Download June edition of Hot Tips

Volume 2, Issue 5
“Hot Tips” is brought to you by the
Child Health nurse educator teamBecky Conway
[email protected]
Tracey Bruce
[email protected]
Office phone ext: 88225
P
is for procedural preparation
Anyone who works with children
in healthcare knows that procedural preparation is incredibly
important. The medical and
nursing things that we do to children when they come to our clinics and hospital departments can
affect how they respond to
healthcare in in the future.
Newsletter from the Child Health Nurse Educators
Outcomes
Children who have are exposed
to poorly managed and painful
healthcare procedures are more
likely to demonstrate increased
pain perception, increased pain
behaviours and medical fear in
later life. Poorly managed pain
can also lead to sleep disturbances, reduced mobility, respiratory complications, and longer
hospital stays.
For this reason, procedural preparation is big business in Child
Health and it includes a
combination approach including using the right
words, engaging the caregiver, play, demonstration,
distraction and quite often
local anaesthetic creams.
and cannulation, things are about
to change. Not only will Emla®
be replaced with a product called
LMX4® at this hospital in midJune, but a new product called
Coolsense will be rolled out in mid
-July. LMX4® does the same job
as Emla® for a fraction of the
cost. Coolsense is differnet again.
You can read all about these new
products inside this issue.
Safe medication process and
practice
Medication safety is a frequent
Hot Tips topic. Inside this issue
are tips on preventing distractions
for prescribers and tips for keeping your skills training for emeds
alive while we await the Child
Health Emeds roll out in midAugust. There are also articles on
the new Child health standing orders and single check medications. It is very important that
A change in creams
After many years of using
Emla® cream as the go-to
product for venepuncture
Inside this issue:
CoolSense
LMX4—what’s this?
MedChart—coming your way soon
Single check medications
Siting local anaesthetic creams
Quick Tips
HealthLearn Update
2-3
5
6
8
10
11
12
P is for procedures and preparation—continued
you know which medications have a standing order and the circumstances in which it is ok to single check a medication for a child.
What we do now affects their futures
In last week’s Press the first article in a series on
the world-renowned Dunedin Multidisciplinary
Health and Development Study was published.
This study follows a cohort of over 1000 children
born in 1972 at Dunedin’s Queen Mary hospital.
These individuals are perhaps now the most
studied beings on the planet, and the results are
fascinating. The study has a lot of evidence
which demonstrates the lifelong impact of early
childhood experiences. It doesn’t take too many
guesses to to surmise that early healthcare experience affect later life. As healthcare professionals
working with children, we always need to be mindful of the impact we are having on their future development.
The series is well worth a look. A supporting documentary called “Why Am I” on TVNZ (Tuesdays at
9:30pm or TVNZ on demand) looks to be a fascinating watch.
-Becky
No pain, more gain: CoolSense Pain Numbing Applicator
Rachel Wilson, CNS, CHOC
“We recognise that consumers have a unique and essential perspective of health services and are able to
provide important information about the experience of
care they receive. By working in partnership, we will be
able to improve their experience of care, as well as
their health and well-being.”
for painful procedures
Preparation
mal effect at a cost of $9.00 per 5g single use tube.
The time delay for the anaesthetic cream to become effective has some disadvantages. The application of the cream can provoke further anxiety for
children around the procedure as they have more
time to anticipate what is about to happen to them.
Additionally the delay is not always clinically appropriate; children may be very ill requiring fluids or
medication intravenously so the cream may only be
applied for a short period of time. This can lead to
ineffective numbing of the skin resulting in a painful
experience for the child.
Across Child Health, children experience a number
of painful procedures including the placement of
intravenous (IV) needles, which many children
are deeply fearful of. Thus anxiety increases
making further interventions increasingly difficult.
Commonly topical anaesthetic creams are used to
numb the site of injection. This intervention has
CoolSense
its own complications including side effects like
rashes, welts or vascular constriction. One topical The CoolSense Pain Numbing Applicator is a device
anaesthetic, Emla cream takes an hour for optioriginally developed and used for cosmetic procePage 2
H O T T I PS F O R J U N E 2 0 1 6
No pain, more gain:
continued
dures. CoolSense is a hand-held pain numbing
device that acts upon application, without chemicals, to cool and numb the site of injection. Post
application, it takes only ten seconds to work
before the injection can then be administered. It
is simple, allergen free and immediate.
The Royal Children’s Hospital Melbourne Medical
Imaging team have successfully performed over
5000 cannulations using the device with overwhelming positive feedback from patients who
reported radically reduced sensations of pain
with IV insertion.
Trial in CHOC
The Children’s Haematology and Oncology Centre (CHOC) have been trialling the CoolSense
device for blood collection (venepuncture), accessing Implantable ports (Central venous access devices) and for subcutaneous injections
(like G-CSF + Clexane). The CoolSense device is
fast becoming known as the ‘Magic Wand’ for a
lot of children who frequent CHOC for treatment.
“The Magic Wand worked really well on
me because it numbed the area straight
away which meant I didn't need to remember to put numbing cream on and hour before, it was also really good when the needle went in because it didn't hurt as much
as it usually would. One thing I could add
is it needs some bling - some sparkles or
stickers on the handle because it's called a
‘magic wand’. “– Nikhita
cause it numbed the area straight away which meant
I didn't need to remember to put numbing cream on
and hour before, it was also really good when the
needle went in because it didn't hurt as much as it
usually would. One thing I could add is it needs some
bling - some sparkles or stickers on the handle because it's called a ‘magic wand’. – Nikhita
It’s just one ‘amazing’ gadget. Easy to use, instant,
no mess, and no need to remember to put Emla
The children and families have reported benefits cream on an hour before! My daughter Nikhita only
including more effective numbing of the IV site felt a slight prick, no more screaming Yeah!
–
and reduced waiting times.
Anita, Nikhita’s Mum
What do our consumers have to say?
Jock hasn't for a very long time, used emla, before a blood test, because he said it never made
a difference. When asked to use the ‘Magic
wand’, he thought he would give it a go. He
said it was really quick and easy, not threatening in anyway, numbed the area and he felt no
pain whatsoever. It WORKED! Not like emla! He
raved about the wand when he was telling Pete
on the phone. In Jocks words, "It was bloody
fantastic!!” – Sarah, Mum of Jock
A better experience
The Magic Wand worked really well on me be-
The cost of the CoolSense Device is $160 NZD which
comes with an alcohol cartridge that yields 350+ uses. Replacement cartridges are $60 NZD for a box of
2, again each cartridge yields 350 + uses. Using the
device as an alternative to emla cream will potentially result in a cost saving to the CDHB of $8780 per
1000 + applications.
In Jocks words, "“It was bloody fantastic!!”
V O L U M E 2, I S S U E 5
The introduction of the CoolSense product has produced a better experience for CHOC patients and
families by reducing pain associated with treatment,
which is vital in preventing future issues related to
needle placement. There is a plan to expand the use
of the product to other areas where children have
the same/similar type procedures across the CDHB.
Saving precious money in our health system
Page 3
Tips for setting up your VDI computer desktop to have
everything you need at your fingertips
Finding where resources and documents are
kept on the intranet and internet for use in clinical situations or for training and development
is a very important part of day-t-day clinical
work. Now that most computers we use have
VDI access, it is possible to set up your computer desk-top with shortcuts to the sites that
you need to access quickly and frequently.
Other nice-to-have shortcuts
Recently, the commencement of an insulin infusion was delayed in part because staff had difficulty finding the correct form for the infusion (it
could be found in e-guidelines under paediatric
infusion charts). This could have had serious
consequences for the child.
Setting up shortcuts is easy: find the website
you are looking for; open it up; right click on
the page and click on ‘create shortcut’
Here is a list of shortcuts that you should have
set up on your own VDI accessed desktop to
give you the best access to everyday resources:

New Zealand Child health nursing knowledge
and skills framework

NZNO

Nursing Council of New Zealand

College of Child and Youth Nurses

Paediatric Society of New Zealand

Office of the Commissioner for Children
You will also have favourites of your own depending on what clinical champion portfolios you have
e.g. infection prevention and control, IV Link,
RT2C, CPR etc.
Next time you have a spare moment in front of
your screen, get your shortcuts sorted. You will
find it much easier to find the resources you need
and you’ll have the world at your fingertips!
Clinical shortcuts

Clinical resources (new standing orders
are in here)

E-guidelines (includes special infusion
sheets)

New Zealand Formulary for Children

Health Connect South

PMS

Lippincott

Patient information leaflets
Educational shortcuts

HealthLearn

Child Health nursing education website

Professional Development Unit

Nurse Entry to Practice Programme, NetP

PDRP

Post graduate Nursing Education

Emeds training site
Page 4
H O T T I PS F O R J U N E 2 0 1 6
Newsflash: LMX4® replaces Emla® cream.
What is it?
LMX4® is a topical anaesthetic cream containing
lidocaine 4%.
Cost
Child Health spends an astounding $15000$20000 per year on topical anaesthetic cream.
For as long as I have worked in Paediatrics, Emla® has been the cream of choice with Ametop® used only sometimes. LMX4® is going to
replace Emla® on our medication room shelves
from mid-June because simply speaking, it does
the same job for a lot less cost. Ametop® and
Emla® patches will still be available. LMX4® is
a multi-use tube where Emla® is single use
tube.
Education
Education on the use of LMX4®will be starting
from Monday June 30th and will continue until
roll-out time.
It’s really important to understand:
Implications for elsewhere
LMX4® will also be used everywhere in the hospital that children are likely to have painful procedures: Anaesthetics, Day Surgery, OOPD, Radiology, DSA, PACU, ED, ICU, Oral Health. It will also be
used in adult areas.

requirements for storage,
CoolSense

how much to use especially for infants in
comparison to older children,

where to put it,

peak effect,
The introduction of CoolSense in July will actually
significantly reduce our use of topical anaesthetic
cream. However, there will most likely always be
situations where an alternative is preferred by the
child or desirable for some other reason.

how long you can leave it and side effects
Further information
Education sessions will be held from 1430 in the
ground floor Riverside meeting room between
wards 21 and 22
If you can’t get to the education sessions you can
find information in the following locations:

Child Health Nursing education website
Start using in wards

NZ Formulary for Children
You will get supplies of LMX4® from Monday
June 13th.

Child Health Medication Standing orders, under topical local anaesthetics
Remember the standing order
The new standing orders include the use of
LMX4. Just like Emla®, LMX4® is a drug and
should be prescribed, even if the prescribing has
to happen after it is applied – that’s why we
have the standing order. You don’t have to delay a procedure getting it charted, but you do
have to make sure the prescribing happens
within 72 hours.
V O L U M E 2, I S S U E 5
Page 5
Countdown to MedChart roll-out in Child Health
Practice tips in MedChart for June
al patients.
August
Many of you have now received your initial
MedChart training. The catch is to remember
what you learned between now and go-live
month.
E-meds rolls out in the last two weeks of August, so start collecting questions that you
might have gathered during your solo practice sessions.
In last month’s Hot Tips we made some suggestions about how you can maintain your
skills.
To practice, go to the Emeds training site.
You can find this on the intranet through the
nursing information link.
Use one of the practice user and password
combinations in ward 5. In ward 5 there are
many “virtual patients” with big drug lists.
You can practice on any one of them. You
can use another practice password combination for the drugs where you need a second
checker.
June
Log in twice a shift if you can. Select a patient and practice giving medications that are
due. Try giving ondansetron 4 mg, then go
back in and give a further 4 mg inserting a
note that the patient was still nauseated.
Other things you can try is delaying an IV
medication because a luer has tissued, withhold digoxin, or give actrapid in a sliding
scale.
July
Try and log in 3-4 times per shift as time
permits, and give medications to 3 or 4 virtuPage 6
H O T T I PS F O R J U N E 2 0 1 6
Preventing harm: how can we stop prescribers from being distracted or interrupted
during critical tasks?
This article is written in response to some reported
errors which were made during the prescribing
phase of medication process. In these instances,
distraction and interruptions were contributing factors to the errors.

Tell others that their behaviour is distracting
– in the moment feedback

Make written lists for non-urgent prescribing
tasks
Reducing errors during the preparation phase
by shutting the medication room door is now
well understood in the department. However,
how often do we think about reducing prescriber interruptions. Like most aspects of medication safety, this requires effort from teams and
individuals.

Keep chatter away from areas where prescribing occurs

Change behaviour – go to a quiet place
What sorts of behavior can you change to reduce prescribing errors?

Tell others that their behaviour is distracting
– in the moment feedback
Nurse

Suggest that non-urgent prescribing requests are logged on a written list

Change behaviour - don’t interrupt

Role model non-interrupting behaviour
Prescriber
If you can think of anything else, we’d really like
to know. Please drop us a line.
Watching movies at work? What are your obligations to the organisation?
Chris Dever, GM, Information Services Group
When a staff member recently downloaded Zoolander2 via staff Wifi using their work IP address, the DHB was given a warning by Paramount Pictures.
All staff have obligations regarding appropriate use of the internet. This reminder follows
a warning being issued by Paramount Pictures to Canterbury DHB this week after
someone with a Canterbury DHB IP address
downloaded a movie owned by Paramount
Pictures (Zoolander2) via staff Wi-Fi on a
Canterbury DHB device. This is not acceptable practice and is in breach of the agreement
every staff member signs when they join the
organisation.
Non-adherence to our Information Security
Management Policy is of serious concern to
Canterbury DHB as it could result in our entire internet being shut down.
With the provision of staff Wi-Fi, CDHB puts
trust in its employees that they will act in an
V O L U M E 2, I S S U E 5
appropriate manner. If this trust proves to
be misplaced, data-caps and other controls
will need to be imposed. In particular, using
Torrent type software to download anything
is explicitly forbidden.
Violation of the policies may be grounds for
disciplinary procedures in accordance with
the Canterbury DHB Code of Conduct and
Disciplinary Action policies.
It can also lead to revocation of system access and privileges, and to restoration of systems to which unauthorised equipment or
software has been added, to their original
state.
If you require any clarification about what is
acceptable use of the Canterbury DHB internet and Wi-Fi talk to your manager in the
first instance, or contact [email protected]
Page 7
Single Check Medications Child Health Service
You will be aware of the new guideline for singlechecking medications in Child Health. Many clinical areas claim to double check EVERY single
medication they give to children. We have taken
the approach that if double checking is to be
done properly (without interruptions, independently and with both nurses present from beginning to the end of the process) that we could
make some exceptions.
What does this mean for nurses in clinical
practice?
When you are new to Child Health nursing you
need to double check EVERY MEDICATION, every
time. This includes new employees, nurses sent
to Child Health for the day, pool nurses, casual
nurses. If you are an experienced nurse in say,
ward 21, and you are sent to another ward like
CHOC for a shift, you may also find yourself
needing to double check medications (e.g. fluconazole) if you are not already familiar with it.
As experienced clinical staff, you need to make
yourself available to double check medications
with other staff. Even if it is a single check medication, if the nurse is unfamiliar with it that medication should be double checked
tion in the administration screen
NB—Any medication that requires reconstitution should be double checking at the preparation stage-e.g. powdered oral antibiotics.
Current list of medications for single
check:
Oral preparations
Acyclovir
AntibioticsBonjela
Chlorhexidine mouthwash
Diclofenac
Difflam spray
Fluconazole
Gaviscon
Ibuprofen
Laxatives: Lactulose, Movicol, Senekot, Coloxyl, Liquid
paraffin. Pico-prep, Klean-prep
Mylanta
Nicotine lozenges, gum
What can be single checked?
Nystatin
Only items on this list may be single checked for
paediatric patients. All other medications and
routes of administration require double independent checking.
Omeprazole
How do I know I am OK to single check the
approved medications?
Pancreatic Enzymes
Nurses must be approved by their CNM and have
completed the following online learning before
they are able to single check medications on this
list:
Sucrose
Ondansetron
Oral rehydration solution
Paracetamol-max 15mg/kg dosing
Vitamin supplements

Guardrails
Inhaled medications

Paediatric IV care

Medication safety
inhaled and nebulised medications may be single
checked :
Exception nebulised Adrenaline
Rectal preparations
If not approved the nurse must ensure that all
medications they administer are double checked.
Note: If using ePA (electronic prescribing & administration) systems the name of the second
checker must be included in the comments sec-
Page 8
Glycerine suppositories, Microlax enema
Topical creams, ointments and patches –may be
single checked:
Exception of topical chemotherapeutic agents or
controlled drugs.
H O T T I PS F O R J U N E 2 0 1 6
Important memo from radiology department for clinical areas
who use 4 french single Lumen PICCs -Pip Francis, DSA
Supply issue which affects some of our
patients
There is a manufacturing supply issue involving the 4fr 4cm mini taper single lumen
PICC.
curved within the dressing window so that
the purple wings can be placed in the
small D window of the dressing to prevent
catheter migration.
How long will this last?
It is expected that the unavailability of this
PICC will continue for the next couple of
months.
The interim solution
As an interim solution the company are
providing a 4fr PICC with an 8cms taper and
when trimmed will have a 6-7 cm external
catheter length instead of the usual 3-4 cms.
This will have implications for dressing and
securement.
Securement
To prevent PICC migration when dressing
the PICC ensure that the external portion is
Out & about in Child health
Launch of the Child
Health Acceleration
Programme CHAP,
on June 1st
Tracey:
“May the
4th be with
you”
V O L U M E 2, I S S U E 5
First CHAP
participants:
Laura Lagan,
Emma Smith,
Emma Dini
Page 9
Siting local anaesthetic cream
This article is written in response to an incident
where a child who was having an intragram infusion had to have a line re-sited twice and suffered
preventable trauma because the topical anaesthetic cream was not sited appropriately.
How do you know where to site local anaesthetic creams for venepuncture and cannulation?

Know the common sites

Inspect the skin and look for veins

Consider the purpose – venepuncture
or cannulation?

If in doubt, get a second opinion form
another nursing colleague or ask the
practitioner (doctor or nurse) who will
carry out the procedure to come and
have a look
Page 10
Helpful resources


Lippincott procedures

IV catheter insertion, pediatric

Venipuncture, pediatric
Standing orders for topical anaesthetic
cream


Find this under Child Health
clinical resources on the intranet
Hospital play specialists
Always remember that proper procedural
preparation will go a long way to helping
the child cope with cannulation and venepuncture
H O T T I PS F O R J U N E 2 0 1 6
Quick Tips: a round up of what’s on and what’s hot
MMR vaccine and its administration is free for those who need it
- if in doubt, vaccinate.
Your time is precious:
Save time in Safety First
From, Ministry of Health
There have been 47 confirmed cases of measles reported in New Zealand since April, with six requiring
hospital treatment. Reported cases have been in
Waikato, Mid-Central, Nelson and Northland.
Free vaccination with two doses of MMR vaccine
should be offered to all patients born from 1 January
1969 who do not have documented evidence of two
doses of MMR vaccine.
Search electronic records for enrolled patients
(particularly those aged 10-29 years), and recall
those who have not received two doses of MMR. If
you cannot easily find records it is appropriate to go
ahead and vaccinate. There are NO safety concerns
about giving too many MMR vaccines and this is a
safer option than delaying by trying to track down
lost records
CoolSense

Is already being used in CHOC

Requires education so that it can be
effective

Will be rolled out in wards from mid
July 2016.

Rachel Wilson will coordinate education and set up each CoolSense device
throughout the department.
To speed up the process of form filling
in safety first:

Look for the little magnifying glass

Enter the patient’s NHI number &
search

Click and confirm the correct patient

Bingo! Your form will be pre-populated
with patient information
Safety first & clinical
emergencies
Did you know that Safety
1st forms are not required
to be routinely completed
in the case of a clinical
emergency. The emergency is followed up by
the CPR coordinators I
through their normal processes, the Clinical Emergency record needs
to be completed as part of this.
Safety First forms only need to be completed
if there is something else related to the incident that would require a form for example
an adverse event that preceded the emergency or if normal processes are not followed. This has been discussed and agreed
by Quality and the resus coordinators.
V O L U M E 2, I S S U E 5
Page 11
Update on HealthLearn-based education
There is an ever increasing range of education
available on HealthLearn. We are working hard
at the moment to transfer existing paper-based
self-directed learning to HealthLearn.
The push for online learning is based on its efficiency – far more people can access courses at a
time and in a place that is convenient to them,
and the feedback is instantaneous (you don’t
have to wait for your answers to be marked).
With the healp of online learning educators, we
can spread ourselves further and do more face-
to-face educating
or competency
assessment
In the table below is a list of courses that are under development and another of courses that are
actually live.
Did you know that you can print your own list of
completed HealthLearn courses? This is the evidence you may need for completing your APC paperwork, performance appraisal and PDRP.
In current use
























Falls
Pressure injury (currently offline as being updated)
Restraint
Calming and Defusing
Standing orders (community providers)
Clinical learning and teaching
Oxygen
ECG
IV theory
CVAD theory
Pain theory (need to attend workshop)
Advanced care planning
Flu HQ
Bed rail use
Deteriorating patient (theory)
Guardrails
Med admin safety
METU opioid safety
Fundamental Series: Respiratory
Safe swallowing
Tracheostomy care
Nurse/Midwife Initiated Radiology
Moving and handling
Prescribing NRT
Smokefree introduction
Under development














Fundamental series: Cardiac
Fundamentals of Nutrition
Dementia
Direction and Delegation
EVIQ for paediatric and non-cancer areas
Dermoscopy for General Practice
e-meds
e-observations
Paediatric Fluid and Electrolyte
management
Paediatric Asthma
Paediatric Nitrous oxide
Perioperative sharps safety ( awaiting approval)
Restraint for the unregulated care giver
Orthopaedics outpatients department Ponseti project
Intravenous management
Professional development, course and conferences
George Abbott Symposium 2016; Christchurch, August 19th and 20th; Christchurch; see Child
Health nursing education website education calendar for more details
Simulation Conference, Wellington; October 14-15 2016; see Child Health nursing education website education calendar for more details
College of Child and Youth Nurses Bi-annual Conference day 15 November, 2016; takes place
the day before the Paediatric Society annual Scientific meeting; Tauranga; theme – Innovate; see Child
Health nursing education website education calendar for more details
Paediatric Society of NZ Annual Scientific meeting – ‘The Science of Healing – the Art of Medicine’;
Tauranga; November 16-18, 2016; see Child Health nursing education website education calendar for
more details