Automated Dispensing Cabinets

We are currently working with pharmacy to get the McKessin cabinets up and running. I found this article on Medscape and thought I would share it on the blog. Happy reading!

From Topics in Advanced Practice Nursing eJournal > Commentary
Automated Dispensing Cabinets: Getting It Right in the Age of Automation
Barbara L. Olson, MS, RN-BC, FISMP


Just as the brand name Kleenex® is commonly used for facial tissues, automated dispensing cabinets (ADCs) are often recognized by manufacturer or product names such as AcuDose®, Omnicell®, and Pyxis®. Currently, 83% of US hospitals report that they use ADCs, indicating widespread acceptance of touchscreen-activated drug storage vaults.[1] Generally welcome additions to busy clinical settings, ADCs provide ready availability of medications (a key component of acute care) while streamlining the process of drug charging.
But ADCs are more than automated teller machines for drugs. These unit-based medication repositories incorporate sophisticated software and electronic interfaces to synthesize high-risk steps in the medication use process. Today's cabinets reflect design advances as well as an appreciation for how specific technologies, such as barcode scanning and clinical decision support, can improve medication safety. Over the years, ADCs have been adapted to facilitate compliance with emerging regulatory requirements such as pharmacy review of medication orders and safe practice recommendations.

Promoting Medication Safety
The "5 rights" of medication administration, a set of objectives well-known to nurses and other frontline clinicians, are often used to describe medication safety goals. When used to their greatest potential, ADCs can increase the reliability of the "5 rights": the right drug, the right dose, the right patient, the right route, and the right time. The mirror image of each medication right is a wrong -- wrong drug, wrong dose, wrong patient, wrong route, and wrong time -- representing a risk point that a strong system design can help to avert.
However, sophisticated, accessible drug storage systems alone do not guarantee safety. Selection, design, implementation, and monitoring of ADCs are also important to mitigate the risk associated with medication use.
In 2008, the Institute for Safe Medication Practices published Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets to help organizations and individuals understand and adopt practices that maximize the safety of ADCs.[2] Twelve distinct core processes that promote safest practices and secure handling of drugs are addressed in this document. While these guidelines do not represent standards of care, they do provide organizations and frontline users with measures for each stage of ADC implementation, from deciding how the technology will be used to staff education and long-term monitoring.
The ISMP guidance document, coupled with other relevant literature and reports of error and near-miss events associated with ADC use, inform the recommendations provided below. These quick-read recommendations are by no means inclusive, but may serve to bridge understanding between executive decision makers, medication safety experts, and frontline clinicians during high-stakes decision processes that involve resource allocation, work-flow, and patient safety. Teams charged with ADC implementation or re-evaluation as well as those interested in defining pharmacy-specific processes to enhance ADC safety are advised to consult ISMP's complete document.[2]

Wrong Drug/Wrong Dose Errors
Wrong drug and wrong dose errors are the most common errors associated with ADC use. Look-alike drug names and drug packages are variables that can lead to wrong-drug/wrong-container selection errors. Morphine and hydromorphone (Dilaudid®), for example, are 2 different opioid analgesics that top the list of the most frequently confused drugs.[3] Alprazolam and lorazepam are another pair of look-alike, sound-alike drugs that are frequently confused.
Environmental factors (such as distraction and lighting) influence how well humans perform tasks involving product selection. Patient information at the point of dispensing, such as allergies and potential contraindications, allow a final cognitive check (matching prescribed drug, dispensed drug, and indication for use) to occur.
Consider this comment, made by a seasoned nurse who responded to a post entitled "Meds & Mindfulness" on Medscape's On Your Meds blog in April 2009:
I have been an RN since 1974 and have worked in many settings. I am currently on a geriatric psychiatric unit and I just wanted to share that my morning med pass is just about the most unnerving thing I have ever done. The area where 2 of us prepare our meds is a small hallway through which people must pass to reach our unit tube system. Folks squeeze by often as we work. On the other end of our small area is our Pixis (sic) machine, which the pharmacy tech comes to stock during the time we are setting up our meds...... Interruption is the name of the game.
This nurse's observations highlight several of the well-known risk points in the medication use process that contribute to wrong drug/wrong dose errors.


Recommendations to Prevent Wrong Drug/Wrong Dose Errors With Automated Dispensing Cabinet Use
System Level Recommendations
System-level considerations that may diminish the risk of wrong drug and wrong dose errors when drugs are retrieved from ADCs include:
-Evaluate unit geography when planning for ADC installation or upgrades;
Minimize the potential for ADC users who stock and remove drugs, to be distracted while working at the ADC;
-Match ADC stock to unit needs meticulously, using unit-dose packaging whenever possible. Overstocking medications predisposes to wrong-dose errors, specifically overdoses, while stocking drugs that are not routinely used predisposes to wrong drug errors;
-Store drugs with look-alike, sound-alike names in different locations within ADCs. Consult published lists such as the ISMP's list of frequently confused drug names to determine which medications stored in each of the facility's ADCs pose the greatest potential to be mixed up in the selection process;
-Examine interdisciplinary workflow issues and eliminate scheduling conflicts so that routine drug stocking and retrieval activities do not overlap;
-Establish procedures for medication administration that avoid distractions related to other duties, especially in settings where nurses care for multiple patients.[4,5] Drug selection is a high-stakes activity, one that may be compared to safety-sensitive tasks that occur during pre-flight activities in the aviation industry. System leaders should evaluate expectations, especially those that involve multi-tasking, to ensure that staff members are not routinely disrupted at high-stakes junctures in medication administration. (If you wouldn't want the captain of your airliner to greet passengers while simultaneously performing pre-flight checks, you should advocate for processes that allow nurse to similar attention to detail during drug selection);
-Maximize the use of barcode technology with ADCs to make sure that the correct products (intended drug in the correct dose units or container size) are stocked in each clinical setting.[6] Bar-code product verification at point of retrieval (or point of administration) further diminishes the likelihood of wrong drug or wrong dose errors. When barcode verification is not possible, high alert drugs should be verified both by the person stocking the ADC and a unit-based nurse;
-Ensure that patient medication administration records (MAR) are accessible to practitioners while they are removing medications from an ADC. To make this a practice norm, select workstations that can be positioned near the ADC. When purchasing hardware (such as wheeled workstations), weigh cost-benefits of integrated patient information repositories in light of nursing time and patient safety. (The process used to deliver food to your table at the average chain restaurant should not be more reliable -- and less cumbersome -- than the process used to bring ordered medications to your bedside in a community hospital);
-The ADC should display drug information in a nonambiguous fashion, matching information provided on the MAR;
-Require pharmacy review of medication orders (which includes measures such as checking the order against known allergies; reviewing appropriateness of the prescribed dose; and evaluating potential for drug-drug interactions) prior to removal of medications, except in emergency situations.[6] Once pharmacy review has occurred, a readily identifiable flag/symbol should signal "go" to frontline clinicians;
-Use computerized alerts, ideally pop-ups that require a confirmation, when medications with high potential for mix-up (look-alike, sound-alike medications) in a given setting are selected. Bring the possibility of drug product confusion to the attention of the clinician at the point of retrieval, especially for other high alert drugs that have look-alike, sound-like qualities. For example, to minimize morphine and hydromorphone confusion risk, the ADC screen may prompt, "This is DILAUDID. Is that correct?" whenever hydromorphone is selected[7];
-Monitor how well ADCs, as configured, support care goals established by frontline providers and expected by patients and other stakeholders. This may be accomplished through proactive order set/clinical pathway review and retrospective review of medication overrides. Investigate causes of ADC overrides, considering the possibility of production pressure, especially in settings where turnover goals may compete with meticulous adherence to safest medication practices;
-Teach front line clinicians, especially those who participate in unit-based practice councils and multidisciplinary committees, the principles that inform safest use of ADCs, especially those that relate to medication stocking and availability. Solicit their input proactively to prepare for anticipated practice changes involving medication use and medication storage;
-Consider providing unit-based practice councils and multidisciplinary teams in specialty units to review ADC metrics (such as results of override reports). With this knowledge, it will be possible to identify deviations from targeted benchmarks, identify barriers to compliance, and champion safest practices;
-Ensure that knowledge of high alert medications and look-alike/sound-alike drugs (particular to a given clinical setting) are included in orientation and initial competency validation measures of individuals who dispense, stock, or administer medications; and
-Create a culture in which concerns voiced by frontline clinicians are seen as valuable. Develop a visible "rapid response" when ADC near-misses or discrepancies are reported.

Individual Level Recommendations
Considerations for individuals that may diminish the risk of wrong drug and wrong dose errors when drugs are retrieved from ADCs include:
-Recognize that medication retrieval from ADCs is a high-risk activity, one in which human error has the potential to cause irreparable harm;
-Utilize bar-code scanning to the fullest extent possible in your practice setting. Report barriers to compliance immediately, using system-wide, near-miss reporting systems. For example, if barcode scanning is prevented by mechanical failures, battery life, or the availability of scanning equipment during high volume medication administration times -- these are reportable events;
-Upon removal of a drug from an ADC, validate that the drug name on the label of the drug-in-hand matches the drug name displayed on the patient's MAR (or prescriber's order if MAR has not been generated);
-Validate that the drug-in-hand is the ordered concentration, dose, and dosage form;
Be suspicious of any dose that would require removal of more than 3 packages/ampules/vials to administer a single dose;
-Avoid excessive use of the override function; it should be limited to true emergencies;
-Be aware that distractions undermine performance. Reduce distractions within your control when you are removing medications from ADCs. Although duties related to medication administration occupy a significant amount of nursing time, accurate performance cannot be assured simply because tasks are familiar. For example, answering cell phones while performing high-stakes activities impairs accuracy. Social exchanges with colleagues, patients, and family members should not occur at the ADC;
-Advocate for practice models that promote the least amount of distraction during medication preparation and administration. If multi-tasking while accessing medications from an ADC is a performance expectation, use professional practice councils and near-miss reporting systems to call attention to this risk;
-Become familiar with the rationale behind the system-level interventions (listed above) that promote safest use of ADCs; and
-Report deviations from ideal or standard practices as near-misses. This may seem "picky," but having a highly reliable medication use system involves meticulous attention to detail, something which requires a high degree of standardization. A system that has to undergo individual interpretation to accomplish routine tasks -- like a 9:00 am medication pass -- is error-prone. Fixing a system is difficult, but possible (in a way that fixing a lethal wrong-drug medication error is not). Here are a few things worth reporting when you notice them: A discrepancy between the way the drug name is displayed on the MAR and on the ADC screen; for example, when tall-man letters used to differentiate a known look-alike, sound-alike drug pair throughout your organization are not used on the pick list of your ADC screen; or when you find a syringe labeled "hydromorphone" in a bin labeled "morphine."

Summing Up: Seeing Beyond "The Box"
ADCs, particularly when they interface with computerized redundancies such as bar-coding and electronic MARS, give front line clinicians powerful tools to deliver reliable results. But reaping the benefits of technology involves more than selecting "the best box."
Knowledge of how automated dispensing cabinets are used by clinicians is essential for realizing the potential of these devices to improve safety, just as they have improved efficiency and charge capture for medications. Individual performance is one aspect of medication safety: how individuals perform is affected by the knowledge and competency each brings to the task at hand along with personal practice habits and choices under each individual's control. But key elements of performance are also influenced by the system in which care is delivered and by factors controlled at the organizational level.
To maximize the benefits of ADCs, organizations should identify and manage risk points that predictably occur when humans, often busy and working under stress, interface with machines to deliver high-stakes therapies. Interdisciplinary guidance, such as those published by ISMP, identify these risk-points and recommend risk-reduction strategies, enabling organizations to align work-flow and performance expectations so that the safety benefits of ADCs are fully realized.

Are Nurse Jackie and Hawthorne helping or harming nursing?

Thought I would forward this information on our Blog:

News Alert from the Center for Nursing Advocacy:
Nurse Jackie and HawthoRNe have created quite a stir in the nursing community, causing excitement about nurses being featured as lead characters on prime time television, but also concern about whether the character profiles and story lines will have a positive or negative impact on the public's understanding of who nurses are and what they do.
Center for Nursing Advocacy board members have been weighing in, and we would like to open a discussion with all of you on what has already become a source of controversy among nursing professionals. Suzanne Gordon, internationally known journalist, advocate for nurses, and a member of our Board of Directors, wrote an op-ed for the Boston Globe on the new shows, and Board chair Mary Dominiak was quoted in a Chicago Sun-Times article.

Please join the discussion at our discussion board. Our discussion board was recently reactivated after removing a deceptive thread started by an unauthorized person who posted false information about the Center's status. Now, we invite your thoughts on the following topics:

Are Nurse Jackie and HawthoRNe harming or helping nursing?

How can nurses, including nursing faculty, use Nurse Jackie and HawthoRNe to educate their peers and students about the importance of becoming advocates for the nursing profession?
We look forward to the discussion!

Nurse Jackie

Nurse Jackie

Click on link above to find out more about this showtime series. Within the link are also spoilers and clips.enjoy!

MRSA

Methicillin-resistant staphylococcus aureus (MRSA) is a micro-organism that has developed a resistance to antibiotics. MRSA is currently the most clinically significant antibiotic-resistant organism (ARO) in Canada.
MRSA is hardy. The bacteria can live up to six weeks on environmental surfaces and is easily transmitted by skin-to-skin contact and touching shared items. Through the implementation of evidence-based strategies, healthcare providers can reduce MRSA transmission and infections.
About 220,000 Canadians develop hospital-acquired infections each year and about 8,000 die from them annually. It costs more to treat MRSA infections than to prevent them. Estimated costs for treating and isolating patients with MRSA infections was $82 million in 2004 and that could reach $129 million by 2010. Total cost per infected MRSA patient averages $12,216, for prolonged hospitalization, special control measures, expensive treatments and extensive surveillance.
The five key components of evidence-based infection control practices that form the basis of successfully reducing MRSA transmission include an aggressive hand hygiene program; systematic cleaning and decontamination of the environment and equipment; precautions for contact with any patient that is infected with MRSA; selected MRSA screening surveillance cultures on admission and at other times during hospitalization if indicated; and regularly reporting of MRSA infection rates to frontline workers and hospital leadership. Participation in this intervention can help your organization meet the MRSA reporting requirements of the Canadian Council on Health Services Accreditation.

Video's on HAI and MRSA

For some really interesting video information regarding HAI's and MRSA, please click the link below.

Video

Beware of basal opiod infusions with PCA therapy

Medication Safety
ISMP Reports:


Problem: A 63-year-old, 109 kg, opioid-naïve patient was admitted to a hospital with fractures sustained in a fall. She was given two doses of morphine 4 mg and one dose of HYDROmorphone 1 mg in the emergency department.
Upon arrival to the inpatient unit, she was started on HYDROmorphone PCA (patient controlled analgesia), which included a basal infusion of 0.5 mg per hour, a demand dose of 0.2 mg with a lockout interval of 10 minutes, and a 4 hour limit of 6 mg. Continuous pulse oximetry was not in use. Five hours later, the patient was found unresponsive. Her respirations were six per minute, and her nail beds were beginning to turn blue. Oxygen saturation was checked with pulse oximetry and found to be 44%. The rapid response team was called, oxygen was started, and two doses of naloxone were administered. In 15 minutes, the patient was alert and talking. It was then that the patient told a nurse she has sleep apnea and had previously used a continuous positive airway pressure (CPAP) machine at home. She hadn’t been using the CPAP recently. So, when the admitting nurse asked her if she used any medical equipment at home, she said “No.”

The patient’s body mass index (BMI) was 38.6 (BMI of 40 or more is morbid obesity), placing her at risk for sleep apnea and hypoxemia during PCA therapy.Although no permanent harm ensued, the hospital’s medication safety team used this case as a learning opportunity. Three root causes of the event were identified, as described below.
Dosing guidance. The PCA standard order form did not help guide prescribers to appropriate doses; instead, it provided a broad range of doses. For example, the range for a HYDROmorphone basal infusion dose was 0.1 to 0.5 mg/hour, and there was no guidance for selecting appropriate candidates for basal infusions. Many prescribers routinely selected a 0.5 mg/hour basal infusion, regardless of patient characteristics. A basal opioid infusion was not appropriate for this opioid-naïve patient.Studies have shown that patients with basal opioid infusions are at least five times more likely to experience respiratory depression.(1-4) The American Pain Society cautions against using continuous basal infusions because studies have failed to demonstrate significant differences in the quality of analgesia with or without basal infusions.(4) There may also be an increased risk of programming errors when basal infusions are prescribed.(5)
Patient screening. The patient was not sufficiently screened for obstructive sleep apnea (OSA) and other risk factors for PCA-induced respiratory depression. The facility had an OSA screening process in place for pre-operative patients, but screening did not occur because this patient was not a surgical candidate. The incidence of respiratory depression in PCA patients ranges from 0.19 to 5.2 percent, depending on how it is measured.(1-4) Figure 1 (in the PDF version of the newsletter) includes risk factors for respiratory depression in PCA patients.
Patient monitoring. No process was in place to trigger an evaluation of the need for continuous pulse oximetry monitoring (or capnography for appropriate patients) during PCA.
Safe Practice Recommendations: The hospital’s medication safety team addressed these root causes by standardizing the PCA dosing process and revising the standard PCA order form as described below.---Prescribers are guided to an appropriate dose based on age and opioid tolerance by providing default doses for three types of patients: most patients, patients over 64 years or with sleep apnea, and opioid-tolerant patients (see Figure 2 in the PDF version of the newsletter).---Basal infusions were eliminated except in opioid-tolerant patients.---Basal infusions in patients with sleep apnea were prohibited.---Opioid orders were rearranged to match the sequence in which the medications appear on the facility’s smart IV pumps.---A registered nurse is required to screen the patient for OSA before PCA initiation, with further assessment by a respiratory therapist if the screening shows two or more risk factors (see Figure 3 in the PDF version of the newsletter).---Continuous pulse oximetry (or capnography if appropriate) is required while on PCA if the patient has a continuous opioid infusion or sleep apnea, or if the patient is morbidly obese or older than 64 years.---Patient education is required and must include instructions to the patient’s family not to push the PCA button for the patient (PCA by proxy).The hospital also uses smart pumps for PCA therapy, with one standardized concentration for each drug and dose limits set in the pump library. Before converting to smart pumps, two PCA programming errors had occurred in recent years, leading to serious respiratory depression. Vast improvements in programming accuracy have been reported since switching to the smart pumps.
In our February 22, 2007 newsletter (www.ismp.org/Newsletters/acutecare/articles/20070222.asp), we recommended avoiding basal infusions unless the patient is opioid-tolerant. Unfortunately, the term “opioid-tolerant” is not well understood. It is defined as “those patients who have received opioids regularly for approximately 7 days or more.” Opioid-naïve patients who present with high opioid requirements may be an exception and require a basal infusion, but additional safety steps should be instituted under these conditions. Our July 24, 2003, newsletter includes many recommendations to improve PCA safety, including the following.---Evaluate the patient’s level of pain, alertness, and vital signs, including rate and quality of respirations, every 2-4 hours.---Evaluate patients with minimal verbal and tactile stimulation to obtain an accurate assessment of their level of sedation.---Monitor patients more frequently during the first 24 hours and at night, when hypoventilation and nocturnal hypoxia may occur.---Employ early warning devices such as apnea alarms at night and pulse oximetry or capnography, which can alert practitioners to respiratory insufficiency.Additional recommendations related to safe PCA use can be found in our July 24, 2003 newsletter (www.ismp.org/Newsletters/acutecare/articles/20030724.asp).

References1) Hagle M. Respiratory depression in adult patients with intravenous patient-controlled analgesia. Orthopaedic Nursing 2004;23:18-29.2) McCaffery M, Pasero C. Pain: Clinical Manual (2nd ed.). Boston : Mosby, 1999.3) Weber L. Implementation of standard order sets for patient controlled analgesia. Am J Health-Syst Pharm 2008;65:1184-91.4) Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (5th ed.). Glenview , IL : American Pain Society, 2003.5) Ashburn M, Love G, Pace N. Respiratory related critical events with patient-controlled analgesia. Clin J Pain 1994;10:52-56.

Saving Lives

Last year, at the ASPAN Conference held in Grapevine, TX, the opening speaker talked for almost an hour about the negative media portrayal of nurses in popular television programmes that include Soap Operas, prime time TV shows such as House and Gray's Anatomy, Scrubs and many more. At the time, there were many people in the audience who spoke up and expressed their opinion that it was 'entertainment', 'nobody believed it to be truth' and that 'some people take themselves too seriously.' I tended to side with them, but then I found a site called The Truth About Nursing which I found to be very interesting. I think my opinion has shifted somewhat. Why can't television programmes be entertaining AND factual? For years it has been driving me crazy that a patient on Life Support is intubated and talking with the side rails down, or on nasal prongs and 'close to death.' One time, I think it was on the Y&R, a young child on life support (and nasal prongs) died while the nurse was just standing there, sadly watching the child die. No CPR, no attempt at any kind of calling out for help...just the thin annoying pitch of a flat line on the monitor. That's just one example.
Anyway, it's food for thought. We all know the important work that we do, and that hospitals around the world could not function without Nurses. Isn't it time that we get the respect that is due?

If you are interested in reading more about this, here is a book that is being promoted by The Truth About Nursing:
Saving Lives: Why the Medias Portrayal of Nurses puts us all at Risk

Information from the dust jacket of Saving Lives:
Popular TV shows like Grey’s Anatomy, ER, and House lead people to think that nurses simply push gurneys, drive romantic plots, and provide a human backdrop for the real action. However, those of us among the 12 million nurses worldwide know the reality is far more fascinating, demanding and important.
Written by the leaders of The Truth About Nursing, the organization at the forefront of challenging and changing representations of nurses, Saving Lives highlights the essential role nurses play. It explores the public’s perception of nurses and spells out the greatest myths about nursing, drawing on examples from television shows, ads, news, and other media.
Saving Lives exposes the media’s role in reinforcing stereotypes that help fuel the nursing shortage. But it is also a call to action. Saving Lives offers concrete steps to help nurses and their supporters educate the public about nursing.
For millions of people worldwide, nurses are the difference between life and death, self-sufficiency and dependency, and hope and despair. Nonetheless a lack of appreciation for nursing has contributed to a global shortage that is one of our most urgent public health crises. There are not enough nurses available to monitor patients, provide high-tech treatments, advocate for patients, and teach patients how to live with their conditions. Poor understanding of what nurses do undermines claims for adequate staffing, and leads to a lack of resources for nursing practice, education, and research. All of that means worse patient outcomes, including death.
Saving Lives is destined to change public perceptions, thereby empowering nurses and helping them get the respect they need to save lives.

The "Not What They Say I Am" flyer sends a message that many media depictions of nurses are not accurate and that nurses object to them, in part because they undermine nurses' claims to adequate resources. This is a key message of the Truth About Nursing, and one explored in detail in our new book Saving Lives.

The ironic "Hooray for Hollywood" flyer sends the message that, in our view, there has been little for nurses to cheer about in recent Hollywood depictions of their work. Popular TV shows like "House" and "Grey's Anatomy" have repeatedly offered inaccurate and damaging images of nursing, and we hope the flyer will cause those who see it to reconsider those images. The small print on the flyers directs people to our book and The Truth's website.

Find more information at http://www.truthaboutnursing.org/

I'll throw the question to you. Do you think that the media's portrayal of nurses is disrespectful and highly inaccurate, or do you think it's all just entertainment and there shouldn't be a big deal made about it?

Opinion - 'Do we really need all these nurses?'

Opinion - 'Do we really need all these nurses?'
Toronto Star, March 10, 2009
Sioban Nelson

If there's one thing nurses know, it's that tough economic times tend to mean cuts to the profession. This has been the pattern over the decades, where nursing from Toronto to Manchester to São Paulo has all too frequently been the health-care service sector that takes the hardest and deepest cuts when the economy takes a nose dive.
There is an obvious reason for this. Nursing salaries account for a major percentage of health-service budgets. As CEOs and CFOs are driven to reduce spending and create efficiencies, the first question that comes to mind is usually: "Do we really need all these nurses?"
This is at one level a legitimate question. The drive to answer it has spawned an entire science that measures workload and efficiency, examines the relationship between the number and skill level of nurses on patient outcomes, and analyzes the relationship between staffing profile turnover and burnout.
The Lawrence S. Bloomberg Faculty of Nursing, through its nursing research unit and faculty research, has made this faculty one of the top sites in the world for health-services research in nursing and health care.
But the question "Do we really need all these nurses?" is not only an empirical one that good research can answer. It is also a rhetorical question that reflects a worrying attitude toward nursing that has bedevilled the profession for more than a century.
Even today, when we finally have the data to show that quality nursing staff is strongly correlated with patient outcomes (including mortality), the question continues to be raised. The tradition of seeing nursing as a resource to be built up in good times and trimmed back in lean times dates back to the very beginning of professional nursing.
For most of the 20th century, nursing-student labour fuelled the engines of the modern hospital. Hospitals hummed with industrious nurses washing patients, bed-making and establishing military order and cleanliness. Behind the scenes, student nurses rolled bandages, mended surgical gloves, sterilized and packaged all the sterile materials and packs, sorted laundry items, stocked and restocked drugs and supplies, cooked special diet meals in ward kitchens, distributed all meals and fed all patients. Nurses managed the wards, their patients, the operating room, the hospital budgets and overall operations.
There was clinical work, too. Early transfusions involved six nurses managing the two patients, careful handling of the delicate glass equipment and ensuring constant flow to prevent clotting. Hypodermic injections involved oil-lamp heating of solutions, and nurses did a great deal of dispensing work in the everyday course of caring for their patients. Pre-antibiotic era nursing meant lengthy and complex irrigations of wounds and douchings.
When students graduated from their programs and completed their staff nurse year, they made their way into the few senior roles that existed within the hospital sector or moved into the community, public health and home-nursing sector, where experienced nurses held their own.
Back in the hospitals, the priority often was volume rather than quality. Young girls were worked hard and long with poor remuneration and little respect for their contribution to patient care. High burnout rates, workplace injuries and poor health status have been the norm for hospital-based nurses around the world for far too long.
It also has led to the idea that nurses are in a sense a disposable resource, replaceable and interchangeable like front-line soldiers in early 20th century warfare. Despite clear advances in nursing's position in many parts of the world, including Canada, with each turn of the economic screw, nurses feel the vulnerability of the sector.
Every time we cut nurses, we hit a pipeline. It is not today's nurses we affect but the next 10 years' worth of nurses. In five years' time, with normal attrition and the retirement of the boomers, there will inevitably be more panicked calls for nurses - but where will they be?
Every time nursing jobs are cut, smart young high-school students watch and learn. They choose other careers. Meanwhile, health-service providers cut services and shed nurses. Overwhelmed services can't cope with the demands of students. They cut places. So when the pendulum swings it is impossible to increase the number of nursing student seats.
Meanwhile, entrepreneurial governments and private providers scour the world for nurses, causing more inequity and suffering in their wake as they contract large numbers of nurses from countries that can ill afford to lose them.
What are the implications for health care with today's economic crisis? The rise in chronic illness along with the aging RN workforce make this a critical moment for the future of our health-care system. If we cut off nurses now, we will feel it for the next decade and beyond -and it will be bad.
Do we really need all these nurses? We do.
We need new graduates developing their skills and knowledge in a safe and supportive environment so they do not burn out and leave. We need advanced practice nurses bringing creative and cost-effective solutions to complex system problems. We need nurse practitioners to provide access to the great number of people the system currently fails and to keep costs down. We need them to prevent illness, manage chronic disease and to keep people well and safe in the community. We need them to track us through the highly dangerous space of the acute in-patient sector and ensure that we avoid life-threatening complications, are well-informed and educated about our treatment and its consequences, and go home in the best position possible to undertake self-management of chronic conditions.
To cut nurses is to cut the system's capacity to do this now and into the future. It is in everyone's interest to make sure our decision-makers understand this and are held accountable for the consequences of their actions. As members of the profession and members of the public, it is our job to ensure this.
Sioban Nelson is dean of the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Sheree BondPublic Relations TeamOntario Nurses' Association85 Grenville Street, Suite 400Toronto, ON M5S 3A2(416) 964-8833, ext. 2430

Inattentional Blindness: What Captures Your Attention?

ISMP (United States) Medication Safety Alert! Febuary 26, 2009 Vol. 14, Issue 4
Inattentional Blindness: What Captures Your Attention?
A nurse pulls a vial of heparin from an automated dispensing cabinet (ADC). She reads the label, prepares the medication, and administers it intravenously to an infant. The infant receives heparin in a concentration of 10,000 units/mL instead of 10 units/mL and dies.

A pharmacist enters a prescription for methotrexate daily into the pharmacy computer. A dose warning appears on the screen. The pharmacist reads the warning, bypasses it, and dispenses the medication as entered. The patient receives an overdose of the medication and dies.

A nurse reaches in the refrigerator for a piggyback antibiotic for her patient. She reads the label, spikes the bag with IV tubing, and administers the medication to her patient. The patient receives a neuromuscular blocking agent instead of the intended antibiotic and dies.

A pharmacy technician labels and delivers an IV infusion to the dialysis unit. The nurse reads the pharmacy label and hangs the bag while preparing her patient for dialysis. The patient receives sterile water for injection instead of 0.9% sodium chloride and dies.

A nurse picks out a prefilled syringe of pain medication for her patient. She reads the label and administers the medication intravenously. The patient receives hydromorphone instead of morphine and experiences a respiratory arrest.

All of these actual errors, and many more in healthcare and other industries, have happened under similar circumstances: the person performing the task fails to see what should have been plainly visible, and later, they cannot explain the lapse.(1) In many cases, people involved in the errors have been labeled as careless and negligent. But these types of accidents are common—even with intelligent, vigilant, and attentive people. The cause is usually rooted in inattentional blindness, a condition all people periodically exhibit.(1)

How do we process information?
Most mental processing occurs outside of conscious awareness. The amount of information that can be taken in by our senses is limitless. But the brain has very limited resources when it comes to attentiveness. Our senses receive much more information than can possibly be processed at one time. To combat information overload, the brain allows large amounts of information through almost entirely unassimilated, peeling off just a few pieces of selected information for a closer look.(2)
In deciding what to focus on, the brain scans about 30-40 pieces of information (e.g., sights, sounds, smells, tactile information) per second, until something captures its attention.(2) Our attention filter selects just a small amount of information to process, and anything leftover gets short shrift. The rest of the information never reaches our consciousness—thus the term inattentional blindness. Unfortunately, the brain is a master at filling in the gaps and compiling an integrated portrait of reality based on just a flickering view.(1)
Accidents happen when attention mistakenly filters away important information and the brain fills in the gaps with what is aptly referred to as a “grand illusion.” (2) Thus, in the examples above, the brains of the individuals involved in the errors filtered out important information on medication labels and computer screens, and filled in the gaps with erroneous information that led them to believe they had the correct medication or had read the warning appropriately.

What captures your attention?
Visual attentiveness, or what captures your attention, is shaped by four factors.

Conspicuity. The degree to which an object or piece of information jumps out to capture your attention falls into two categories: sensory conspicuity and cognitive conspicuity. Sensory conspicuity deals with the physical properties of information. For example, a high degree of contrast with the background is the most important feature in making information conspicuous,(1) and luminance (brightness) contrast is more important than color contrast.(3) Factors such as bright colors, movement, and flicker do not ensure conspicuity;(1) however, pre-attentive properties (the brain automatically processes the information without being aware of it) such as color and shape have been used successfully on visual displays to call attention to specific items or categories.(3)

Cognitive conspicuity deals with the perceived relevance of the information. The “cocktail party” effect(4) is a classic portrayal of this factor. This is the term used for the phenomenon of being in a crowd, listening to a conversation, and still being able to hear your name mentioned across the room.(3) Functioning somewhat like the volume control on a radio, you can turn down the volume of background noise at a cocktail party and turn up the volume as you listen attentively to one conversation at a time. While engaged in conversation, if someone behind you mentions your name, you are automatically attracted to the other conversation because it is meaningful to you. Meaningful visual information can also jump out at you automatically, such as scanning the newspaper and finding your attention drawn to articles that include the first name of your child. Attention to something of particular relevance can also be purposeful. For example, you may scan a luggage carousel for your black suitcase, looking purposefully for the broken wheel or yellow ribbon that distinguishes your suitcase from all the other black suitcases on the carousel.

Mental workload and task interference.
Inattentional blindness is more likely to occur if part of your attention is diverted to secondary tasks, like answering the phone while entering prescriptions into the computer, or even thinking about your dinner plans while transcribing an order. We all learn to function amazingly well while multi-tasking, but more complicated tasks require our full attention. However, auditory tasks (listening to the radio) will interfere less with visual tasks (seeing a pedestrian crossing the road) than would a second visual task (focusing on a street sign).(1)
Low workload causes boredom and reduces the mental attention given to tasks, as does carrying out highly practiced tasks, such as drawing medication out of a vial into a syringe. In fact, we spend a large majority of our waking life functioning with the equivalent of an automatic pilot, with occasional conscious checks to ensure tasks are being carried out properly. This makes us particularly prone to inattentional blindness. Reliance on technology has also lessened our ability to notice abnormalities.

Expectation.
Expectation has a powerful effect on our ability to pay attention and notice information. If the medication we are looking for comes in a carton with a highly stylized label, we come to expect this presentation every time we look for the medication. If a new medication comes in a similar looking carton, our brain may not pay attention to any information that disconfirms our belief that the new medication is the old one—a well-known phenomenon called confirmation bias to which highly experienced practitioners are most prone.
Our past experiences also teach us what is relevant. Errors occur when new or unusual circumstances happen in highly familiar situations. The nurse who picked up a vial of heparin in the wrong concentration had never experienced removing the wrong medication from an ADC cabinet before this event. The pharmacist who did not notice important information on a computer warning had rarely encountered a clinically significant computer alert. The nurse who picked the wrong pain medication from the narcotics cabinet did not remember making such an error in the past. Each of the practitioners in the examples above had subconsciously learned that there was nothing important to see when carrying out these tasks. Nothing had ever happened, so attention was automatically filtered away from the details to conserve mental processing.

Capacity.
The capacity to pay attention is variable from person to person and influenced by age and mental aptitude. From time to time, attention is also variable within an individual due to influences such as distractions, alcohol, drugs, and fatigue.
It is difficult to reduce the risk of inattentional blindness, as it is an involuntary and unnoticed consequence of our adaptive ability to defend against information overload. Error-reduction strategies such as education, training, and rules are of little value. Instead, efforts should center on increasing conspicuity of critical information, and decreasing diversions of attention and secondary tasks when carrying out complex tasks.
References: 1) Green M. “Inattentional blindness” and conspicuity. Visual Expert 2004 (www.visualexpert.com/Resources/inattentionalblindness.ht ml). 2) Angier N. Blind to change, even as it stares us in the face. The New York Times April 1, 2008 (www.nytimes.com/200 8/04/01/science/01angi.htm?_r=2&ex=1207713600&en=204&oref=slogin). 3) Federal Aviation Administration (FAA). FAA human factors awareness course. (www.hf.faa.gov/webtraining/Intro/Intro1.htm). 4) Arons B. A review of the cocktail party effect. MIT Media Lab; 1992. (www.media.mit.edu/speech/paper s/1992/arons_AVIOSJ92_cocktail_party_effect.pdf).

Updates and Spine Program

It's time to update this Blog!
A warm welcome to Prema Arulanantham who survived the George Brown Critical Care course and is now finished her orientation to PACU. Stacey Lauzon is currently in the GBC Critical Care Course, and we wish her continued success as she starts Phase 2 of the program.
Farewell to Betty Manino who remains within the PeriAnesthesia environmentand in the Endoscopy Clinic, and Nadiya Arkhipova who has returned to the TECC program.

The Surgical Short Stay Unit continues to expand! They are now up to 8 beds and patients now also include Spinal patients who stay for one night in the SSSU and are transfered to the Holland Centre in the morning.

For more information on the Spine Program, click HERE!

SDS Hand Hygiene Compliance rates

Late last year a hand hygiene audit was done in the SDS by a Master's student in Epidemiology. Her study included Pre-and Post InService data.

Here are the results. Good Job!!!

Hand hygiene compliance rates among RNs

	HH performed	HH opportunities	HH compliance
1st moment	3	52	6%
2nd moment	1	34	3%
3rd moment	8	21	38%
4th moment	19	63	30%
Overall compliance	31	170	18%

Post intervention - hand hygiene compliance rates among RNs

	HH performed	HH opportunities	HH compliance
1st moment	25	63	40%
2nd moment	10	27	37%
3rd moment	16	24	67%
4th moment	33	62	53%
Overall compliance	84	176	48%

Hand hygiene compliance rates among Anesthesiologists

	HH performed	HH opportunities	HH compliance
1st moment	2	7	29%
2nd moment	4	18	22%
3rd moment	2	2	100%
4th moment	2	10	20%
Overall compliance	10	37	27%

Post intervention hand hygiene compliance rates among Anesthesiologists

	HH performed	HH opportunities	HH compliance
1st moment	4	9	44%
2nd moment	1	8	13%
3rd moment	2	2	100%
4th moment	2	10	20%
Overall compliance	9	29	31%

The Day Surgery Unit demonstrated an overall HH compliance rate of 19% (220/41). By HCW, the HH compliance rate among the nurses was 18% (170/31) with the lowest compliance during the 1^st and 2^nd moment at 6% (52/3) and 3% (34/1), respectively. Among the anesthesiologists, the compliance rate was 27% (37/10), with lowest compliance during the 4^th moment at 20% (10/2). Post intervention, the compliance rate, among nurses, increased substantially. Within this group, HH compliance increased from 18% (170/31) to 48% (176/84). This increase in compliance was significant (p<0.001). With regards to the anesthesiologists, with whom the intervention was not performed, results indicated that HH compliance went from 27% (37/10) to 31% (29/9). This was shown to not be significant (p=0.768).

*** Please note that the intervention was only carried out with the nurses.

Surgical Site Infection

It has come to the attention at the Surgical Site Infection committee for General Surgery, that many patients are showing up for surgery and they have shaved the area where they think they are going to be operated on, at home.
The CDC Guidlelines recommends that patients are clipped (not shaved) just prior to going into the OR. This helps to prevent Surgical Site Infections (SSI’s).
The following guidelines were found in this article: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf


2. Operative Characteristics: Preoperative Issues
a. Preoperative antiseptic showering
A preoperative antiseptic shower or bath decreases
skin microbial colony counts. In a study of >700 patients
who received two preoperative antiseptic showers,
chlorhexidine reduced bacterial colony counts ninefold
(2.83102 to 0.3), while povidone-iodine or triclocarbanmedicated
soap reduced colony counts by 1.3- and 1.9-fold,
respectively.155 Other studies corroborate these findings.
156,157 Chlorhexidine gluconate-containing products
require several applications to attain maximum antimicrobial
benefit, so repeated antiseptic showers are usually indicated.
158 Even though preoperative showers reduce the
skin’s microbial colony counts, they have not definitively
been shown to reduce SSI rates.159-165
b. Preoperative hair removal
Preoperative shaving of the surgical site the night
before an operation is associated with a significantly higher
SSI risk than either the use of depilatory agents or no
hair removal.16,100,166-169 In one study, SSI rates were 5.6% in
patients who had hair removed by razor shave compared to
a 0.6% rate among those who had hair removed by depilatory
or who had no hair removed.166 The increased SSI risk
associated with shaving has been attributed to microscopic
cuts in the skin that later serve as foci for bacterial multiplication.
Shaving immediately before the operation compared
to shaving within 24 hours preoperatively was associated
with decreased SSI rates (3.1% vs 7.1%); if shaving
was performed >24 hours prior to operation, the SSI rate
exceeded 20%.166 Clipping hair immediately before an operation
also has been associated with a lower risk of SSI than
shaving or clipping the night before an operation (SSI rates
immediately before = 1.8% vs night before = 4.0%).170-173
Although the use of depilatories has been associated with a
lower SSI risk than shaving or clipping,166,167 depilatories
sometimes produce hypersensitivity reactions.166 Other
studies showed that preoperative hair removal by any
means was associated with increased SSI rates and suggested
that no hair be removed.100,174,175

I know that you are not encouraging patients to shave pre-op, but perhaps some patients think that they are ‘helping’ or perhaps they are modest and think that they can avoid having the doctor shave them in sensitive areas. At any rate, I will add a statement in out new PAC Booklet to emphasize that patients are NOT to shave themselves at their surgical site. Please emphasize this to the patients when you are doing your teaching.

Workshops

New Workshops Announced in Ontario!

Please check out the following from NursingLinks.ca to check out new dates for workshops.

Question & Answers Re: Droperidol

Thanks to Delia for requesting information regarding the correct route of Droperidol administration. As per the following emails, the end result is that Anesthesiologists should not be ordering Droperidol for PONV until it has been passed through the P&T committee.

Question:
Hi Helen (Zhong) and John (Iazzetta)
Recently there have been anesthesiologists ordering Droperidol for post-op nausea and vomiting in the PACU. I can’t seem to find it in the Sunnybrook formulary, nor under the IV authorization for Nurses. Is this a new medication being used at SB? If it is, the trend seems to be that we will be using it more frequently in PACU as drug of choice for PONV and it should be added to the above pharmacy sections.
Can you find out how it is meant to be given ie: can the RN’s push it (like gravol) or does it need to be hung in a minibag?
Thanks for clarifying, I look forward to your response!
Ramona


(email from John Iazzetta, Pharm.D.Drug Information Service)
As you may be aware, Jason is proposing revising the PONV algorithm, especially the rescue antiemetics. One change is the routine use of IV droperidol in the PACU. A major for this change are that it is considered by many to be the most effective antiemetic in the PONV setting.

The reason for it’s lack of use over the years is that case reports published years ago had associated it’s use with prolonged QT-interval and rarely, Torsade de Pointe. As a result of these reports the FDA required a black box to be included in the product monograph, warning of the potential for this arrhythmia. Because of the black box most anesthesiologists stopped using it because medical-legal concerns.

However, over the past few years the initial reports implicating droperidol have been critically reviewed by many experts in this area and concluded that the warning was unfounded because in the majority of cases there were other contributing factors and the doses used greatly exceeded the usual antiemetic doses used in PONV.

Many experts and consensus guidelines have concluded that droperidol is an effective and relatively safe antiemetic when used in low doses (eg 1mg) and for one or two doses. As safeguards, the anesthesiologists/APS should still screen patients who might be at risk for QT-prolongation and patients should undergo ECG monitoring during and for a brief period following the dose. In recalling my discussion with Jason, we agreed to administer the dose via a minibag, at least initially.

The plan is to take the revised PONV algorithm to P&T for approval, at which time we would request that the PACU nurses be authorized to administer droperidol IV. My suggestion is that the anesthesiologists be requested to not prescribe the drug with the expectation that the PACU nurses will administer until it is officially approved by P&T (pharmacy cannot add droperidol to the authorized IV list without P&T approval). In the interim, although it may not be practical, the physicians are free to administer droperidol IV at their discretion.

(From John)
Dr. Morningstar has responded to the email and has offered to review the literature on the efficacy and safety of IV droperidol for PONV and propose a protocol for its administration in the PACU. Unfortunately, because of scheduling conflicts the earliest we can present this issue at the P&T Committee is in April.

Until there is an approved protocol we would ask that that you please refrain from prescribing the drug.

Thank you for your cooperation.

John

A Nurse's Christmas Poem
T'was the week before Christmas,
and all through the floor,
The Lasix was filling
the Foleys galore.

Stockings were worn

to prevent emboli.

They came in two styles:

knee- and thigh-high.

The patients were nestled

half-assed in their beds,

While visions of stool softeners

danced in their heads.

We in our scrubs,

and they in their gowns

- Fashions created

to hide extra pounds.

When down in the E.R.

it became such a zoo.

They called for admissions

for me and for you.

They're coming, they're going,

they're looking the same.

My patience for patients

is starting to wane.

Now call lights are ringing, the patient expounds

"I have not had my peri-care, please send someone down."

So now delegation seems like a good plan.

We pass on to others the needs of this man.

When, what to my wondering eyes should appear

But Santa himself and 8 tiny reindeer.

He states that he came in from Central Supply

To bring us LR, NS, and D5.

The doctors then scribbled what no one could read.

Orders for patients, to measure their pee.

We try to decipher illegible words.

Orders for patients, to soften their turds.

The new shift arriving, our day is now through.

How'd the stool and the emesis get in my shoe?

We give them report and pass on the facts,

And tell them of Duoderm lining the cracks.

And the Nurses exclaimed as they drove out of sight,

"Ativan to all! And to all a good night!"

Which mask?

Hello Everyone,
There has been much confusion regarding which masks are to be worn for MRSA patients. I have contacted Barb Catt and the following is her response:

"In SB mask policy, all HCWs when required to wear a mask are to wear the PCM 2000 mask.
The exceptions include:
OR, surgical procedures the surgical mask is required (tied) and
then with those patients requiring airborne precautions which would be for example TB, then the N95 fit tested respirator is be worn by the HCW.
The only time that an ear loop mask is to be worn is with symptomatic patients who perhaps can be infectious with respiratory organisms and they need to go for a test and/or the visitors."
Barb

The Sunnybrook mask policy can be found HERE

Corporate Nursing Council Meeting

Have you ever wondered what is being discussed at the monthly Nursing Council Meetings held at the McLaughlin Auditorium? Here are the minutes. Sandi and Betty will be taking turns attending, but anyone who is interested in becoming involved, please step forward.

NURSING COUNCIL MEETING
MINUTES
DATE: - November 26, 2008

Location: Sunnybrook, McLaughlin Auditorium EG 18a
Co-Chair: Julie Diemert, RN, BScN, SB Site
Co-chair: Anita Long, RN, BSN, SB Site
Recorder: Aaron Dumanat, RPN, Holland Site



Agenda Item
Issue/Discussion
Decision/Action
Gathering of Community & Call to Order
Called to order at 0740

Review Agenda & Approval of Minutes
Read over, and a few grammatical/spelling corrections made
Sophie Baranik, Bridget Jackman
Announcements & Comments
Obstetrics Rounds – Friday Nov 28
4th Annual Oncology Education day on Feb 12
Recertification Schedule: (WHMIS, Fire safety etc)
Organizational Workshops
RNAO- E-health workshop
Quality Improvement workshop on December 10 & 11
A Culture of Inclusion Sessions
Advisory meeting held for the future goals of Nursing
Brief report on NAC retreat. New Grad Initiative- Unfortunately a decrease in funding in the next year.

Welcome New Members
K1C, C2, C6

Professional Practice Updates
Frances Flint & Cathy O’Neil
Developing a policy for hand over protocol for the tri-campus to increase patient safety. Template given to members to review. Protocol to help decrease workload for nurses.
Add neurological status to the form, pain management, nutrition status, and family contact number. Travel Pass for a patient from diagnostic imaging. Include RPN, HFN/Armband check, special treatment, language spoken, lab/diagnostics pending, main service contact, include documentation of when patient has left the floor as well as when nurse gave report to the receiving nurse & list of units. Accountability in the policy.
Pilot: Holland Centre(3E), C3, and P & G.
Bladder Scanner
Due to the weather conditions, deferred to next month.

Nursing Rounds: Continence Care
Sue Sebastian
Becoming 21st Century Nightingale. Time spent in China. BNCC = Beijing Nightingale Consultation Corporation Limited. To share with our continence program with China’s Nursing Body. Goal: To promote bladder/bowel function to eligible patients.
Presentation to be sent out.
Open Session with EVP, Programs/Chief Health Professions and Nursing Executive
Confirmation for the New Grad Initiative for 2009/10 funding.
December 5th, a big meeting with the directors, PCM for how to recruit new grads for next year and to confirm going forward with the externs next year.
The Resource Pools are growing, still need to develop more.
No new money expected after 2009/10 for the corporate budgets.
We have 10 CCAC managers. There is increased funding to help with the patients who need ALC (funding for patients to have increased CCAC services so they can remain at home while waiting for placement).
New Nursing Clinic set up at CNIB for IV antibiotic treatment, dressing changes etc.
Christian (PCM) is looking at developing a plan for helping with the orientation of Internationally Educated Nurses.
Communicating with Care Program will have Internationally Educated Nurses be buddied with a staff nurse to observe the staff nurse interacting with the different groups.
ABC program: with the University of Toronto to have the nursing students who have a degree and are now going for their nursing degree to pre-select the hospital where they will do all their clinical placements.
NAC Retreat: missing representatives from the NC. Set goals and objects for the next two years.
Input to be given to Sue for where we would see Nursing in the next 18 months.
Follow up to develop strategies to improve participation.
Reports from Workgroups
Best Practice: Presented the results from the survey that was done by the nursing council members
Nursing Voice/Nursing Rounds: Reviewed the Terms of Reference
Nursing Research: Went to the Library and spoke with Henry and had help to use the online resources and have been able to tighten up the question.
Information & Technology: RNAO eHealth champions workshops (fill out the application to attend with a letter of recommendation from management), RNAO education day happening at Sunnybrook in February
New Member Orientation: Three new members

Adjournment
Next Meeting – December 17, 2008, Sunnybrook, McLaughlin Auditorium (EG18a)

Survey Monkey

Hello Everybody!
SPANC is trying hard to collect as much information as possible for the PeriAnesthesia Handover tool to make it as user-friendly as possible. Your input from Survery Monkey would be very much appreciated. Click Here to take survey It's quick! It's easy! Your opinion is valued!

Quiz of the Month

Laurie Mahoney has been so kind as to forward a Neuro Quiz from The Foothills Hospital in Calgary. Thought I'd pass it on to you (though I tweaked it a bit)


1. The internal reference point, when levelling intracranial EVD’s is called:____________
2. The external reference point, when levelling intracranial EVD’s, is located: ____________
3. Lumbar EVDs are “typically” levelled to the area of insertion site or area of injury.
True or False
4. Flushing of the EVD transducer may only be performed when the waveform is dampened or is absent and other, less invasive, troubleshooting methods have been tried. List 5 less invasive, troubleshooting methods that must be tried prior to flushing the transducer.
5. Is it possible for a Richmond Screw to have a drainage system attached? Y or N
6. Is it possible to monitor ICP with a Richmond Screw? Y or N

7. You are setting the ICP alarm limits on the monitor but the physician has given you no guidelines. What should you set your high ICP alarm at?

8. List 3 common nursing interventions that are employed in PACU for control/maintenance/management of ICP.

9. What does CPP tell us?
10.What is considered to be an acceptable CPP?
11. What are the 4 major components of a neurological assessment?

12. The Glasgow Coma Scale is:
a. is always a 15 point scale
b. measures level of conscious sedation
c. less valid when used by inexperienced users
d. only scale where you can be dead and still score a 3

13. When assessing pupil size, it is most appropriate to measure and document AFTER testing reactivity to light. True or False



ANSWERS:
1. Foramen of Monroe
2. Between the outer aspect of the eye and top of the ear
3. True
4. http://sunnynet.ca/Default.aspx?cid=100244-100445-100446-100675
5. http://sunnynet.ca/Default.aspx?cid=100676&lang=1
6. http://sunnynet.ca/Default.aspx?cid=100749&lang=1
7. http://sunnynet.ca/Default.aspx?cid=100749&lang=1
8.
Adequate oxygenation, maintaining normal C02 levels
Control of N+V
HOB 30 or as ordered
Head and neck properly aligned
Normothermia
Accurate I+O
Adequate pain control
Seizure prophylaxis
Quiet environment
9. The adequacy of the perfusion to the brain
10. 60-70, 70 being more ideal for adequate perfusion
11. pupil response, GCS, VS, sensory and motor power
12. c
13. False