I found the following information on the Opana Website and was wondering what you thought? SDS has been doing a great job capturing all the patients that require pre-op warming (laparotomy patients). Patients are warmed with the Bair Hugger blankets and we will find out in the coming months whether the SSI (surgical site infection) rate is down.
My question for the PACU nurses is the following: currently our discharge criteria from PACU is 35.5 degrees C. OPANA and Safer Healthcare Now indicates tha Best Practice is that normothermia is 36-38 degrees C. Do you think that we should change our discharge criteria to 36 degrees C to support Best Practice?
OPANA recommends the following guidelines to maintain normothermia in the perioperative area. Please remember that your institution's policies and the recommendations of your anesthesia departments may not concur with the following guidelines and must supersede these standards. All information given below is referenced and is based on evidence found in the literature written on this subject.
Background:
In 2002, researchers conducted a point prevelance survey of nosocomial infections among 6,745 patients in 29 Canadian acute care hospitals across nine provinces. Canadian surgical site infection rates were found to account for 21% of five types of infections surveyed, ranking third most common in nosocomial infections. (1)
Surgical Site Infections can increase mortality, readmission rate, length of stay and cost for patients who incur them. While rate of surgical site infection ranges between 2-3% for clean cases, an estimated 40-60% of these infections are preventable. (2)
The Canadian Patient Safety Institution was developed to look into these and other risks to patients in hospitals. Subcommittees were organized to focus on specific areas of the healthcare environment where patients may be at risk of injury or nosocomial insult. The campaign to deal with Surgical Site Infections and other potential risks to patients in hospital, was the "Safer Healthcare Now!" campaign. It focussed on 10 areas of healthcare with high rates of negative outcomes which were occurring predominantly in Intensive Care Units, Surgical Suites, geriatric and medical inpatient units. (3)
One of the topics that Safer Healthcare Now! focussed on, that is most relevant to the perianesthesia nursing group, was "Surgical Site Infection", based on the above findings from the research.
Goal of the Safer Healthcare Now! Intiative for Surgical Site Infections:
"Prevent Surgical Site Infections (SSI) and deaths by reliably implementing ideal perioperative care for all surgical patients." (3)
After investigation and searching the literature into studies in this field, the contributing factors for negative outcomes related to surgical site infections were determined and were categorized into just 4 main groupings. Interventions for consideration and implementation, based on evidence in the research that was related to these infection rates, were then recommended.
Interventions for the Prevention of Surgical Site Infections:
1. Appropriate use of prophylactic antibiotics (including appropriate selection, timing and discontinuation)
2. Appropriate hair removal at the surgical site: minimally, and if necessary, clipping of hair rather than shaving
3. Maintaining post-operative glucose control for major cardiac surgery patients cared for in an ICU
4. Perioperative normothermia for all open abdominal surgery patients
**Note: Normothermia: Medical literature suggests that patients have a decreased risk of surgical site infection if they are not allowed to become hypothermic at any time during the perioperative period. Although temperature control may benefit other surgical patients, such as intentional therapeutic hypothermia for hypothermic cardioplegia, for the SHN campaign this measure only applies to the colorectal or open abdominal surgical population for the purposes of national measurement. Open abdominal surgery includes all open urology, nephrectomies, prostatectomies, hysterectomies, excluding vaginal hysterectomies, thoracic, pneumonectomies and pulmonary thoracic surgeries.(2)
Contributing Factors for Hypothermia:
Extremes of age
Females
BMI
Length and type of surgical procedure
Cold irrigants and wet skin preparations
Fluid shifts
Room temperature
Comorbidites (the presence of large open wounds, endocrine diseases, pregnancy, burns, peripheral vascular disease)
Type of anesthesia used (general, regional)
Anxiety
Negative Outcomes from Hypothermia:
Surgical site infection (impaired wound healing)
Patient discomfort (shivering)
Increased need for blood products (impaired platelet function, reduced coagulation)
Altered drug metabolism
Unexpected, negative cardiac events
Increased need for mechanical ventilation
Reducing the Risk of Hypothermia in the Perioperative Visit:
The prevention of Surgical Site Infections from hypothermia in the open abdominal surgery, and in any surgical group, can be accomplished or reduced by maintaining a normal temperature (36º - 38º C) through all stages of the perioperative course:
a) Preoperative warming of patients: warm flannel blankets from electric blanket warming cabinets, forced-air convection "housecoats", clothing to cover patients' extremeties and heads, preoperative monitoring of patient temperature, observation of overt indicators of hypothermia (regardless of core temperature): shivering, peripheral vasoconstriction, piloerection
b) Intraoperative warming of patients: warm fluids such as intravenous and irrigants, blood warmers, continuous monitoring of patient temperature (core preferable, tympanic) throughout the procedure, humidified and warm gases, warming blanket under patient on the operative table
c) Postoperative warming of patients: warm flannel blankets from electric blanket warming cabinets, forced-air convection blankets, circulating water mattresses, warm IV fluids, immediate and frequent monitoring of patient temperature until normalized (core preferable, tympanic), observation of overt indicators of hypothermia (regardless of core temperature): shivering, peripheral vasoconstriction, piloerection
Outcome Indicator: The postoperative surgical patient will have a normal temperature between 36.0º - 38.0º C in the PostAnesthesia Care Unit. (2)
Data collection for the SSI Campaign for Normothermia, Inclusion/Exclusion Criteria:
1. Total number of patients during this month who had an inpatient surgical procedure of this type (colorectal surgery). If more than one surgical procedure was performed during a single index hospitalization, include data only from the first surgical procedure.
2. Exclude patients whose age is less than 18 yrs on admission to hospital.
3. Exclude patients whose principal diagnosis code or admission diagnosis is suggestive of a preoperative infectious disease
4. Exclude patients who were admitted for treatment of burns or for organ transplantation (3)
Goal Rate:
95% patients who have undergone open abdominal surgery, or colorectal surgery specifically, will have documented postoperative temperatures in the range of 36.0º - 38.0º C. (3)
PeriAnesthesia Nursing Interventions:
1. Preoperatively: PreAdmission Units can instruct patients to bring their own warm housecoats, slippers, pyjama bottoms and headwear to the hospital for the day of surgery.
On the day of surgery, a preoperative temperature should be taken. Monitoring patients for obvious signs of hypothermia is necessary (shivering, peripheral vasoconstriction, piloerection). Patients should wear their own housecoats, socks, pyjama bottoms and headwear until entering the Operating Room. Only after induction of anesthesia should the clothing be removed (it may be necessary to have the patient remove his own outer "housecoat" prior to general anesthesia) and only the clothing that is necessary to remove in order to access the surgical site.
Any signs of infection (fever, rigor) should be reported to a healthcare professional on the morning of surgery and prior to entering the Operating Room.
2. Postoperatively: Post Anesthetic Care Units and Day Surgery Units should monitor postoperative temperatures IMMEDIATELY upon admission from the Operating Room and document these on the postoperative document (paper or online). Temperatures outside of the range of 36º - 38º C should be treated at once (warming measures should begin at once if temperature less than 36º C; report temperatures greater than 38º C to the surgical team for immediate treatment).
Once measures for treatment have been taken, postoperative temperatures should be taken every 30 minutes until the patient's temperature is within normal range. Once normothermia has been reached, frequent postoperative temperature tracking is no longer necessary in the PACU/DSU environment until just prior to transfer or discharge, unless other signs of hypothermia appear: shivering, peripheral vasoconstriction, piloerection. Complete documentation on the patient's chart of all temperatures should be recorded.
Written by Paula Ferguson
References:
1. Brennan. N Engl J Med. 1991; 324: 370-376.
2. CIHI Healthcare Canada, 2004. Unpublished data from D. Gravel, the Point Prevelance Working Group, the Canadian Nosocomial Infection Surveillance System, the Canadian Hospital Epidemiology Committee, "Point Prevalence Survey of Nosocomial Infections Within Seleced Health Care Insitutions" (2004).
3.www.saferhealthcarenow.ca
Monday, October 27, 2008
Thursday, October 16, 2008
QUICK ECG Interpretation
Steps to Interpretation
1: Rhythm Analysis
Interpret ECG rhythm at bottom of 12 lead
Measure PR, QRS, QT
Analyze rate, regularity
2: Lead Grouping
Group the leads that reflect each wall of the left ventricle
Inferior Wall ––II, III, aVF (sometimes V4)(RCA AFFECTED)
Lateral Wall ––aVL, I, V5, V6 (CIRCUMFLEX AFFECTED)
Septal Wall ––V1 (RCA AFFECTED)
Anterior Wall ––V2, V3, V4 (sometimes Lead I)(LAD AFFFECTED)
3: Assess Each Grouping
Ischemia--ST Depression
Injury--ST elevation
Infarction--possible Q wave
Damage as cardiac tissue depleted of oxygen escalates with time from ischemia, injury to infarction.
Damage will be displayed in only leads facing the injured myocardium
Friday, October 10, 2008
New Staff Members
I have been late welcoming Stacey to PACU on this Blog. Stacey is a New Grad who recently graduated from the University of Windsor, and passed her RN's with flying colours in June. Stacey (and her sister!) Shelley have been working together through her Preceptorship in PACU and from what I've heard, it has been a wonderful opportunity for both of them.
Tuesday, October 7, 2008
Care of the Pre-Operative Opthalmic Surgical Patient
Care of the Pre-Operative Opthalmic Surgical Patient
•Advances in opthalmic surgical techniques and improved anesthetics have lessened the duration of the Peri-op and Post-op period.
•Most surgeries are completed within an hour.
•The goal of management is to maximize patient’s level of comfort using the least amount of sedation.
•Advances in opthalmic surgical techniques and improved anesthetics have lessened the duration of the Peri-op and Post-op period.
•Most surgeries are completed within an hour.
•The goal of management is to maximize patient’s level of comfort using the least amount of sedation.
Discharge planning is coordinated in the Surgeon’s office pre-operatively. Patients must have a responsible adult drive them home and stay with them for the first 24 hours.
•Communication between the Circulating RN, the Block RN and Anesthesia is essential due to the quick turnover of cases.
•Efficient and effective time management while maintaining patient focused care is vital
Common Opthalmic Surgeries
Cataract Surgery
Normal Eye: A healthy, clear lens allows a sharp image to fall on every part of the retina allowing a crisp, clear image to be seen.
Cataract Eye: A cloudy lens scatters light, causing a hazy image to be seen.
•Usually less than 45 minutes
•Outpatient procedure
•Almost painless
•Usually only topical anesthetics (eye gtts) and lidocaine gel
VITRECTOMY
•a surgical procedure in which instruments are introduced into the eye to treat or repair various diseases and conditions of the retina and vitreous.
•performed under local anesthesia and in an ambulatory or outpatient operating room.
•30 minutes to 2 hours depending on the nature of the condition and the complexity of the operation.
•Some of the diseases that can be treated with a vitrectomy include retinal detachment, diabetic retinopathy, macular hole.
TRABECULECTOMY
•Patients with dangerously high IOP (glaucoma) that can not be treated with eye gtts, may require a trabeculectomy.
•a "flap valve" is made on the top of the eye, the white part of the eye hidden under the upper eyelid. This becomes a bypass for the blocked natural drain relieving the eye pressure
PRE-OP EYE DROPS
•Orders checked by Surgeon on the Department of Opthalmology Surgical Record
•Started 1 hour pre-op in SDS, continued in Block area
•Located on the SDS drug cart and pre-bagged.
MYDRIATICS AND CYCLOPLEGICS
Mydriatics dilate the pupil - tropicamide
- phenylephrine
Cylcoplegics dilate the pupil and cause paralysis of accommodation (inability to focus) -tropicamide
-cyclopentolate
-homatropine
NSAID
•Flubiprofen gtts
- Inhibition of intra-operative miosis (constriction) and inflammation of the eye.
TOPICAL AGENTS
•Tetracaine 0.5% gtts routinely used and given as prescribed by Anesthesia.
–Currently no standing order, but anesthesia will give a verbal
–Onset of action 5-10 seconds
–Gtts go in both eyes
–Located in blue bin on shelf in Block area
–Lidocaine gel is sometimes instilled by anesthesia to complete block
BLOCK MEDS
•Rovicaine/ Lidocaine
•Hyaluronidase: an enzyme that inactivates the Collagen Tissue
1. Less quantity of the anaesthetic solution required when the enzyme is used.2. Greater diffusion of the anaesthetic solution 3. Prolonged effect of the injected solution.
NURSING CONSIDERATIONS
•Instillation of gtts improve with tilting pts head upward
•place first gtt inside the lower lid
•Other drops may be instilled from above with pt looking downward.
•Avoid placing gtts on cornea
•The natural blinking of the eye distributes the drug
•Avoid touching the tip of the applicators to any part of the eye
ROLE OF THE BLOCK NURSE
•Admit pt to block area, receive report from SDS RN – when is next gtt due?
–TIP: at bottom of SDS nursing record the schedule will be noted ie:
•#1 0900 KL #2 0915 #3 0930 #4 on call
•Identify correct pt: check armband, check allergies
•Confirm laterality of operative site. SDS RN usually marks operative side with surgical marker, if it is not done, Block RN can do it.
•In order to increase efficiency, the Block RN will do the check on the OR side of the pre-operative checklist. This is necessary also, because as the Block Nurse, you also want to ensure that everything is complete and accurate before the anesthetist gives the block
–Anesthetic record
–H&P
–Consent
–Etc.
–NOTE: pt’s on anticoagulant therapy need a recent InR
•Ensure pt has voided
•Ask pt to move up on stretcher so head fits comfortably in the head support. TIP: place a rolled blanket under pt’s neck
•Place a blanket under pt’s knees
•Apply ECG lead and BP cuff. These will remain on for the entire surgical procedure (the leads will be returned with the next patient)
•NP can be applied and O2 turned on once versed is given by anesthesia
•Continue with the application of gtts. Communicate with anesthesia when you have given the 3rd dose
•Tetracaine gtts: 3 gtts OU intervals of 1 gtt per eye
•Topical Betadine solution to operative eyelid
•Anesthesia then ready to inject local anesthetic and the BLOCK
•After block, eye is taped shut to prevent corneal abrasions
•Monitor VS q5min until transfer to OR 18
HONAN BALLOON
•A Honan Balloon is sometimes used, especially with Dr. Dixon’s patients.
GUIDELINES FOR USING THE HONAN BALLOON
•All patients should be monitored for signs of bradycardia (Oculocardiac reflex) while pressure is being applied to the eye.
•The optimum pressure to be used should be well below pressure in the central retinal artery. Using the 20 to 30 mm Hg of monitored pressure for 30 to 60 minutes before surgery, clinically results in very soft, safe, surgical eyes. With a soft eye excess vitreous pressure is typically absent.
•Also encourages the block anesthetic agent to be absorbed posteriorly
•Some surgeons believe that when using the balloon, Intraocular lens implantation is much easier and safer. From the surgeon’s viewpoint, there is much less stress and strain.
RETROBULBAR BLOCKS
•Most anesthetists prefer to do Peri-bulbar Blocks, however some (Dr. O) likes the Retrobulbar as that is what he was trained to do. It used to be the ‘Gold Standard’
•Retro-bulbar is a longer needle, but uses less anesthetic. Drug is placed intraconally (between the rectus muscles and the optic nerve)
•slightly higher chance of Brainstem anesthesia
PERIBULBAR BLOCKS
•Local anesthetic agents are placed within the orbit, but do not enter the area of the cone of the rectus muscles.
•It was introduced as a safer method, but complications have also been reported.
•Local anesthetic agents are placed within the orbit, but do not enter the area of the cone of the rectus muscles.
•It was introduced as a safer method, but complications have also been reported.
Medial Canthus Peribulbar Block
Infero-temporal Peribulbar Block
•The signs of a succesful block are:
•Ptosis (drooping of the upper lid with inability to open the eyes)
•Either no eye movement or minimal movement in any direction (akinesia)
•Inability to fully close the eye once opened.
•Since the local anaesthetic is placed outside the muscle cone the concentration around the optic nerve may not be sufficient to abolish vision completely. Some light perception will therefore remain; however the patient is not able to see the operation.
COMPLICATIONS OF BLOCKS
Potential for:
•Seizures: treat like any other seizure: ABCD’s
•Vasovagal: from muscle tugging—vagal stimulant—bradycardia: treat with atropine
•Brain stem paralysis: observe change in LOC, RR, HR—will need critical care support: EMERGENCY!
•Hemorrhage: arterial/venous
•Perforation of the globe: Treatment is Vitrectomy
Notice how anesthetist asks pt to try to keep eye open during block. They are looking for tugging and twitching. If suspected will withdraw needle and reinsert
Tuesday, August 26, 2008
Necessary EKG Workshop
Marye Kellermann, creator of the NECESSARY NP REVIEW, will present one of her most popular workshops: NECESSARY EKG, in Toronto on September 15, 2008.
This workshop is for anyone who knows nothing about rhythm strips and EKGS , or knows an little, but fears a lot……nurses, faculty, nursing students, NP’s, NP students, EKG techs, medical students and physicians.
Date: Monday Sept. 15, 2008
Time: 8:00AM till 4:00 PM
Where: Sunnybrook HealthSciences Centre Room D 506 ( D wing , 5 th floor)
Contact Hours: 8.4
Cost: Please refer to the registration form for pricing schedule and refund policy
To register for this outstanding workshop simply complete and mail the registration form and cheque to the address provided. Register before August 25, 2008 to receive the early bird price.
These workshops are presented using accelerated adult learning techniques, developed by Dr. Howard Gardner of Harvard University and used by Marye over the past twenty years. She has used these proven techniques with thousands of nursing students and practicing nurses to prepare them for nursing exams, as well as providing continuing education.
Marye Dorsey Kellermann, RN,MSN,CRNP, is an international speaker, author and is the creator of the NECESSARY WORKSHOPS. She has been nominated for the National League for Nursing’s award for Outstanding Leadership in Education , as well as being nominated in 2004 for the Outstanding Educator Award - National Organization of Nurse Practitioner Faculties.
This workshop is for anyone who knows nothing about rhythm strips and EKGS , or knows an little, but fears a lot……nurses, faculty, nursing students, NP’s, NP students, EKG techs, medical students and physicians.
Date: Monday Sept. 15, 2008
Time: 8:00AM till 4:00 PM
Where: Sunnybrook HealthSciences Centre Room D 506 ( D wing , 5 th floor)
Contact Hours: 8.4
Cost: Please refer to the registration form for pricing schedule and refund policy
To register for this outstanding workshop simply complete and mail the registration form and cheque to the address provided. Register before August 25, 2008 to receive the early bird price.
These workshops are presented using accelerated adult learning techniques, developed by Dr. Howard Gardner of Harvard University and used by Marye over the past twenty years. She has used these proven techniques with thousands of nursing students and practicing nurses to prepare them for nursing exams, as well as providing continuing education.
Marye Dorsey Kellermann, RN,MSN,CRNP, is an international speaker, author and is the creator of the NECESSARY WORKSHOPS. She has been nominated for the National League for Nursing’s award for Outstanding Leadership in Education , as well as being nominated in 2004 for the Outstanding Educator Award - National Organization of Nurse Practitioner Faculties.
Friday, August 22, 2008
Upcoming Conferences
1. Just a reminder that the Early Bird deadline for the OPANA Conference is August 31st.
2. This conference information arrived in my email today and I thought I would pass it on. Some of the speakers sound fascinating.
2. This conference information arrived in my email today and I thought I would pass it on. Some of the speakers sound fascinating.
Wednesday, August 13, 2008
Would you like to attend a conference, but never seem to be able to take the time off work? Now you can go to a conference every day from the comfort of your own home, on your break, or when you have some downtime at work. Consider it educational research!
(Click below to redirect yourself to the site)
(Click below to redirect yourself to the site)
24 hours a day/7 days a week/365 days a year!
Wednesday, July 30, 2008
Fentanyl transdermal patch and fatal adverse reactions
This article was forwarded to me by Pharmacy and comes from The Canadian Adverse Reaction Newletter. I thought it might be of interest to you.
The fentanyl transdermal system is indicated for the management of moderate to severe chronic pain that cannot be managed by other means such as opioid combination products or immediate-release opioids.1 The safety of this system is contingent on its use according to the conditions recommended in the Canadian product monograph.1 The fentanyl transdermal system has been marketed in Canada under the brandname Duragesic since 1992. In July 2006, 2 generic products were introduced: Ratio-Fentanyl and Ran-Fentanyl transdermal systems.
Health Canada continues to monitor reports of serious adverse reactions (ARs) suspected of being associated with fentanyl transdermal patches. Fatal outcomes were previously described in this newsletter involving opioid-naive adolescents and adolescents who abused this medication.2,3 The Canadian product monograph for Duragesic was revised in 2005 to emphasize safety information following reports of death related to inappropriate use of this product. Related advisories were issued in September 2005.4,5 Numerous publications have highlighted safety issues related to the use of fentanyl patches.6‑9
From Jan. 1, 1992, to Dec. 31, 2007, Health Canada received 105 reports of ARs suspected of being associated with fentanyl transdermal patches wherein a fatal outcome was reported. Twenty-seven of the reports were received after the last Health Canada risk communications.4,5 As part of the ongoing monitoring of AR reports, the data were analyzed to identify potentially preventable incidents and to increase awareness regarding the safe use of this product. In 33 of the 105 reports, the cause of death was reported to be unrelated to the fentanyl transdermal patches; in 20 cases, insufficient information was provided in the report for evaluation. The remaining 52 reports are summarized in Table 1.
Health care professionals are reminded to follow the directions in the product monographs for fentanyl transdermal patches.1 Guidance on the safe use of this product is essential for patients, caregivers and their families, including the safe storage of fentanyl patches to prevent their accessibility for abuse and prevention of accidental overdose.
Marielle McMorran, BSc, BSc(Pharm); Maria Longo, BScPharm, Health Canada
Acknowledgement: Health Canada acknowledges the collaboration with Sylvia Hyland, RPh, BScPhm, MHSc (Bioethics), of the Institute for Safe Medication Practices Canada (ISMP Canada) and member of the Expert Advisory Committee on the Vigilance of Health Products, in the analysis of this data and preparation of this article.
____________________________________________________________________
Table 1: Summary of reports of 52 adverse reactions with a fatal outcome suspected of being associated with fentanyl transdermal patches submitted to Health Canada from Jan. 1, 1992, to Dec. 31, 2007*,†
Dose initiation and titration (6 Adverse Reactions-AR) Prescribed to opioid-naive patient (3 cases). Initiation dose high (1 case). Dose titration too quick (2 cases) Concomitant use with other central nervous system (CNS) depressants ( 1 case)
Death occurred within 24 hours after initiation of 100-µg/h fentanyl patch. Cause of death reported as probable central nervous system depression due to combination of fentanyl with other CNS depressants. (1 case)
Drug interaction between fentanyl and CYP3A4 inhibitor (1case) Death occurred less than 4 days after initiation of lopinavirBritonavir (Kaletra), a CYP3A4 inhibitor, during fentanyl therapy
Application of patch by patient (6cases total)
Patient applied more patches than prescribed (4 cases). Patient left old patches on when applying new patch (1 case). Patient changed patch every day instead of every 3 days (1 case)
Application of patch by caregiver (3cases)
Health care professional folded patch in half in attempt to reduce dose (1 case). Health care professional left old patches on when applying new patch (1 case). Caregiver damaged patch by pressing on it because it would not stick; fentanyl gel leaked and patient died of accidental overdose overnight (1 case)
Use of patch prescribed for another patient ( 1 case) To treat back pain, a 64-year-old man applied a 50-µg/h fentanyl patch that had been prescribed for his spouse. The patient was found unresponsive, having vomited and aspirated, and died 5 days later from pneumonia and renal failure
Accidental overdose or overdose effect (5 cases) Patient was elderly and had lean body weight
(1 case). Patient died of cardiac arrhythmia due to accidental overdose of fentanyl and elevated levels of antidepressant (1 case). Patient found dead with toxic level of fentanyl after second dose of 25-µg/h patch (1 case). Limited information provided in 2 cases
Intentional overdose or suicide (4 cases)
Intentional drug abuse (25 cases) Cases described abuse of fentanyl patches
* These data cannot be used to determine the incidence of adverse reactions (ARs) because ARs are underreported and neither patient exposure nor the amount of time the drug was on the market has been taken into consideration.
† The analysis is based on the information as reported in the cases.
_____________________________________________________________
References
1. Duragesic (fentanyl transdermal system) [product monograph]. Toronto: Janssen-Ortho Inc; 2007.
2. Raymond B, Morawiecka I. Transdermal fentanyl (Duragesic): respiratory arrest in adolescents. Can Advers Reaction News 2004;14(4):1-2.
3. Raymond B. Trandermal fentanyl (Duragesic): abuse in adolescents. Can Advers Reaction News 2005;15(3):1.
4. Duragesic (fentanyl transdermal system) safety information [Dear Health Care Professional letter]. Ottawa: Health Canada; 2005 Sept 13. (accessed 2008 Jun 3).
5. Duragesic (fentanyl transdermal system) safety information [public advisory]. Ottawa: Health Canada; 2005 Sept 16. (accessed 2008 Jun 3).
6. Transdermal fentanyl: a misunderstood dosage form. ISMP Canada Safety Bull 2006;6(5).
7. Fentanyl patch linked to another death in Canada. ISMP Canada Safety Bull 2007;7(5).
8. Ongoing, preventable fatal events with fentanyl transdermal patches are alarming! Horsham (PA): Institute for Safe Medication Practices; 2007 June 28.
9. Fentanyl transdermal system (marketed as Duragesic and generics) information for Healthcare Professionals. Rockville (MD): US Food and Drug Administration; 2007 Dec 21. (accessed 2008 Jun 3).
The fentanyl transdermal system is indicated for the management of moderate to severe chronic pain that cannot be managed by other means such as opioid combination products or immediate-release opioids.1 The safety of this system is contingent on its use according to the conditions recommended in the Canadian product monograph.1 The fentanyl transdermal system has been marketed in Canada under the brandname Duragesic since 1992. In July 2006, 2 generic products were introduced: Ratio-Fentanyl and Ran-Fentanyl transdermal systems.
Health Canada continues to monitor reports of serious adverse reactions (ARs) suspected of being associated with fentanyl transdermal patches. Fatal outcomes were previously described in this newsletter involving opioid-naive adolescents and adolescents who abused this medication.2,3 The Canadian product monograph for Duragesic was revised in 2005 to emphasize safety information following reports of death related to inappropriate use of this product. Related advisories were issued in September 2005.4,5 Numerous publications have highlighted safety issues related to the use of fentanyl patches.6‑9
From Jan. 1, 1992, to Dec. 31, 2007, Health Canada received 105 reports of ARs suspected of being associated with fentanyl transdermal patches wherein a fatal outcome was reported. Twenty-seven of the reports were received after the last Health Canada risk communications.4,5 As part of the ongoing monitoring of AR reports, the data were analyzed to identify potentially preventable incidents and to increase awareness regarding the safe use of this product. In 33 of the 105 reports, the cause of death was reported to be unrelated to the fentanyl transdermal patches; in 20 cases, insufficient information was provided in the report for evaluation. The remaining 52 reports are summarized in Table 1.
Health care professionals are reminded to follow the directions in the product monographs for fentanyl transdermal patches.1 Guidance on the safe use of this product is essential for patients, caregivers and their families, including the safe storage of fentanyl patches to prevent their accessibility for abuse and prevention of accidental overdose.
Marielle McMorran, BSc, BSc(Pharm); Maria Longo, BScPharm, Health Canada
Acknowledgement: Health Canada acknowledges the collaboration with Sylvia Hyland, RPh, BScPhm, MHSc (Bioethics), of the Institute for Safe Medication Practices Canada (ISMP Canada) and member of the Expert Advisory Committee on the Vigilance of Health Products, in the analysis of this data and preparation of this article.
____________________________________________________________________
Table 1: Summary of reports of 52 adverse reactions with a fatal outcome suspected of being associated with fentanyl transdermal patches submitted to Health Canada from Jan. 1, 1992, to Dec. 31, 2007*,†
Dose initiation and titration (6 Adverse Reactions-AR) Prescribed to opioid-naive patient (3 cases). Initiation dose high (1 case). Dose titration too quick (2 cases) Concomitant use with other central nervous system (CNS) depressants ( 1 case)
Death occurred within 24 hours after initiation of 100-µg/h fentanyl patch. Cause of death reported as probable central nervous system depression due to combination of fentanyl with other CNS depressants. (1 case)
Drug interaction between fentanyl and CYP3A4 inhibitor (1case) Death occurred less than 4 days after initiation of lopinavirBritonavir (Kaletra), a CYP3A4 inhibitor, during fentanyl therapy
Application of patch by patient (6cases total)
Patient applied more patches than prescribed (4 cases). Patient left old patches on when applying new patch (1 case). Patient changed patch every day instead of every 3 days (1 case)
Application of patch by caregiver (3cases)
Health care professional folded patch in half in attempt to reduce dose (1 case). Health care professional left old patches on when applying new patch (1 case). Caregiver damaged patch by pressing on it because it would not stick; fentanyl gel leaked and patient died of accidental overdose overnight (1 case)
Use of patch prescribed for another patient ( 1 case) To treat back pain, a 64-year-old man applied a 50-µg/h fentanyl patch that had been prescribed for his spouse. The patient was found unresponsive, having vomited and aspirated, and died 5 days later from pneumonia and renal failure
Accidental overdose or overdose effect (5 cases) Patient was elderly and had lean body weight
(1 case). Patient died of cardiac arrhythmia due to accidental overdose of fentanyl and elevated levels of antidepressant (1 case). Patient found dead with toxic level of fentanyl after second dose of 25-µg/h patch (1 case). Limited information provided in 2 cases
Intentional overdose or suicide (4 cases)
Intentional drug abuse (25 cases) Cases described abuse of fentanyl patches
* These data cannot be used to determine the incidence of adverse reactions (ARs) because ARs are underreported and neither patient exposure nor the amount of time the drug was on the market has been taken into consideration.
† The analysis is based on the information as reported in the cases.
_____________________________________________________________
References
1. Duragesic (fentanyl transdermal system) [product monograph]. Toronto: Janssen-Ortho Inc; 2007.
2. Raymond B, Morawiecka I. Transdermal fentanyl (Duragesic): respiratory arrest in adolescents. Can Advers Reaction News 2004;14(4):1-2.
3. Raymond B. Trandermal fentanyl (Duragesic): abuse in adolescents. Can Advers Reaction News 2005;15(3):1.
4. Duragesic (fentanyl transdermal system) safety information [Dear Health Care Professional letter]. Ottawa: Health Canada; 2005 Sept 13. (accessed 2008 Jun 3).
5. Duragesic (fentanyl transdermal system) safety information [public advisory]. Ottawa: Health Canada; 2005 Sept 16. (accessed 2008 Jun 3).
6. Transdermal fentanyl: a misunderstood dosage form. ISMP Canada Safety Bull 2006;6(5).
7. Fentanyl patch linked to another death in Canada. ISMP Canada Safety Bull 2007;7(5).
8. Ongoing, preventable fatal events with fentanyl transdermal patches are alarming! Horsham (PA): Institute for Safe Medication Practices; 2007 June 28.
9. Fentanyl transdermal system (marketed as Duragesic and generics) information for Healthcare Professionals. Rockville (MD): US Food and Drug Administration; 2007 Dec 21. (accessed 2008 Jun 3).
Tuesday, July 29, 2008
Workshops in Toronto
Hello Everyone!
Just to let you know that there are workshops being offered in Toronto that some of you may be interested in:.
Interpretation of Lab Tests (October 14, 2008)
Sharpening Physical Assessment Skills (November 3, 2008)
12 Lead ECG Analysis (November 4, 2008)
Pharmacology Update for Nurses (December 2, 2008)
Diabetes Update (December 9, 2008)
For more information, click
Here
Just to let you know that there are workshops being offered in Toronto that some of you may be interested in:.
Interpretation of Lab Tests (October 14, 2008)
Sharpening Physical Assessment Skills (November 3, 2008)
12 Lead ECG Analysis (November 4, 2008)
Pharmacology Update for Nurses (December 2, 2008)
Diabetes Update (December 9, 2008)
For more information, click
Here
Thursday, July 17, 2008
OPANA
"The Ontario PeriAnesthesia Nurses Association is dedicated to the education of all of Ontario's perianesthesia nurses. With this as their mission, OPANA continues to sponsor annual conferences, held in October every year.
October was chosen as the time of year for the conferences since it follows the month when routine schedules return to normal: September is the month for returning to school and work after months of nice weather and vacations. October is early enough that it doesn't interfere with the hectic preparations for Christmas, and the conference is always planned after Thanksgiving and well before Hallowe'en. October is cool enough to be comfortable, even if we risk the chance of rain. The scenery is beautiful with the fall colours.
OPANA's conference brochure always references the season with the fall colours displayed throughout the brochure. The brochure is mailed at the beginning of the summer each year to give perianesthesia nurses enough time to plan ahead, adjust their work schedules in order to be able to attend the conference. Many hospitals prepare nurse's schedules up to 14 weeks in advance, so plenty of advanced notice for the conference is required in order to request days off for this weekend in October.
An early bird rate for registration offers the organized registrant the opportunity of a significant savings. Deadline for Early Bird Registration is August 31, 2008. Registration fees include: 2 breakfasts, 1 hot lunch and 3 snacks, as well as a reduced rate for hotel rooms and two full days of interesting and relevant presentations.
A hospitality suite is hosted by OPANA every Friday evening of the conference weekend. Pre-registration is available at this event, one ticket for an alcoholic beverage and hot and cold snacks are supplied. There is a cash bar and plenty of music and conversation with your peers. Please join us to meet the OPANA volunteers who make this event possible.
Sponsors and exhibitors line the hallways mainly on the Saturday of every weekend offering the attendees the opportunity to learn about the latest equipment, supplies and technology available for use in their practice. Vendors offer the conference attendees the ability to purchase many items: books, clothing, Sigvaris support hose, and others. OPANA's own Conference Committee organizes a looooong Silent Auction Table for the auction of special gifts and baskets. OPANA's Board of Directors sells OPANA Wear (a line of clothing with the OPANA logo), OPANA pins, and other OPANA souvenir items. There is always a 50/50 raffle ticket draw and many other activities.
Poster presentations are encouraged. If you have recently, or if you will soon, produce a poster, please present it at the OPANA conference, entirely free! We encourage displaying all of your work and will provide the space and poster board (please see "Call for Submissions of Abstracts for Oral or Poster Presentations" available to the left of this page for more details).
At each conference, all attendees are given a "conference portfolio", a bag with the OPANA logo, and a variety of surprise items in each bag. The conference brochure is complete with a "door prize" ticket, and draws are held throughout the two days for many prizes.
All in all, the conference is sure to be a great weekend every year. OPANA is pleased to announce that this year's conference is being held at the Sheraton Centre Hotel, Queen Street, Toronto on October 18, 19, 2008, in the Dominion Ballroom, second floor. The hospitality suite is being held on the Friday, October 17 from 7 p.m. - 1030 p.m. See you there!
Update: As of May, 2008, OPANA's Conference has been given the name, "Inspirations", meaning a weekend full of motivational ideas and leading edge information. Inspirations also refers to the A and B in ABC: Airway and Breathing, the PeriAnesthesia Nurse's primary concerns in PeriAnesthesia nursing. "
STAY TUNED FOR THE DRAFT OF OUR NEW PERIANESTHESIA HANDOVER TOOL. WE HOPE TO SUBMIT IT AS A POSTER PRESENTATION AT THE OPANA CONFERENCE IN OCTOBER.
October was chosen as the time of year for the conferences since it follows the month when routine schedules return to normal: September is the month for returning to school and work after months of nice weather and vacations. October is early enough that it doesn't interfere with the hectic preparations for Christmas, and the conference is always planned after Thanksgiving and well before Hallowe'en. October is cool enough to be comfortable, even if we risk the chance of rain. The scenery is beautiful with the fall colours.
OPANA's conference brochure always references the season with the fall colours displayed throughout the brochure. The brochure is mailed at the beginning of the summer each year to give perianesthesia nurses enough time to plan ahead, adjust their work schedules in order to be able to attend the conference. Many hospitals prepare nurse's schedules up to 14 weeks in advance, so plenty of advanced notice for the conference is required in order to request days off for this weekend in October.
An early bird rate for registration offers the organized registrant the opportunity of a significant savings. Deadline for Early Bird Registration is August 31, 2008. Registration fees include: 2 breakfasts, 1 hot lunch and 3 snacks, as well as a reduced rate for hotel rooms and two full days of interesting and relevant presentations.
A hospitality suite is hosted by OPANA every Friday evening of the conference weekend. Pre-registration is available at this event, one ticket for an alcoholic beverage and hot and cold snacks are supplied. There is a cash bar and plenty of music and conversation with your peers. Please join us to meet the OPANA volunteers who make this event possible.
Sponsors and exhibitors line the hallways mainly on the Saturday of every weekend offering the attendees the opportunity to learn about the latest equipment, supplies and technology available for use in their practice. Vendors offer the conference attendees the ability to purchase many items: books, clothing, Sigvaris support hose, and others. OPANA's own Conference Committee organizes a looooong Silent Auction Table for the auction of special gifts and baskets. OPANA's Board of Directors sells OPANA Wear (a line of clothing with the OPANA logo), OPANA pins, and other OPANA souvenir items. There is always a 50/50 raffle ticket draw and many other activities.
Poster presentations are encouraged. If you have recently, or if you will soon, produce a poster, please present it at the OPANA conference, entirely free! We encourage displaying all of your work and will provide the space and poster board (please see "Call for Submissions of Abstracts for Oral or Poster Presentations" available to the left of this page for more details).
At each conference, all attendees are given a "conference portfolio", a bag with the OPANA logo, and a variety of surprise items in each bag. The conference brochure is complete with a "door prize" ticket, and draws are held throughout the two days for many prizes.
All in all, the conference is sure to be a great weekend every year. OPANA is pleased to announce that this year's conference is being held at the Sheraton Centre Hotel, Queen Street, Toronto on October 18, 19, 2008, in the Dominion Ballroom, second floor. The hospitality suite is being held on the Friday, October 17 from 7 p.m. - 1030 p.m. See you there!
Update: As of May, 2008, OPANA's Conference has been given the name, "Inspirations", meaning a weekend full of motivational ideas and leading edge information. Inspirations also refers to the A and B in ABC: Airway and Breathing, the PeriAnesthesia Nurse's primary concerns in PeriAnesthesia nursing. "
STAY TUNED FOR THE DRAFT OF OUR NEW PERIANESTHESIA HANDOVER TOOL. WE HOPE TO SUBMIT IT AS A POSTER PRESENTATION AT THE OPANA CONFERENCE IN OCTOBER.
How to Respond to a Post
I know some of you have tried to respond to a post before, but weren't sure how. I'd appreciate your comments to know whether you find this information helpful, if you disagree with something that is posted, if you have your own info that you'd like to share, or even if you want to vent about something.- At the bottom of each post you will find the time that the post was entered.
- Beside the time, hover the mouse over "comment" and click.
- A new box will open.
- Type your thoughts.
- You can choose to sign your name to the post, or not.
- Then, click on the circle beside "Anonymous."
- Next, click on the bar that reads "Publish Comment."
- Your comment will be added to the post almost immediately. Please note that anything that is rude or hurtful will be edited.
When there are comments to be read, you will see that there is a number beside "comment". When you click on "comment" you will be able to read all the responses to that particular post. I'll leave the first comment, so you can see what I mean.
Wednesday, July 16, 2008
Questions & Answers
A question arose today in PACU regarding verification of correct IJ central line placement post PVI. No post-op note had been written regarding the placement of a line and therefore a CXR had been taken in PACU. Unfortunately, there was no Cardiology MD available to view the xray and hence the RN was uneasy at using the line.I referred to Jen Kirkland RN (Arrythmia Services,) who had given PACU a PVI in service last winter, and who will hopefully be able to repeat it soon.
Here is her response: (and Thank-you Delia for posing the question!)
Hi Ramona,
These procedures are done under constant X-Ray. The only difference is there isn't an EPR copy of the X Ray record. There is a centrally located copy of these films in the Xcelera system based in the cath lab. These films are retrievable by HFN or name.
I would suggest, if there is NO note of potential hemo/pneumothorax in the procedural note, that the nurse/MD, use the stethescope available to listen to breath sounds. If they are diminished over the right upper lobes and there is downward trend of SaO2's, persue the CXR method. You have to imagine that this IJ line has probably been in place for approximately 3-4 hours. Sat's/VS have been followed by anesthesia during this time. Patients have been heparinized, which will excellerate the risk/presentation of a hemo/pneumo.
I think we definitely need to have an inservice to explain the basics of what we do. Could you post the basics of this email for those who don't have access to email. I hope to be able to help you but am waiting to hear back from my new boss. I'll copy Dr. Crystal to see if he has any other advice.
Best of luck,
Jen
Late Entry: A post procedure note must be written by the physician stating that the central line is the correct position and safe to use. There will be an inservice in the next few weeks with Jen and Dr. Crystal. Have your questions ready!
Friday, July 11, 2008
Welcome
I am a little behind on introducing two new PeriAnesthesia Nurses.
First, Prema Arulananthan RN, has joined the PACU and is our pioneer PACU Holding RN. She will be responsible for taking care of PACU Phase 2patients who are awaiting their bed availability. Prema previously worked on D6. She spent many years working in Norway and is fluent in Norwegian if anyone needs a translator!
Next, a warm welcome to Mila Kaplansky RN, who has recently started her orientation in SDS. Mila has previously worked in CCU, and returns to Sunnybrook after her maternity leave.
Thank you to both RN's for choosing PeriAnesthesia and their newest area of specialization!
Good Work Everyone!
Hello Mrs. Gragtmans,Thank you very much for your kind words.
I am very pleased that your experience at Sunnybrook was positive, and wish you a very speedy and healthy recovery.
I have copied the staff that you have mentioned in the email to let them know of your appreciation.
Kind regards,
Carol
Dear Caregivers,
In response to Debbie Jugmohan's call to inquire about my post-surgery condition,
I am glad for the opportunity to send you a note of appreciation for the excellent care, physical as well as emotional, before, during and after surgery.
From the moment we arrived at the 'Same Day Surgery' department, we have felt that we were in caring hands.
The fact that all stages of the procedure were explained beforehand and our questions were answered, contributed to our feeling secure and at ease.
We very much appreciated the gesture of Dr. Nedzelski's team to introduce themselves to us just before entering the operation room and nurse Christina's smiling face seemed to promise a perfect outcome!
Thank you for your expertise and dedication!
My time in the overnight room has been made comfortable by the loving care of my attendants, of whom Stanla was the main caregiver. I did not ask names, probably was too dozy!
A big and heart-felt "Thank you!" to all those who made my hospital stay a comfortable experience.
Sincerely,
Loeky Gragtmans
At the last APN/CE meeting I went to a Social Worker spoke about a new Elder Abuse Policy she had been working on and I'd like to bring it to your attention. Initially I had thought that it would be very relevant for the PAC (Pre-Admission Clinic) as they are one of the first nurses to assess patients, but I also think that it is something we should all be aware of, in and out of the hospital.
Check out www.ONPEA.org. It has interesting tools for assessment: FreeFromHarm .
For anyone who would like more information, there is a workshop being held here at Sunnybrook on October 16, 2008. Location is McLaughlin Auditoreum, EG 18a, 9am -12. The cost is $25 and breakfast is included. Contact mcheung@nyseniors.org
Check out www.ONPEA.org. It has interesting tools for assessment: FreeFromHarm .
For anyone who would like more information, there is a workshop being held here at Sunnybrook on October 16, 2008. Location is McLaughlin Auditoreum, EG 18a, 9am -12. The cost is $25 and breakfast is included. Contact mcheung@nyseniors.org
Wednesday, July 9, 2008
How to Ask for a Raise
I, P. Niss, hereby request a raise in salary for the following reasons:
I do physical labor.
I work at great depths.
I plunge headfirst into everything I do.
I do not get weekends or public holidays off.
I work in a damp environment.
I work in a dark workplace that has poor ventilation.
I work in high temperatures.
My work exposes me to contagious diseases.
Sincerely,
P. Niss
The Response:
Dear P. Niss
After assessing your request, and considering the arguments you have raised, the administration rejects your request for the following reasons:
You do not work 8 hours straight.
You fall asleep after brief work periods.
You do not always follow the orders of the management team.
You do not stay in your designated area and are often seen visiting other locations.
You do not take initiative - you need to be pressured and stimulated in order to start working.
You leave the workplace rather messy at the end of your shift.
You don't always observe necessary safety regulations, such as wearing the correct protective clothing.
You will retire well before you are 65.
You are unable to work double shifts.
You sometimes leave your designated work area before you have completed assigned task.
And if that were not all, you have been seen constantly entering and exiting the workplace carrying two suspicious-looking bags.
Sincerely, V. Gina
I do physical labor.
I work at great depths.
I plunge headfirst into everything I do.
I do not get weekends or public holidays off.
I work in a damp environment.
I work in a dark workplace that has poor ventilation.
I work in high temperatures.
My work exposes me to contagious diseases.
Sincerely,
P. Niss
The Response:
Dear P. Niss
After assessing your request, and considering the arguments you have raised, the administration rejects your request for the following reasons:
You do not work 8 hours straight.
You fall asleep after brief work periods.
You do not always follow the orders of the management team.
You do not stay in your designated area and are often seen visiting other locations.
You do not take initiative - you need to be pressured and stimulated in order to start working.
You leave the workplace rather messy at the end of your shift.
You don't always observe necessary safety regulations, such as wearing the correct protective clothing.
You will retire well before you are 65.
You are unable to work double shifts.
You sometimes leave your designated work area before you have completed assigned task.
And if that were not all, you have been seen constantly entering and exiting the workplace carrying two suspicious-looking bags.
Sincerely, V. Gina
Tuesday, July 8, 2008
For those of you who are interested in attending a Nurse's Conference on Regional Anesthesia & Pain Medicine, please have a look at THIS .
Reflective Thought for the Week of July 7-13, 2008
“Nothing is a waste of time if you use the experience wisely.”
-Auguste Rodin
A reminder that July's SPANC meeting will be held tomorrow (Wed) in MB206 over the lunch hours, from 11:30-14:30.
We will be working together to develop the PeriAnesthesia Handover Tool.
Be There, Or Be Square!
“Nothing is a waste of time if you use the experience wisely.”
-Auguste Rodin
A reminder that July's SPANC meeting will be held tomorrow (Wed) in MB206 over the lunch hours, from 11:30-14:30.
We will be working together to develop the PeriAnesthesia Handover Tool.
Be There, Or Be Square!
Monday, July 7, 2008
Remember this Post?!
Well, there is a new initiative amongst the Trauma General Surgeon's called ACCESS "ACute Care Emergency Surgical Services" that will enable surgeon's to have protected OR time Monday to Friday between 1600-1900. This will include cases such as Lap Appy's and Lap Chole's. Below is the latest policy for ACCESS. It begins today in the O.R. (Today was the first day I've heard about this) Any questions please refer them to Dr. Brenneman.
ACute Care Emergency Surgery Service (ACCESS)
Background
The ACCESS service is designed to create a new medical model of care for existing Emergency Department general surgery patients. The main principle of this model is based on a one week service rotation, wherein one general surgeon is responsible for managing a team solely dedicated to the care of all new ED consults, and existing ACCESS service patients.
In the recent 5 year review of Sunnybrook’s Division of General Surgery, Dr. Don Buie commented that ….“This (ACCESS) initiative has the potential to concentrate general surgical care separating it from the two primary focuses of oncology and trauma. It allows academic surgeons to plan their time more efficiently by concentrating call at specific times. Thus blocks of time without call can be more productive. It can be integrated into a trauma model as both services can be done on a weekly rotational basis. In addition it maintains the focus of individual services within their area of expertise. From an educational point of view it provides a concentrated general surgery experience for a resident assigned to this service. During the day, the remaining residents can focus on learning objectives for their assigned rotation. As trauma surgery is becoming more non-operative, there is a need to ensure that trauma surgeons keep up their skill level. The ACCESS service provides such an outlet.” Further, Dr. Buie recommended in his report that the hospital should “ensure there is dedicated operating room time so that urgent/emergent cases can be done in a timely fashion without interrupting elective bookings. This improves efficiency of patient care both for the acute service and the emergency department.”
This model of care has been recently implemented in some large AHSCs in Canada including Calgary, Montreal, and Vancouver. It has also evolved in the United States in conjunction with existing trauma surgery services at level 1 trauma centers. The reasons for Sunnybrook to implement an ACCESS service include benefits to the patient, surgical trainee, hospital, and surgeon, as outlined below:
Potential Benefits of an Acute Care General Surgery Emergency Service Model of Care
1. Benefits for the patient
· improve patient care with shorter time to GS consultation in the ED
· improve patient care by more timely access to the OR for semi-emergent surgery (eg. appendicitis, acute cholecystitis)
· improve overall patient and family experience on general surgery service, attributed to advantages of having a dedicated service managing all general surgery emergency patients
2. Benefits for the general surgery residents, medical students
· increased focus on emergency general surgery education
· improve bedside teaching with a dedicated ACCESS team for these patients
· formal teaching rounds on general surgery (non-trauma) emergencies
· easier to deal with one attending surgeon for all emergency GS patients on a dedicated ACCESS team, than to deal with multiple attending surgeons for fewer patients on each (existing) team
3. Benefits for the hospital
· improve hospital LOS for emergency general surgery patients
· improve patient flow for general surgery patients, thereby improving bed utilization and efficiency
· improve time to consultation and time to final management decision for general surgery patients in the Emergency Department
· improve patient satisfaction scores
· decrease general surgery after hours OR utilization
· easier for the general surgery ward nurses to deal with one resident/attending surgeon team for the week than to deal with multiple residents and multiple attending surgeons for the same compliment of patients
4. Benefits for the general surgeons
· compartmentalize general surgery acute care into weekly blocks
· will decrease the number of after hours general surgery operations
· helps to protect time for research
· ensures continuity of patient care in one week blocks
· financial issues (in a fee-for-service model) unclear at this point in time, but likely to be neither a gain nor a loss of income for the general surgeon as a result of this model of care.
Description of the Acute Care Emergency Surgery Service
The new ACCESS service will involve the following:
1. The patients to be INCLUDED on this new service are Emergency Department general surgery patients, and in-patient general surgery consults (see exclusions).
2. The patients to be EXCLUDED are surgical oncology patients (eg. malignant bowel obstruction, new cancer patient referrals), trauma patients (patients with any injury, regardless of whether or not they were seen by the trauma team), consults for PEGs and trachs (to be done by trauma surgeons), and post-op elective surgery patients with complications (to be managed by the original operating surgeon).
3. One week rotation for the attending general surgeon starting every Friday at 8:00am
4. The general surgeon on ACCESS will be expected to restrict other scheduled clinical work during that week in order to provide dedicated time to the ACCESS service. For example, the ACCESS surgeon will not have an elective scheduled OR list while on the ACCESS service.
5. Friday’s 8:00am sign-over is intended to allow for seamless continuity of care of general surgery patients. This may be a challenge and will require particular attention in order to achieve good outcomes. Sign-over will include both the “incoming” and the “outgoing” ACCESS attending surgeons, ACCESS team residents and medical students, and representation from C6 nursing and social work. It will occur in a reserved room on or near C6. These rounds will be focused working rounds for sign-over purposes only, and should take up to 30 minutes.
6. The general surgeon on service for the week is MRP for these general surgery patients. If a patient is admitted during an “off surgeon” night on call, the patient is to be admitted under the “off” general surgeon and transferred to the ACCESS surgeon the following morning.
7. The general surgeon’s service will round every day (7 days) on all ACCESS service patients. Particular attention to timely hospital discharge planning will be an important aspect of these rounds.
8. A nurse practitioner, patient care coordinator, or charge nurse will attend these daily rounds (weekdays) and assist with discharge planning.
9. There will be protected “ACCESS” OR time every weekday (Monday to Friday) for 3 hours to allow for overnight appes, lap choles, etc to get to the OR in a more timely fashion, thereby decreasing their length of stay. This OR time has been approved by the OR Management Committee, and will occur between 1600 – 1900 hours on weekdays for a 3 month trial period commencing July 7, 2008. If an ACCESS patient needs to go to the OR emergently during the day, the ACCESS case will bump the general surgery scheduled operating room for that day. However, the GS scheduled OR will be allowed to run until 1900 hrs on that day (in the ACCESS OR time).
10. OR cases – the ACCESS attending surgeon must be in the OR at all times with the resident team. This must be an efficient operating room. All pre-op ACCESS patients must be ready for the OR when the OR calls for the patient. The OR booking sheet should indicate “ACCESS” surgical case.
11. ED consults to the ACCESS team. The ACCESS team will commit to a maximum 30 minute response time (measured from the time the consult is called to the time the patient is first seen by the ACCESS team), and a 2 hour time from consult to final decision regarding disposition.
12. If any ACCESS patient becomes chronic, the MRP stays with the ACCESS team. It is felt that the ACCESS team is best suited to deal with placement of these patients.
13. The residents on this new service rotate for one to two month blocks. This will create a new resident team at Sunnybrook and ideally will include a senior resident, junior residents and medical students.
14. The attending surgeon for the week will rotate as per a predetermined schedule. This schedule will be created 3 months in advance, and will include a 6 month period. (for example, create the July-Dec 2008 schedule in April 2008).
15. ACCESS patient follow-up is with the surgeon who did the operation. If no surgery, then the surgeon on service at the time of hospital discharge will arrange follow-up.
16. A one page outcome measures and quality improvement data collection sheet will be completed by the attending ACCESS surgeon daily in a prospective fashion. This data will be entered into a database by general surgery administrative staff.
17. Discharge summaries are the responsibility of the ACCESS surgeon on service at the time of hospital discharge (ie. the MRP).
18. All general surgeons at Sunnybrook will be expected to participate in the ACCESS service rotation in an equitable distribution. However, the trauma general surgeons have the option of only taking part in the “off surgeon” on call nights, because they already have a 1 in 5 trauma on call commitment, and in addition 3 of them also have ICU weeks on call.
Weekly On Call Surgeon Schedule
10-on and 4-off schedule
Surgeon A = ACCESS surgeon of the week
“off surgeon” is done by either the same surgeon or different surgeons for that particular week. “Off” call is from 7:00pm to 7:00am on weekdays and 5:00pm to 8:00am on Saturday night.
Well, there is a new initiative amongst the Trauma General Surgeon's called ACCESS "ACute Care Emergency Surgical Services" that will enable surgeon's to have protected OR time Monday to Friday between 1600-1900. This will include cases such as Lap Appy's and Lap Chole's. Below is the latest policy for ACCESS. It begins today in the O.R. (Today was the first day I've heard about this) Any questions please refer them to Dr. Brenneman.
ACute Care Emergency Surgery Service (ACCESS)
Background
The ACCESS service is designed to create a new medical model of care for existing Emergency Department general surgery patients. The main principle of this model is based on a one week service rotation, wherein one general surgeon is responsible for managing a team solely dedicated to the care of all new ED consults, and existing ACCESS service patients.
In the recent 5 year review of Sunnybrook’s Division of General Surgery, Dr. Don Buie commented that ….“This (ACCESS) initiative has the potential to concentrate general surgical care separating it from the two primary focuses of oncology and trauma. It allows academic surgeons to plan their time more efficiently by concentrating call at specific times. Thus blocks of time without call can be more productive. It can be integrated into a trauma model as both services can be done on a weekly rotational basis. In addition it maintains the focus of individual services within their area of expertise. From an educational point of view it provides a concentrated general surgery experience for a resident assigned to this service. During the day, the remaining residents can focus on learning objectives for their assigned rotation. As trauma surgery is becoming more non-operative, there is a need to ensure that trauma surgeons keep up their skill level. The ACCESS service provides such an outlet.” Further, Dr. Buie recommended in his report that the hospital should “ensure there is dedicated operating room time so that urgent/emergent cases can be done in a timely fashion without interrupting elective bookings. This improves efficiency of patient care both for the acute service and the emergency department.”
This model of care has been recently implemented in some large AHSCs in Canada including Calgary, Montreal, and Vancouver. It has also evolved in the United States in conjunction with existing trauma surgery services at level 1 trauma centers. The reasons for Sunnybrook to implement an ACCESS service include benefits to the patient, surgical trainee, hospital, and surgeon, as outlined below:
Potential Benefits of an Acute Care General Surgery Emergency Service Model of Care
1. Benefits for the patient
· improve patient care with shorter time to GS consultation in the ED
· improve patient care by more timely access to the OR for semi-emergent surgery (eg. appendicitis, acute cholecystitis)
· improve overall patient and family experience on general surgery service, attributed to advantages of having a dedicated service managing all general surgery emergency patients
2. Benefits for the general surgery residents, medical students
· increased focus on emergency general surgery education
· improve bedside teaching with a dedicated ACCESS team for these patients
· formal teaching rounds on general surgery (non-trauma) emergencies
· easier to deal with one attending surgeon for all emergency GS patients on a dedicated ACCESS team, than to deal with multiple attending surgeons for fewer patients on each (existing) team
3. Benefits for the hospital
· improve hospital LOS for emergency general surgery patients
· improve patient flow for general surgery patients, thereby improving bed utilization and efficiency
· improve time to consultation and time to final management decision for general surgery patients in the Emergency Department
· improve patient satisfaction scores
· decrease general surgery after hours OR utilization
· easier for the general surgery ward nurses to deal with one resident/attending surgeon team for the week than to deal with multiple residents and multiple attending surgeons for the same compliment of patients
4. Benefits for the general surgeons
· compartmentalize general surgery acute care into weekly blocks
· will decrease the number of after hours general surgery operations
· helps to protect time for research
· ensures continuity of patient care in one week blocks
· financial issues (in a fee-for-service model) unclear at this point in time, but likely to be neither a gain nor a loss of income for the general surgeon as a result of this model of care.
Description of the Acute Care Emergency Surgery Service
The new ACCESS service will involve the following:
1. The patients to be INCLUDED on this new service are Emergency Department general surgery patients, and in-patient general surgery consults (see exclusions).
2. The patients to be EXCLUDED are surgical oncology patients (eg. malignant bowel obstruction, new cancer patient referrals), trauma patients (patients with any injury, regardless of whether or not they were seen by the trauma team), consults for PEGs and trachs (to be done by trauma surgeons), and post-op elective surgery patients with complications (to be managed by the original operating surgeon).
3. One week rotation for the attending general surgeon starting every Friday at 8:00am
4. The general surgeon on ACCESS will be expected to restrict other scheduled clinical work during that week in order to provide dedicated time to the ACCESS service. For example, the ACCESS surgeon will not have an elective scheduled OR list while on the ACCESS service.
5. Friday’s 8:00am sign-over is intended to allow for seamless continuity of care of general surgery patients. This may be a challenge and will require particular attention in order to achieve good outcomes. Sign-over will include both the “incoming” and the “outgoing” ACCESS attending surgeons, ACCESS team residents and medical students, and representation from C6 nursing and social work. It will occur in a reserved room on or near C6. These rounds will be focused working rounds for sign-over purposes only, and should take up to 30 minutes.
6. The general surgeon on service for the week is MRP for these general surgery patients. If a patient is admitted during an “off surgeon” night on call, the patient is to be admitted under the “off” general surgeon and transferred to the ACCESS surgeon the following morning.
7. The general surgeon’s service will round every day (7 days) on all ACCESS service patients. Particular attention to timely hospital discharge planning will be an important aspect of these rounds.
8. A nurse practitioner, patient care coordinator, or charge nurse will attend these daily rounds (weekdays) and assist with discharge planning.
9. There will be protected “ACCESS” OR time every weekday (Monday to Friday) for 3 hours to allow for overnight appes, lap choles, etc to get to the OR in a more timely fashion, thereby decreasing their length of stay. This OR time has been approved by the OR Management Committee, and will occur between 1600 – 1900 hours on weekdays for a 3 month trial period commencing July 7, 2008. If an ACCESS patient needs to go to the OR emergently during the day, the ACCESS case will bump the general surgery scheduled operating room for that day. However, the GS scheduled OR will be allowed to run until 1900 hrs on that day (in the ACCESS OR time).
10. OR cases – the ACCESS attending surgeon must be in the OR at all times with the resident team. This must be an efficient operating room. All pre-op ACCESS patients must be ready for the OR when the OR calls for the patient. The OR booking sheet should indicate “ACCESS” surgical case.
11. ED consults to the ACCESS team. The ACCESS team will commit to a maximum 30 minute response time (measured from the time the consult is called to the time the patient is first seen by the ACCESS team), and a 2 hour time from consult to final decision regarding disposition.
12. If any ACCESS patient becomes chronic, the MRP stays with the ACCESS team. It is felt that the ACCESS team is best suited to deal with placement of these patients.
13. The residents on this new service rotate for one to two month blocks. This will create a new resident team at Sunnybrook and ideally will include a senior resident, junior residents and medical students.
14. The attending surgeon for the week will rotate as per a predetermined schedule. This schedule will be created 3 months in advance, and will include a 6 month period. (for example, create the July-Dec 2008 schedule in April 2008).
15. ACCESS patient follow-up is with the surgeon who did the operation. If no surgery, then the surgeon on service at the time of hospital discharge will arrange follow-up.
16. A one page outcome measures and quality improvement data collection sheet will be completed by the attending ACCESS surgeon daily in a prospective fashion. This data will be entered into a database by general surgery administrative staff.
17. Discharge summaries are the responsibility of the ACCESS surgeon on service at the time of hospital discharge (ie. the MRP).
18. All general surgeons at Sunnybrook will be expected to participate in the ACCESS service rotation in an equitable distribution. However, the trauma general surgeons have the option of only taking part in the “off surgeon” on call nights, because they already have a 1 in 5 trauma on call commitment, and in addition 3 of them also have ICU weeks on call.
Weekly On Call Surgeon Schedule
10-on and 4-off schedule
Surgeon A = ACCESS surgeon of the week
“off surgeon” is done by either the same surgeon or different surgeons for that particular week. “Off” call is from 7:00pm to 7:00am on weekdays and 5:00pm to 8:00am on Saturday night.
Friday, July 4, 2008
Approved Minutes from May 30th
PACU STAFF MEETING
Friday May 30, 2008 – 0900
Present: Carol Deriet, Ramona Hackett, Delia Muresan, Eric Staines, Cathy Bendayan, Julie King, Clyde Vivares, Vicky Lloyd, Shelley Warwick, Dale Peterson, Hong Ling Wu
Recorder: Joan Munro
Team Leader Role Profile: Carol Deriet distributed copies of the Team Leader role profile to be reviewed by the staff. Carol will put a sheet on the window for everyone to sign after reading the role profile. The Team Leader position will be posted once the schedule has been voted on.
New Schedule: The new schedule will be in effect by September, 2008. According to NAPAN standards, there must be two nurses to recover a patient in PACU which means two nurses must be scheduled for weekends. The workload and acuity of patients has increased over the past year. Having two nurses will provide a safe environment for patients and staff. If PACU is quiet for a period of time, the second PACU nurse should be involved in other duties, i.e. stocking or committee work. Carol Deriet will support these activities, rather than having the second PACU nurse pulled to another area by the shift manager.
TWO MASTER SCHEDULES HAVE BEEN DISTRIBUTED. PLEASE VOTE FOR MASTER #1 OR #2 AND PLACE YOUR BALLOT IN BALLOT BOX AT NURSING STATION.
OPANA: Sunnybrook staff have not been involved with OPANA in recent years, and Carol Deriet encourages PACU staff to become involved. Carol has committed to a poster presentation at the OPANA conference in October. The focus will be development of a hand-over tool to improve communication between departments. Carol welcomes any suggestions or involvement in this SPANC project.
PACU Absenteeism Policy: Copies of the policy were distributed to the staff, and will also be emailed to all staff members, to serve as information for new staff, and a reminder to all staff.
Safety Walkabout: Carol discussed the focus issues of the safety walk-about that was recently conducted. The full report will be emailed to all staff.
Handover of patients from OR to PACU: Action - Carol and Ramona are working on a tool, including questions to ask anaesthesia. The draft will be sent to PACU staff for comments and suggestions.
OR Activity varies from day to day: Action – There are some engineering graduate students working on an OR Calming project, to adjust OR bookings to be more equal from day to day. This will take time to implement, as it will impact doctors’ office hours. Patient Flow staff are more involved with OR and PACU. There is a bed huddle every day at the OR desk at 1330hrs to discuss the following days OR activity and potential bed issues. If M-Ground ORs are not using the SSSU beds, they become available for appropriate M2 patients, but M2 cannot pre-book SSSU beds at this time. The PACU holding area will open next week, Monday to Friday, 1300 – 2100.
Inadequate labeling of narcotics: Action – The PACU nurse will no longer accept narcotics from anaesthesia. Anaesthesia can give the narcotic and document it should the patient require analgesic directly on admission to PACU. If the nurse is to give narcotics, (s)he must draw own medication.
Communication: Action – Ramona posts information on her blog. SPANC opens communication within peri-anesthesia services.
Physician care of critically ill patients in PACU: Action – Carol will be meeting with OR Executive, CrCU physicians and Dr. Keith Rose to establish a policy. In the meantime, CrCU and PACU are working together for the benefit of the patients. Please forward any suggestions to Carol. Meeting is set up for July 10 with OR Management and CrCU management.
Near Misses: Action – There is a new on-line safety report for incidences and near misses. The staff reaction is that the process is long and time consuming and discourages staff from completing reports. Carol will pass this information to Cynthia Bailey.
Intimidating behavior from physicians and other units: Action – All incidents of intimidation or disrespectful attitude should be reported to Carol, who will follow-up with the individuals involved.
Nurse Safety Concerns on M-Ground: The nurses can’t see the patients well, and suggested a change in the configuration of the beds. Julie King will send an email to all staff with proposed new lay-out and ask for feed-back. Carol will investigate implementation of a new bed lay-out.
Friday May 30, 2008 – 0900
Present: Carol Deriet, Ramona Hackett, Delia Muresan, Eric Staines, Cathy Bendayan, Julie King, Clyde Vivares, Vicky Lloyd, Shelley Warwick, Dale Peterson, Hong Ling Wu
Recorder: Joan Munro
Team Leader Role Profile: Carol Deriet distributed copies of the Team Leader role profile to be reviewed by the staff. Carol will put a sheet on the window for everyone to sign after reading the role profile. The Team Leader position will be posted once the schedule has been voted on.
New Schedule: The new schedule will be in effect by September, 2008. According to NAPAN standards, there must be two nurses to recover a patient in PACU which means two nurses must be scheduled for weekends. The workload and acuity of patients has increased over the past year. Having two nurses will provide a safe environment for patients and staff. If PACU is quiet for a period of time, the second PACU nurse should be involved in other duties, i.e. stocking or committee work. Carol Deriet will support these activities, rather than having the second PACU nurse pulled to another area by the shift manager.
TWO MASTER SCHEDULES HAVE BEEN DISTRIBUTED. PLEASE VOTE FOR MASTER #1 OR #2 AND PLACE YOUR BALLOT IN BALLOT BOX AT NURSING STATION.
OPANA: Sunnybrook staff have not been involved with OPANA in recent years, and Carol Deriet encourages PACU staff to become involved. Carol has committed to a poster presentation at the OPANA conference in October. The focus will be development of a hand-over tool to improve communication between departments. Carol welcomes any suggestions or involvement in this SPANC project.
PACU Absenteeism Policy: Copies of the policy were distributed to the staff, and will also be emailed to all staff members, to serve as information for new staff, and a reminder to all staff.
Safety Walkabout: Carol discussed the focus issues of the safety walk-about that was recently conducted. The full report will be emailed to all staff.
Handover of patients from OR to PACU: Action - Carol and Ramona are working on a tool, including questions to ask anaesthesia. The draft will be sent to PACU staff for comments and suggestions.
OR Activity varies from day to day: Action – There are some engineering graduate students working on an OR Calming project, to adjust OR bookings to be more equal from day to day. This will take time to implement, as it will impact doctors’ office hours. Patient Flow staff are more involved with OR and PACU. There is a bed huddle every day at the OR desk at 1330hrs to discuss the following days OR activity and potential bed issues. If M-Ground ORs are not using the SSSU beds, they become available for appropriate M2 patients, but M2 cannot pre-book SSSU beds at this time. The PACU holding area will open next week, Monday to Friday, 1300 – 2100.
Inadequate labeling of narcotics: Action – The PACU nurse will no longer accept narcotics from anaesthesia. Anaesthesia can give the narcotic and document it should the patient require analgesic directly on admission to PACU. If the nurse is to give narcotics, (s)he must draw own medication.
Communication: Action – Ramona posts information on her blog. SPANC opens communication within peri-anesthesia services.
Physician care of critically ill patients in PACU: Action – Carol will be meeting with OR Executive, CrCU physicians and Dr. Keith Rose to establish a policy. In the meantime, CrCU and PACU are working together for the benefit of the patients. Please forward any suggestions to Carol. Meeting is set up for July 10 with OR Management and CrCU management.
Near Misses: Action – There is a new on-line safety report for incidences and near misses. The staff reaction is that the process is long and time consuming and discourages staff from completing reports. Carol will pass this information to Cynthia Bailey.
Intimidating behavior from physicians and other units: Action – All incidents of intimidation or disrespectful attitude should be reported to Carol, who will follow-up with the individuals involved.
Nurse Safety Concerns on M-Ground: The nurses can’t see the patients well, and suggested a change in the configuration of the beds. Julie King will send an email to all staff with proposed new lay-out and ask for feed-back. Carol will investigate implementation of a new bed lay-out.
Good Job!
The following is from a Thank You card received in PACU:
To The Recovery Room
"First off I'm sorry if I have forgot someone, but there are only two names I remember but I know enough people were involved with saving my life. I just wanted to thank you from the bottom of my heart, I was probably a pain in the ass too, so thank youo for putting upn with me. I really remember Betty being there for me and for always's letting me use the swab to wet my mouth, I was just dying of thirst, ha ha. But Thank you very much for putting up with me I am not the nicest person when I'm in that state apparently. You guys deal with that everyday and I admire you for that.
Thank you very much
God Bless,
Conrad P.
Thursday, July 3, 2008
FYI---Biochemistry Update
Hello All,
We are making some process improvements in Biochemistry as a result of new instrumentation. We are happy to report that this will translate to decreased blood collection for some of the routine chemistry tests.
Currently you have been collecting an extra SST (yellow top) tube for Troponin and CK-MB, in addition to any routine chemistry orders that require an SST tube (calcium, liver etc.). On Monday, June 30, 2008 it will no longer be necessary to draw an additional tube for Troponin and CK-MB; these orders will print out on the same label as the other chemistry tests that would require an SST tube.
Please let the nursing staff know that they should pay attention to how many and type of tubes that are required as indicated on the barcode label that prints out after order entry to avoid unnecessary extra tubes being collected. At this point it is only Troponin and CK-MB that is changing, we will keep you updated as further improvements are in the pipeline.
Please let me know if you require further information or clarification.
We are making some process improvements in Biochemistry as a result of new instrumentation. We are happy to report that this will translate to decreased blood collection for some of the routine chemistry tests.
Currently you have been collecting an extra SST (yellow top) tube for Troponin and CK-MB, in addition to any routine chemistry orders that require an SST tube (calcium, liver etc.). On Monday, June 30, 2008 it will no longer be necessary to draw an additional tube for Troponin and CK-MB; these orders will print out on the same label as the other chemistry tests that would require an SST tube.Please let the nursing staff know that they should pay attention to how many and type of tubes that are required as indicated on the barcode label that prints out after order entry to avoid unnecessary extra tubes being collected. At this point it is only Troponin and CK-MB that is changing, we will keep you updated as further improvements are in the pipeline.
Please let me know if you require further information or clarification.
Tammie Taylor MLT
Supervisor Biochemistry Department of Clinical Pathology
Great Work!
By Email (carol.deriet@sunnybrook.ca)
July 3, 2008
Sunnybrook Health Sciences Centre
Short-Stay Unit
Attention: Ms. Carol Deriet
Dear Ms. Deriet:
Re: Recognition of Excellent Care
I was an outpatient at Sunnybrook on July 2, 2008, and would like to express my gratitude to the entire staff of the same day surgery unit. They were at all times caring, attentive, gentle and respectful. Without minimizing everyone's efforts in making my stay as comfortable and stress-free as possible, I do want to emphasize the superlative care provided to me by Kristen Gifford between 7:40 p.m. and 9:00 p.m. that evening.
Ms. Gifford was patient and kind, and even while assisting me with some very intimate tasks, always left me with my sense of dignity intact. She willingly explained the medical reasons behind my physical discomfort, and equally willingly repeated them to my husband. She was at all times empathetic and unhurried in the care she provided. She was a godsend, and I feel very lucky to have landed in her care. I told her how much I appreciated all she did for me, but I would have felt remiss if I did not more officially express my gratitude.
Sincerely,
Elisabeth Colson
July 3, 2008
Sunnybrook Health Sciences Centre
Short-Stay Unit
Attention: Ms. Carol Deriet
Dear Ms. Deriet:
Re: Recognition of Excellent Care
I was an outpatient at Sunnybrook on July 2, 2008, and would like to express my gratitude to the entire staff of the same day surgery unit. They were at all times caring, attentive, gentle and respectful. Without minimizing everyone's efforts in making my stay as comfortable and stress-free as possible, I do want to emphasize the superlative care provided to me by Kristen Gifford between 7:40 p.m. and 9:00 p.m. that evening.
Ms. Gifford was patient and kind, and even while assisting me with some very intimate tasks, always left me with my sense of dignity intact. She willingly explained the medical reasons behind my physical discomfort, and equally willingly repeated them to my husband. She was at all times empathetic and unhurried in the care she provided. She was a godsend, and I feel very lucky to have landed in her care. I told her how much I appreciated all she did for me, but I would have felt remiss if I did not more officially express my gratitude.
Sincerely,
Elisabeth Colson
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