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

Learning from e-Safety Reports: Opiod Analgesics

Improving Patient Safety
Patti Cornish, Sandra Knowles, and Dr. Ed Etchells, Patient Safety Service

Opioids, also known as narcotic analgesics, (e.g., morphine, HYDROmorphone, oxycodone, fentanyl) are high-alert drugs, because there is an increased risk of harm when they are used in error. Errors are not necessarily more common with high-alert drugs than other drugs, but when they occur, the consequences are potentially more devastating.
The pharmacists with the Patient Safety Service review all e-Safety reports involving medication and look for trends. Information from Sunnybrook’s e-Safety Reporting system from the past 9 months indicates that medication incidents involving opioid analgesics are commonly reported. Opioid analgesics constitute the largest single category of drugs involved (i.e., 15% of all reports).

Fortunately, the vast majority of opioid errors at Sunnybrook from Jan-Sep 2008 were not associated with any significant harm; in only 7% of the incidents was the harm listed as moderate or severe at the time of the report. In terms of specific opioids mentioned in the e-Safety reports, the breakdown was as follows: hydromorphone – 31%; morphine – 26%; oxycodone/OxyCONTIN® - 23%; fentanyl – 7%; and others – 13%.
This newsletter is intended to highlight three commonly reported errors with opioids and provide some suggestions for safety improvements.
Confusion between HYDROmorphone and Morphine

Case: A 93-year-old female patient was ordered morphine 2 mg subcutaneously q4h prn post-operatively. Both HYDROmorphone 2 mg/1 mL vials and morphine 2 mg/1 mL ampoules were stocked in the narcotic drawer on the patient care unit. On one occasion, HYDROmorphone 2 mg was inadvertently selected from the narcotic drawer and administered to the patient instead of morphine 2 mg. Shortly thereafter, the patient seemed unusually groggy and the error was identified. The physician was informed and the patient was closely monitored for several hours – vital signs remained stable and the patient recovered completely.

Mix ups between HYDROmorphone and morphine are common and potentially serious errors. Although in this situation the patient recovered, confusion between these two drugs can be fatal. A high-profile error occurred several years ago at an emergency department of a hospital in Alberta where a 69-year-old patient received HYDROmorphone 10 mg intramuscularly instead of 10 mg of morphine. The patient was discharged from the emergency department shortly after the drug had been administered, deteriorated on the drive home, arrested and died at another rural Alberta hospital.

HYDROmorphone is a very potent opioid – it is generally considered to be at least five times more potent than morphine, meaning that a dose of 10 mg of HYDROmorphone is equivalent to at least 50 mg of morphine. Over the past decade, the role of HYDROmorphone in acute and chronic pain management has been increasing. HYDROmorphone is often used when patients are unable to tolerate the adverse effects of morphine. As well, HYDROmorphone is becoming increasingly preferred for use in elderly patients or those with renal or hepatic impairment. As a result of this more extensive usage, the availability of HYDROmorphone in patient care areas has been necessarily increased, enhancing the potential for errors and confusion with morphine.
There are several important factors that contribute to the risk of substitution errors with HYDROmorphone and morphine:
The drug names both look-alike and sound-alike.
Both HYDROmorphone and morphine injections are available in the same strengths – i.e., 2 mg/1 mL and 10 mg/1 mL. For the oral dosage forms of these drugs, the strengths are different; however, substitution errors are also reported with the oral products.
Lack of familiarity with HYDROmorphone (some of the reported mix-ups have been due to the mistaken belief that HYDROmorphone is a generic or chemical name for morphine).

Over the past few years, several strategies have been implemented at Sunnybrook to safeguard the use of HYDROmorphone. First and foremost, the high concentration injectable formats of HYDROmorphone (i.e., ≥ 10 mg/1 mL) have been eliminated as much as possible from patient care areas (exceptions include palliative care, oncology, intensive care). Our Sunnybrook "in-house" drug labels and narcotic documentation records use TALLman lettering to emphasize the "HYDRO" portion of HYDROmorphone, to help distinguish it better from morphine. Despite these strategies, there is still an ongoing risk of substitution errors with HYDROmorphone and morphine and further attention to this problem is required. Referring to HYDROmorphone by its traditional brand name "Dilaudid®" to reduce name confusion with morphine has been considered. However, the availability of several generic HYDROmorphone products makes this strategy problematic to implement.
The following safety tips are simple improvements that can be employed in any patient care area to further minimize the risk of errors with these opioids.
Safety Tips to Reduce the Risk of Errors with HYDROmorphone and Morphine
1. Ensure that staff is familiar with the difference between HYDROmorphone and morphine – i.e., HYDROmorphone is five times more potent than morphine. [a pocket card on equianalgesic doses of opioids is available from Pharmacy and also on SunnyNet: http://sunnynet/data/pharmacy/htdocs/misc/Opioid_Dose_Equiv_Card.pdf]

2. In narcotic storage areas, segregate HYDROmorphone from morphine injection (e.g., place in separate compartments of the narcotic drawer, store on different shelves in the narcotic cupboard).

Outer Packaging
Morphine Ampoule and HYDROmorphone Vial
3. If high concentration HYDROmorphone injection (10 mg/1 mL) is issued to a patient care area to meet the needs of a specific patient, ensure that it is returned to pharmacy as soon as the patient is discharged or no longer requires it.

4. Always read back telephone or verbal orders to the prescriber to ensure that you have heard the correct drug name. If needed, ask for clarification by using HYDROmorphone’s brand name (e.g., Do you mean Dilaudid®?).

5. Consider the role of an independent double-check before administration of injectable opioids. [see link to Sunnybrook’s procedure for independent double-checks: http://sunnynet/Default.aspx?cid=100865&lang=1]

6. When implemented, Computerized Provider Order Entry (CPOE) will help to reduce the risk of errors at the time of ordering by including TALLman lettering for all HYDROmorphone entries, accompanied by the brand name "Dilaudid®".
Confusion between Short- and Long-Acting Oral Opioid Analgesics
Sustained release (long-acting) oral formulations of opioid analgesics are designed to deliver the medication gradually over an 8- or 12-hour period. This compares to immediate-release (short-acting) opioid analgesics that require doses to be administered every 2 to 4 hours. When properly used, long-acting opioid analgesics provide a decrease in frequency of administration, longer periods of consistent pain control and may lower the incidence of adverse effects. Short-acting opioid analgesics are often used in conjunction with long-acting opioids to help manage breakthrough pain. Unfortunately, confusion may occur between the long- and short-acting formulations of opioid analgesics, especially when they contain the same drug in the same dose. Although most medication error reports document confusion with short- and long-acting formulations of oxycodone (i.e., oxycodone and OxyCONTIN®), there have also been reports with HYDROmorphone (HYDROmorphone and Hydromorph CONTIN®) and morphine (Statex® and MS CONTIN®, M-Eslon®).
When a long-acting opioid analgesic is inadvertently substituted for a short-acting preparation, this can potentially result in accumulation of the opioid analgesic leading to toxicity. For example, a patient was ordered short-acting oxycodone 10 mg orally every 2 hours when needed. The long-acting product (OxyCONTIN® 10 mg) was selected in error and several doses were administered every 2 hours because the patient was not experiencing adequate pain relief. This is explained by the fact that OxyCONTIN® slowly releases the drug for absorption and peak blood levels are not achieved for several hours. After 8 to 12 hours, the patient became excessively sedated due to the cumulative effect of repeated doses of OxyCONTIN®. The error was recognized and the patient recovered completely.
Conversely, when a short-acting opioid analgesic is accidentally substituted for a long-acting preparation, this may result in excessive opioid effects initially, followed by lack of pain control later in the dosing interval. For example, a patient was scheduled to receive a long-acting product, Hydromorph CONTIN®, 12 mg orally every 12 hours. Inadvertently, immediate-release HYDROmorphone 12 mg was given. Since the immediate-release preparation is formulated to release HYDROmorphone rapidly and provide analgesia over a 3 to 4 hour period, the patient experienced excessive sedation within one hour of administration, followed by the need for breakthrough medication in the last half of the dosing interval due to inadequate pain control.
Confusion between the short- and long-acting formulations of opioid analgesics may be the result of several contributing factors including:
Lack of awareness of the differences between the immediate- and sustained-release formulations of opioid analgesics. At Sunnybrook, a Table outlining the characteristics of commonly used oral narcotic preparations (the "pink sheet") is available in every narcotic binder.
Similarity between the names of the various preparations (e.g., oxycodone and OxyCONTIN®; HYDROmorphone and Hydromorph CONTIN®). At Sunnybrook, all long-acting opioid formulations that are packaged "in-house" have fluorescent pink labels and auxiliary stickers ("long-acting") attached to the package. (see photos in Figure 2)
Figure 2: Oxycodone Immediate-Release and Sustained-Release (OxyCONTIN®) Packaging
Safety Tips:
1. Physically separate short- and long-acting preparations of opioid analgesics in the narcotic storage area (e.g., place in different compartments of the drawer or store on separate shelves in a cupboard).

2. Understand the differences between short- and long-acting products; short-acting formulations are typically administered every 2 to 6 hours and long-acting products are administered no more frequently than every 8 to 12 hours. [see link to document on oral opioid products: http://sunnynet/data/pharmacy/htdocs/misc/Opioid_Oral_Products_Table.pdf]

3. Never crush or allow patients to chew long-acting products – this will destroy the sustained-release properties of the product.

4. When implemented, Computerized Provider Order Entry (CPOE) will help to reduce the risk of ambiguous orders by using full drug names and clearly designating which products are sustained-release. As well, CPOE will include default dosing options to ensure that immediate- and sustained-release products are ordered at appropriate intervals.
Fentanyl Patches: Caution Needed
There have been several patient deaths linked to inappropriate prescribing of the fentanyl patch in opioid-naïve patients despite warnings from Health Canada, the US Food and Drug Administration and the pharmaceutical manufacturer. Luckily we have not had a reported serious adverse event at Sunnybrook, although numerous medication incident reports highlight issues surrounding the use of the fentanyl patch.
Case: A 65-year-old woman with a history of osteoarthritis of the right knee underwent a right total knee replacement. Prior to surgery, she was on NO regular opioid pain medication. Post-op, her pain was well managed with oxycodone, gabapentin and acetaminophen, although she experienced severe nausea and vomiting in addition to extreme drowsiness. Her gabapentin was discontinued and her long-acting oxycodone (OxyCONTIN®) dose was reduced from 20 mg every 8 hours to 5 mg every 8 hours over a three-day period, supplemented with short-acting oxycodone for breakthrough pain.. Despite these changes, the nausea and vomiting continued and the patient refused further OxyCONTIN® doses. On the weekend, the patient was started on fentanyl patch 50 mcg to be applied every 3 days in order to maintain pain control and to possibly reduce her nausea and vomiting. Concern was raised by an RN due to:
Inappropriate use of the fentanyl patch: the fentanyl patch is not recommended for relief of post-op pain
Inappropriate dose: on the previous day, the patient had received a total oxycodone dose of 45 mg (equivalent to 75 mg of morphine) which translates to a 25 mcg fentanyl patch (not 50 mcg as prescribed)
The fentanyl patch was discontinued two days later. Luckily, the patient did not develop any adverse effects from this event.
Fentanyl patches contain a very strong opioid and it is imperative that the following best safety practices be followed in the prescribing and use of this product:
• Fentanyl patches should NOT be used for the management of short-term, acute or post-op pain. Non-tolerant patients may develop respiratory depression, potentially leading to death.
• Fentanyl patches can be used for the management of persistent, chronic moderate to severe pain. They should ONLY be considered for use in adults who have already been receiving opioid therapy for a minimum of one week at a total dose of at least 60 mg/day oral morphine or equivalent. (A fentanyl patch of 25 mcg/hour is equivalent to approximately 60 to 130 mg of oral morphine per day).
• Fentanyl patches are intended for use in patients who require continuous (around the clock) opioid administration for an extended period of time.
• Fentanyl patches are generally administered every 3 days. It is important that the previous patch be removed at the time of application of a new patch since there is enough residual drug remaining in the old patch to potentially cause harm.
• A heat source should NOT be applied to the patch (e.g., heating pad, hot water bottle) as this can result in increased and/or faster release of fentanyl from the patch.
• Used patches contain residual drug and most be disposed of safely.
Correct disposal of used patches in hospital: fold the sticky sides together and dispose of in the sharps containers.
Correct disposal of used patches in the community: fold the sticky sides together and flush the used patch down the toilet.
• Fentanyl patches are available as 12, 25, 50, 75 and 100 mcg/hour patches. Cutting of the patch to accommodate unusual doses must NOT be done as this can result in leakage and uncontrolled release of the medication.
Safety Tips:
1. Fentanyl patches should only be used in patients who have been on a stable dose of an opioid analgesic (e.g., morphine, oxycodone, hydromorphone) for a minimum of one week.

2. Never cut fentanyl patches.

3. Always remove the previous fentanyl patch before applying a new one.

4. Dispose of used fentanyl patches in the sharps container (NOT the regular garbage).
The Patient Safety Service would like to thank Mona Sawhney of the Acute Pain Service at the Holland Centre for reviewing this newsletter.

ACLS course for RN's

ACLS COURSE For RNs

MARCH 6-8, 2009

AT SUNNYBROOK HEALTH SCIENCES CENTRE
Fri. 5:30 p.m.-8:30 p.m.

Sat. 8:30 a.m.-4:00 p.m.

Sun. 9:00 a.m.-12 Noon
________________________________________________________________

This is a Regular Weekend ACLS Certification Course, exclusively for RNs.

To Register, please contact Terry G. Smith in the ACLS office.
Online information and Registration is available.

Email: terryg.smith@sunnybrook.ca
Telephone: 416-480-4943 Office: Room H-265

FEES: $360.00, payable by cheque made out to “Sunnybrook Hospital”.
(Fee includes the current edition of the ACLS Provider Manual,
Instructional CD and Pocket Cards)
Ask your department head about re-imbursement.

SIGN-UP SOON AS SPACE IS LIMITED


REGISTRATION FORMS AND FEES MUST BE SUBMITTED BY
FRIDAY FEBRUARY 13, 2009

Strategic Balanced Scorecard

Here is information regarding The Strategic Balanced Scorecard that I'm sure will give you an idea of all of the objectives Sunnybrook has and how Sunnybrook is performing. The public also has access to this website.

"Welcome to Sunnybrook’s Strategic Balanced Scorecard. The purpose of this site is to give you an electronic window on the hospital to see how we are doing in meeting our eight strategic goals that were established in our 2006 Strategic Plan. You can view our strategic goals by selecting the "Strategic Model" link above. Each of our eight strategic goals has a number of objectives and indicators, and in this site you will be able to see how Sunnybrook is performing in the dimensions of: quality of patient care, research and teaching, and sustainability and accountability. We encourage you to explore this interactive version of our Strategic Balanced Scorecard to obtain the most out of information we are providing.

Download theprintable report

While viewing our results, if you see a target we have not met, please click on the bar in that specific chart to learn about our action plan to improve.Our Strategic Balanced Scorecard provides an unprecedented level of transparency for our communities. We believe it is important for the many communities we serve across the province to see how we are meeting their needs to deliver excellent care, conduct innovative research, and offer rewarding educational experiences. We are providing this information in an easy to understand format with written explanations, and in many cases, our staff and physicians provide video clip messages along with the various measurements.Since we are reporting on Sunnybrook’s Goals and Objectives, not all of this information is directly comparable with what other hospitals have chosen to report on their balanced scorecards. We plan to update this information twice a year and you should generally expect to see gradual advancement towards our targets. We hope you find this site useful. If you have any questions or would like to contact us about any of the information contained here please contact us via the email at questions@sunnybrook.ca
We thank you for taking the time to visit our webpage. "

Question & Answers 'Seton's'

A question was asked by Rose D from Same Day Surgery regarding Setons as they have been seeing these procedures done on patients who have rectal fistulas. I posed the question to the surgeon performing these procedures and also asked her to look over an article I found on-line. Routine Use of Setons for the Treatment of Anal Fistulae

According to Dr. F, "they are a comfortable loosely placed soft small piece of material that is no maintenance. It really doesn’t require discharge teaching in Same Day. I review everything with the patients in the office. I just looked at the picture (see article) you have. I use a softer material and it is never left with long ends….most patients hardly notice it is there…but this is the principle.
The seton is a drain that is placed between the internal opening of the fistula and the external. It is a loop. It is not a cutting seton – I never put a seton drain in that needs to be tightened. It is basically just a little piece of soft plastic requiring no maintenance on the part of the patient and no home care.

Thanks Rose for posing the Question!

SPANC Minutes

SPANC Meeting Minutes
November 5, 2008

In Attendance
Ramona Hackett
Sandi Weir
Janet Stimec
Jane Atkinson
Rose Diamond
Betty Mannino
Debbi Jugmohan
Delia Muresan
Anna Jackson
Mila Kaplanski
Carol Deriet

Meeting commenced at 11:35

1. It was noted that many months have passed since there has been a formal SPANC meeting. Minutes from Jan 31, Apr 3, and June 4 reviewed and discussed.
2. Meeting times discussed and revised. Decision made to conduct SPANC meetings first Wednesday of every month between 11:30-13:30 in room MB206
3. As SPANC is intended to be inclusive of ALL PeriAnesthesia areas, it has been decided that it is necessary to have a representative, and co-representative for each unit. The representatives will encourage staff to attend SPANC meetings
Janet Stimec has agreed to be the representative for PACU with Sandi Weir being the co-representative.
Debbi Jugmohan has agreed to be the representative for SSSU.
Volunteers are required to be representatives and co-representatives for PAC and SDS

4. Betty Mannino and Sandi Weir have agreed to take turns attending Corporate Nursing council every other month. Jane Atkinson has indicated an interest in rotating through.
5. Ramona would like to see more people contributing towards the Blog. Ideas are needed that will address concerns, promote education and information, quizzes, etc.
6. Handover Tool discussed. It has been noted that SDS has not been completing their section of the tool. It is felt that there is already so much documentation to do and that there is not enough time to fill in one more document when the priority is preparing the patient for the OR. Some of the information in their section is redundant. Discussed that this project was to promote continuity of communication, and to be one of the first PeriAnesthesia areas in the country to trial this. Agreed that as it is a trial, there is room for adding/eliminating sections. In the meantime, SDS encouraged to try to complete their section, or at least the areas pertaining to CPAP and patient Belongings.
7. Carol added that there have been too many cases now where CPAP machines have gone missing and that there needs to be a sign-over sheet from one RN to another, or porter to RN etc.
8. PACU is trialing new lunch hours 11, 12, 13,1400hrs. Evening shift would like to change their break hours as well---is this possible?
9. Discussion of Policies that need to be worked on:
-Visitor policy in PACU
-Medication policy for RN’s working in PAC/Ambulatory assessment
-Pre-op diabetic protocol (what should the RN’s be telling patients who are insulin dependant?)

10. SDS would like to update patient discharge information. Tracey DasGupta (APN from Odette) would also like to be involved with this project. Need to determine Surgeon’s preference as well.
11. Poster presentation at the NAPAN conference regarding Handover Tool.
*possible poster presentation regarding Best Practices in normothermia---something to think about


ACTIONS REQUIRED PRIOR TO DEC 3 MEETING
1. Book MB206 for the first Wednesday of every month 11:30-13:30. DONE
2. SSSU Co-Reprehensive: ___Seema Ratanshi____
PAC Representative: _____________________________________
PAC Co-Representative:__________________________________
SDS Representative: _____________________________________
SDS Co-Representative:___________________________________
3. Sandi Weir to addend Corporate Nursing Council November 26th. Betty to give Sandi the package. -Sandi to arrange schedule with Vicky.
-Jane to arrange schedule if she would like to attend this month.
4. All members to forward ideas for Blog to Ramona
5. All areas to complete their section of the Handover Tool during this trial period
6. CPAP sign-over sheet to be designed and implemented
7. Bring PAC Booklet to Dec 3 meeting to start discussion re: policy development surrounding visitors and medications
8. SDS RN’s to develop list of surgeries requiring discharge information
9. Discuss with SSI group regarding temperature discharge criteria for laparotomy patients
Meeting adjourned at 13:10
Next SPANC meeting Wednesday, December 3, 2008 - MB206 - 1130-1330

SSI-Normothermia

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

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

Another reminder that the OPANA conference is next weekend.

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.

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.

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.

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

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.

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.

Article

Time to start reading!

Best Practice Guidelines: Collaborative Practice Among Nursing Teams

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)

The First Canadian Healthcare Conference...

24 hours a day/7 days a week/365 days a year!

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).

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

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.