WEEKLY MA CO 11.9.23

Medical Assistant Orientation

November, 2023

Orientation Etiquette

Your manager will be contacted if you do not follow etiquette. We have the right to ask you to leave. You will have to repeat Orientation.

Actively Participate

NO Sleeping

Cell Phones put away and on silent

What Clinic will you work in?

Where do you live? Where are you from?

Tell us about you!

Family?

Experience?

(0800-0815)

Suture/Staple Removal and Wounds (0845-0945)

Professionalism and the Ambulatory Setting (0815-0845)

Medication Administration (1000-1100)

15 Minute Break - (0945-1000)

Sterile Technique (1100-1130)

Lunch 1130-1215

Phlebotomy (1215-1315)

Vital Signs & Intake Scenario (1315-1445)

Emergency Response (1500-1545)

15 Minute Break - (1445-1500)

Clinic Specific

Glucometer Blood Sugar Testing (1545-1630)

Electrocardiogram(EKG/ECG) (1630-1645)

01

Ambulatory setting / Professionalism / Orientation requirements

Objectives

• Understand how VMG fits within VUMC
• Understand expectations in Attendance and Punctuality Policy
• Discuss professional attire for clinic setting
• Understand proper use of cell phones in clinic setting
• Demonstrate CREDO behavior
• Demonstrate correct usage of AIDET
• Demonstrate SBAR reporting
• Understand requirements of orientation period

The Ambulatory Setting

VSRH Vanderbilt Stallworth Rehabilitation Hospital

VUMC Vanderbilt University Medical Center

Who Are We?

VUH Vanderbilt University Hospital

VWCH Vanderbilt Wilson County Hospital

VBCH Vanderbilt Bedford Hospital

Monroe Carell (MCJCH) Monroe Carell Jr. Children's Hospital

Vanderbilt Medical Group (VMG)

VTHHVanderbilt Tullahoma -Harton Hospital

VPH Vanderbilt Psychiatric Hospital

Over 200 Clinics and Growing!

CLINICS: Throughout the local Nashville area and Middle Tennessee, as well as clinics in Alabama and Kentucky.

Vanderbilt Medical Group (VMG)

SPECIALTIES:

• Heart and Vascular Institute
• Lung Institute
• Ingram Cancer Center
• Primary Care Clinics
• Neurosciences
• Orthopaedics
• Dermatology
• Digestive Diseases
• Center for Women's Health

• Interventional Pain
• Weight Loss
• Surgical Specialties
• Eye Institute
• Eskind Diabetes
• Transplant
• and MORE!

Professionalism

Attendance and Punctuality

• Regular and timely attendance is an expectation for all.

• Follow departmental notification procedures if you will be late, ill, or absent for any reason.

• VUMC follows a progressive disciplinary process for absences:
• Occurrences acrue from:
• Absence: Not working as scheduled
• One occurrence - each day absent
• If absence lasts several consecutive days (illness) only accrue one occurence
• Tardiness
• Late to work, extended meal break, leaving early
• Missed clock in/outs

Attendance and Punctuality

New Hire Orientation Period:

• During the orientation period, an employee who has 2 occurrences should receive a Written Warning (step 2).

• If the employee has more than 2 occurrences during their Orientation period, employment may be terminated (step 4).

• If Orientation period is extended, this rule continues.

Dress and Appearance

• Professional attire (scrubs)

• Clean / not wrinkled / fit appropriately

• No offensive writing / pictures
• Plain or Vanderbilt logo

• Shoes closed toe

• No slippers, sandals or flip flops

• Clean (hair, beard, moustache)

• Pulled back / off face

• Finger nails - VUMC policy: IP 10-10.07 (Hand hygiene Policy IV. B.)

• Anyone with direct patient care: Artificial nails prohibited
• Artificial nails include: acrylic nails, all overlays, tips, bondings, extensions, tapes, inlays, and wraps.

• Nail jewelry prohibited

Cell Phone Usage

• Cell phones are NOT to be used in patient care areas.
• No texting
• No picture taking
• No TikTok
• No streaming

• Use of cell phones in patient areas is disrespectful, and can be perceived by the patient as a HIPPA violation.

• If you need to take an emergency phone call, let your coworkers know and step out of the clinical area to take the call.

• DO NOT CLOCK IN OR OUT ON YOUR CELL PHONE - this is an HR violation!

CREDO Behavior

• CREDO is the framework for how VUMC employees treat our patients, visitors, and each other.

• CREDO behavior is an expectation for all employees.

• Why?
• We desire to serve others.
• Our patients deserve the best as they are an important part of the healthcare team.
• We aim to provide excellence in healthcare.
• We treat others as we wish to be treated.
• We continually evaluate and improve our performance.

Workplace Courtesy

• Treat others the way you would like to be treated!

• Be friendly and courteous to patients / coworkers / providers

• Be present.

• Make eye contact with your patient

• If clinic set up puts your back towards the patient when you document, please turn around and address the patient.

Examples of CREDO Behaviors

On Stage vs Off Stage Behavior

The Disney Company originated the idea of being 'On Stage' whenever in a customer-facing role.

• Onstage:
• The customer (patient) can see you and/or hear you.
• You are a part of their experience - both good and bad.

• Offstage:
• Customer (patient) cannot see you or hear you.
• You are NOT part of their experience.

Please keep all "issues" (personal/work/social), staff dissatisfactions, and social media out of the customer experience!

AIDET Communication

• How we introduce ourselves as professionals, begin patient interactions, and improve our culture of service.

• Allows us to communicate effectively, reduce patient anxiety, and increase patient confidence.

(47 seconds)

SBAR Communication

Use to communicate with provider, RN/LPN, outside facilities, and when giving report to peers. (Written, telephone, or face to face communication) SBAR structures your communication to ensure you have included all needed information.

• S = Situation

• A concise statement of the problem.
• Who / why?

• B = Background
• Pertinent information related to current situation.
• History? Recent hospitalizations / office visits?

• A = Assessment (MAs do not assess, but can relay information)

• Current data. Vitals signs / patient complaints

• R = Recommendation

• Action requested.
• What do you want / result of this communication?

Orientation Requirements

1) Orientation Checklist 2) Learning Exchange Modules

"Link" to your Orientation Checklist will be sent to you in an email from your Education Specialist. Please save email to use the link! Work on your Orientation Checklist with your preceptor for 5-10 minutes at the end of each day to document your accomplishments. Complete Checklist and Learning Exchange Modules within 90 days of hire!

Orientation Checklist

For each section of the checklist, the preceptor is to choose ONE method of validation. First choice is ALWAYS for preceptor to observe you performing function of role.

Preceptor places their VUMC ID here Date you performed function

Checklist is to be filled out over time, NOT all on one day.

Orientation Checklist cont.

When you have completed all aspects of the checklist, your preceptor will validate that you are ready to come off orientation. Preceptor enters date. Preceptor enters their full name/VUMC ID If you had more than 1 preceptor, each preceptor should enter their name/VUMC ID at the bottom Sign your Orientation Checklist

Preceptor Requirements

• Attend Preceptor Training

• Complete Progress Tool regularly to track new hire's progress during orientation

• Validate new hire's competency on their checklist

• When Orientee is assigned to a preceptor, they are to have ONE ASSIGNMENT

• Orientee begins by watching preceptor
• Progresses to where orientee will correctly perform all functions with preceptor watching them

• Duration of time assigned with preceptor is determined by individual clinics / specialty areas.

Unit Specific Learning Exchange Modules

• 2024 FY VMG Certified/Tech Orientation Modules (HOME UNIT NAME)

VMG Nursing Website

One stop shop for all things Clinic related: Answers to questions and resources.

QUESTION

How long do you have to complete your orientation checklist and Learning Exchange Modules?

1 month (30 days)

2 months (60 days)

3 months (90 days)

250 POINTS

RIGHT!

You have 3 months (90 days) to complete your Orientation Checklist and Learning Exchange Modules

QUESTION

You may fill out your Orientation checklist by yourself at the end of your orientation period.

TRUE

FALSE

250 POINTS

RIGHT!

You and your preceptor are to work on your Orientation Checklist throughout your orientation period.

QUESTION

ONE occurrence will be accrued for which of the following?

Multiple absent days in a row due to same illness.

Multiple absent days in a row with no call / no show.

6 tardies due to oversleeping.

RIGHT!

Multiple absent days in a row due to same illness.

Medical Terminology

Self Enroll in the Learning Exchange

Return

Staple/Suture/Steri-Strip Wound Dressings Wound cleaning with NS Extremity Wrapping

02

Wounds

Objectives

• Demonstrate technique for suture and staple removal
• Understand how to clean wound

• Demonstrate use of piston syringe for irrigation of wound
• Apply and tape wound dressing
• Demonstrate wrapping wound dressing
• Demonstrate tegaderm removal

WOUNDS

Pre - Staple & Suture Removal

• Obtain sterile staple or suture removal kit.

• Hand hygiene.

• Don clean gloves.

• Verify correct patient (2 identifiers).

• Explain procedure to patient and ensure patient agrees.

• Clean staples / suture incision area with sterile Normal Saline or antiseptic swabs (per organzation's practice).

Suture and Staple Removal: General timing

Do not remove until instructed.

Staple Removal

• Place TWO lower jaws of the staple extractor under the first staple to be removed.

• Depess the upper handle of extractor fully down.
• Extractor will bend the center of staple downward and ends upward.

(BAT WINGS)

• Lift the extractor straight up.

• Remove every OTHER staple.

• If incision remains intact, remove all staples.

• Cleanse area per protocol.

• Document # of staples removed by creating a note.

Using only one lower jaw will bury the staple

practice staple removal

Suture Removal

• Place sterile scissors in dominant hand and forceps in nondominant hand.

• Grasp suture KNOT with the forceps and gently pull it up.

• Slip tip of scissors under suture and cut suture as close to the skin as possible.

• With forceps, pull suture from skin, and place on a gauze pad.

• Remove every OTHER suture.

• If incision remains intact, remove all sutures.

• Clean area per protocol.

• Document # sutures removed by creating a note.

practice suture removal

Placing Medical Tape (Steri-Strips)

• Apply skin adhesive to surrounding skin of wound and allow to dry (1 minute - tacky).

• Cut strip to size with an overlap of 2 to 3 cm (1 inch) on each side of the wound.

• Place first tape strip perpendicular to incision and secure on one side.

• Approximate wound edges and apply the other half of the tape strip
• Secure by pressing fingers along tape to help set adhesive.
• DO NOT TUG wound together.

• Continue applying required tape strips; leave smalls gaps between each strip.

Removing Medical Tape (Steri-Strips)

To remove tape strip:

• With forceps or fingers, gently grasp one end of each strip by peeling it towards wound. Repeat same at the opposite end of strip so both ends are 'free'.
• May require adhesive remover at edges

• Once both ends are free (up to the incision area), gently lift both ends up at the same time and remove the strip from skin.

https://point-of-care.elsevierperformancemanager.com/skills/19315/quick-sheet?skillId=AM_098&virtualname=vuebl-tnnashville

Dressing Change

• Hand hygiene.

• Don clean gloves.

• Verify correct patient (Scan ID Band or 2 identifiers).

• Explain procedure to patient and ensure patient agrees.

• Remove tape and dressing in direction of hair growth and discard.

• Remove gloves and perform hand hygiene.

• RN or provider must assess wound.

Cleaning Wounds Normal saline

• Don clean gloves.

• Clean area with sterile NS soaked gauze.

• Starting at incision area and use long strokes.

• Incision/wound site is considered 'clean'.

• Move from clean to contaminated
• Progressively move outward from incision/wound.

• Use a clean gauze with NS for each stroke.

• If drain present, use circular strokes starting at drain and moving progressively outward.

Start at incision / wound

Irrigating Wounds with Normal saline

• Obtain sterile irrigation tray (Piston syringe).

• Don clean gloves.

• Fill container with sterile NS.

• Place drape to protect patient or position plastic tray beneath wound.

• Remove cap from Piston syringe and draw up sterile NS into syringe.

• Push syringe plunger with thumb while using a sweeping motion while hovering above wound.

• Continue motion until wound drains clear.

Dressing Change

• Remove gloves and perform hand hygiene.

• Don clean gloves.

• Apply sterile gauze over the wound - only touching top side or corner of dressing.

• If drain present, apply a precut split 4x4 gauze around drain.

• Apply tape in a windowpane fashion.
• Wraped gauze or a binder may be used instead of tape (see next slides).

• Label tape with date/time/initials per protocol.

• Remove gloves and perform hand hygiene.

Abdominal Binder

Abd Pads

Xeroform Dressing

Used to maintain a moist environment:

• Surgical incisions
• Circumcisions
• Skin grafts
• Burns
• Large abrasions

How to Use:

• Clean wound per protocol

• Cover entire area of wound with Xeroform

• Cover Xeroform with a sterile, non-adherent secondary dressing (i.e., fluff roll or bandage roll)

Place unused Xeroform back in foil pouch and seal

Applying a wrapped elastic or gauze bandage

(start around 30 seconds and end before stump - approximately 1 1/2 minutes

practice Dressing change and wrapped bandage

Then do tegaderm removal next slide

Tegaderm Dressing

Removing tegaderm:

• Place finger/thumb gently on one corner of dressing and apply slight pressure

• Gently stretch opposite corner of dressing while keeping parallel to skin. (Do NOT lift up).

• Stretch and relax dressing until edges are free

(Dressing change guide)

3M (2023).Tegaderm-absorbent-when-to-change-dressing-guide.pdf Retrieved 4/4/23. https://multimedia.3m.com/mws/media/868913O/tegaderm-absorbent-when-to-change-dressing-guide.pdf?&fn=70-2010-9234-6.pdf

QUESTION

When removing staples or sutures, in what order do you remove them?

Remove every other one. Remove the remaining if incision is intact.

Start at one side and remove each one in order.

Begin in the middle and work your way outward.

RIGHT!

Begin by removing every other staple or suture. Keep spinning the wheel!

QUESTION

What is the preferred solution when cleaning wounds?

Sterile water

Normal Saline

Antiseptic spray

RIGHT!

Sterile normal saline is the preferred solution for cleaning wounds. It is nontoxic, isotonic and does not damage healing tissues.

15 Minute Break

Return

Medication administration

03

ONLY CERTIFIED MA's May Give Medications

INDEX

1. Principles of medication safety

2. Bar Code Medication Administration (BCMA)

3. Monitoring and actions during adverse reaction

4. Medication documentation

5. List of MA administration medications

6. Routes of administration

medication Safety

5 rights of medication administration

4. Right Route

1. Right Patient

5. Right Time

2. Right Medication

+6. Documentation

3. Right Dose

• Verify patient allergies

• If patient has a history of serious reaction or allergy to the medication
• STOP - DO NOT ADMINSTER
• Report it to Nurse or Provider

Place ID Band on patient wrist. Verify patient correct name / DOB Compare to ID band.

BAR CODE MEDICATION ADMINISTRATION (BCMA)

• Minimizes medication errors

• Improves patient safety

• Improves quality of care

1. SCAN PATIENT - This can be done from the whiteboard to open patient chart!

2. SCAN MEDICATION

3. VERIFY MAR

Troubleshooting BCMA Scanners

There should be a card / paper near your workstation with the directions. You may 'test' the scanner after re-setting by scanning the example medication barcode.

Medication REview - documentation

• Medication name? (generic/brand)

• Dose?
• Route?
• Frequency?
• Reason?
• Last time taken?
• Do you ever skip doses or take extra doses? Why?
• Is there anything that limits you from taking as Rx?
• **If no longer taking medication, document 'not taking' and why
• Include over the counter and herbal substances.

Two reliable resources:

• eStar
• Medication bottles
• Home medication list
• Pharmacy list
• Nursing facility records
• Patient / caregiver’s oral history
• Previous clinic notes

aDMINISTRATION responsibILITIES

1. Correct administration of medications (per VUMC policy) 2. Discuss any concerns with prescribing Provider or RN 3. Educate patient about potential adverse reactions 4. Correct documentation

Post Administration Monitoring

Visual Observation Vital signs Level of Consciousness (LOC) If anything does not seem right, tell RN or provider

Duration and frequency of monitoring is affected by:

• Patient's condition
• Type of medication
• Route of medication

Adverse reactions

Skin

Cardiovascular

Respiratory

Swelling of lips or tongue, trouble breathing, wheeze, cyanosis (turning blue)

Rash, itching, flushing

Decreased Blood Pressure, fainting, dizzy

TELL NURSE OR PROVIDER

CALL FOR HELP FROM NURSE OR PROVIDER! Make sure patient is lying down. If patient is unstable: - Dial 1-1111 on Medical Center Campus. - Dial 911 for ANY off campus clinic

medication documentation

Vaccine Documentation

VACCINES:

• Lot #
• Manufacturer
• Expiration date
• Site
• Date VIS given to patient

BARCODE Scanning will auto fill many of these hard stops

Medical Assistants who are certified receive training and competency verification during unit-level orientation and may administer medications in ambulatory outpatient clinics under the supervision of a Registered Nurse (RN) or Provider. “Medications Approved for Administration by Certified Medical Assistants (MA)” are reviewed and approved by the VUMC Clinical Practice Committee. Certified Medical Assistants may administer only ready to administer dosage forms of medications ...

VMG Approved MA Medication Administration

• Oral - by mouth (swallow)

• Inhalation - breathe into lungs by MDI or nebulizer

• Irrigation - flush / wash site with liquid (wound)

• Topical - cream / ointment applied to skin

• Intramuscular (IM) - inject into muscle of deltoid

Oral adminstration

• Ask patient if they have ever had any issues swallowing medication.

• Perform hand hygiene and don gloves.

• Open medicine package, and place tablet or capsule directly into a medicine cup or into the cupped palm of patient's hand (per their preference).

• Do not touch the medication with ungloved fingers.

• Offer water to help the patient swallow medication.

• Observe the patient until they have swallowed the medication.

• Document medication administration only after observing the patient swallow the medication.

• If the tablet or capsule falls to the floor, discard it and administer a new dose.

Oral - Examples

• If medication comes in a large/multidose container, use for one patient ONLY
• Discard remainder of container

• Do not administer medication to altered skin unless provider ordered.

• Inspect medication for particulates / discoloration

• Place required amount of medicine on gloved fingertip or in palm of gloved hand
• You may rub between hands/fingers to warm it.

• Spread evenly over skin surface following direction of hair growth

• Observe for adverse or allergic reaction

Topical

https://point-of-care.elsevierperformancemanager.com/skills/19320/quick-sheet?skillId=AM_057&virtualname=vuebl-tnnashville

Topical - Examples

Irrigation (wounds)

Brand Name:Normal Saline (NS) Generic Name: 0.9% Sodium Chloride

Sterile normal saline is preferred cleaning solution. It is a nontoxic, isotonic solution that does not damage healing tissues.

Inhalation

Brand Name: Proventil, Ventolin, and others Generic Name:Albuterol Drug Class:Bronchodilator

Used to treat bronchospasm in patients with asthma, bronchitis, emphysema, and also bronchospasm caused by exercise.

• Metered dose inhaler (MDI) is commonly referred to as a “puffer”.

• It aerosolizes the medication so patient can inhale it deep into their lungs.

• A 'spacer' attachment, holds the medicine in place temporarily, so patient can time their inhalation. This helps patient receive the full dose of medication.

Instruct Patient to Clean Spacer

IM - Deltoid (Adult)

• Certified MAs may give vaccinations after:

• Observation of 2 adminstrations by RN or provider (Check offs)

• MAs may only give vaccinations when a RN or provider is in clinic to provide supervision

• 22-25 gauge needle

• Needle length:

• 1 inch < 152 lbs

• 1.5 inch for men > 260 lbs or women > 200 lbs

https://www.cdc.gov/vaccines/hcp/admin/downloads/IM-Injection-adult.pdf

VIS

safe injection practices

CDC

• MA's may ONLY administer single dose injections.

• Discard syringe / needle in sharps container.
• Never recap needle!

• Review potential side effects with patient

• Provide Vaccine Information Sheet (VIS) to patient for all vaccines adminstered.
• Print directly from the Center For Disease Control (CDC), available through eStar.

IM Deltoid (Adult) Landmarks

• Find anatomical landmark: bony prominence on shoulder (Acromion Process)
• Place 3 fingers laterally below bony prominence
• Make 'V' shape with 2 fingers of other hand
• Injection site is middle of the 'V'

Shoulder Injury Related to Vaccine Adminstration (SIRVA)

SIGNS AND SYMPTOMS:

• Shoulder pain / decreased range of motion.
• Symptoms appear within 48 hours of receiving vaccine.
• Over-the-counter pain meds do not improve symptoms.

HOW / WHY ?

• Vaccine given into the wrong part of upper arm causing:

• Trauma from the needle.
• Damage to
• Ligaments
• Tendons
• Bursae sac

SIRVA occurs from inappropriate vaccine adminstration.

Never take short cuts! Always use Deltoid Landmarks for vaccines.

https://www.webmd.com/vaccines/what-is-sirva

• Check patient's bleeding risk prior to injection

• H/H and don gloves

• Clean site with alcohol and allow to dry

• Administer into selected site at a 90 degree angle

• Do NOT aspirate

• Activate the safety mechanism on the injection needle and discard into sharps container

• Apply bandage to the injection site

• Perform H/H and document

IM DELTOID (Adult) ADMINSTRATION

CAUTION: Fainting can occur after adminstering vaccine

Signs/symptoms of reaction:

• Changes in breathing
• Wheezing
• Hives
• Swelling
• Weakness
• Change in Blood Pressure
• Change in Level of Consciousness

Anaphylaxic Emergencies

Know where your clinic keeps its Anaphylaxis Kit. It should be near where the medications are stored If your clinic does not have a kit, ask your manager to request one from pharmacy

Medication resources

Lexicomp Mobile App

Phone APP phone that can tell you about the medication and also how to prpnounce medication!

Aldosterone Agonists

Top 10 Adult Medications

Medications prescribed in the US as of November 2021

1. Atorvastatin (Lipitor)
2. Lisinopril (Prinivil, Zestril)
3. Albuterol (Ventolin, Preventil)
4. Levothyroxine (Synthroid, Levoxyl, Unithroid)
5. Amlodipine (Norvasc)
6. Gabapentin (Neurontin)
7. Omeprazole (Prilosec)
8. Metformin (Glucophage)
9. Losartan (Cozaar)
10. Hydrocodone/Acetaminophen (Vicodin, Norco, Xodol)

1. Atorvastatin (Lipitor)

(Hover over globe for answer)

What is?

2. Lisinopril (Prinivil, Zestril)

(Hover over globe for answer)

What is?

3. Albuterol (Ventolin, Preventil)

(Hover over globe for answer)

What is?

4. Levothyroxine (Synthroid, Levoxyl, Unithroid)

(Hover over globe for answer)

What is?

5. Amlodipine (Norvasc)

(Hover over globe for answer)

What is?

6. Gabapentin (Neurontin)

(Hover over globe for answer)

What is?

7. Omeprazole (Prilosec)

(Hover over globe for answer)

What is?

8. Metformin (Glucophage)

(Hover over globe for answer)

What is?

9. Losartan (Cozaar)

(Hover over globe for answer)

What is?

10. Hydrocodone/Acetaminophen (Vicodin, Norco, Xodol)

(Hover over globe for answer)

What is?

Policies/Resources

Medication Reconciliation https://vanderbilt.policytech.com/dotNet/documents/?docid=18950

Medication Reconciliation Outpatient SOP https://vanderbilt.policytech.com/dotNet/documents/?docid=18952

Injectable Medication Preparation: Outside of Pharmacy

Medication Administration

https://vanderbilt.policytech.com/dotNet/documents/?docid=27315

https://vanderbilt.policytech.com/dotNet/documents/?docid=35215

Medication Storage and Handling

https://vanderbilt.policytech.com/dotNet/documents/?docid=27458

Updated 9/27/23 EC

Go to next slide for questions

QUESTION

On a busy day in clinic you have 2 patients in rooms next to each other. They both need a flu vaccine. How do you proceed?

Obtain 2 vaccines and carry one in your pocket while adminstering the other vaccine to the first patient.

Put both patients in one one room and administer them together.

Obtain one vaccine for the first patient and administer it. Then obtain a vaccine for the second patient and administer it.

RIGHT!

Obtain one vaccine for the first patient and administer it. Then obtain a vaccine for the second patient and administer it.

Keep spinning the wheel!

QUESTION

Suzie received an order to administer a vaccine to her patient. Which steps should she complete before administering the vaccine?

Check the expiration date on the vaccine.

Perform hand hygiene, check the expiration date on the vaccine, visually inspect vaccine for discoloration and particulates.

Perform hand hygiene, and check vaccine for discoloration and particulates.

RIGHT!

Perform hand hygiene, check the expiration date on the vaccine, visually inspect vaccine for discoloration and particulates.

Keep spinning the wheel!

QUESTION

Before administering a medication, what are the 5 Rights you need to check?

Right Medication, Right Patient, Right Dose, Right Route, Right Provider

Right Patient, Right Medication, Right Provider, Right Arm, Right Time

Right Patient, Right Medication, Right Dose,Right Route, Right Time

RIGHT!

Right Patient, Right Medication, Right Dose, Right Route, Right Time

Keep spinning the wheel!

QUESTION

Tom just administered a medication to his patient. A couple of minutes later, he notices the patient is having a harder time breathing and is itching their arms. What should Tom do?

Stay with the patient and watch them for 15 minutes.

Notify the Nurse and/or Provider immediately.

Do nothing. His task is complete and he has another patient waiting. The provider will be in to see the patient soon.

RIGHT!

Notify the Nurse and/or Provider immediately.

practice skills

Return

04

sterile technique

Objectives

• Recognize sterility of supplies
• Demonstrate opening a sterile field
• Demonstrate putting on sterile gloves
• Understand process for 'Time-Out'

Wrapped pan Sterility

• Load sticker
• Date of sterilization
• Autoclave number
• Load number
• No sticker = not sterile

• Label with name of pan
• Tape stripes turn dark brown when sterilized
• No holes, tears, or signs of moisture
• Expiration date current
• Integrator line is dark in the accept region

• Load sticker
• Integrator line is dark in the accept region
• Item labeled
• Steam indicator on back of package turned dark
• No holes, moisture,tears
• Expiration date current

PEEL PACK

manufacturer package

• Expiration date current
• No holes, tears, or signs of moisture

Before Setting Up a Sterile Drape or Towel

• Remove watch/bracelets and any large jewelry (rings with stones).

• Remove or tuck in ID lanyard/Badge so it does not hang into sterile area.

• Remove jacket. If wearing long sleeve shirt, sleeves must be pushed up to elbows.

• Perform hand hygiene.

• Don clean gloves.

• Sterile field must be set up on a tray or table that is at least waist high

• Determine the integrity of the sterile package.

• Confirm expiration date is current.

• Position patient for comfort and accessibility if required.

• Per organizations practice, you may need to don one or more of the following:
• Gloves (clean / sterile)
• Mask
• Gown
• Eye protection (eye shield/goggles)
• Head covering

STERILE FIELD PREPARATION

https://point-of-care.elsevierperformancemanager.com/skills/19319/quick-sheet?skillld=AM_090#scrollToTop

Opening a Sterile Package

(3:32 minutes)

Sterile Drape or Towel

Allow top half of the drape to unfold over the bottom half of the work surface.

Position bottom half of drape over the top half of the work surface.

Grasp corners of the drape and hold drape straight out over the work surface with arms extended.

1 inch border is considered NOT-STERILE

Donning Sterile Gloves

Open package and identify right and left glove.

Remove outer glove package wrapper.

Slip gloved fingers inside cuff of the second glove, lift glove up and insert non-dominant hand into glove. You may now reposition fingers if needed.

Pick up glove of dominant hand at the cuff with thumb and first 2 fingers of non-dominant hand and pull on glove.

MAINTAINING STERILITY

Interlock the fingers of gloved hands.

Keep hands above waist level and in front of you at all times.

Touch only sterile areas or items.

Do not reach over the sterile field.

Do not turn your back on the sterile field.

Assisting With Sterile Procedure

Mask (with faceshield)

Sterile Gloves

You may be asked to assist a provider or nurse with a sterile procedure. Be prepared to:

• Don appropriate sterile or clean coverings
• Hold patient or equipment
• Add items to the sterile field

Gown (Protective or Sterile)

"TIME OUT"

• Verify correct patient, procedure, and site

• Pre-procedure verification - match procedure, treatment, supplies to the correct patient (involve patient if possible)
• Site / side marking (as applicable)

• Performed immediately prior to ANY invasive procedure
• laser
• incision
• electrosurgery (hyfrecator)

practice skills

Return

LUNCH

05

Phlebotomy and PIV removal

Objectives

• Verbalize importance of aseptic technique
• Demonstrate proper phlebotomy technique

• Understand proper technique for removing PIV

Phlebotomy Site Contraindications

Avoid areas of:

• Hematoma
• Phlebitis
• IV infiltration
• Side of mastectomy / node removal / tumor
• Lymphatic compromise
• Exposure to radiation
• Tissue injury
• Affected side of stroke
• Dialysis shunt/fistula

Phlebotomy

• Verify lab order, scan ID Band (2 identifiers)

• Review record for latex allergies, bleeding risk, adverse reactions, site contraindicators.

• Gather supplies (check expiration dates).

• Hand hygiene and don clean gloves.

• Apply tourniquet several inches above potential site.

• Do not leave on longer than 1 minute

• Avoid contraindicated sites.

How to draw blood

Elsevier: Blood Specimen Collection: Venipuncture Vacuum-Extraction Method (Ambulatory)

(3:50 minutes)

Phlebotomy

Sky -coags Grass - Na/K Flowers -H&H

Order of blood draw

Phlebotomy

This poster should be available in your clinic.

Labeling Specimens

Print specimen label(s) 1 - Scan patient ID Band

• Verify name and DOB

2 - Collect specimen3 - Scan specimen label Label specimen in the patient's presence, and ask patient to inspect the labeled tube for correct identification.Complete task in eStar.

Specimen tube

Specimen Labeling

Urinalysis tube

• Patient name reads left to right.

• Place label lengthwise on tubes.

• Labels MUST be placed evenly so the lab machine can read them.
• Machine will reject specimen if it cannot read label properly.

• ONE tube of blood for each label.

Blood Culture Bottle

• Align label with the top of taper, not the manufacturer’s label.

Dressing puncture site and Peripheral IV / INT removal

• Apply a sterile 2 × 2-inch gauze pad to the insertion site.

• Withdraw the needle / cannula.

• Exert and hold pressure for several minutes.
• Patients on anticoagulant therapy have increased bleeding times.

• Immediately discard the needle / peripheral cannula and pigtail in biohazard container.

• Apply tape / band aid pressure dressing / elastic wrap (coban) per facility protocol.

• Instruct patient to leave in place for 15-60 minutes.

• Remove gloves and perform hand hygiene.

practice Phlebotomy skills

Return

06

Vital signs & intake Scenario

Objectives

• Perform all components of patient intake
• Demonstrate obtaining manual vital signs
• Demonstrate 2 step BP
• Understand how to perform Orthostatic Blood Pressures
• Understand differences in special populations

Right side of eStar screen - Intake Checklist (completed tasks)

Left side of eStar screen - Required during intake

Highlighted in RED

Telehealth

• Same requirements as face to face intake with the exception of vital signs.

• Make sure you have the following for every patient:
• Full name
• Verified address of the patient at the time of service
• Verified phone number of parent/guardian for adolescents
• Verified email address
• Emergency contact name and number

Telehealth

Patient Resources:

Getting Started with My Health at Vanderbilt

Telehealth: Prepare for Your Appointment

Preparing for Your Telehealth Visit(patient handout)

Intake

• Retrieve patient from waiting area

• Place ID Band on patient wrist

• Verify correct patient using two patient identifiers
• Name and DOB
• Compare to patient ID Band

• AIDET

• Obtain height (cm) and weight (kg)

Vital Signs

Before Obtaining Vital Signs:

• Hand hygiene before all patient contact.
• Confirm site and device are appropriate for your patient.
• Explain procedure to the patient.
• Assist patient to a comfortable position.

NORMAL ADULT vital sigNS

O2

BP

RespiratoryRate

Temperature

Blood Pressure

Oxygen Saturation

Heart Rate/Pulse

96.8° F - 99.7° F

95 - 100 %

90/60 mmHg -120/80 mmHg

12 - 20 breaths per minute

60 - 100 beats per minute

Vital Signs

• Normal or expected vital signs can vary depending on clinic and medical specialty.

• Know the expectations specific to your population.

• Change in vital signs may indicate a patient concern.

• Elevate to RN or provider

Normal Adult Oral Temperatureapproximately 96.8-99.7

Temperature can be affected by:

• Gender
• Women may have higher body temperatures.
• Age
• Older people may have lower body temperatures.
• Circadian rhythms
• Body temperatures increase later in the day (afternoon).
• Environment
• Air conditioning, heat, clothing, outside temperatures all affect body temperature.

https://point-of-care.elsevierperformancemanager.com/skills/672/quick-sheet?skillId=GN_17_1A&virtualname=vuebl-tnnashville

https://www.health.harvard.edu/blog/time-to-redefine-normal-body-temperature-2020031319173

Common Modes of Temperature Measurement

Oral

Tympanic

Temporal

PULSE (Heart Rate)

SYSTOLE: Pumping / contraction of heart DIASTOLE: Filling / heart at rest

Normal adult heart rate 60-100

(1:41 minutes)

Radial Pulse (Heart Rate)

Allow patient to relax for several minutes:

• Patient in a sitting position.
• Bend elbow to 90 degrees.
• Support the lower arm.

• Place 2-3 fingers over groove along the radial (thumb) side of patient wrist.

• Lightly press until pulse is easily palpable.

• Count rate (number) for 30 seconds and multiply by 2.
• If pulse is irregular, count rate for full 60 seconds.

• Document findings.

• Elevate findings if appropriate.

https://point-of-care.elsevierperformancemanager.com/skills/19221/quick-sheet?skillId=AM_067&virtualname=vuebl-tnnashville

RESPIRATIONS

Inspiration - air in; diaphragm and thoracic muscle contractExhalation - air out; diaphragm and thoracic muscles relax

Normal rate 12-20

Respirations

Wait several minutes after patient has entered room:

• Ask patient to NOT speak during the procedure.

• Observe breathing pattern.
• Normal breathing is regular and unlabored.

• Count respirations by watching rise and fall of chest.

• If breathing regular - count for 30 seconds and multiply by 2.

• If breathing irregular or RR < 12 or > 20 - count for 60 seconds.

• Document RR, include depth of respirations (shallow, normal or deep).

• Elevate findings if appropriate.

BLOOD PRESSURE

Systole: Peak pressure exterted as ventricles contract and eject blood Diastole: Minimum pressure exerted between cardiac contractions (heart at rest)

Normal adult BP 120/80

Cuff size is key to an accurate BP reading: TOO BIG = FALSE LOW BP TOO SMALL = FALSE HIGH BP

Taking a Blood Pressure Measurement

Is the patient ready to have Blood Pressure taken?

Is patient in proper position for Blood Pressure Reading?

Placing BP Cuff

YES

NO

+ info

+ info

+ info

Please hover on + info boxes

Taking a Blood Pressure Measurement

• Perform hand hygiene / don clean gloves.

• Position patient.

• Place BP cuff above antecubital fossa.

• Place stethoscope diaphragm over brachial artery and below the lower edge of the BP cuff

• Do not let diaphragm touch cuff or clothing.

• Quickly inflate cuff to desired mm HG.

• Slowly release pressure valve to allow needle to fall at a rate of 2-3 mm HG per second.

• Observe the point on the manometer at which the first Korotkoff sound is heard (Systolic BP).

• Continue to deflate cuff gradually.

• Observe for point at which all Korotkoff sounds disappear (Diastolic BP).

Please hover on + info boxes

Targeted BP / Two Step BP

• Locate the radial pulse with fingertips of nondominant hand.

• Palpate the pulse while inflating the BP cuff until pulse disappears.

• Note number mm Hg.

• Deflate the cuff fully.

• Wait 1-2 minutes.

• Reinflate cuff to 20-30 mm Hg above the number where the pulse disappeared and obtain BP per protocol.

Estimating patient systolic BP with palpation

practice 2-step Blood Pressure

Orthostatic Hypotension Blood Pressure

Patient to lie supine for 5-10 minutes before beginning measurements.

• Support patient arm at heart level

• Use same arm for all measurements.

• With each "change in position"
• Question patient about weakness, dizziness, or visual dimming.

• Observe for pallor and/or diaphoresis.

• Terminate measurement if patient becomes extremely dizzy,

needs to lie down, or experiences syncope.

Orthostatic Hypotension BP cont.

Measure Blood Pressure / Pulse 3 times: Supine, sitting, and standing.

• Obtain Blood Pressure / Pulse.
• Change patient to sitting position.

• Wait 1-3 minutes.

• Obtain Blood Pressure / Pulse.
• Change to standing position.
• Wait 1-3 minutes.

• Obtain Blood Pressure / Pulse.

• Document all readings.

Oxygen Saturation (SpO2)

• Place probe on patient finger.
• Do NOT place on thumb.
• Do NOT place on same extremity as electronic BP cuff.
• May warm site if cold.
• Remove dark nail polish - light must shine through.

• Align light source and photodetector sensor directly opposite of each other.

• Observe pulse waveform until it reaches a constant value.

• Read the SpO2 on the digital display.

• Document reading in patient’s record.

• Elevate results if appropriate.

• Disinfect device after every patient.

Normal 95-100% for healthy adult

SPECIAL POPULATIONS

Normal Pediatric Vital Signs

The younger the child:

• Higher Heart Rate / Respiratory Rate

• Lower BP

By adolescence, Vital Signs are similar to adult.

VUMC CHOC Vital Signs Resource Sheet. 2021.

Center for Women's Health (CWH)

Did you know...

• During pregnancy, the woman’s heart works harder to pump more blood to the uterus.

• As cardiac output increases, resting heart rate speeds up (as high as 90 beats per minute).

• We must be familiar with physiological changes during pregnancy so we can give the most accurate information to the provider!

MedlinePlus. Low blood pressure.

• High blood pressure can affect development of the placenta.

• Can lead to:
• Early delivery
• Low birth weight
• Placental separation
• Other complications for baby.

Cleveland Clinic. High blood pressure (hypertension) during pregnancy.

Blood Pressure Ranges in Pregnancy

Accepted blood pressure threshold for a pregnant patient is less than 140/90.

Accepted blood pressure threshold for a pregnant patient with cardiac considerations is less than 160/110. Before reporting any out of range BP value to a provider, please review their problem list first!

Normal threshhold for adults is 120/80.

BARIATRIC PATIENTSSeverely Obese -Things to Consider...

• Blood Pressure measurement can be inaccurate due to poorly fitting BP cuff.

(Leblanc et al., 2013).

• BP measurement at the wrist should be considered if a correctly fitting upper arm cuff cannot be applied.

• Wrist BP must be taken while cuff is held at the level of the heart.

(Irving et al., 2016).

Intake

4:27

Intake

6:18

QUESTION

Temperature can vary based on person and environment. Which of the following are generally true?

Temperature may increase in the afternoon

Younger people may have lower temperature than older people

Men may have higher temperaturesthan women

RIGHT!

Temperature may increase later in the afternoon. Keep spinning the wheel!

QUESTION

How do you know high to inflate your BP cuff?

Pump to 160 mm Hg. Pumping higher than that will hurt older people's arms.

Pump to 220 mm HG to ensure that you capture any high systolics.

Look at previous BP readings and pump 20-30 mm Hg higher or do a 2 step BP.

RIGHT!

Look at previous BP readings and pump 20-30 mm Hg higher or do a 2 step BP. Keep spinning the wheel!

QUESTION

Who can perform the Medication Review?

Any MA can perform the Medication Review

Only Certified MA's may perform the Medication Review

RIGHT!

Only Certified MA's may perform the Medication Review

References:

Prabhavathi, K., Selvi, K. T., Poornima, K. N., & Sarvanan, A. (2014). Role of biological sex in normal cardiac function and in its disease outcome - a review. Journal of clinical and diagnostic research : JCDR, 8(8), BE01–BE4. https://doi.org/10.7860/JCDR/2014/9635.4771

Treas, L. & Wilkinson, J. (2018). Basic nursing: Thinking, doing, and caring (2nd Ed.) Philadelphia, PA: F.A. Davis. ISBN 978-0-8036-5942-1

Zhang, D., Wang, W., & Li, F. (2016). Association between resting heart rate and coronary artery disease, stroke, sudden death and noncardiovascular diseases: a meta-analysis. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 188(15), E384–E392. https://doi.org/10.1503/cmaj.160050

practice Intake Scenario

Secure Login

Enter your VUMC ID and password. It should take you here - choose EPIC Playground

eStar Virtual Desktop Choose: EPIC PLY

Log In

User ID: MA# Password: train

You can look up your patient BUT... We want you to scan your patient's ID Band instead

Scan ID Band

Choose Arrived Appt and then click 'Accept'

Choose Intake TAB

Choose Vital Signs

Always check allergies and mark as reviewed before giving medications.

Scroll down to see required intake sections (They will be highlighted in red).

Enter Vital Signs, and other intake screenings/measurements - When done select the MAR TAB to administer a medication

Verify patient has been scanned. Look for GREEN body and check mark scanned Scan medication barcode.

• Pink dot alerts you that dose scanned is different than the dose ordered.

• Scan both tablets for correct dose.

• Scroll down and 'Accept' ONLY after dose given.

After dose has been given, it will change to green. Next, choose the Immunization TAB to give a vaccine.

Influenza shows as incomplete - Scan vaccine barcode. Fill in any boxes with a RED exclamation point (!) Administer vaccine. Then click "Accept'.

Vaccine shows as given on Adminstration History

15 Minute Break

Return

07

Emergency response

Stroke Acute Coronary Syndrome Mock Code

Stroke: Signs and Symptoms

A: ARMS Arm or leg weakness

F: FACE One side of face is drooping

• Sudden severe headache

• Sudden change in:
• Strength
• Speech
• Vision
• Coordination

T: TIME Call for ambulance Immediately

THINK F.A.S.T.

S: SPEECH Difficulty with speech

Stroke Facts:

Call For Help Immediately!

• Stroke can happen anywhere at anytime

• Leading cause of adult disability

• 5th leading cause of death

• Every 45 seconds, someone suffers a stroke

• VUMC Campus: dial 1-1111

• Off Campus: dial 911

Be able to answer: Time of symptom onset Patients name Address of Clinic

Acute Coronary syndrome

Umbrella term for a group of conditions that suddenly reduce or block the flow of blood to the heart. #1 Cause of Death

Atypical: Women / diabetics / elderly

• Heartburn or indigestion
• Diaphoresis (sweating)
• Back pain
• Nausea / vomiting
• Dizziness
• Fatigue / weakness
• Palpitations
• Altered mental status

Symptoms

Common: Men

• Pain in chest, arms, neck or jaw
• Shortness of breath
• sudden symptom onset

Mock Code & Emergency Preparedness

Next

Objectives

• Demonstrate how to properly activate emergency response based on department or clinic location
• Discuss team roles in a code situation
• Demonstrate use of available emergency equipment
• Engage in meaningful debrief
• Demonstrate MA responsibilities for anaphylaxis kit

Next

Clinic Code Demonstration # 1

Next

What went wrong here?

Next

Clinic Code Demonstration # 2

Next

What went right?

Next

Closed Loop Communication

POINT, BE CLEAR, USE NAMES

RECEIVER SHOULD REPEAT IT BACK

Next

What are some things you do to prepare for a code in your clinic?

Who would you call in a code situation in your clinic?

Next

Review who to call

• Main Campus call 1-1111
• One Hundred Oaks (OHO) Call 911
• Off-site clinics Call 911

Prepare to give location information (know your clinic address!)

Next

What are the team roles in a code?

Review Team Roles In a Code

What is an adult compression to breath ratio?

Next

Remember...

Plug in the tubing to the oxygen! Turn the oxygen all the way up (15L)

If there are enough rescuers, 2 people should be on the bag valve mask (Ambu bag) One rescuer holds the mask with 2 hands using the "E-C grip" with both hands Other rescuer will give the breaths

EMS Safety.

Next

Emergency Equipment

Phillips AED

This differs per clinic! Get familiar with what your clinic has and how it works.

Zoll Monitor/Defibrillator

Zoll AED

Next

Zoll R Series Review

Click on pictures to see larger image!

Turn monitor to ON - it will automatically be in AED mode

Next

Zoll Electrodes

Electrode 1: Roll the patient onto their side and then roll the 1st electrode onto patient's back to the left of their spine and under the shoulder blade

Electrode 2: Includes a CPR compression sensor The sensor should be placed where the red line is mid sternumn and horizontal red line is between the patient's nipples.

Next

Zoll Electrodes for Adult

Click on pictures to see larger image!

Electrode 1

Electrode 2

For female patients, lift up the breast to position the electrode underneath.

Next

Zoll Electrodes for Pediatric Patients

Click on pictures to see larger image!

The R series detects whether pediatric or adult electrodes are connected and automatically adjusts the arrhythmia analysis.

Place Back Electrode First Place the eletrode so that it is centered on the spine.

Front Electrode Turn the patient and apply the front electrode over the cardiac apex.

Next

Phillips AED Review for Adults

Place monitor pads on patient like you see in diagram:

Next

AEDMarket.

Phillips.

Seton.

Phillips AED Review for Pediatrics

The Phillips FRX uses the same pads for adult & pediatrics but you MUST insert the key to enable pediatric voltage.

Next

ZOLL AED Review

This AED uses the same pads for adults and pediatrics.

Press here to activate child mode for children <55 lb or approx 8 years old

Next

Arrest Record

Documentation

Provider and nurse sign Arrest Record

Permanent part of patient record - scan form into eStar

How to print from Medex

Fax Arrest Record to number at bottom of form

You will also need to fill out a VERITAS

If transferring to ED, call Patient Flow Center

Next

Debriefing

Discuss with your team after an emergency situation

Discuss emotional support

• Chaplain
• Employee Assistance Program
• Emotional support for patient, family, visitors

• What went well?
• What would you change?
• Ask questions at the debriefing – NEVER be afraid to speak up.

Next

VMG Badge Buddy

practice - mock code simulation

Return

References

VUMC. Cardiopulmonary Resuscitation (CPR) policy. PolicyTech. Retrieved from https://vanderbilt.policytech.com/dotNet/documents/?docid=21641 VUMC. Resuscitation Team. Retreived from https://www.vumc.org/resuscitation-program/welcome

08

Blood glucose

Learning Objectives

• At the conclusion, participants should be able to:
• Navigate all functions on the Accu-Chek Inform II glucose meter.
• Demonstrate how to perform quality control tests.
• Recall how to properly handle glucose reagents.
• Verbalize understanding of how to perform patient tests.
• Discuss cleaning and troubleshooting of the meters.

Testing Personnel

Only trained personnel are permitted to perform glucose testing.

• New users receive certification upon completion of initial training.

• To maintain glucose testing privileges, each user must be annually recertified for competency.

• VandyWorks will warn users 120 days prior to expiration that it is time to recertify.

• The glucometer will warn users 90 days from their expiration date that it is time to recertify.

• Recertification requires reviewing the procedure, taking a quiz to prove procedural knowledge, and performing both levels of QC and a patient sample in front of a designated trainer or a member of Point of Care.

• Operators who have not been recertified will be automatically locked out of the meter.

VUMC ID

• All analysis performed on the glucometer REQUIRES access with your VUMC ID as the operator ID.

• Do not allow other staff to use your VUMC ID for patient testing or quality control. Doing so will result in disciplinary action.

Glucose System Components

Quality Control-  2 vials of liquid quality control solution (“HI/LO”)

Storage Case– conveniently stores and transports meter and supplies

Glucometer- with rechargeable battery

Testing Strips-small sample volume (6µL)

Base Unit- acts as a charging station (indicated by a blue light) and a downloader (indicated by a green light) for the glucometer

Anatomy of the Glucometer

Front of Glucometer

Glucometer Base Unit

• Always return the meter to base unit to charge the battery.

• A battery takes 2 hours to drain, and 4 hours to reach a full charge.

• To confirm the meter is charging, look for the charging icon (battery with a lightning bolt) on the lower right portion of the glucometer.

• If the meter is not fully charged, the screen will go black during charging to conserve battery power – tap the screen to ensure it is charging.

Glucometer Base Unit

• “Why is the glucometer not charging?

It’s been in the base station all day!”

• Please do not unplug the base unit to charge your personal cellular device or any other devices.

Glucometer Base Unit

Every 10 minutes all glucometers wirelessly upload to the EMR. If wireless connectivity is unavailable, dock the meter in a downloader/green light base station.

• This synchronizes the information in the meter with the system (patient lists and results, operator lists, strips, and controls).

• In the event the background of the glucometer reads “Busy,” “Synchronizing Data,” or “Communicating,” wait until the screen returns to “Idle” to perform analysis.

Glucose Reagents: Test Strips

The red circle highlights the silver side/computer chip that is inserted into the glucometer.

• Store test strips in the original container.

• Ensure the cap is on tight as container must remain closed.

• Improperly stored test strips will produce inaccurate results and must be discarded.

• Test strips can be used until the expiration date printed on the vial.

• The silver side is the computer chip that is inserted into the meter.

• The grey side contains the specimen window. The sample (6µL) loads via capillary action from the tip of the strip.

Glucose Reagents for Quality Control (QC)

• Opened control solutions expire 3 months from opening or the “Use By” date on the bottle, whichever comes first.

• Control solutions must be dated with both the open and discard dates. Please obtain appropriate labels from your unit management team.

• Both QC levels (level 1 and level 2) must “Pass” at least every 24 hours.

• Perform QC at the following times:
• When a new vial of test strips are opened.
• When the results are questionable

• When the glucometer has been dropped or mishandled.

QC Solutions: Level 1 and Level 2

Labels for QC solution can be ordered from the print shop by unit management team.

Performing Glucose Quality Control (QC) Tests

Performing Glucose Quality Control (QC) Tests

1. Turn the meter on by pressing the power button on the front.
2. The meter will automatically perform several system checks.
3. Enter your operator ID (VUMC ID) either by scanning your barcode or manually typing it in.

Performing Glucose Quality Control (QC) Tests

4. Press the “Control Test” button.

5. Scanning the barcode on the QC vial will identify the correct level you are testing.

Performing Glucose QC

7. The meter is now ready to insert a strip.

• The silver end/computer chip portion of the strip goes into the meter with the writing side up.
• The meter should “beep” to alert you it has accepted the strip.

6. The glucometer will prompt, in the upper left corner, for the strip lot to be scanned. Aim the scanner at the vial of strips and press the barcode icon to scan.

Performing Glucose QC

8. The meter prompts for the application of the control solution to the strip when the blood drop flashes on the screen. ***Avoid holding the glucometer vertical/upright so the control solution sample does not enter the test strip insertion site. Only a small drop of solution is needed to be dispensed into the sample window at the end of the strip.***

Performing Glucose QC Continued

9. An hourglass will be displayed briefly.

• If the hourglass does not appear and the blood drop icon is still flashing, you can add more sample within five seconds.
• The glucose meter should remain horizontal during testing.

10. If the result is “PASS,” press the checkmark to accept the result and return to the menu.

11. Repeat the QC process (steps 4-10) with the other level. Both QC levels must be done every 24 hours

Performing Glucose QC Continued

• If QC should fail, an “Out of Range” message will display on screen and the comment bubble icon will flash.

• Touch the comment bubble and select the appropriate comment(s).

• Repeat QC.

• If QC fails again, try another vial of strips or another bottle of liquid QC.

• After attempting to repeat QC with a fresh bottle of QC and a new vial of test strips, the operator should STOP testing and contact the POCT office for assistance.

Approved Patient Sample Types

The following sample types are approved for use with the ACCU-CHEK Inform II System:

• Arterial whole blood
• Venous whole blood
• Capillary (finger-stick and neonate heel-stick)

Performing A Patient Test

1. Turn the meter on by pressing the power button on the front.
2. The meter will automatically perform several system checks.
3. Enter your operator ID (VUMC ID) - either by scanning your upper-case barcode or manually typing it in.
4. Press the “Patient Test” button.
5. As per the glucometer’s request, identify the patient with the 13-digit account number/CSN ENCOUNTER.
6. Scan the patient’s barcode, or manually type in the account number (not recommended to manually type in account number as this increases risk for error).

Performing a Patient Test

1. Scan barcode on strip vial.
2. The meter is now ready for you to insert a strip.
3. The silver end of the strip goes into the meter with the writing side up.
4. The meter should “beep” to alert you it has accepted the strip.
5. At this point, perform the specimen collection. While keeping the glucometer horizontal, add the specimen to the test strip.
6. If performing a finger or heel stick, ALWAYS wipe away the first drop of blood before analysis.
7. Avoid getting blood in the test strip port.
8. If the hourglass does not appear and the test has not started, you may add more blood to the strip within 5 seconds.

Performing a Patient Test

11. After analysis, the result will flash on the screen. 12. If any comment needs to be attached to this result, comment BEFORE touching the check mark to accept the result.

• Touch the “Comment Bubble” icon and enter a custom comment or select a pre-generated comment from a list provided on the meter. Examples of pre-generated comments include:
• “Provider Notified,”
• “Procedure Error,” and
• “Repeat Test.”
• Once the comment is selected or free texted into the meter, touch the “Checkmark” ( √ ) icon to accept the result.

13. Once the check mark icon is touched, results will be sent to the EMR wirelessly.

Glucometer Meter Ranges

Normal glucose fasting range result is: 70-99 mg/dL.

• The glucometer meter’s measuring range is from 25-600 mg/dL.
• Results <25 mg/dL will be displayed as “LO”
• Results > 600 mg/dL will be displayed as “HI”.

Glucose Results: Critical Ranges

Glucose Results: Critical Ranges

Any critical result MUST be communicated to the provider and addressed: 1. Document action in the meter using an appropriate comment. You cannot proceed with further testing until a comment is attached to the critical results. Comments must be made on critical values per a requirement of the Joint Commission. Remember there will be pre-determined comments that you will be able to select or choose from. 2. Notify the provider of the critical result and document notification of provider in the patient’s chart.

Questionable Results

• If at any time the blood glucose result does not reflect the patient’s clinical symptoms, or seems unusually low or high, perform a control test on the meter.
• If the control test is acceptable, the test system (including operator, meter, and strips) is working properly.

• Repeat the blood glucose test on a new blood sample.
• If the repeated result is still unusual, consider sending a sample to the lab for analysis.

Patient Testing Limitations

The ACCU-CHEK Inform II has not received FDA clearance for use with patients receiving intensive medical intervention or therapy. This means the meter cannot be used on "critically ill patients". For the purpose of point-of-care glucose testing, VUMC defines "critically ill" as meeting one of the criteria below: Do not perform analysis in any of the following situations:

• Hematocrits <10% or >65%.
• Triglyceride levels > 1800 mg/dL
• Blood concentrations of galactose >15 mg/dL
• Intravenous administration of ascorbic acid resulting in blood concentrations of ascorbic acid >3 mg/dL
• Glucose testing by Inform II glucose meter should not be performed during a high dose vitamin C infusion or for 24 hours beyond termination of the infusion.
• Intravenous administration of N-acetylcysteine which results in blood concentrations >5 mg/dL
• Capillary samples performed on poorly perfused patients/patients with impaired peripheral circulation.

Impaired Peripheral Circulation

• If peripheral circulation is impaired, collection of capillary blood is not advised as the results may not be a true reflection of the physiological blood glucose level.

• Examples of circumstances where peripheral circulation could be impaired include:

• Severe dehydration as a result of diabetic ketoacidosis or due to hyperglycemic hyperosmolar non-ketotic syndrome
• Hypotension
• Shock
• Decompensated heart failure NYHA Class IV
• Peripheral vascular disease

• If a patient is poorly perfused (as assessed by RN), a venous or arterial sample should be obtained. This blood sample can be analyzed on the glucometer.

Impaired Peripheral Circulation - Report to RN

• Possible signs and symptoms of impaired peripheral circulation could include:

• Pigmentation, mottling, or texture changes in skin, including peripheral cyanosis
• Temperature changes in fingertips or heels, specifically cooler
• Delayed capillary refill time (greater than 3 seconds)
• Diminished or absence of a pulse
• Bilateral or unilateral edema
• Sensation of touch decreased or lost, i.e. diabetic neuropathy
• Pain, aching or throbbing
• Clubbing of nail beds

Reference: Rhoads, J. & Peterson, S.W. (2014). Advanced Health Assessment and Diagnostic Reasoning (2nd ed.). Jones and Bartlett. pp. 238-69.

What if I performed testing on the wrong patient?

1. Comment on the patient’s result BEFORE uploading the result wirelessly.
2. Call POCT at 615-343-5707 (Main) or 615-443-2539 (Wilson Co.) to inform them of the event.
3. POCT will send you a “Glucose correction form” that you will fill out and fax back to POCT.
4. POCT will then investigate and correct the issue within the electronic health record.
5. Fill out a Veritas.

Resetting the Glucometer

If the Serial Number starts with UU14 (the glucometer doesn’t have the reset button on the battery cover) 1. Press and hold down the power button for a continuous 12-15 seconds. 2. Place it in the docking station to accept configuration. When docking is complete, the meter display will read “Idle.” Do not remove the meter from the base until “Idle” is displayed. 3. Remove the meter from the base. 4. Turn it on to check that the reset worked. 5. Perform QC.

Infection Control

• WASH IN, WASH OUT

• Clean the glucometer after every paitent! The device should also be cleaned prior to docking the meter in the charging station.
• Squeeze out excess fluid from any wipes before wiping the meter.
• Do not allow any moisture in the test strip port when cleaning.

• Clean meters with:
• Super Sani-Wipes (a.k.a. purple top) wipes for most patients
• Clorox wipes (10% bleach solution) when used on patients that are known/suspected of having C. diff or Norovirus infections.

CLEAN METERS WITH:

NEVER USE

OR

Infection Control

Follow hospital infection control guidelines at all times.

• Perform hand hygiene and wear gloves when performing any analysis or cleaning the glucometer.

• Sharps must be discarded in puncture proof containers

• All other biohazardous waste must be discarded in designated containers.

References

• Point-of-Care Testing (POCT) Program.

• Rhoads, J. & Peterson, S.W. (2014). Advanced Health Assessment and Diagnostic Reasoning (2nd ed.). Jones and Bartlett. pp. 238-69.

• SOP. Point-of-Care Testing (POCT) Bedside Glucose Monitoring – Accu-Chek Inform II

practice accuchek

GO TO EVALUATION SLIDE

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09

Electrocardiogram(EKG/ECG)

Objectives:

Upon completion of this presentation, the learner will be able to:

• Describe the purpose of an ECG
• Discuss appropriate patient position for performing an ECG

• Identify anatomical landmarks for appropriate lead placement
• Describe how to prep the patient’s skin prior to applying electrodes
• Demonstrate lead placement in a left sided and right sided ECG
• Identify ways to reduce artifact

What is an Electrocardiogram?

• Measure of the heart’s electrical activity
• Paints a picture of the heart’s electrical activity by recording information from 12 different perspectives

ECG Demo Video by Morgan Johnson, MSN, ANP-BC

(11 Minutes)

Reducing artifact

• Ask patient to lay still and not to talk during ECG
• Turn off electrical devices and equipment if possible
• Check for cable loops and avoid running cables adjacent to metal objects because it can affect the signal
• Inspect wires and cables for cracks or breaks
• Ensure secure connection between patient cable and the ECG device

Step 1: Patient Position

• Ensure electronic devices are removed to decrease artifact.
• Cell phones, hearing aids, watches, etc.

• Assist the patient into a resting, supine position (laying flat).
• If patient cannot lie flat, you may semi-recline.

• Ask patient to lie with arms flat, relax shoulders, keep legs uncrossed.

• For patients that do not fit comfortably on the bed or exam table due to size, ask them to cross their arms on their stomach to reduce muscle tension and movement.

• Ask the patient to lie still and quiet until exam is completed.

Step 2: Skin Preparation and Electrode Integrity

• Skin should be dry, remove any lotions, oils, or moisture.
• Use a guauze pad to rub area briskly where electordes are to be place.
• If patient is diaphoretic / sweating, dry skin before applying electrodes.

• Remove backing from electrodes, and ensure the conducting gel is moist and sticky before placing on patient.

• Dry electrodes with inadequate gel reduces the conduction of the ECG signal.
• Dry electrodes are a result of incorrect storage.
• Do not remove electrodes from pouch until ready to use.

• Always date whenever you open new package of leads.

Step 3: Electrode placement

• Clip hair as necessary for good electrode contact.

• Place on patient ensuring full contact with patient's skin.

• Do not place electrodes over bones, incisions, irritated skin, and body parts where there can be a lot of possible muscle movement.

• Use electrodes of the same brand. Using different brands can hinder an accurate ECG .

ECG lead placement

• STEP 1: Identify clavicles & Angle of Louis
• V1- Fourth intercostal space; Right sternal border
• V2- Fourth intercostal space; Left sternal border
• V3- Midway between placement of V2 & V4
• V4- Fifth intercostal space at the midclavicular line
• V5- Anterior axillary line on the same horizontal level as V4
• V6- Mid-axillary line on the same horizontal level as V4 and V5
• RA- Right arm (limb lead, choose fleshy area)
• RL- Below right torso & above right ankle (limb lead)
• LA- Left arm (limb lead, choose fleshy area)
• LL- Below left torso & above left ankle (limb lead)

ECG lead placement

Lead placement

• Ensure limb leads are placed evenly on each side

• When counting down the 4th ICS, identify the 1st ICS located underneath the clavicle

• The 5th ICS is approximately the nipple line on men

• For any patient with larger breasts, place leads V3-V6 in the crest underneath the left breast

Right sided ECG

• Exact opposite of left sided ECG placement
• Allows you to see a right sided infarct

MA Clinical Orientation Evaluation

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