Reduce Use of CXRs for PICC Placement Confirmation

Project manager: 

  • Elizabeth Sin, MS, BSN, CCRN, Unit Director, Centralized Telemetry/Vascular Access Team

Sponsors: 

  • Sheila Antrum, MHSA, RN, President and Senior VP, UCSF Health – Adult Services
  • Tina Mammone, PhD, RN, CENP, NEA-BC, Vice President and Chief Nursing Officer

Participants: 

Adult Vascular Access Team members:  Anna Liang, MS, RN, CPNP-AC, VA-BC; Lynne Tom, MSN, RN, VA-BC; Michele Nomura, MSN, RN, VA-BC;  Yunhee Lee, BSN, RN, VA-BC; Todd Dayton, BSN, RN; Vivian Phan, RN; Kenichi Uyeda, RN, VA-BC; Shannon Sutherland, RN, VA-BC

Summary:

Elimination of confirmatory chest x-ray in selected patient population for tip location of Peripherally Inserted Central Catheter (PICC) utilizing electrocardiogram (ECG) based technology. This methodology is endorsed by the Infusion Nurses Society as it allows greater accuracy, more rapid initiation of infusion therapies, and reduction of radiation exposure as well as reduces costs for patient care.  

Count In Progress

Principal Investigator

  • Margo Peterson, MS, RN, CNOR, Clinical Nurse Supervisor IV, Mt. Zion Operating Room

Medical errors related to interruption of critical tasks are well documented in the clinical setting including the operating room.  Numerous strategies have successfully reduced interruptions during medication administration including the use of attention attention-getting vests, lanyards, or sashes along with signage alerting those in close proximity to the critical nature of medication administration.

The surgical count is the front line of defense against retained surgical items (RSI).  The Count In Progress project adopted the concept of visible signage into the operating room in the form of a bright orange visual indicator with ‘Count In Progress’ boldly printed across it.  The sterile visual indicator announcing the surgical count process is placed directly on the surgical field during the final count thus alerting direct providers as well as charge nurses and ancillary staff of the count process. Limiting the detrimental effects of interruptions during the final surgical count improves the surgical count process making it more effective and efficient thus improving patient outcomes by preventing exposure to unintended radiation, avoiding extended anesthetic and operative times, and potentially averting retained surgical items.

The purpose of this innovation project was to improve counting performance by visually alerting the entire perioperative team when the final count process takes place.  Interruptions during critical tasks result in errors -- This fact has been repeatedly recognized during the task of medication administration in a variety of health care settings.  Medical literature reveals the implementation of an array of interruption management strategies have effectively reduced medication administration errors consequently enhancing the culture of safety. One strategy used in medication administration is a visual indicator alerting others to limit conversations and interruptions while the critical task is performed.

Liberally borrowed from the medication administration techniques, the sterile bright orange visual indicator provides a simple and consistent method to alert perioperative staff in real-time to the count process.  Placed directly onto the surgical field during the count, the visual indicator erases ambiguity by communicating to everyone in the perioperative setting the critical task of the surgical count is taking place.      

All surgical procedures performed at UCSF’s main operating rooms during the three-week trial period whether scheduled or emergent, adult or pediatric, were provided with the orange visual indicator and a data collection sheet in the surgical case cart.  As the trial was voluntary, and although encouraged to use the visual indicator on every surgical procedure, the perioperative staff elected when to display the visual indicator during the closing surgical count process.  The sterile visual indicator was to be opened up and spread upon the sterile field or Mayo stand during the closing count process.  At the conclusion of the count the visual indicator was to be moved away from the sterile field onto the backtable.  The visual indicator could also be displayed during the closure of a cavity within a cavity, during permanent relief counts, or for the skin count. This innovation sought to increase awareness of the count in progress. 

 

Safety Attendant

Implementation of AvaSure and decision making regarding sitter use

AvaSys is a remote patient observation system that enables audio and visual monitoring of patients at risk for falls. It is the first line of defense for patients at risk, allowing staff to immediately and directly intervene when a patient is at risk of self-harm. The technology is deployed as a portable, wireless unit.

Project manager: :

Elizabeth Sin, MS, BSN, CCRN, Unit Director, Centralized Telemetry/Vascular Access Team

Participants:

  • Florlina Agudelo, BSN, RN, BMTCN, Unit Director, Adult Hematology, Oncology and BMT
  • Julie Anderson, RN, Clinical Nurse, Adult Hematology, Oncology and BMT
  • Brett Austin, RN, Unit Director, Nursing Hospital Supervisors
  • Karri Ballard, RN, Assistant Patient Care Manager, Adult Hematology, Oncology and BMT
  • Lindsay Bolt, MS, RN, CMSRN, Clinical Nurse Educator, Adult Acute and Transitional Care
  • Irish Criseno, BSN, RN, Unit Director, Central Resource Group
  • Amy Dunne, MS, RN, ACCNS-AG, CCRN, Adult Critical Care Clinical Nurse Specialist
  • Kiran Gupta, MD, MPH, Assistant Professor of Medicine
  • Craig Johnson, MSN, RN-BC, FNP, Clinical Nurse Informaticist
  • Sudha Lama, BSN, RN, Clinical Nurse, 8L Neurosciences Acute Care
  • Melissa Lee, MS, RN, CNS, Adult Acute and Transitional Care Clinical Nurse Specialist
  • Michelle Macal, MS, RN, CNS, Adult Acute and Transitional Care Clinical Nurse Specialist
  • Carrie Meer, MS, RN, CNS, CPHQ, Interim Director, Nursing Performance Improvement
  • Jennifer Miranda, MSN, MBA, RN, Unit Director, 15L Acute Medicine
  • Mary Moore, MS, RN, CPHQ, Performance Improvement Nurse
  • Annette Neill, BSN, RN, SCRN, Assistant Patient Care Manager, 8L Neurosciences Acute Care
  • Andrea Plati MSN, RN, OCN, Unit Director, Adult Hematology, Oncology and BMT
  • Mary Reid, BSN, RN, NE-BC, Unit Director, 6L Adult Neurological Transitional Care and 8L Neurosciences Acute Care
  • Stephanie Rogers, MD, MPH, Assistant Professor of Medicine, Division of Geriatrics
  • Krystle Rowlands, RN, Clinical Nurse, 8L Neurosciences Acute Care
  • Katie Segev, MS, RN, OCN, Assistant Patient Care Manager, Adult Hematology, Oncology and BMT
  • Marjorie Smallwood, MPH, Manager, Workplace Violence Prevention Program
  • Julie Vavuris, BSN, CCRN, Assistant Unit Director, Central Resource Group

Perioperative Services - Caseview

By Ho Lom Lee and Joyce Nacario, RN

Perioperative services developed a solution in-house to address the need for multiple disciplines to view surgical case information in real time. 


The effective management of surgical operating rooms is crucial in ensuring safe, high quality and cost-effective patient care. However, such management can be very challenging due to the number of staff, patients and rooms involved, in addition to the necessary coordination of equipment, medications and supplies. To address this important issue, the UCSF operating room has developed a novel, easy-to-use tool to visualize and manage operating room use in real time. The purpose of this study was to examine cost effectiveness and efficiency levels resulting from the use of CaseView as a web-based resource to expedite patient care and cost-saving for an operating room in clinical practice. 
Resources collaborated to assess the needs of the teams that care for patients undergoing surgery. This spanned all areas from pre-op, through the operating room (OR) all the way to the patient floors that would eventually care for patients after surgery. 

Background

It takes a lot of coordination on the part of many individuals to effectively run an operating room. Surgeons, anesthesiologists, nurses and ancillary staff need to know anticipated case volumes, scheduled case times, complexity of cases, acuity of patients, staff availability with mixed skill levels, medications, supplies and equipment needed to deliver safe, high quality patient care.  As cases are added, rearranged and cancelled over the course of a day, providers and staff must have access to the latest information in order to plan their next actions.

Individuals outside the OR also have an interest in the status of surgical cases.  Staff at the surgical waiting area must provide updates to families of patients who are having surgery.  The clinics need to know the whereabouts of their surgeons. The Admitting department needs to verify that patients having surgery are properly admitted into the system.  Nurses in the units need to be able to anticipate when their patients are due back from surgery.

CaseView addresses these needs by providing a powerful yet intuitive visual interface to data that already exists in clinical databases, but which is otherwise difficult to obtain and interpret.  It allows interested individuals to make decisions based on the most up-to-date information, and promotes efficiency and situational awareness of what’s happening in the ORs.
When everyone is literally looking at the same display, decisions are made wisely and effectively with certainty.

Overview

  • A visual representation of past, present, future operating room cases at UCSF locations: Moffitt / Long, Mount Zion, Ambulatory Surgery Center
  • Real-time information – display is updated as cases progress; represented by a vertical line
  • Users identified using network account
  • Multiple views of cases
  • Hovering mouse over case displays information about case
  • Clicking on case opens popup window with more detailed information about case to enhance hand-offs including skin assessment, procedure names, drains, EBL, etc
  • Cost-saving and “green” for the environment by eliminating hundreds of daily paper print-out

Enhancing Medication Safety through High-Fidelity Simulation Training

It has been proven that students who received simulation-based training show statistically significant improvement in cognitive knowledge, both in the clinical and non-clinical settings. The aviation industry is a classic example of a field where simulation has been used for many years.  Key to simulation is providing a realistic and safe environment for practice and to learn new procedures or to test new devices or workflows. The more realistic (or high fidelity) the scenario, the more the learner can immerse themselves into the situation. 

UCSF Medical Center Patient Care Services is in the process of training staff to prepare for the transition from a paper based Medication Administration Record (MAR) to an electronic MAR or eMAR with barcode scanning. This transition must not only be smooth, but also cannot compromise patient safety related to medication administration errors. To address this, traditional methods of online learning modules and classroom training have been supplemented with mandatory simulation learning. 
The simulation team has developed a simulation area with patient rooms, medication areas, and separate debriefing rooms. The curriculum and room set up, using high fidelity manikins, create a realistic -- yet safe environment -- for clinicians to simulate medication administration using eMAR and barcoding.

Simulation Team

  • Craig Johnson, RN, MSN, FNP, Patient Care Services Clinical Information Coordinator
  • Daphne Stannard, RN, PhD, CCRN, CCNS, FCCM, Associate Chief Nurse Researcher and Perianesthesia Clinical Nurse Specialist
  • Adam Cooper, RN, MSN, Nurse Educator
  • Melissa Lee, RN, MS, GCNS-BC, Med / Surg Clinical Nurse Specialist
  • Nina Manke, RN, MSN, Simulation Lab Coordinator
  • Sandy Ng, RN, MSN, RN-BC, Patient Care Services Clinical Information Coordinator
  • Maureen Buick, RN, MS, Director of Nursing Education and Performance Improvement

Simulation Videos

  • eMAR / BCMA Sim Lab Video
  • Local news coverage of UCSF Sim Lab