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 1 of 5
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: July 16, 2014 Scribe: Tonya Hughes, PSA Timekeeper:
Out Today: Location: Leprino Room 620 Time: 1000-1200

Topic Discussion Recommendations / Actions Follow-up
Welcome/
Introductions
New Member Nanette White, THRU RN
Regina Fink filling in this month for Melanie Sandoval
Nanette not able to attend this months
meeting. She will be introduced at the
next scheduled meeting.

SharePoint Website
for Policies &
Procedures How
Posting of Policies will
be Affected
Policies & Procedures for Memorial and Poudre have been converted
to SharePoint. Centrals conversion has been temporarily delayed
due to internal links to policies within various computer systems.
Co-Chair will provide updated status
report when available.

Previous Month
Meeting Minutes
Review & Approve Previous Month Meeting Minutes

Assign who will complete tip sheet for current meeting
June Minutes Approved

Shannon Johnson-Bortolotto will
compose Take back tips.


Take back tips to be posted on
PPPPC Resources HUB page
POLICY
Adult Enteral Feeding
and Tube
Management
Jennifer Beams
Formally: Adult Enteral Tube Feeding
Situation: The Adult Enteral Tube Feeding policy is regularly
accessed by nurses who are seeking policies and procedures
regarding the placement, management, and removal of tube
feeds. Those components are not included in any existing hospital
policies; instead nurses are referred to a manual which is not
available or is out of date on many floors. Gastric lavage is another
practice which is ordered and performed in the hospital which does
not have a policy or procedure to guide practice. The nasal bridle is
currently used and has a guideline for its use.
Approved with changes

Convert to new template.
Add to accountability tube feedings
and tube management
Table of contents needs to be
reordered / renumbered
I.B.10 document securement device
I.12 clarify wording related to
confirmation of placement


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 5
Background: This policy was updated in the Fall of 2013; however,
many areas integral to nursing practice, as listed above, were not
updated during that time. During a review of existing policies,
procedures and guidelines that are related, it was determined by the
nurse educators that the Nasal Bridle Guideline should be
incorporated into the Adult Enteral Tube Feeding policy. This
guideline is currently used by ICU nurses who are trained in the use
of nasal bridles.
Assessment: Based on searches which are frequently made by
nurses seeking policies and procedures to guide their practice, it was
determined that significant updates needed to be made to provide
evidence to inform current practice.
Recommendation: We recommend the incorporation of procedures
for the placement and removal of nasogastric tubes, gastric lavage,
and the nasal bridle. Robin Saucier and the Nutrition Committee
revised some of the language in the open vs closed system tube
feeding areas following implementation of closed system tube
feeds. Additionally, we recommend changing the name of the policy
to Adult Enteral Feeding and Tube Management to reflect the robust
changes made to the policy.
In addition to these changes, we are still in the process of receiving
approval to use a feeding tube attachment device at UC Central as
well as approval to utilize the nasal bridle in all inpatient areas as
opposed to just using it in the ICU. These two changes are in the
process of being approved by the Clinical Products Committee.
As the changes already made to this policy are integral to nursing
practice, it is the recommendation of myself, Robin Saucier, and the
Nurse Educator Council that we submit this policy for approval as it
stands, with the understanding that we will submit for a revision
once the feeding tube attachment device and the nasal bridle for
floor use have been approved.
I.A.5 remove lubricant / second
sentence
I.B.5 add do not use additional
lubricant; refer to package insert
I.A.14 define Salem sump in
definition section; add attach
reflux valve
III.B.1 consider wording related to
the fact that monitoring should be
appropriate for level of care.
Remove #1. Insert monitoring for
large volume. Include
temperature in vital signs.
Review transport policy to see if it
needs to be listed as related policy
Work with Christine King regarding
related resources / Epic dashboard
IV.E put in securement device
VIII.C do not should be changed
to not advised for administration
via enteral tube
VIII.E should not to be changed to
never crush EC tabs
X.B clean up trained language
Update TRIP sheet to reflect practice
changes

Keywords to be used:
Nasogastric, dobhoff, bridal, gastric
lavage

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 3 of 5
Donation After
Circulatory Death
Kerri Jeppson
Formally: Donation After Cardiac Death
Situation: Donation after cardiac death needed to be updated
Background: Term change to donation after circulatory death,
reference updated, CRS updated, terms updated to fit EMR, added
statement for neuro awake patients, added pertinent policies,
eliminated 2 appendixes, changed pronouncement of death to 2 min
instead of a range of 2-5min.
Assessment: Read proposed changes and offer comments
Recommendation: Approve changes
Approved with changes

Name change and added decision
making capability
Updated references
Need to update to new format
V.A. paralytics remove per end of
life policy. Discuss with MD if 4/4
training is not obtained.
EMR changes to EHR (II.C)
III.A add additional criteria for
calling donor alliance
Use APA formatting
Needs LOEs (work with Regina Fink)
IV.A drugs administration

Keywords to be used:
DCD, Cardiac Death, Donor, End of Life,
Withdrawal

6mo Follow-up: No

Patient Controlled
Analgesia (PCA): Adult
and Pediatric Aurora
Davis
Situation: University of Colorado Health has made several changes to
PCA practice since the last time the policy was updated.
Background: The last PCA Policy update was January, 2011.
Assessment: Current practice changes include the use of the EPIC
electronic medical record system and electronic physician order
entry, the use of new Alaris PCA pumps with accompanying standard
drug dose changes, the increased use of subcutaneous PCA infusions,
and the use of a new sedation scale.
Recommendation: The PCA policy has been updated to reflect all
current practice changes.
Approved with changes

Need to update to new template
EHR terminology must be used
Accountability #3 change level of
care (not change in unit);
accountability #4 spell out PACU for
first use
II.B PCU, CAD, LVP
II.M. add #5 to match empty
syringe; full to match documentation


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 5
II.B.3 specify which policy or use
langue pre manufacturer guidelines
/ recommendations.
Reference #7 needs revisions

Keywords to be used:
Subcutaneous, opioid sedation, Alaris

6mo Follow-up: No
PROCESS
Policy Template
Change Shelly Limon
Members reviewed the new template format. New format posted on the HUB. Policies
currently in review will cut/paste content
into this new format.
Shelly Limon requesting time
on manager/ educator council
meetings to review new
changes.
Overall Policy Process
Shannon Johnson-
Bortolotto, Robin
Scott, Barb Wenger
Shannon, Robin and Barb created a step by step process to help staff
revise and create a policy. Member feedback solicited.
Shannon agreed to modify the template
and send back out to members for final
approval.
Step by step instructions will
be posted on the PPPPC
website once approved.
APA Formatting
Guidelines
Temporary
Replacement
Document Posted on
the HUB Shelly
Limon
Questions raised about the content on the APA resources provided
on the PPPPC website. Tonya modified the document slightly to re-
form the look of the form. Joanne Delmonte approved the changes.
The nurse research scientists reviewing
materials on the PPPPC HUB.


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

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 5
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.