Professional Practice Policy & Procedure Committee

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In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
Page 1 of 10
Purpose: To define and clarify professional clinical practice
standards and scope of clinical practice for nurses,
pharmacists, respiratory therapists, physical therapists,
occupational therapists, social workers and ancillary
healthcare providers across the organization.
Facilitator:
Shelly Limon, Nurse Manager Neuroscience
Holly Phillips, Manager - Pharmacy
Sponsor:
Date: June 18, 2014 Scribe: Tonya Hughes, PSA Timekeeper:
Out Today: Location: Leprino Room 620 Time: 1000-1200

Topic Discussion Recommendations / Actions Follow-up
Welcome/
Introductions
Committee recognized and thanked Dena Read for filling the interim
committee PSA role.
MaryBeth filling in this month for Melanie Sandoval

Stakeholder Letter
Shelly revised the stakeholder letter and was brought to the
committee for approval. Amount of time was extended to 14 days.
There have been some concerns raised regarding key Stakeholders
not reviewing policies within a timely fashion.
New Stakeholder letter approved.
Tonya will post revised Stakeholder letter
to the HUB and a link to the PPPPC
Resources page indicating that author
should contact Shelly directly if they are
not getting a response from a
Stakeholder.

New SharePoint
Website link for
Policies & Procedures
Policies & Procedures are in a testing phase of being posted to
SharePoint instead of on the HUB.
All PPPPC members are encouraged to go
to the link to familiarize their selves with
the new look and feel.

https://pnp.uchealth.org/pnptest/Pages/
SearchCentralTest.aspx

Previous Month
Meeting Minutes
Review & Approve Previous Month Meeting Minutes

Assign who will complete tip sheet for July
May Minutes Approved

Robin Scott will compose Take back tips
and send to Shelly for distribution to
PPPPC.
Take back tips posted on
PPPPC site
E-Vote POLICIES
(15 votes needed for
approval)



Mechanical Traction
Stephanie Nelson
This policy did receive enough E-Votes by the deadline date.
Approved as written with committee
member recommendations.

Critical Care Survey This Scope of practice is no longer in use. It was created for the CCSU Approved for deletion

Professional Practice Policy & Procedure Committee
We improve lives. In big ways through learning, healing and discovery.
In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
Page 2 of 10
Unit/Neuro ICU
Overflow Scope of
Practice Justin Oeth
overflow unit. This area is no longer in existence as of 2013.
POLICY
Patient Management
of Implanted Cardiac
Rhythm Devices
Sandra Morrell
Situation: We have these guidelines as an informal practice protocol.
We would like to formalize the practice within the Cardiac and
Vascular Clinic.

Background: No formal guidelines are in place for this high risk
population of patients.

Assessment: There needs to be a formal practice guideline in place.

Recommendation: A clear practice protocol in place for Device Clinic
staff, VAD coordinators & EP Fellows.
Approved with changes

Policy needs to be reformatted per
the formatting template on the HUB
PPPPC Resources & Documents
section.

Add page numbers in the footer.

Reformat the Table of Contents.

Add Policy and Procedure section
title after the Table of Contents

Remove the L in LVAD

EP needs to be spelled out for the
first time it is referenced in the
policy. Ex: Electrophysiology (EP)

All references to EMR need to be
changed to EHR for Electronic Health
Record. EHR needs to be spelled out
for the first time it is used in the
policy.

Policies and Procedures section:
o Spell out <> less than or greater
than references
o A. Add of clinic patients to
the end of the sentence
o A. 1. Change sentence to All


































Professional Practice Policy & Procedure Committee
We improve lives. In big ways through learning, healing and discovery.
In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
Page 3 of 10
UCH patients will be scheduled
to see a physician in EP clinic
annually.
o A. 2. Move (capture
management, A Cap, PaceSafe
RV) to definition section under
Auto Capture. RV needs to be
spelled out for the first time it is
referenced in the policy. Ex:
Right Ventrical (RV)
o A. 9. & 10. Sandra to
collaborate with Shannon &
Robin to review and revise as
necessary.
o C. 3. Spell out POD for the first
time it is referenced in the
policy. Ex: Post Op Day (POD)

References section:
o Update information on
currently listed references
o Reformat to meet the PPPPC
modified APA formatting
o Update LOEs

Keywords to be used:
Pacemaker, Defibrillator,
Reprogramming, Interrogation, EP

6mo Follow-up: No










Sandra to collaborate with
Shannon & Robin to review
and revise statement.
Continuous Cardiac
Monitoring (ECG) and
Emergency Precautions
for the Adult Patient:
Adult Critical Care Areas
Evote CXd Katie
Sabin
Situation: Alarm fatigue is a serious problem that develops when a
person is exposed to an excessive number of alarms, which can lead
to sensory overload, desensitization to alarms, and may cause
potential harm to the patient. According to AACN, 80%-99% of ECG
monitor alarms are false or clinically insignificant.

Background: On January 1, 2014 The Joint Commission added
Approved with changes

Policies and Procedures section:
o A. 1. i. Change analyze to
visualize.
o B. 2. Change every 24 hours
to daily.


Professional Practice Policy & Procedure Committee
We improve lives. In big ways through learning, healing and discovery.
In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
Page 4 of 10
National Patient Safety Goal 06.01.01: Improve the safety of clinical
alarm systems (i.e. Alarm Fatigue). The American Association of
Critical Care Nurses (AACN) issued an Alarm Management Practice
Alert back in April of 2013 listing expected practice and nursing
actions related to alarm management. Expected practice and nursing
actions listed in the safety alert includes changing ECG electrodes
daily (you can find the practice alert here:
http://www.aacn.org/wd/practice/docs/practicealerts/alarm-
management-practice-alert.pdf).

Assessment: ECG electrodes are not currently being changed daily
which can lead to an excessive number of alarms and can lead to
potential harm to the patient.

Recommendation: ECG electrodes should be changed every 24
hours to decrease unnecessary alarms and reduce the risk of alarm
fatigue. Education should be provided to staff caring for patients
regarding alarms and how to decrease unnecessary alarms. An
updated policy regarding ECG monitoring should address issues
related to alarms. Expected practice and nursing actions listed in the
AACN Alarm Management Practice Alert should be followed.
o G. 2. Change the beginning of
the sentence to read If a
significant rhythm change
occurs

References section:
o Reformat to meet the PPPPC
modified APA formatting
o Confirm with MaryBeth that
references are listed correctly.
o Update LOEs

Keywords to be used:
EKG, Telemetry, ICU, electrodes,
dysrhythimia

6mo Follow-up: No
Intra-Aortic Balloon
Pump Sara Knippa
Situation: The current policy and procedure does not mention any
guidelines for managing fiberoptic IABP catheters, treating variations
in helium balloon pressure, or steps for transferring consoles.

Background: Fiberoptic IABP catheters were introduced to UCH in
2013. The ACT 1 console has been discontinued, so only one type of
IABP console is currently in use. All CICU and CTICU nurses charge &
relief charge nurses were trained in 2013 to perform a console
transfer at the rooftop helipad.

Assessment: Nurses have asked for a resource to help guide them
when managing fiberoptic IABP catheters, transferring consoles, and
treating variations in helium balloon pressures.

Recommendation: The policy was revised to address these topics.
Approved with changes

All references to EMR need to be
changed to EHR for Electronic Health
Record. EHR needs to be spelled out
for the first time it is used in the
policy.

Related Policies and Procedures
section:
o Confirm policies listed and
update names to reflect
appropriate policies

Approved by section:
o Change Patient and Assessment

















Professional Practice Policy & Procedure Committee
We improve lives. In big ways through learning, healing and discovery.
In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
Page 5 of 10
Subcommittee to Professional
Practice Policy & Procedure
Committee

Definitions section:
o Move the Trained RN
definition to the Accountability
section.
o Change Trained to RN or
Designated RN.

Table of Contents section:
o Correct formatting. This section
should be automatically
populated by the remainder of
the document.
o The first reference to bedside is
spelled incorrectly.

Policies and Procedures section:
o II. D. 3. d. Change beginning of
the sentence to read: Push
FOS/MAP/CAL button

References section:
o Confirm with MaryBeth that
references are listed correctly.
o Update LOEs

Keywords to be used:
IABP, fiberoptic, helipad, heart failure

6mo Follow-up: No

























Confirm with MaryBeth that
references are displayed in
APA format with the
appropriate LOE.
Intraosseous Lines
Ryan Morissette
Situation: The current policy states placement of IO catheters to be
only inserted by competent physicians, nurses, EMT and EMT-P and
only in code situations. No preference for access site identified.

Approved with changes

Add Table of Contents if final draft of
policy is 5 pages or longer.





Professional Practice Policy & Procedure Committee
We improve lives. In big ways through learning, healing and discovery.
In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
Page 6 of 10
Background: Prior to the suggested changes EMT and EMT-P
providers were allowed to place IO catheters after completing
training. Per their medical director, they are no longer able to place
these lines and it is not included in their scope of practice at UCH.
The previous policy and/or understanding was to only place IOs in
Codes, with unresponsive, pulseless, and/or apneic patients. This
policy more clearly defines the patient populations suitable for IO
placement. This enables IOs to placed in pre-code patients, ones
with life threatening injuries or illness (i.e. anaphylaxis, status
epilepticus, status asthmaticus, trauma, airway compromise, and
hemodynamic instability). Emphasis is placed to ensure use only in
emergent or critical situations.

Assessment: The current policy needs clarification to identify the
appropriate staff to place IOs and the patient status/situations
where it is appropriate for IO placement. The optimal placement
sites for IO should also be included in policy. The references and
some minor grammatical changes have also been made.

Recommendation: To approve these changes in interest of
improving patient outcomes based on current research and expert
opinion.

All references to EMR need to be
changed to EHR for Electronic Health
Record. EHR needs to be spelled out
for the first time it is used in the
policy.

Related Policies and Procedures
section:
o Remove: Intravenous (IV) Care
and Maintenance. This is not a
policy.
o Add: Adult IV (Push,
Intermittent and Continuous)
Medication Administration

Accountability section:
o Remove (Intraosseous) under
Physician.
o Emergency Technicians section
needs to be worded so that it is
more general.
o Under Emergency Technicians
correct the spelling of after
completing training.

Policies and Procedures section:
o I. Remove (Intraosseous)
o I. A. Change the beginning of
the second sentence to read If
acuity permits, two
o I. A. Remove (Intraosseous)
o IV. Robin Scott to help with
bands requirement.
o IV. Barb Wenger to work with
Ryan on the wording associated
with watching the site after




























Robin to aid in wording
associated with bands
requirement.







Professional Practice Policy & Procedure Committee
We improve lives. In big ways through learning, healing and discovery.
In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
Page 7 of 10
o removal based on the
standards. Need to highlight
what should be documented.
o IV. C. 8. Remove stabilizer
dressing or


References section:
o Update LOEs

Keywords to be used:
IO, code access, resuscitation, EZIO,
emergency

6mo Follow-up: No
Barb to aid in wording
associated with site care post
removal.
Use of Patients Own
Medications and
Dietary Supplements
Holly Phillips
Situation: The current patients own medication policy does not
specifically assign the responsibility of verifying POMs. It is left to
any authorized healthcare provider, which leaves large variations in
practice. It has also resulted in medication errors as pharmacy has
verified medications without physically seeing them first.

Background: Historically, nurses have been asked to identify the
medications using Micromedex or pharmacists as a resource. This
practice is not as safe as allowing pharmacy to own the process, and
it also adds additional workload to the nurse. We have a history of
noncompliance with this policy as a result.

Assessment: Workflow needs to be specifically spelled out to ensure
patient safety.

Recommendation: Change policy to have pharmacy own verification
of POMs
Approved with changes

Approved section:
o Updated Revised date.

Accountability section:
o Remove when a consent form
is signed from the 2
nd

paragraph, last sentence. Need
to verify with Joan Adams to
confirm that consents are not
used in this case in Ambulatory.

Definition section:
o Change the definition of
Healthcare Professional /
Provider to fit CGSS guidelines.

Policies and Procedures section:
o I. A. 1. Correct typo one
should be once.

Joan Adams to confirm if
consents are used in
ambulatory.

Professional Practice Policy & Procedure Committee
We improve lives. In big ways through learning, healing and discovery.
In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
Page 8 of 10
References section:
o Reformat to meet the PPPPC
modified APA formatting.
o Update LOE

Keywords to be used:
POM, marijuana, herbal, TPN

6mo Follow-up: No
Neutropenic/Immuno
compromised
Management for
Hematologic
Malignancies and
Hematopoietic Stem
Cell Transplant
Patients Pam Heinke
Situation: Recent NCCN/ IDSA neutropenic practice guidelines
prompted the development of a revised policy for the Hematologic
Malignacy/ BMT service regarding the management and care of their
neutropenic population.

Background: Presently we have a combined Oncology/ Hematologic
Malignancy/ BMT policy. Due to these changes for just this specialty
area, we will need to separate the policies to indicate the changes for
better continuity of care and safety of this population.

Assessment: There is now a specific rapid response fever protocol
developed by the Hematologic Malignancy/ BMT service to address
these changes for patients admitted through the BIC, ED and direct
admits to the 11
th
floor.

Recommendation: Originally, this was thought to be a new
guideline for the Hematologic Malignancy/ BMT service line. After
presenting at the May Guidelines committee meeting, it was
determined to be a policy since it involves the BMT service line,
other inpatient units and the Emergency Department.
Approved with changes

Related Policies and Procedures
section:
o Remove Standard Precautions
from the 1
st
policy.
o Add the Inpatient and
Emergency Department
Metered Dose Inhaler (MDI)
Administration and Common
Canister Program policy.
o Correct the Diet Restrictions
policy to include
Immunocompromised Patient at
the end.

Table of Contents section:
o Need to correct formatting.

Policies and Procedures section:
o I. Remove extra line between B
& C
o II. E. Spell out BID for 1
st

occurrence in the policy.
o III. A. 5. Typo fix ect to ext.
o III. C. Change title to Protective
Measures for Febrile and/or
Neutropenic Patients


Professional Practice Policy & Procedure Committee
We improve lives. In big ways through learning, healing and discovery.
In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
Page 9 of 10
o III. C. 10. a. Update CHG to
clorhexidine (CHG).

References section:
o Spell out all authors on
reference #1.

Appendix B:
o Remove patient triage and
add bed placement.
o Under bullet item Notify
Resource Nurse, change to
Notify Charge Nurse

Keywords to be used:
BMT, neutropenic, HST, ANL

6mo Follow-up: No
Specimen Integrity
Rebecca Bradenstein
Situation: Large amount of laboratory errors throughout the
hospital with approximately 45-60% of the reported errors are due to
extra patient labels in the bag.

Background: 2014 National Patient Safety Goal from Joint
Commission listed #1 Identifies Patients Correctly. From May 2013-
May 2014, there have been 913 laboratory labeling errors that have
been reported by the clinical laboratory that required re-collection of
specimens.

Assessment: To eliminate these labeling errors, Quality Safety
Advocate Committee, in collaboration with Nurse Managers and
Nurse Educators and Clinical Laboratory are revising the process for
specimen labeling and transport.

Recommendation: To have any extra labels for the same patient to
be placed on a card, have the labels affixed to the card with
collectors name and employee number and placed into the bag
accompanying the specimen to the lab. Educate staff on changes in
Approved with changes

Policies and Procedures section:
o I. B. Change Ziploc to
biohazard.
o Update all bulleted items to
start with a capital letter
instead of lower case.

References section:
o Update References
o Update LOEs

Keywords to be used:
labeling, blood, biohazard, label, orange

6mo Follow-up: No


Professional Practice Policy & Procedure Committee
We improve lives. In big ways through learning, healing and discovery.
In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
Page 10 of 10
the policy.

UCHealth Global Path to Success
1. Quality and Patient
Experience
2. Engaged Workforce 3. Growth 4. Clinical & Non-Clinical
Integration
5. Deliver Superior Value 6. Academic Enterprise 7. Mission, Vision and
Brand Awareness
Ensure universal, distinctive
standard of quality and patient
experience.
Attract, retain and excite a
unified and engaged workforce.
Enhance reach and relevance
through growth.
Integrate clinically and non-
clinically across our system.
Deliver superior value to
remain an option for most
payor plans.
Maintain, enhance and
leverage the academic
enterprise.
Enhance messaging around
the mission, vision and
brand

Magnet Model Components
1. Transformational Leadership 2. Structural Empowerment 3. Exemplary Professional Practice 4. New Knowledge, Innovations & Improvements 5. Empirical Outcomes
Leadership that results in extraordinary
outcomes by empowering, influencing,
and motivating others.
Strategies used to support shared
leadership decision-making, life-long
learning and professional development.
Interprofessional collaboration to ensure
patient safety resulting in high-quality
outcomes.
Integration of evidence-based practice and research
into practice. New ways of achieving high-quality,
effective and efficient care through innovation.
Measurable outcomes related to the impact
of structure and process on patients, staff,
and the organization.