Professional Practice Council Members Name Credentials … · 2016-07-15 · Working on healthy nursing initiative for 2015. Suggested do a race and if staff participate in race they

Professional Practice Council Members

Name Credentials Department TitleAndressi, Lori BSN, RN, CPN SDS Senior Professional Staff NurseArnold, Colleen RN Quality Patient Safety SpecialistBarr, Amber BSN, RN CPN PRN Professional Staff NurseBower, Amy AND, RN, CPN 6B Senior Professional Staff NurseBridgman, Amy MSN, CPN, RN-BC Training and Education Advanced Clinical Education SpecialistBrytus, Jeanne BSN, RN, CPN Quality Infection Control Specialist

Butler, Gabriella MSN, RN Quality

Manager of Clinical Resource Management, Solutions for Patient Safety and Clinical Quality Analitics

Carlson, Maureen BSN, RN, CPN 6B Clinical Leader- Sr. Professional Staff NurseCepullio, Chris BSN, RN Ancillary Services Quality Nurse- Coordinator, PharmacyClapp, Dawn RN, CPN PRN Professional Staff NurseCole, Ashley MSN, RN, CCRN CICU Programmatic Nurse SpecialistCooper, Heather-Dawn BSN, RN, CPN ED ClinicianCoultura, Jordan BSN, RN, CPHON 9B Sr. Professional Staff NurseDering, Diane BSN, RN Dialysis Sr. Professional Staff NurseDigiandomenico, Randall RN Dialysis Professional Staff NurseDowds, Vittoria BSN, RN, CPN 6A Professional Staff NurseDvorsky, Courtney BSN, RN 9A ClinicianEvans, Melissa BSN, RN CICU Sr. Professional Staff NurseFischer, Gina BSN, RN SDS Sr. Professional Staff NurseFleck, Sandra BSN, RN, CPN Nursing Administration Administrator on DutyGiannettino, Grace BSN, RN 7A Clinical Leader- Sr. Professional Staff NurseGoff, Jeff MSN, RPh Ancillary Services Sr. Director PharmacyHairston, Kesha RN, CPN CHRU Sr. Professional Staff NurseHarold, Danielle BSN, RN Infusion Center Sr. Professional Staff NurseHarris, Heather BSN, RN, CCRN CICU Clinical Leader- Sr. Professional Staff NurseHavel, Marilyn RN, CPN 9C Professional Staff Nurse

Hupp, Diane DNP, RN, NEA-BC Administration VP Patient Care Services, Chief Nursing OfficerImes, Dawn MSN, RN, ANCC Infusion Center Sr. Professional Staff NurseKamnikar, Michelle BSN, RN, CPN 7C/ PRN ClinicianKatlubeck, Andrew MSN, CRNP 8B Sr. Professional Staff NurseKilgore, Caitlin RN, CPN Obs Unit Sr. Professional Staff NurseKostie, Kylie RN, CCRN PICU Professional Staff NurseKorol, Erin RN 6E Professional Staff NurseKuziak, Kelly BSN, RN, CPN 7C Clinical Leader- Sr. Professional Staff NurseLenhart, Melinda BSN, RN, CPHON Tr & Ed Clinical Education SpecialistLicata, Jodi MSN, RN, CCRN, CNL PICU Programmatic Nurse SpecialistLipinski, Kim BSN, RN, CPN Nursing Administration Administrator on DutyMalcolm, Giovanna RN OR Sr. Professional Staff NurseMastrangelo, Beth BSN, RN, CPN Quality Quality NurseMcClain, Melissa BSN, RN, CPN 7B Professional Staff NurseMcsteen, Michael BSN, MBA, CCRN, CNPT Transport Team Sr. Professional Staff NurseMerulli, Amber BSN, RN, CPN 6B Sr. Professional Staff NurseMeyer, Lisa BSN, RN, CPN Infomatics Infomatics Nurse Mills, Janice BSN, RN NICU Professional Staff NurseMingrone, Teresa MSN, RN, CCRN NICU Programmatic Nurse SpecialistMorris, Brianne MSN, RN, NNP-BC NICU Nurse Practitioner- NICUPacelli, Caitlin AND, RN, CPN ED/OBS Sr. Professional Staff NursePaul, Julie BSN, CPN PACU Sr. Professional Staff NursePasek, Tracy BSN, MSN, RN, DNP, CCNS, CCRN, CIMI PICU Programmatic Nurse SpecialistPetrill, Amanda BSN, RN, CPN 6A ClinicanRuefle, Megan BSN, RN ED Professional Staff NurseSaville, Al BS, RRT Respiratory Services Educator, Respiratory ServicesSchenkel, Kathleen MSN, RN, CPEN ED Programmatic Nurse SpecialistSeelhorst, Annette BSN, RN, CPN PACU Sr. Professional Staff NurseSmith, Lauren BSN, RN, CCRN NICU Sr. Professional Staff NurseStine, Chris BSN, RN, CPN 8B Clinical Leader- Sr. Professional Staff Nurse

Straka, Kristen DNP, RN, CPN, NEA-BC Nursing AdministrationSr. Director Pharmacy, Ambulatory, Heart and Rehab

Thomas, Dawn MSN, RN, CPN, VA-BC IV Team Clinician IV TeamTipping, Colleen MHMS, BSN, RN, CPN, CCRN Trauma Services Trauma Nurse CoordinatorValenta, Cynthia MSN, RN, CNRN Administration Clinical DirectorVonHofen, Geraldine BSN, RN 6E Outpatient Nurse Coordinator IIVincett, Carrie MSN, RN, CPN CICU, 7A Unit DirectorVincze, Durae MSN, RN Nursing Administration Clinical DIrectorWasco, Fern BSN, RN North Surgery Center Professional Staff NurseWible, Susan MSN, MBA, RN, CPN 9A Unit DirectorWietholder, Julie BSN, RN, CPN North Surgery Center Sr. Professional Staff NurseZwier, Kathy BSN, RN, CPON 9C Clincian

PRACTICE COUNCIL

October 28, 2014 CONFIDENTIAL AND PRIVILEGED

In attendance: A. Petrill, M. Carlson, A. Merulli, M. Kamnikar, G. Giannettino, D. Harold, D. Thomas, A. Katlubeck,

A. Spence, K. Schenkel, M. Ruefle, G. Malcolm, G. Fischer, A. Seelhorst, H. Harris, J. Licata, T. Mingrone, J. Brytus, J. Wietholder, R. DiGiandomenico, M. Lenhart, A. Bridgman, M. Miller, G. Butler, L. Meyer, M. McSteen, C. Valenta

Phoned in: A. Adams, M. McClain, A. Bower, C. Tokarsky, K. Kostie, D. Imes, K. Hairston, S. Gardner, TOPICS DISCUSSION FOLLOW-UP I. CALL TO ORDER II. System PPC updates:

A. Petrill J. Weitholder

M. McSteen called the meeting to order. Minutes were reviewed from the September 26, 2014 meeting. Working on healthy nursing initiative for 2015.

• Suggested do a race and if staff participate in race they will receive healthy points.

• Senior Professional Nurse – Schooling – New Hires will have 2 years to enroll for BSN. Tuition Forgiveness is $2 more an hour. This will not affect the current staff.

Minutes were approved and will be available on SharePoint.

Policies/Information only

107.04 Organizational Ethics This policy was presented at the October Practice Council meeting

Information only / approved

100.48 Medical Record Copies for Transfer of Patients to another Facility or Coroner Case

This policy was presented at the October Practice Council meeting

Information only / approved

Policies for Council Approval October 2014

141 Admission Nurse - Jeanne Brytus

This policy was presented at the October Practice Council meeting.

Approved

325 Enteral Feeding Policy - Amber Merulli


Approved w/change

373 Enteral Decompression Tubes - Amber Merulli


Approved w/change

492 Surgical Inplants / Explants - Darci Opalko


Approved

Practice Issues

ED to Acute Care Transfers K. Schenkel

Practice Alert for ED to Acute Care Transfers was brought back to Practice Council with feedback. There needs to be better communication with the ED and better teamwork. Overall it seems that the process has improved. - There is still an issue with receiving the eval

complete and the patient immediately being brought to the floor. Discussion followed.

- Gabriel Butler presented 2 months of data collected from Unit 6A. (amount of time between when the unit is paged by ED HUC and when the patient actually arrives to the unit) Discussion followed.

- Data will be collected on a medical unit and

analyze the data. It will be collected from Unit 8B.

Informed Consent Update B. Mastrangelo

- Clarification of who can legally give consent for surgery should be done as soon as it is known that the patient will be having surgery. - If the person with the minor patient is not a biological parent, social service is to be called immediately. -If the RN is asked to witness a consent and they have not established family relationships they need to verify with the person signing that they are the parent or legal guardian. -Phone consent can be obtained with 2 witnesses. The reason as to why the verbal consent was done instead of being done in person should be noted in the chart. -Medical Consent Authorization forms can be found on www.chp.edu if parents will not be here to sign consent.

- Guidelines for establishing Authority to Consent for Informed Consent Procedures will be posted to SharePoint under “hot topics”.

Unit Initiatives

Same Day Surgery – Gina Fischer

Gina Fischer presented Same Day Surgery department’s unit initiative.

The power point is on the PC share point site.

PACU – Annette Seelhorst Annette Seelhorst presented PACU’s department’s unit initiative.


http://www.chp.edu/

New Business 0900 Viral hemorrhagic fever / Ebola Shawn Moody / Terri Roberts

Shawn Moody and Terri Roberts presented the group with information regarding Viral hemorrhagic fever / Ebola. Information on this topic is changing on a daily basis. Here is the most current information from:

• UPMC infonet • CDC gov

UPMC protocol is available on infonet.upmc.com Highlights:

1. Background a. Ebola is not new b. 5 different strains

2. Transmission a. Direct contact b. Patient has to be symptomatic c. Bodily fluids

3. Timeline a. March – outbreak noted b. August – 2 infected Americans c. September – 1st patient arrives in Texas

4. Screening a. August 13th began travel illness screening

in ED b. Need to assess for newly emerging

diseases c. Currently screening for MERS & Ebola d. 9 “positives” – all have been ruled out in ED

5. Signage posted 6. Screening tool varies slightly from UPMC 7. Isolation

a. National b. Bio containment unit

Keep checking UPMC infonet for updates

8. UPMC System a. CHP b. Presby c. Altoona d. Hamot

9. CHP dedicated isolation rooms a. ED Room #38 b. PICU Room #1

10. PPE (personal protective equipment) a. Level 1 b. Level 2 c. Guidelines recently revised to correspond

w/CDC 11. Lab Testing

a. No specimen testing @ UPMC facilities until Ebola is ruled out.

12. SICE a. Screen b. Isolate c. Call – ID attending, if case definition met:

1) contact medcall 2) activate HICS Team

d. Evaluate Magnet Strategic Plan PPM Feedback PPM Survey

PPM Feedback:

• Tweek the crayons • Not in favor of the wordy diagrams • Should be in line w/our current hospital

PPM Survey:

• Recommended survey to be sent out.

Questions/Discussion

The meeting was adjourned at 10 am Call in number: 1-800-744-8762 Access code: 692-5126

The next meeting is scheduled for Tuesday, November 18th at 8a-11a in the Plaza Building Room 307. 2014 PC meeting schedule is on the PC share point.

PRACTICE COUNCIL

November 18, 2014 CONFIDENTIAL AND PRIVILEGED

In attendance: D. Ankney, A. Merulli, G. VonHofen, M. Kamnikar, D. Thomas, C. Tokarsky, A. Katlubeck, J.

Coltura, A. Spence, K. Schenkel, G. Fischer, J. Licata, L. Riordan, J. Brytus, J. Wietholder, D. Dering, D. Imes, M. Lenhart, A. Bridgman, M. Miller, G. Butler, T. Pasek, L. Meyer, A. Petrill

Phoned in: D. Harold, A. Bower, K. Kostie, A. Barr, K. Hairston, M. McClain, M. McSteen, J. Paul TOPICS DISCUSSION FOLLOW-UP I. CALL TO ORDER II. System PPC updates:


J. Brytus called the meeting to order. Minutes were reviewed from the October 28, 2014 meeting.

• Pressure Ulcers – UPMC attorney discussed the importance of documenting all pressure ulcers and all preventative measures we take. If an ulcer is present, it should be clearly documented and the care should be noted. This is paramount in cases where the patient or family files a lawsuit.

• Horizontal Violence Presentation • UPMC Nurse Week will be celebrated April 28-

May1st – see Julie W. if interested in helping with the festivities


Policies for Council Approval November 2014

100.06 Outpatient Prescription - Kristen Straka

This policy was presented at the November Practice Council meeting.

Approved

100.42 Medical Ethics - Cindy Valenta

This policy was presented at the November Practice Council meeting

Approved

125 Documentation - Heidi Dolinich


Approved w/changes

128 Review and Viewing of Orders - Heidi Dolinich


Approved

206 Arterial Line - Kylie Kostie


Policy on hold for further review

226 Blood Sampling from Arterial Lines - Jodi Licata


Approved

270 Cleft Lip – Care of Patient with Repair - Amber Merulli


Approved

275 Cleft Palate – Care of Patient with Repair


Approved

325 Feeding – Enteral Care - Amber Merulli


Hold for education

366 Intra-Abdominal Pressure Monitoring - Kylie Kostie


Approved

373 Enteral Decompression Tubes – Insertion and Care of - Amber Merulli


Hold for education

405 Admission, Discharge, Transfer - Jen Iagnemma


Approved

493 Specimen Release - Darcie Opalko


Approved

515 Traction – Buck’s Extension Skin Traction - Amanda Petrill


Approved

525 Traction – Skeletal - Amanda Petrill


Approved

688 Shunt Tap – Assisting with - Amanda Petrill


Approved

383 Oncology Patient Playroom Guidelines - Ann Spence


Approved

Practice Issues


Practice Alert for ED to Acute Care Transfers was brought back to Practice Council with feedback. Overall it seems that the process is improving and all is going well. - Data collected from Unit 8B will be brought back

to the December meeting.

MRI / Pump Safety D. Cancilla

D. Cancilla presented a powerpoint presentation regarding MRI / Pump Safety - MRI scanner is always on - If MRI scanner is quenched it costs $1 million to

bring it back up. - All patients and staff going into MRI must be

screened - Any object can become dangerous - Gold jewelry and eye glass frames are usually

safe near an MRI machine - Heat is another safety issue – we need to screen


for medication patches, etc. that can cause burns - We maintain a list of MR-safe and MR-

compatible equipment, including restrictions for use. This list is kept in every MR center by MR safety officer

Zones 1-4 - Develop a “time out” or “pause” process prior to

start of procedure - Develop a screening form - Non-MR members are to leave phones on unit

and have assignments covered Peer Review / Pump Safety - All RN educated high alert medications

If patient comes to Radiology on a pump you must have: - Strong battery - Enough fluid for duration of exam - Make sure ticket to ride has a phone # on it for

who to call Unit Initiatives

EMU – Gerri VonHofen

Gerri VonHofen presented EMU department’s unit initiative.


New Business

Magnet Strategic Plan PPM Feedback PPM Survey

PPM Survey:

• Survey was sent out • Less than 10% participation • Survey will be resent again

For next meeting: - Results from new survey

• Encourage staff to complete survey

A. Send flyer to be posted so staff will know to check email and complete survey

B. Suggested incentive for staff to complete. Recommendation: 3 options - Original crayon box - Crayons spilling out of box - Patient & family in middle

Keep original crayon box and resend survey w/more options.

- Share new ideas


The meeting was adjourned at 10 am. Call in number: 1-800-744-8762 Access code: 692-5126

The next meeting is scheduled for Tuesday, December 16th at 8a-11a in the Plaza Building Room 300. 2014 PC meeting schedule is on the PC share point.

PRACTICE COUNCIL

December 16, 2014 CONFIDENTIAL AND PRIVILEGED

In attendance: D. Ankney, A. Petrill, G. VonHofen, K. Kuziak, M. McClain, D. Thomas, A. Katlubeck, J. Coltura, A.

Spence, K. Schenkel, L. Andreassi, A. Seelhorst, J. Licata, L. Riordan, J. Brytus, J. Wietholder, R. DiGiandomenico, M. Lenhart, M. Miller, K. Hairston, M. McSteen

Phoned in: H. Harris, A. Merulli, A. Bower, H. Dawn-Cooper, G. Giannettino, K. Kostie TOPICS DISCUSSION FOLLOW-UP I. CALL TO ORDER II. System PPC updates:


J. Brytus called the meeting to order. Minutes were reviewed from the November 2014 meeting.

• Disability Resources available to pt/families. - Hearing impaired - Blind - Resources are available for family / visitors

and call this number – 412-605-1483. - Contact Social Work for assistance - Department of Justice – not good on

disability – there will be housewide education regarding this

• Nursing Grand Rounds - CHP would like to host one - Suggested topics needed

• Holly Lorenz – Ebola


- 3 doz. Hospitals are signed on - UPMC Site

• Highmark - Zero premiums - CHP is good until 2022

• New Flu Strain is the H3N2

Policies for Council Approval December 2014

10.6 Outpatient Prescription Writing/Renewal - Renee Bischoff

This policy was presented at the December Practice Council meeting

Approved

107.51 Medical Record Forms Management Policy - Carrie Pesce


Approved

612 Bladder Scanning - Amanda Petrill


Approved

847 Insulin IV Infusion - Jeff Goff


Approved

853 IVIG - Jeff Goff


Approved

861 Peripheral Nerve Block - Jeff Goff


Approved

874 Medication Brought in by Patients - Jeff Goff


Approved

890 Transcription, Administration, and Documentation of Medication Orders - Jeff Goff


Approved w/change

260 Cervical Collar -


Approved w/change. Reference Skin Care Policy

Practice Issues


Practice Alert for ED to Acute Care Transfers was brought back to Practice Council with feedback again. Overall it seems that the process is improving and all is going well. - Data collected from Unit 8B still needs to be

brought back to the next meeting. - The biggest complaint from the units is still

receiving an eval complete before receiving the patient.

Care Model Update – PCT hand-off report process D. Thomas

The process for PCT hand-off report: • PCTs changing their time from 6:30 am – 7:00

pm • Bedside rounding – hand-off • Give brief report • PCT floor hand-off form will be coming out

soon • Will be taken to the Unit Director meeting. • PCTs are to be giving patients baths before

they go to the OR and if the patient comes down to the OR dirty, f/u with the managers are to be done.

Unit Initiatives

CHRU – Kesha Hairston

Kesha Hairston presented CHRU department’s unit initiative.


New Business

Ethics Survey Results Sheila Hahner (8:15 am)

Ethics survey results: • 5 question survey – sent to all U.D. to pass out

to staff • 324 respondents • Results where shared with the group. • 17% volunteered to become Ethics Champions

(mostly nurses, resp. and PCTs) • Kick-off meet and greet will be held January

26th beginning at 8:00 a – 9:00 am in Conference Room #6503.

PICU PFCC White Rose Project J. Licata

Jodi Licata presented the PFCC White Rose Project to the group.

The White Rose Project presentation is on the PC share point site under Shared Documents.

Magnet Strategic Plan PPM Feedback PPM Survey

PPM Survey:

• Survey was sent back out to staff • Data did not change • Staff disagree with the PPM being the driving

force of nursing care • PPM should change as Healthcare changes • Look to PPM to look for growth

A sub-group to be formed within Practice Council to come up with different concepts for PPM and bring back to the group in several months. Those who volunteered for the group:

• Michael McSteen • Heather Ambrose • Heather-Dawn Cooper • Jordan Coltura • Melinda Lenhart • Annette Seelhorst • Ann Spence • Julie Weitholder

If you have any ideas send them to the Practice

Council email box.



The next meeting is scheduled for Thursday, January 22nd at 8a-11a in the Plaza Building Room 300. 2015 PC meeting schedule is on the PC share point.

PRACTICE COUNCIL

January 22, 2015 CONFIDENTIAL AND PRIVILEGED

In attendance: A. Petrill, M. Carlson, E. Karr, M. McClain, A. Bower, M. Kamnikar, G. Giannettino, D. Thomas, C.

Tokarsky, A. Spence, K. Schenkel, M. Ruefle, G. Malcolm, G. Fischer, A. Seelhorst, H. Harris, J. Licata, T. Mingrone, L. Riordan, J. Brytus, J. Wietholder, D. Imes, C. Rennick, M. Miller, S. Gardner, T. Pasek, D. Vincze, D. Lesniak, M. McSteen, H. Dawn-Cooper, A. Lukanski

Phoned in: K. Kuziak, K. Kostie, M. Lenhart, TOPICS DISCUSSION FOLLOW-UP I. CALL TO ORDER II. System PPC updates:


M. McSteen called the meeting to order. Minutes were reviewed from the December 2014 meeting.

• Brief conference call held for the meeting • Discussed new charter • Nurse’s Week discussed • Nurse’s Week will be April 29 – 30, 2015 &

May 1, 2015 • Working on guest speaker


Policies for Council Approval January 2015

218 CHG Bathing - Ann Spence

This policy was presented at the January Practice Council meeting

Approved – Hold for education Ref. CHG Policy

232 Infant Sleep Environment - Durae Vincze


Approved – Hold for education

310 External Ventricular Drain - Amy Lukanski


Approved

818 CVAD Care - Ann Spence


Approved – Hold for education

107.10 EMTALA - Deb Lesniak


Approved

Practice Issues

PCAs - Tracy Pasek

The PCA policy is under review. Please instruct parents NOT to press the PCA button for patient. If the patient is unable to push the button and it is not ordered as a nurse demand, please contact the ordering service immediately. If a patient has PCA orders from the Critical Care Service and are transferred to an acute care unit, Pain Service must be consulted.

Unit Initiatives

None to report for this month.

New Business

Changes in UPMC Schools of Nursing Curriculum: What does that mean for the bedside nurse? - Mary Beth Langdon

MSN, RN-BC

Concept-based Curriculum: • Conceptual Based Approach • Focus is on concepts across various settings

and lifespans & throughout the wellness-illness continuum

• 16 month program with structured clinical days Objectives:

• Understand what a concept based curriculum entails

• Identify the impact of a conceptual based education on a clinical day and the student/nurse partnership

Why Change:

• Regulatory requirement • Best overall approach to nursing for today’s

learner • General Practitioner

- Back to basics - Less minutia

• Faculty report spending most of their time

supervising students in hands-on procedures, leaving little time to focus on fostering the development of clinical reasoning skills

A Conceptual Based Clinical Day:

• Clinical day focus - The concept being taught in theory - Safety with medication, patient care and best practices - QSEN competencies

• Various activities and assignments - Some days students will provide total patient care

- Some days students will focus on an activity related to the concept

What does this mean for our clinical partners: • Students will not always provide total patient

care and will not always complete tasks with their instructor

• Staff will be informed of the concept of the day and the students goals for the day

• Staff expertise is important in fostering the development of “thinking” skills related to the concepts and patient care

EMTALA - Deb Lesniak

D. Lesniak discussed the new map regarding the ED Response Team and what areas they respond. ED Response Team responds to all adult conditions. Areas they respond to:

• AOB • 2 Clinics (Eye Clinic, PTRC) • Bridges • Neuro (in faculty building) • Education • Gym

Rangos – 911 Ronald McDonald House - 911 Faculty Pavilion – 911

Magnet Strategic Plan PPM

The group met and discussed the changes that were suggested with the PPM.

• Keep current model but make adjustments to it • Change some crayons and move them around

• Crayon count stays the same • Add exemplary nursing • Remove Pride • Collaboration instead of teamwork • Values are moved out of the box • Add community • New crayons will be brighter so everyone

would know they are new

Present to PCL and show rationale as to why changes are being made. Need to educate staff more about the PPM.



The next meeting is scheduled for Thursday, February 26th at 8a-11a in the Plaza Building Room 300. 2015 PC meeting schedule is on the PC share point.

PRACTICE COUNCIL

February 26, 2015 CONFIDENTIAL AND PRIVILEGED

In attendance: A. Petrill, A. Adams, M. Carlson, E. Carr, G. Giannettino, D. Thomas, C. Tokarsky, J. Coltura, A.

Spence, D. Vincze, K. Schenkel, M. Ruefle, L. Andreassi, G. Fischer, A. Seelhorst, H. Harris, T. Mingrone, L. Riordan, R. DiGiandomenico, M. Lenhart, D. Hupp, M. McSteen, C. Valenta

Phoned in: A. Merulli, M. McClain, M. Kamnikar, D. Harold, K. Kostie, J. Wietholder, H. Dawn-Cooper TOPICS DISCUSSION FOLLOW-UP I. CALL TO ORDER II. System PPC updates:


M. McSteen called the meeting to order. Minutes were reviewed from the January 2015 meeting. Cindy Valenta is the Practice Council’s new Facilitator.

• Culture of Service – March kickoff • Mandatory for staff – 8 hour class – help with

improving patient experience • Grand Rounds – Holly Lorenz will be visiting all

the hospitals • Nurse’s Week will be April 29 – 30, 2015 &

May 1, 2015 • Professional Development – Cumberland

Woods Village – March 13th


III. CNO Updates D. Hupp thanked all staff who worked 16 hour shifts to accommodate the inpatient / ED high census.

• Recruiting more RNs • 30 vacancy spots • 14 offers are going out with more to come

If the census remains to climb we will need to have 30-50 more nurses on board. Due to high census, we are working with Leadership to:

• Cancel classes • Meetings • Clinicians, U.D.s will be helping in the numbers

Please let D. Hupp know if you feel as a unit that you cannot provide safe care due to high census. President Chris Gessner is leading hospital’s strategic plan for 2016-2026. There are 5 working groups to be formed to discuss current state, ideal state, and top ten priorities of following 5 strategic imperatives:

1. Growth of programs/services through partnerships/cultivation of new markets

2. Transformational care through continuous process and quality improvement

3. Maximize potential and productivity of CHP physicians and staff to enhance recruitment and retention

4. Innovative research and education 5. Improving health and growth of our children

Policies for Review Only

HS-NA0417 – Linen Management Guidelines

- Diane Hupp

This policy was presented at the February Practice Council meeting

Approved

Policies for Council Approval February 2015

100.68 Multidisciplinary Committee Plan for High Census / Emergency Department Surge - Deb Lesniak


Hold

801 Aerosolized Meds - Jeff Goff


Approved

804 Innovative Consent Form - Jeff Goff


Approved

805 Antimicrobial Lock Therapy - Jeff Goff


Approved

808 Anticoagulant Management Program - Jeff Goff


Approved

810 Automatic Stop of Medications - Jeff Goff


Approved

846 Subcutaneous Catheters - Jeff Goff


Approved / grammar changes

852 Medication Orders - Jeff Goff


Approved

866 Medication Carts - Jeff Goff


Approved

869 Medications via Pneumatic Tube System - Jeff Goff


Approved

873 Administration of MDI / DPI - Jeff Goff


Approved

877 Non-Formulary Drug Orders - Jeff Goff


Approved

893 Security of Medications - Jeff Goff


Approved

897 Standard Medication Administration Times - Jeff Goff


Approved

Practice Issues N/A

Unit Initiatives

None to report for this month.

New Business

Standards of Care – Peri-Op - Jan Eswein

Hold for next meeting.

Emergin Update - Ann Spence

• A task force has been in place • Central monitor • What alarms need to go to the phones • How many back up phones are needed • Take back to staff for feedback

Input to come back to this Council next month.

IMPACT Award - Alissa Adams

Nominations are now being accepted for the second annual Evidence-Based Practice (EBP) and Research IMPACT Award. This award was created to recognize nurses and allied health professionals who are actively advancing patient care with EBP projects, research, case studies, or bench studies. If you or someone you know has an EBP or research project, consider submitting a nomination. The form is on CHPlink on the Evidence-Based Practice site.

Magnet Strategic Plan PPM

PPM task force revised current PPM. Draft to be sent to corporate communications for proof.


The meeting was adjourned at 9:10 am. Call in number: 1-800-744-8762 Access code: 692-5126

The next meeting is scheduled for Thursday, March 26, 2015 at 8a-11a in the Plaza Building Room 300. 2015 PC meeting schedule is on the PC share point.

PRACTICE COUNCIL

May 26, 2016 CONFIDENTIAL AND PRIVILEGED

In attendance: C. Valenta, A. Petrill, V. Dowds, M. Carlson, A. Bower, M. Kamnikar, D. Thomas, C. Stine, C. Dvorsky, A. Katlubeck, M. Ruefle, G. Fischer, J. Paul, J. Brytus, J. Wietholder, D. Imes, M. Havel, A. Bridgman, C. Tipping, T. Pasek, L. Meyer, J. Goff, C. Cepullio, M. McSteen, B. Mastrangelo, A. Degener (Student/PICU) Phoned in: C. Pacelli, H. Harris, G. Giannettino, D. Clapp, M. McClain, K. Kostie, L. Smith, E. Korol, J. Licata,

TOPICS DISCUSSION FOLLOW-UP I. CALL TO ORDER

Michael McSteen called the meeting to order at 8:00 am. Minutes were reviewed from the March 24 and April 28, 2016 meetings.

Both minutes were approved and are available on SharePoint.

II. System PPC updates: Julie Wietholder

• RNs presented from Western Psych about care of the Autistic patient, including communication with non-verbal patients. Kris Kenney from CHP will present at our July meeting.

• June 8 – A suicide / homicide risk assessment starts across UPMC. CHP has already been doing this

• Handling of potentially infectious waste has been a issue. There is an educational link on the Infonet. Please share with your staff.

III. CNO Updates

Diane Hupp was unable to attend. Nothing to report this month.

Policies for Information Only

PTCADM 185 – Chain of Command Communication This policy was presented at the May Practice Council meeting Information Only

Policies for Review

PTCMDIV 802 – Central Venous Catheter Clearance Using Alteplase or Hydrochloric Acid

This policy was presented at the May Practice Council meeting Approved

PTCMDIV 807 – Safe Handling of Cytotoxic Agents and Waste Products


PTCMDIV 817 – Blood Derivatives


PTCMDIV 819A – Totally Implantable Central Venous Port


PTCMDIV 819B – Totally Implantable Central Venous Port-High Flow for Red Cell Apheresis


PTCMDIV820C – Management of Chemotherapy Infiltration / Extravasation


PTCMDIV 841 – Parenteral Nutrition: Discharge of Patients


PTCMDIV 845 - Immunizations This policy was presented at the May Practice Council meeting Hold – awaiting

current Vaccine Refusal form

PTCMDIV 856 – Investigational Medications


PTCMDIV 858B – Labeling of Medications & Solutions On or Off the Sterile Field in the Procedural Setting


PTCMDIV 862 – Look-alike, Sound-alike Medications


PTCMDIV 878 – Schedule II Controlled Substance Administration Record for Continuous Infusions


PTC-RN 315 – Oral Feeding This policy was presented at the May Practice Council meeting Approved

PTC-RN 491 – Pulmonary Artery Catheter


Practice Issues

NG / PE tubes dwelling time Discussion was that it is per manufacturer’s guidelines. It is difficult to tell what that is once package is discarded. Will check what EBP & Research Council found in their literature search.

Follow-up with EBP & Research Council

PDI Prevantics Keep alert for any PDI Prevantics Swabs (Chlorhexidine Gluconate & Isopropyl Alcohol) in the hospital. The use of these swabs for scrubbing hubs is not a part of any UPMC policy. These swabs produce a sticky residue that can lead to other problems. If you find them, please alert your Unit Leadership.

Alert staff

Blood Product updates / scanning

New PPID Cerner Bridge: • Used to scan blood products • New process • Here are the 4 scans:

- Blood Product - Unit – E code - Expiration Date - Blood type

It was suggested that the 2nd witness be dropped when scanning blood products. Some facilities still use the 2nd witness. During downtime the 2nd witness will need to be utilized. The Practice Council group was all in agreement to keep the 2nd

Keep the second witness even when using new PPID Cerner Bridge blood product scanner. Roll out this summer

witness.

New Professional Practice Model

The New Professional Practice Model was presented to the Practice Council group. There was a Task Force that worked to revise the PPM based on feedback from surveys sent to nursing staff. The revised PPM was brought back to Practice Council for approval. Will be presented to Patient Care Leadership Council prior to staff dissemination / education. Volunteers needed for PPM dissemination / education taskforce. The Practice Council group approved the newly revised Professional Practice Model.

Approved. Task Force will plan strategies for dissemination and education

Sub-Committee Updates

Med PI - Chris Cepullio / Jeff

Goff

Due to time constraints, no update this month

Unit Initiatives

Transport Team – Michael McSteen

Mike McSteen presented the Transport Team department’s unit initiative.


Old Business

Breast Milk in Feeding Bags Amy Bridgman / Shiela Hahner

Deferred

High Alert Meds - Cindy Valenta

Task-force meeting. More information to follow

Complete oral rehab disposition of specimens

If a loose tooth is pulled by anesthesia or during surgery, it may be given to the parent after being rinsed and properly packaged. However, teeth that are removed as part of a Complete Oral Rehabilitation (COR) procedure are not to be given to the family.

Inform staff

New Business

Humpty Dumpty Falls Assessment Scale

- Michelle Kamnikar

Current Falls Program at CHP:

• CHP has low incidence of falls causing harm. • Experienced successful centerline shift following implementation

of parent education and updated SPS bundle. Rate per 1000 Patient days – 0.10 rate

• Current Falls Assessment tool is not validated or based on best pediatric practice

• Literature Review: - Humpty Dumpty Falls Prevention in Children’s Hospitals - Collaboration among healthcare providers and families Unintentional injury is leading cause of death in children older than 1 year - Lack of patient specific risk factors results in under assessing risk - Literature concludes that involving the family is paramount in prevention of injury

• Humpty Dumpty Falls Program is validated and recognized by Magnet

• Humpty Dumpty Assessment Tool: - Age - Gender - Diagnosis - Cognitive Impairment - Environmental factors - Response to surgery - Medication usage

• From 2006 – 2014 – 41% drop in Falls (1.23 → 0.42) from Magnet Conference presenting hospital

Powerpoint presentation on the Sharepoint. Form a Falls Task Force to roll this out. Would like to have a rep from every unit.

Groups response: - more useful - more accurate - more objective - less risk The group was in favor of moving to the Humpty Dumpty Falls Program

Aromatherapy Aromatherapy: refers to nearly anything with a pleasant odor, including objects, candles, potpourris, essential oils. How can it be administered:

• Inhalation • Topical • In baths

The presentation focused on aromatherapy through scents, not clinical aromatherapy Aromatherapy Tools:

• Diffusers • Scentsy Buddies • AromaTabs

We use aromatherapy as a form of normalization, distraction/refocusing, and overall betterment of the patient experience. Why our patients ask for it:

• To disguise unpleasant smells • Help to alleviate nausea • Makes the hospital feel more “home” like • Overall enjoyment of pleasant smells

Each patient should be looked at from a case by case stance when deciding the appropriateness of offering these products and trust the judgement of parents/guardians. Michelle Kamnikar suggested it may work to enhance mood of nurses if used at nursing stations.

Presentation by Child Life Specialist Jacob Wheatley

Acute Care / Critical Care Monitoring Guidelines

Task force will work on merging these two policies into one. Cindy Valenta will coordinate

Elections Please send nominations for yourself or another PPC member for Co-Chair to this service account by June 15th. Elections will be via Survey Monkey after nominations are submitted.

Magnet

Document writing continues.

Tracey Pasek


The meeting was adjourned at 10:10 am Call in number: 1-800-744-8762 Access code: 692-5126

The next meeting is scheduled for Thursday, June 23rd from 8a-11a Conference Room 6417.