support staff that assisted me were all first class professionals. This includes my initial contact and visit with Dr. Marks' and his office, the pre-op session a week before my surgery, the pre-surgery prep and the post surgery recovery. It is hard to tell what actually went on while I was in the operating room as I was knocked out-but all indications are that it was a big success!

Please pass this note on to all the departments involved as I would like to thank them for the excellent medical care they proviced to me.

Your Truly,

Mr. C."

Interested in Cardiac Care Nursing????

Would you like to learn more about:
v Coronary Artery Disease?
v Dysrhthmia interpretation?
v Hemodynamics?
v Acute Coronary Syndromes?
v Incorporating research and best practice into nursing care?


Why not register for the George Brown College - Cardiology Nursing I
Course Code NURS 9064?
http://coned.georgebrown.ca/owa_prod/cewskcrss.P_CrseGet?subj_code=NURS&crse_numb=9064

Where: Onsite at the Sunnybrook campus
When: classes are held 1 day/week
v 6 hrs each day for total of 36 hours
v Start mid July – end August

For more information contact:
Danielle Herold- APN – Acute Care Nursing Resource TeamExt: 89688 or Danielle.herold@sunnybrook.ca

Journal of the Month

The Journal of the Month has really worked out to be a 'Journal of the Season' however, this may be an article that can actually help us out. Let me know what you think. It is from the Joint Commision Journal on Quality and Patient Safety, and is about the SBAR tool.
Check it out HERE!

ARTICLE AT A GLANCE
Background: The importance of sharing a common
mental model in communication prompted efforts to
spread the use of the SBAR (Situation, Background,
Assessment, and Recommendation) tool at OSF St.
Joseph Medical Center, Bloomington, Illinois.
Case Study: An elderly patient was on warfarin sodium
(Coumadin) 2.5 mg daily. The nurse received a call
from the lab regarding an elevated international normalized
ratio (INR) but did not write down the results
(she was providing care to another patient). On the
basis of the previous lab cumulative summary, the
physician increased the warfarin dose for the patient; a
dangerously high INR resulted.
Actions Taken: The medical center initiated a collaborative
to implement the use of the SBAR communication
tool. Education was incorporated into team
resource management training and general orientation.
Tools included SBAR pocket cards for clinicians and
laminated SBAR “cheat sheets” posted at each phone.
SBAR became the communication methodology from
leadership to the microsystem in all forms of reporting.
Discussion: Staff adapted quickly to the use of SBAR,
although hesitancy was noted in providing the “recommendation”
to physicians. Medical staff were encouraged
to listen for the SBAR components and encourage staff to
share their recommendation if not initially provided.

Reminder

Hi Everyone,

This is a reminder that there will be a SPANC meeting next Wednesday between the hours of 11:30-14:30. This is a Brown Bag Lunch Hour drop-in, and I'd like to encourage everyone to try to make it. I know that you will be spending your valuable lunch hour at a meeting, but I'm hoping that these times will better accommodate those nurses who want to be a part of Sunnybrook Peri-Anesthesia Nursing Council.

We have some great ideas to get this Nursing Council up and running with some definite goals in mind. An agenda will be organized for next Wednesday, anyone with agenda items they would like to discuss, please either leave a comment here at the end of this post, or email me.

There is an RSVP at the top right of this blog, can you please respond so that we have an idea of how many people will attend.

Thanks, and have a great weekend!

Great Job SDS!

The following email was forwarded from Carol:

To Whom it May Concern:

My husband, John Eason, was at Sunnybrook Health Sciences Unit on Wed. May 7th for Same Day Surgery to have a tumour removed from his bladder at 9:30 a.m. He was very nervous about the procedure and we would like to take this opportunity to thank everyone for his excellent care. The staff’s good sense of humour helps to put patients at ease. When Christopher and Chris came to move the bed upstairs to the operating area they began with introducing themselves as well as explaining the next step in the day. Small gestures like this do make a difference. It also seemed apparent that the staff on duty that day enjoyed their jobs and demonstrated that they understood the patient’s needs.
Please keep up the great work.

Thank you.

John and Jill E.
Great work Same Day Surgery!

In-Patient Allergy Policy and Documentation Tool Implementation

From Frances Flint, Director of Nursing Practice and Informatics:

Implementation of the Allergy Policy and documentation tool, the Inpatient Allergy Record is scheduled for the week of June 2, 2008. The policy has been approved by NAC, PAC and MAC and is now posted on the intranet. The link is http://mysb.ca/data/1/rec_docs/6990_I_A_2150.pdf

The Inpatient Allergy Record is available through print shop PR # 999968. Please note the instructions on the reverse side of the form. Please inform the PAA’s of the new form and add it to your pre-admission packages.
The Inpatient Allergy Record should be placed in front of the physician order sheet of the health record. In due course the physician order sheet will be changed to indicate completion of the new Inpatient Allergy Record.

Over the past few months we have had more CrCU, B5ICU and D4ICU patients staying for extended periods in PACU. Patients who are intubated (and are expected to remain intubated,) have central lines, or chest tubes inserted in the OR MUST have a post-op CXR done to check placement of these invasive lines. It is a safety issue, hospital protocol, and the expected standard of care. Please refer to Central Line Insertion and Chest Tube Insertion. Management of the patient who remains intubated and/or ventilated is an advanced nursing competency, and as a PACU RN there is a professional responsibility and accountability to ensure that the skill is maintained in a competent and safe manner. If anesthesia does not order a CXR post op, please remind them that it is necessary, and insist upon it! Let them know that you will page them once the CXR has been taken. Also, if you know that a patient is going to remain intubated for an extended period of time, it is prudent to have an order for an NG Tube (if the patient does not have a basal skull fracture.) A good time to insert this would be prior to the CXR being taken.

Trauma patients whether intubated or not, with spines not cleared, should have a neck collar on, and should still be nursed with the HOB up 30 degrees, by placing the patient in Reverse Trendelberg (head higher than the feet.) For Head injured patients, this helps with ICP, but for all intubated patients, it helps with lung expansion, and prevention of aspiration. ALL patients whose spines have not been cleared in the ER, must have their spines cleared radiographically AND clinically before C-T-L Precautions can be discontinued. It is very important to continue to reposition your patient by logrolling q2h. Think about it: patients have been on a backboard from the field, to ER, to the OR. Pressure Ulcers can, AND DO already start at this time. TIP: A long wedge can be made by rolling together 3-4 flannel blankets. One flannel is helpful under the head to maintain C-spine alignment. Please note that if your patient is awake and able to answer questions appropriately, spines can be cleared by paging the appropriate service. Orthopedics and Neurosurgey take weekly turns being the Spinal On-call. You can find this information in the Trauma notes.

Hope this information helps!

Another New Staff Member!

As you all know, we have been on a MAJOR hiring spree this year! Please help me to welcome our newest PACU employee, Hongling Wu. Hongling comes to us from the ICU at Humber River Regional Hospital.

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Since we do have such a large number of new staff members in all areas, I would like to take this opportunity to point all all of you in the direction of Professional Specialty Organizations relating to PeriAnesthesia. ASPAN is the American Society of PeriAnesthesia Nurses. International membership costs $100, but it is well worth the price. You will receive Journals and Newsletters in the mail, plus discounts on seminars, conferences and educational material. Check it out Here.

OPANA is the Ontario PeriAnesthesia Nurses Association. "This is the province of Ontario's only non-profit professional nursing association serving nurses who practice patient care, including Pre-Anesthetic care, in all areas of health care where all types of anesthetics are administered.
These areas include, but are not limited to:
Pre-Admission Clinics
Ambulatory Clinics
Post Anesthetic Care Units (PACU)
Day Surgery Units
Free Standing Dental and Plastic Surgery Clinics
Endoscopy Units
Cystoscopy Units
Labour and Delivery Units
Any other area of health care where local, general or regional anesthetics or sedation are given to patients undergoing a wide variety of treatments or surgery.
The purpose of OPANA is to lead the provinces' perianesthesia nurses through perianesthesia nursing education, practice standards and research. This is accomplished through communication, networking, knowledge exchange, evidence-based research activities and incorporating them ultimately into Practice Standards."

"All OPANA members are members of NAPAN© and a portion of the membership fees goes towards supporting this national association.
OPANA is working towards developing a certification exam in collaboration with associated professional groups (i.e., CNA, NAPAN(c))."

January 1 until December 31 of the year of application. Members who join OPANA throughout the year or at the time of registration for the annual conference, are considered to be members of OPANA for that calendar year only. It is through membership, that OPANA's members can receive membership discounts for the conference.

Membership costs $40 and there is a reduced rate if you are also a member of the RNAO. Click Here for more info!

If you haven't had the chance to catch up on the latest issue of Nursing Voice, or you would like to read some back issues, you can find the link Here.

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I know PEP Day was a while ago, but there is still some outstanding info. The Complaint Free Bracelets will be arriving soon. Apparently they were sent by mule. (Was that a complaint?!)

Also, CONGRATULATIONS TO ALL P.E.P. DAY DOOR PRIZE WINNERS!!!

1) $100 gift certificate to Civello Spa Jean Ford SD
2) $100 gift certificate to Civello Spa Erin Stainer PACU
3) $50 gift certificate to Yorkdale Rowena Supat OR, SB
4) $50 gift certificate to Yorkdale Marie McEachnie OR, SB
5) $50 gift certificate to Want Boutique Zera Ratensi PAC
6) $50 gift certificate to Want Boutique Valerie Cramer OR, HOAC
7) Gift package from Bacardi Andrea Clarke PAC
8) Gift package from Bacardi Jane Gannon OR, HOAC
9) Gift package from Bacardi Tatyana Milenkovic, OR, HOAC
10) Gift package from Bacardi Irina Zaslavsky, OR, HOAC
11) Gift package from Vichy Michelle Sparkes, OR, HOAC
12) Gift package from Vichy Bente Willis, PAC
13) Gift package from Vichy Michelle Bertrand, OR, SB
14) Gift package from Vichy Cristal Hurst, OR, HOAC
15) Garden Gift Basket Stephanie Taylor, porter, HOAC
16) Adidas Bag Becky Wong, OR, SB
17) Adidas Bag Maria DaSilva, PAC
18) 3M gift basket Biddy Chang, OR, SB
19) J.C. Creations necklace Robyn Fosbury, PACU
20) $50 gift certificate to Bon Appetit Marilyn Gunn, SB, OR
21) $50 gift certificate to Bon Appetit nurse speaker L. Mahoney, PACU
22) $50 gift certificate to Bon Appetit nurse speaker M. Gunn, SB, OR
23) $50 gift certificate to Bon Appetit nurse speaker G. Groetzch, HOAC


SPONSORS FOR PEP DAY:

Sherry Mullen & Kristy Walker (Covidien), $750 for lunch
Mark Hunks (J & J Dupuy), $350 for lunch
Sue Heyland (Cardinal Health), $100 for lunch
Jason Pearson (ConMed), prizes 20-23
Larry Pyykko (GE Healthcare), “Believe in the Power of Nursing” booklets
Wendy Gilmore, motivational speaker, prizes 1- 4 & loot bag items
Alexandra Leeksma, “A Complaint Free World” package
Carol Deriet & Helen Vandoremalen, coffee break & dessert



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Great Work!

WOW! The nurses in SSSU must be gushing with all the kind words they've received from their patients! Here is another letter:

Hello Carol,

This quick note is intended to provide feedback regarding your staff in the Short Stay unit at Sunnybrook hospital. I had out-patient surgery on Friday May 9, 2008 however I was unable to go home that evening because my blood pressure was too low and I was experiencing severe dizziness. I was admitted into the Short Stay unit where your staff went above and beyond to help me through the initial recovery. In particular Maggie was available to assist me "on demand" in getting in/out of bed to use the washroom, she allowed my husband to stay well beyond visitor hours and allowed him to re-enter the hospital at 10pm so he could bring me a special meal to accommodate my food allergy. She also tried on several attempts to reach my doctor to inform him that I was staying in the hospital overnight. I was released the next morning and am still recovering at home but I wanted to send a quick note to thank you and your staff for not only providing me with much needed help during the first 12 hours after my surgery but also for making my brief stay in the hospital as comfortable as possible. Thankfully my experience with hospitals has been minimal so far but I am happy to see that Sunnybrook has staff that is accommodating and attentive.

Once again, thank you.

Sincerely,

Katerina M

Happy Nurses Week from the Provincial Chief Nursing Officer

Ministry of Health and Long-Term Care
The Nursing Secretariat
12th Floor
56 Wellesley Street West
Toronto ON M5S 1S3
Tel.: 416 327-9689
Fax: 416 327-1878
Website: http://nursingsecretariat.on.ca

May 12, 2008
Dear Nurses,
Re: National Nursing Week – Think you know nursing? Take a closer look…
Nursing week is a time of celebration and acknowledgement of the significant contributions that nurses make to enrich the lives of patients, families, communities, and the health care system. As the Provincial Chief Nursing Officer, I am very aware of the deep commitment and professional knowledge of nurses across the province. I would like to take this opportunity to offer my sincere appreciation and personal greetings to all nurses in recognition of your enduring effort to promote the profession of nursing and support the delivery of quality care to Ontarians.
Every day, nurses demonstrate leadership and dedication to patients and family members experiencing alterations in health status. Using knowledge and expertise to promote the health of patients, clients and residents, nurses provide holistic and compassionate care and play an integral role in positively impacting both the quality and safety of care delivery.
I wish you great success and enjoyment of the various nursing events that your organization has planned for the week. Most of all, I wish that during Nursing Week and always, you will take some time to celebrate yourselves and your colleagues for the truly remarkable work that you do.
Sincerely,
Vanessa Burkoski
Provincial Chief Nursing Officer

Great Job SSSU!

The following letters were received from a past patients.

Letter #1

Attention SSSU PCM CAROL DERIET

Just a note to say how wonderful the nursing care was when I was in the short stay unit on Fri. Apr. 25. There was 4 nurses Fri afternoon-Debbi & Debbie and Maggie & Martha overnight. I found them to be kind, pleasant, considerate and most helpful.

I hope they will continue to serve for many years to come.

Please pass my thanks on to them! Sincerely, Joseph G.

Letter #2

Dear Dr. McLellan,

I would like to take this opportunity to share my very positive experience that I recently had with Sunnybrook and Dr. Marks in connections with my ACL replacement surgery. It was my first time to have surgery or any medical procedure for that matter and I must say the whole operation was very professional and efficient/ While it is not possible for me to remember all of the names of those that were involved in my surgery I would like to say that the medical and support staff that assisted me were all first class professionals. This includes my initial contact and visit with Dr. Marks' and his office, the pre-op session a week before mu surgery, the pre-surgery prep and the post surgery recovery. It is hard to tell what actually went on while I was in the operating room as I was knocked out-but all indications are that it was a big success!

Please pass this note on to all the departments involved as I would like to thank them for the excellent medical care they provided to me.

Yours truly,

Daniel C.

Nursing week, PEP day, Herbal Products, and a new staff member.

Most of you have probably seen this joke before, but it's funny the second time around too!

You know you are a Nurse when...

1) the front of your scrubs reads “Nurses…here to save your butt, not kiss it!”
2) you occasionally park in the space with the “physicians only” sign… and knock it over.
3) you believe some patients are alive only because it’s illegal to kill them.
4) you recognize that you can’t cure stupid.
5) you own at least three pens with the names of prescription medications on them.
6) you believe there’s a special place for the inventor of the call light.
7) you believe that saying “it can’t get any worse” causes it to get worse just to show you it can.
8 ) you wash your hands BEFORE you go to the bathroom.
9) you believe that any job where you can drive to work in your pajamas is a cool one.
10) you consider a tongue depressor an eating utensil.
11) eating microwave popcorn out of a clean bedpan is perfectly natural.
12) you have been exposed to so many x-rays that you consider it a form of birth control.
13) you have heard a patient with a nose ring, a brow ring, and twelve earrings say “I’m afraid of shots.”
14) you have placed a bet on someone’s blood alcohol level.
15) you have told a confused patient that your name is that of a coworker and to call if they need help.
16) your bladder can expand to the size of a Winnebago’s water tank.
17) you have seen more penises than any prostitute could dream of.
1 you believe that not all patients are annoying…some are unconscious.
19) your family and friends refuse to watch medical sitcoms with you because you spend the whole time correcting everyone and pointing out upside down x-rays.
20) you don’t get excited about blood, unless it’s your own.
21) you have sworn to have “do not resuscitate” tattooed on your chest. Soon.
22) discussing dismemberment over a gourmet meal is perfectly normal to you.
23) your idea of fine dining is anywhere you can sit down to eat.
24) your idea of a good time is a cardiac arrest at shift change.
25) you believe in the aerial spraying of Prozac.
26) you believe that “shallow gene pool” should be a recognized diagnosis.
27) you believe that the government should require permits to reproduce.
2 you believe that unspeakable evils will befall anyone who utters the phrase, “Wow, it’s really quiet, isn’t it?
29) you have wanted to write a book entitled, “Suicide: getting it right the first time.”
30) you have ever had a patient look you straight in the eye and say “I have no idea how that got stuck in there.”
31) you have had to leave a patient’s room before you begin to laugh uncontrollably.

HAVE A GREAT WEEK!

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It has been a while since I've posted anything, but I have lots of updates and new information to share from the ASPAN Conference. It will take me a while, but I will pass on as much info as I can. I did leave a copy of the AANA Journal (American Association of Nurse
Anesthesia) in the Block Binder along with some pamphlets about Nurse Anesthesia for anyone who might be interested in this role.

Thanks to all who came to the PEP retreat, feedback was very good, and I thought I would share the evaluations with you.

PEP DAY EVALUATIONS MAY 2TH, 2008
Evaluations collected – 58
1. Was this retreat what you expected?
Yes:48 No: 10
2. Did you enjoy it?
Yes:57 No:1
3. Were the presentations relevant to your practice?
Yes:58 No: 0
4. Did you realize anything today that might make you deal with the challenges you face each day a little easier?
Yes: 52 No:6

What did you like best? (In order of popularity)
All Aboard the Change Train-Rosita Hall
Out of Africa-Peter Chu
EVAR-Andrew Dueck
RNFA-Grace Groetzsch
A Complaint Free World-Ramona Hackett
What didn’t you like?
· IP&C – they were very rude & accusatory
Not the right venue to do this
Too much equipment thrown in the garbage
Other Comments
· Good Job – thank you
· Fun upbeat day
· Well organized
· Very Exciting day – enjoyed
· I enjoyed the whole day – by far the best
· Excellent motivational speaker
· To all educators – an excellent job
· Everything was great – no more complaining
· Vegetarians need protein – not just cheese
· Lunch need more meat or chicken no vegetables
· More social seating for lunch and coffee
What ideas do you have for next year?
· NP role
· Have a paid speaker again
· More presentations by the nurses
· Praise and recognition of staff
· Blood conservation
· Retirement
· Nurses in business
· Benchmarking
· Patient outcomes and patient flow issues

*****************************************

At the ASPAN conference, I picked up an interesting pamphlet about Herbal Products and Anesthesia.

Herbal products are also known as dietary supplements, alternative therapies, complementary medicine, and homeopathic health care. There are few instructions on proper use and dosage requirements, and little information about possible side effects, toxicity and possible drug interactions. While many herbal products offer noticeable health benefits when used correctly, taking these products right up until the day of surgery may have an impact on the success of the anesthetic and/or procedure.

Herbal products should be stopped at least two weeks prior to the scheduled procedure to prevent side effects. Surgeon, anesthesiologist and nurses need to be aware of any herbal products that are being taken including over-the-counter drugs, dietary supplements, minerals, and teas.

The following are some popular herbal products and possible side effects when interacting with anesthetics:

Ephedra-used for the treatment of asthma, hay fever, and the common cold. It is primarily used as a nasal decongestant, but has also been found in diet aids to promote weight loss. the side effects are BP changes, exaggerated response to high BP meds, risk of heart attack and stroke.

Feverfew-used to treat fever, migraines, arthritis, and digestive problems. The major risk is prolonged bleeding, but also insomnia and anxiety.

Garlic- claimed to help prevent heart disease including atherosclerosis, high cholesterol, high BP, and cancer. Side effects include blood pressure changes and a risk of prolonged bleeding.

Ginger- may decrease joint pain from arthritis, and may have blood thinning and cholesterol lowering properties that may make it useful for treating heart disease. Commonly used to aid nausea, some cultures use it to treat the common cold, flu and diarrhea. Ginger is contraindicated in people suffering from gallstones as the herb promotes the release of bile from the gallbladder. Also contraindicated in people who are taking warfarin. Interactions with anesthetics include sedative effects, risk of bleeding.

Ginseng-is promoted as an adaptogen (a product that increases the body's resistance to stress,) a nourishing energy drink, an aphrodisiac, and in the management of Type II Diabetes. Side effects include insomnia and irritability, and risk of cardiac effects and blood pressure changes.

Kava-is marketed against stress, insomnia and anxiety. Mixed with anesthetics there is a risk of additive effect to medications, increased sedative effects.

St. John's Wort-used as an antidepressant, may help to decrease alcohol intake, and commonly used as an herbal tea. there are many adverse interactions with other medications, some which may prolong the effects of anesthesia. May also cause blood pressure changes.

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Last, but not least I'd like to make an announcement about another new staff member in PACU. Lindsay Richmond comes to us via CrCu. Previous to that she moved to Toronto from London, Ontario where she also worked in ICU. Welcome Lindsay!

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