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An Evidence Based Study on the Minimum Volume of Blood Wastage from Arterial Lines
ANNUAL ASPAN CONFERENCE ABSTRACTS INCREASING COMPLIANCE TO PERIOPERATIVE CARDIAC RISK REDUCTION THERAPY (PCRRT) THROUGH PATIENT EDUCATION Janet G. Jule, RN MSN Project Leader/Presenter; and ASU Staff Nurses, Veterans Affairs Medical Center San Francisco, CA
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AN EVIDENCE BASED STUDY ON THE MINIMUM VOLUME OF BLOOD WASTAGE FROM ARTERIAL LINES Wanda Rodriguez, MA, RN, CCRN, CPAN, Doreen McCarty, BSN, RN, CPAN, Stephanie Nolan, MS, RN, CPAN, Joyce Kane, MSN, RN, CCRN, Mary O’Sullivan, BSN, RN, CPAN, Denise Stone, BSN, RN, CPAN Memorial Sloan-Kettering Cancer Center, New York, New York
Background: About 600,000 patients undergo cardiac surgery and about 30 million undergo non-cardiac surgery everyday. Of these numbers, about 6 million are at risk for perioperative cardiac morbidity. Studies have shown that perioperative beta blockade reduces the incidence of MI and mortality in patients with intermediate or high risk. Pre-operative teaching contributes to the most favorable outcome for patients in the post-operative period. Objective: To increase compliance with PCRRT through repetitious and thorough patient education. Process of Implementation: PCRRT is initiated during the surgical or anesthesia pre-op visit as appropriate. The ASU nurses educate the patient on PCRRT on several occasions: during the clinic visit, during the pre-op phone call, and on the day of surgery. The pre-op note was revised to include a PCRRT reminder and documentation of med administration. Successful Practice: Compliance to PCRRT increased from 83% (October 2007) to 100% (June, July, August 2008) Positive Outcomes: - Clearer process for patient education and teaching - Increased staff satisfaction for outstanding QI results - Clear documentation of perioperative beta blockade or clonidine administration Implications: Patient education yields positive outcomes and must be part of the perioperative nursing care plan.
Frequent laboratory testing, convenience of arterial catheters and inconsistent practices contribute to blood loss in postoperative patients. EBP Question: What is the minimum discard volume required when drawing blood from arterial lines? 50 evidence-based articles were reviewed. Expert opinions and guidelines were evaluated. Literature recommends using a blood-conserving device or equating the discard volume to double the arterial line dead space from the catheter tip to the sampling port. Given the compromised immunity of our patients, a closed system was not optimal. We measured 3ml to be double the arterial line dead space. A dedicated 3ml waste tube was proposed and approved by our multidisciplinary partners, resulting in decreasing the discard volume from 9ml to 3ml.This practice change provides standardization and numerous safety advantages in PACU and ICU settings. The waste tube is plastic as opposed to glass and is significantly more cost effective. It is distinct from our current inventory of laboratory tubes so to avoid being mistakenly analyzed as a diagnostic test. A dedicated 3ml waste tube has maintained accurate test results while minimizing blood loss to the adult perianesthesia patient.
ANTIBIOTICS – TIMING IS EVERYTHING
DREAMS BECOME LEGACY: FAMILY CENTERED CARE IN A RURAL GUATEMALA HOSPITAL
Mary Ann Pengiel, RN, MS MacNeal Hospital, Berwyn, IL Purpose: To develop procedures in order to ensure that the antibiotics are given in the 30 to 60 minute range prior to incision and that they are subsequently discontinued within 24 hours as per the guidelines of the Surgical Care Improvement Project (SCIP). Method: The Perioperative area went through several missteps trying to make certain that our antibiotics were infused on time. We began by having the antibiotics, via intravenous (IV) piggy-back, started in Same Day Surgery (SDS), by the nurse from that unit when the operating room (OR) team would come to take the patient to the surgery. We then moved on to having the IV antibiotic started by either anesthesia or the OR nurse just as they took the patient into surgery. Finally, we instituted the use of pre-mixed syringes. Anesthesia or the OR nurse obtains them in SDS and the antibiotic is given in the OR, IV push, by anesthesia, after the patient is moved onto the OR table. This method has been our greatest success. To address the issue of discontinuation, a simple matter of instituting the use of a stamp, noting when the surgery ends and when the first dose of the antibiotic was given, aids the units and pharmacy in keeping the timing of the dosages on the correct time schedule. Results: An overall decrease in outliers of both on time administration and discontinuation of antibiotics for surgical procedures. Implications: The changes in our methods enable us to better ensure that we are following protocols put forth by SCIP.
Denise Sullivan, MSN, RN,BC, CPAN, CNA-BC, Eileen Oates, MSN, RN, ANP-BC, APHN-BC, CEN Riverview Medical Center Red Bank, New Jersey and Jersey Shore University Medical Center, Neptune, New Jersey Background: What started over 30 years ago as a small dispensing pharmacy is today a medical facility offering health care services in a familycentered environment. The hospital has expanded to include other family oriented programs, including a malnutrition therapy clinic. The hospital annually treats over 15,000 patients from Guatemala, Mexico and other parts of Central America. Of this number US surgical teams perform surgery on 1600 of the 5000 patients they see during their visits. Objective of the project: To provide accessible and affordable medical and health care to a population of Central America that would otherwise have none. Implementation: Volunteer US surgical teams including PACU nurses visit the hospital four times a year. During these visits a variety of surgeries are performed based on the specialties represented on the team. Teams consistently achieve positive outcomes and high patient satisfaction, based on absence of postoperative infections and complications, and the smiles of discharged patients and families. Implications for PACU Nurses: Practice in a rural setting without the benefit of advanced technology requires PACU nurses to use critical thinking and basic nursing skills to successfully care for patients and families, while challenged with the barriers of location, language, education and resources.
e15
AN EVIDENCE BASED STUDY ON THE MINIMUM VOLUME OF BLOOD WASTAGE FROM ARTERIAL LINES Wanda Rodriguez, MA, RN, CCRN, CPAN, Doreen McCarty, BSN, RN, CPAN, Stephanie Nolan, MS, RN, CPAN, Joyce Kane, MSN, RN, CCRN, Mary O’Sullivan, BSN, RN, CPAN, Denise Stone, BSN, RN, CPAN Memorial Sloan-Kettering Cancer Center, New York, New York
Background: About 600,000 patients undergo cardiac surgery and about 30 million undergo non-cardiac surgery everyday. Of these numbers, about 6 million are at risk for perioperative cardiac morbidity. Studies have shown that perioperative beta blockade reduces the incidence of MI and mortality in patients with intermediate or high risk. Pre-operative teaching contributes to the most favorable outcome for patients in the post-operative period. Objective: To increase compliance with PCRRT through repetitious and thorough patient education. Process of Implementation: PCRRT is initiated during the surgical or anesthesia pre-op visit as appropriate. The ASU nurses educate the patient on PCRRT on several occasions: during the clinic visit, during the pre-op phone call, and on the day of surgery. The pre-op note was revised to include a PCRRT reminder and documentation of med administration. Successful Practice: Compliance to PCRRT increased from 83% (October 2007) to 100% (June, July, August 2008) Positive Outcomes: - Clearer process for patient education and teaching - Increased staff satisfaction for outstanding QI results - Clear documentation of perioperative beta blockade or clonidine administration Implications: Patient education yields positive outcomes and must be part of the perioperative nursing care plan.
Frequent laboratory testing, convenience of arterial catheters and inconsistent practices contribute to blood loss in postoperative patients. EBP Question: What is the minimum discard volume required when drawing blood from arterial lines? 50 evidence-based articles were reviewed. Expert opinions and guidelines were evaluated. Literature recommends using a blood-conserving device or equating the discard volume to double the arterial line dead space from the catheter tip to the sampling port. Given the compromised immunity of our patients, a closed system was not optimal. We measured 3ml to be double the arterial line dead space. A dedicated 3ml waste tube was proposed and approved by our multidisciplinary partners, resulting in decreasing the discard volume from 9ml to 3ml.This practice change provides standardization and numerous safety advantages in PACU and ICU settings. The waste tube is plastic as opposed to glass and is significantly more cost effective. It is distinct from our current inventory of laboratory tubes so to avoid being mistakenly analyzed as a diagnostic test. A dedicated 3ml waste tube has maintained accurate test results while minimizing blood loss to the adult perianesthesia patient.
ANTIBIOTICS – TIMING IS EVERYTHING
DREAMS BECOME LEGACY: FAMILY CENTERED CARE IN A RURAL GUATEMALA HOSPITAL
Mary Ann Pengiel, RN, MS MacNeal Hospital, Berwyn, IL Purpose: To develop procedures in order to ensure that the antibiotics are given in the 30 to 60 minute range prior to incision and that they are subsequently discontinued within 24 hours as per the guidelines of the Surgical Care Improvement Project (SCIP). Method: The Perioperative area went through several missteps trying to make certain that our antibiotics were infused on time. We began by having the antibiotics, via intravenous (IV) piggy-back, started in Same Day Surgery (SDS), by the nurse from that unit when the operating room (OR) team would come to take the patient to the surgery. We then moved on to having the IV antibiotic started by either anesthesia or the OR nurse just as they took the patient into surgery. Finally, we instituted the use of pre-mixed syringes. Anesthesia or the OR nurse obtains them in SDS and the antibiotic is given in the OR, IV push, by anesthesia, after the patient is moved onto the OR table. This method has been our greatest success. To address the issue of discontinuation, a simple matter of instituting the use of a stamp, noting when the surgery ends and when the first dose of the antibiotic was given, aids the units and pharmacy in keeping the timing of the dosages on the correct time schedule. Results: An overall decrease in outliers of both on time administration and discontinuation of antibiotics for surgical procedures. Implications: The changes in our methods enable us to better ensure that we are following protocols put forth by SCIP.
Denise Sullivan, MSN, RN,BC, CPAN, CNA-BC, Eileen Oates, MSN, RN, ANP-BC, APHN-BC, CEN Riverview Medical Center Red Bank, New Jersey and Jersey Shore University Medical Center, Neptune, New Jersey Background: What started over 30 years ago as a small dispensing pharmacy is today a medical facility offering health care services in a familycentered environment. The hospital has expanded to include other family oriented programs, including a malnutrition therapy clinic. The hospital annually treats over 15,000 patients from Guatemala, Mexico and other parts of Central America. Of this number US surgical teams perform surgery on 1600 of the 5000 patients they see during their visits. Objective of the project: To provide accessible and affordable medical and health care to a population of Central America that would otherwise have none. Implementation: Volunteer US surgical teams including PACU nurses visit the hospital four times a year. During these visits a variety of surgeries are performed based on the specialties represented on the team. Teams consistently achieve positive outcomes and high patient satisfaction, based on absence of postoperative infections and complications, and the smiles of discharged patients and families. Implications for PACU Nurses: Practice in a rural setting without the benefit of advanced technology requires PACU nurses to use critical thinking and basic nursing skills to successfully care for patients and families, while challenged with the barriers of location, language, education and resources.