Category: Clinical Corner

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Clinical Corner: Clinical Corner: COWs, and WOWs, and HIPAA! Oh My!

by Joe Bryowsky RN, CCRN Clinical Manager

Many hospitals are increasingly using COWs (computers on wheels) or WOWs (workstations on wheels) these days. (By the way, I’m told that use of the name COWs is considered politically incorrect these days, but we still call them that at the hospital I currently work at. Therefore I apologize in advance to any PCs out there on a wheeled work station that may take offense to this. J, but I digress … )

This is good for nurses in that we can spend less time (and energy) running back and forth to the nurses’ station to chart, and more time taking excellent care of our patients. There is a potential downside to this convenience, though. Having COWs or WOWs either in patient’s rooms or in the hallways also opens up a huge potential for theft of information as well as HIPAA violations. This can manifest in many different ways such as not logging off or “locking” the computer when leaving the area, people walking by, etc.

So how can we protect patient information as well as ourselves from this threat? Below are some very simple steps to follow:

  • Create a strong password. (Check out our helpful hints for creating a strong password below.)
  • Do not share your password with anyone and always be aware if anybody is around you when keying in your password.
  • When using a COW or WOW, position yourself or the computer so the information is difficult to see, and minimize screens detailing a patient information system if someone walks up to you.
  • ALWAYS log off or lock your computer whenever leaving the computer even if only for a short time.

Using these methods will reduce the risk of information theft as well as the potential for HIPAA violations.

Helpful hints for strong passwords

“Strong” passwords are hard to guess … either by human or machine. Creating a strong password requires doing the following:

  • Do make them long, at least 8 characters, ideally longer
  • Do use at least four different characters (don’t just repeat the same ones)
  • Do include mixes of uppercase letters, lowercase letters, symbols like !@#&, and numbers.
  • Do change your passwords regularly (some systems force the user to do this)
  • Do use different passwords for different systems (ex. PYXIS vs COW password)

Creating strong passwords require NOT doing certain things too:

  • Don’t use words associated with personal characteristics that others may know (family names, pet names, addresses, etc.)
  • Don’t use consecutive letters or numbers (ex. 1234567 or abcdefg)
  • Don’t use your name or nickname
  • Don’t use adjacent characters on your keyboard. (ex. zxcvbnm)
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Clinical Corner: Patient Falls

By Lalah Landers BSN, RN Clinical Nurse Manager at Medical Solutions

Did you know: Falls are the most frequently reported incidents in adult inpatient units? Actually, 30-50% of falls result in some injury, varying from bruises to severe wounds or fractures.

Patients at Risk for Fall (and a few tips to help address the risk):

Patients with Altered Mental Status – This includes patients with delirium or at-risk for delirium (patients with hip fractures, advanced age, baseline dementia, medication).

Patients With Impaired Gait or Mobility – Such as patients who entered the hospital and already use an assistive device like a cane or walker (make sure they are in good repair or obtain one from the hospital), patients who have new fractures, DVTs, hip replacements, knee replacements, recent stroke, spinal stenosis, or osteoporosis. For these patients you may consider bedside commode use.

Patients With Frequent Toileting Needs – For example, patients with incompetent bladder/bowel and patients on diuretics. These patients should be taken to the toilet on a regular basis or pre-set schedule and may consider bedside commode use.

Visual Impairment – For these patients it helps to have corrective lenses within reach, assistance up to use the restroom, or bedside commode.

Patients High Risk Medications – For example, psychotropic medications may cause orthostatic hypotension; new anti-hypertensives may cause hypotension or dizziness.

Patients with a History of Frequent/Recent Falls – For these patients put side rails up and bed alarms on.  The only caveat here is that you MUST respond to bed alarms; they can’t be ignored. Notify your nursing aides and co-workers around you that you have a patient at risk for falls.  Ask them to please respond if you aren’t available.  Remember:  YOU ARE ULTIMATELY RESPONSIBLE FOR YOUR PATIENT’S SAFETY!!

How Can You Prevent Patient Falls?

  • Use your facilities Fall Risk Scale (MORSE, Stratify, etc.)
  • Use Falling Star Door Markers or your facilities method of alert
  • Ensure your patient has a yellow arm band, yellow socks, etc., to alert staff of their risk of fall
  • Make sure you communicate fall risk during your shift to shift report and ensure it is noted on the patients chart
  • Use bed alarms
  • Make hourly rounds on patients
  • Have family sit with patient if possible
  • If possible, move fall risk patients closer to nurses’ station
  • Ensure bed is in low position
  • Document and follow up on any patient status changes that may increase their risk of fall
  • Instruct patient and family to call nurse/staff for assistance when ambulating
  • Do not leave patient alone in bathroom
  • Make sure your patient has non-skid slippers or their own shoes.
  • Lock bed wheels, wheelchairs, stretchers and commodes
  • Keep water, personal items within reach
  • Physician intervention for sitter or  restraints as required ( refer to facility restraint policy)

References:

http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/CurrieL_FIP.pdf

http://www.ncbi.nlm.nih.gov/pubmed/21939135

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Clinical Corner: Patient Identifiers

by Joe Bryowsky RN, CCRN Clinical Manager

A myriad of problems could occur because a patient was not identified correctly. The most common is medication errors but that is only the tip of the iceberg, so to speak. Other detrimental results such as wrong surgeries, wrong discharge instructions, improperly taking/giving blood or blood products and other specimens for clinical testing are just a few of the others that could occur if a patient is not properly identified.

In 2004 The Joint Commission (TJC) recognized the need for proper patient identification when it issued their very first Patient Safety Goal which is referred to as the “two Identifier Rule”. There are 2 basic parts to this rule and they are:

1.) Use at least two patient identifiers when administering medications, blood, or blood components; when collecting blood samples and other specimens for clinical testing; and when providing treatments or procedures. The patient’s room number or physical location is not used as an identifier.

2.) Label containers used for blood and other specimens in the presence of the patient

Acceptable patient identifiers can vary from hospital to hospital and it’s always best to consult the hospitals policy and procedure manual for what is acceptable at a particular facility. The most common patient identifiers are:

1.) Name

2.) Date of birth

3.) Telephone number

4.) An assigned identification number

5.) Address

6.) Photograph

7.) Social Security Number (most institutions don’t use this due to the proprietary nature)

These TJC “rules” are pretty straightforward yet regrettably not always followed, or are followed improperly. When confirming two patient identifiers with patients, it’s not enough to provide the information and have the patient confirm (the patient may be confused, hard of hearing, etc. and the patient may just confirm what you’re telling them whether right or wrong). You must ask the patient to identify themselves/provide the patient identifiers. When identifying a patient remember that the number one rule is to ask only open-ended questions. Examples of this are:

A.) Would you please state your name?

B.) Would you please state your date of birth?

C.) How are you feeling today?

If the patient is not alert and oriented, or is deaf, the patient arm band can usually be used for identification but one needs to proceed with caution with this. There have been documented cases where the name band has been either put on the wrong patient, or the wrong patient was input by admissions.

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Clinical Corner: Incident Reports

by Joe Bryowsky RN, CCRN – Clinical Manager

Incident reports play an integral part in preventing, detecting and investigating medical errors. They help to maintain a safe environment for patients, visitors and employees. An incident report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone—patient, visitor or staff member is injured or involved in a situation with the potential for injury, an incident report is required.

Examples include, but are not limited to:

  • Needle sticks
  • Falls
  • Procedure errors
  • Misuse of, or faulty equipment
  • Other types of injuries or accidents
  • Property loss or damage
  • Theft
  • Fires

Most events or errors happen because of process issues:

  • Many “little” failures lead to a “bigger” failure
  • Rarely a “person” failure

The incident  report should be completed immediately (or as soon as possible) by the employee involved or the employee giving care at the time of the incident.

When filling out an incident report remember to include only the facts. Include the full names of anyone involved and of any witnesses, as well as how, or if they were affected. Describe what you saw or heard that led you to believe an incident had taken place. Be sure to use only nonjudgmental and non- criticizing statements when filling out an incident report.

***Remember to record all clinical observations in the chart, not in the incident report.

Most hospital policies dictate not to make any mention of the incident report in the patient record but this varies widely from hospital to hospital. Always make sure you familiarize yourself with the hospitals policy before having to file an incident report.

There is a lot of controversy as to whether a patient’s attorney can request and receive an incident report and use it in a malpractice lawsuit. The law varies from state to state but most hospitals label the incident report as an integral part of the quality assurance process, which usually suffices to keep the reports from being discoverable.

 

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Clinical Corner: HIPAA in a Nutshell

by Joe Bryowsky RN, CCRN – Clinical Manager

What is HIPAA?

In 1996 the U.S. government enacted the Health Insurance Portability and Accountability Act. This law is meant to keep a patient’s medical information private.

What constitutes a HIPAA violation?

  • Showing or sharing the information to an unauthorized person: If any health-care provider shares medical information about a patient without the patient’s consent, that is a HIPAA violation. This includes telling people about the patient’s condition, discussing the patient’s condition in public, or using the patient’s information in a medical brief without the patient’s consent. This would also apply to today’s technology which includes cell phones that take pictures, Facebook, texting, etc.
  • Excessive Views: Too many looks at a medical record or more often than needed, can constitute a violation of the law. Sometimes this happens when a patient with an abnormal condition comes into the hospital or because people are simply curious.
  • Health discrimination: Sometimes employers violate HIPAA. If an official from the company you work for reads your medical information and uses it to make a decision about you, that is a violation.
  • Improper disposal: Hospitals, Medical offices and Clinics are required to shred, and dispose of, any medical records. The violation would be against any one of these entities due to neglect if records were disposed of improperly.

These are all important points for all healthcare workers to be knowledgeable in. One of these points however is the one most frequently overlooked and that is the first bullet point above:

Showing or sharing the information to an unauthorized person: Under the privacy rule, a healthcare provider may “disclose to a family member, other relative, or a close personal friend of the individual, or any other person identified by the individual,” the medical information directly relevant to such person’s involvement with the patient’s care or payment related to the patient’s care.

Uses and disclosures for involvement in the individual’s care and notification purposes are clearly permitted. Right?

Here’s the catch, and it’s the one that most healthcare workers fail to think about at one time or another. The rule states that if the patient is present, the healthcare provider may disclose medical information to such people if the patient does not object. If the patient is unable to agree or object to disclosure because of incapacity or an emergency circumstance, the covered entity may determine whether the disclosure is in the best interests of the patient.

How many times have we gone into a patients room, friends and/or family members are present, and the patient asks us a question about their care, treatment modalities, diagnosis, etc.? Just about every day, right? And how many times have we just answered their question and thought nothing about it? After all that’s just part of delivering excellent patient care, right?

Think again. HIPAA violation!! All healthcare workers must remember to always ask the patient if it is OK to share that information in front of anyone in the room that is not a healthcare worker who is directly involved in the patient’s care.

Also

Always remember: “Protect the patient and protect yourself”!

 

For more information go to:  http://www.hhs.gov/ocr/privacy/

 

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Clinical Corner: CRE’s (Carbapenem-resistant Enterobacteriaceae)

by Joe Bryowsky RN, CCRN – Clinical Manager

There’s been a lot of talk in the news lately about CRE’s. This was precipitated when Dr. Thomas Frieden, Director of the CDC, made the statements that “CRE are nightmare bacteria” and “Our strongest antibiotics don’t work and our patients are left with potentially untreatable infections”.

But what are CRE’s and what precautions should healthcare workers take in reducing the spread of CRE’s?

CRE, which stands for carbapenem-resistant Enterobacteriaceae, are a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. Enterobacteriaceae are a family of more than 70 bacteria which share the characteristic of being gut-dwelling (entero). They include Klebsiella, Salmonella, Shigella and E. coli. Carbapenems are a “last-resort” family of antibiotics (imipenem, meropenem, doripenem and ertapenemen.) which are used against these bacteria when they have become resistant to other drugs.

Healthy people usually don’t get CRE infections. Infections caused by CRE most commonly occur in people who have:

  • Chronic medical conditions
  • Recent prolonged stays in healthcare settings
  • Invasive devices such as ventilators, IV catheters, urinary catheters
  • History of taking certain antibiotics for long periods of time

Just when we thought super bugs like MRSA (methicillin-resistant staphylococcus aureus), VRE (vancomycin-resistant enterococci) etc. were bad enough with about a 20% mortality rate, we’re now seeing an increase in CRE’s, with about a 50% mortality rate, becoming ever more present in our healthcare settings!

Am I at risk in taking care of patients with carbapenem-resistant Enterobacteriaceae?

This type of infection generally occurs in more sick patients following long courses of broad spectrum antibiotics. As a healthy individual, you are not at risk of “catching” this type of infection. However, without taking proper infection control precautions, you are at risk of spreading carbapenem-resistant Enterobacteriaceae to other patients.

How can carbapenem-resistant Enterobacteriaceae infections be prevented in the healthcare

setting?

To prevent spreading CRE infections between patients, healthcare personnel must follow specific

infection control precautions (See: Guideline for Isolation Precautions: Preventing Transmission of

Infectious Agents in Healthcare Settings 2007 at www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf.

All patients colonized or infected with CRE should be placed on contact precautions. These

precautions include wearing gowns and gloves when they enter carbapenem-resistant

 

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Clinical Corner: New AHA Stroke Guidelines Part 2

by Joe Bryowsky RN, CCRN – Clinical Manager. This is the second part of Clinical Corner: New AHA Stroke Guidelines Part 1

Points to Ponder:

• Worldwide, stroke is the second leading cause of death, responsible for 4.4 million (9 percent) of the total 50.5 million deaths each year.
• Stroke is the No. 3 cause of death in the U.S., behind heart disease (with which it is closely linked) and cancer.
• Stroke affects more than 700,000 individuals annually in the United States (approximately one person every 45 seconds). About 500,000 of these are first attacks, and 200,000 are recurrent attacks.
• Someone in the U.S. dies every 3.3 minutes from stroke
• Stroke is the leading cause of disability among adults in the U.S.
• More than 4 million people in the United States have survived a stroke or brain attack and are living with the after-effects.
• Four out of five families will be somehow affected by stroke over the course of a lifetime.

Remember:

F.A.S.T.an easy way to remember the sudden signs of a stroke:
• Face drooping: Does one side of the face droop or is it numb?
• Arm weakness: Is one arm weak or numb?
• Speech difficulty: Is speech slurred, are you unable to speak, or are you hard to understand?
• Time to call 9-1-1: If you have any of these symptoms, even if the symptoms go away, call 9-1-1 and get to the hospital immediately.

For more information regarding new stroke guidelines please visit: http://www.heart.org/HEARTORG/

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Clinical Corner: New AHA Stroke Guidelines Part 1

by Joe Bryowsky RN, CCRN – Clinical Manager

On January 31, 2013 the American Heart Association announced the updated Guidelines for the Early management of Patients with Acute Ischemic Stroke.The new recommendations replace the guidelines last issued in 2007.

While some of the guidelines from 2007 remain the same other guidelines have been added, changed or eliminated.

The revised and new recommendations:

• Supports aggressive treatment of acute stroke with IV tPA (Tissue plasminogen activator)

• Shows evidence that patients benefit from the development of stroke systems of care. (EMS along with Acute Stroke Ready Hospitals, Primary Stroke Centers (PSC’s), and Comprehensive Stroke Centers (CSC’s)

• Recognizes that the addition of telemedicine
(telestroke) has further expanded the radius of stroke care delivery

• Recommends that EMS bypass hospitals that do not have resources to treat acute stroke

• Highlights pre-hospital notification by EMS

• Reiterates that only a limited number of laboratory and radiologic tests are required before administering IV tPA (blood glucose check and non-contrast enhanced CT or MRI)

• States that door to tPA bolus time interval of 60 minutes or less maximizes benefits of IV tPA

• Suggests that intra-arterial mechanical thrombectomy has emerged as a promising therapy for a subset of stroke patients that are identified with advanced neuroimaging

• States that tPA can now be considered for a larger group of patients, including some who present up to 4.5 hours from stroke onset

These guidelines also address the lack of clinical evidence in the following for the treatment of acute stroke:

• The use of devices to augment cerebral blood flow
• Drug induced hypertension
• Volume expansion
• Hypothermia

Continue reading part 2 of Clinical Corner: New AHA Stroke Guidelines

For more information regarding new stroke guidelines please visit: http://www.heart.org/HEARTORG/

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