2 Fountain Valley Regional Hospital Non-Employee GENERAL ORIENTATION (Nurses) PLEASE COMPLETE THE SIGNATURE PAGE AND RETURN TO: Nursing: Staffing Office Non-Nursing: Department Manager 3 I. Welcome to Fountain Valley Regional Hospital Medical Center (FVRH). II. Our Mission and Vision Our Mission: To provide world class healthcare the diverse patients of our community in an environment of compassion, competence and quality, where both physicians and staff are committed to those patients, as well as each other. Our Vision: To maintain a comprehensive range of services that meet the needs of the regional area we serve To use all of our resources to deliver outstanding care and extraordinary service to our patients while being sensitive to their cultural differences To provide opportunities for education to our physicians and staff that will assist in their professional growth and their ability to care for our patients To distinguish ourselves both through our high quality of care delivery and integrity with which we deliver it. III. Parking Policy: Parking is available at no charge in the Employee lot (See map). IV. Dress Code вЂў вЂў вЂў вЂў All employees/students are required to wear identification badges at all times while on duty. All employees/students are expected to be professional in appearance. Attire shall be modest, safe, and clean while on duty. Employee/Student appropriate attire is defined as, but not limited to the following: 1. Artificial nails, nail extenders, silk wraps or other nail overlays, or nail jewelry are not allowed for staff with direct patient contact or contact with patient care supplies and equipment. 2. Fingernails must be kept neatly trimmed, Вј inch maximum length, and clean. 3. If worn, polish will be light in color and in good repair (i.e. no chips or cracks). 4. As appropriate, hose or socks are required. 5. Closed toe shoes are required. Extreme colors, style, heel height, sandals, beach flip-flops are not acceptable. 6. Department specific dress code may be required. Sportswear such as jeans, denim pants of any colors, stretch pants, legging, shorts, walking shorts, skirts, T-shirts, sweatshirts, sleeveless shirts, bare shoulder or spaghetti strapped blouses, tank tops or sun dresses are not permitted. 7. Clothing must be modest and professional. Sheer, low cut, spandex, clinging, 4 bare or revealing clothing must not be worn. Proper undergarments must be worn at all times. 8. Long hair will be pinned up or tied back. 9. For safety reasons, it is requested that if jewelry is worn, it be conservative. Items such as earrings worn in areas other than the earlobe are considered unprofessional and not allowed. 10. Mustache and/or beards are required to be neatly trimmed. V. Smoking Policy: FVRH is вЂњsmoke freeвЂњcampus. Smoking is totally banned inside the hospital. Smoking is only permitted outside in designated smoking areas. VI. Breaks and Lunches вЂў You are allowed a ten (10) minute paid rest period for every 4 hours that you work. вЂў You are allowed thirty (30) minutes unpaid meal period per 8 hour shift. вЂў 12 hour shifts are required in certain clinical areas. Please ask your department resource for break and lunch period information. вЂў Rest period and meal breaks may not be combined. VII. Body Mechanics Вѕ All staff is expected to practice safe body mechanics. Use of ARJO lift and position assistive equipment is required. If you need equipment orientation, please ask your staff resource. Key Points to remember: Вѕ To maintain a safe and healthy working environment Fountain Valley Regional Medical Center attempts to prevent injury to employees who perform lifting as a part of their job duties. Therefore, it is crucial that all employees demonstrate safe lifting, transporting and proper back care techniques at all times. Вѕ Fountain Valley Regional Hospital and Medical Center is firmly committed to maintaining a safe and healthful working environment. To achieve this goal, we have implemented this comprehensive Injury & Illness Prevention Program. This program is designed to prevent workplace accidents, injuries, and illnesses wherever possible. Вѕ Good housekeeping is an integral part of any effective Safety Program. Keeping workplace areas neat and clean reduces the chance of accidents and injuries. Well-organized areas also increase the ability of employees to perform their jobs effectively. Each employee is responsible for keeping his or her work area neat and orderly. Вѕ All direct care employees shall function as a вЂњlift teamвЂќ by providing patient handling assistance to colleagues when needed. If an urgent or emergent 5 need has been identified by the nurse, PT or OT may provide support to nursing. Employees are encouraged to actively be involved in maintaining a safe environment by reporting any unsafe conditions to the unit supervisor Вѕ Be familiar with the general proper body mechanics and ergonomics techniques VIII. Hazardous Materials вЂў Under the "Right to Know" requirements employees working in a healthcare environment have a "Right to Know": 1. 2. 3. 4. 5. 6. What chemical hazards exist in the facility? What their exposure potential may be? What precautions have been taken to protect the employee? What "work practice controls" are in place to protect workers? What systems are in place (engineering controls) to limit exposure? What personal protective equipment has been provided? вЂў The leadership within the organization is required to: 1. Establish policies and procedures for the safe use, handling and storage of hazardous substances. 2. Orient and train staff on the potential exposure hazards and hospital policy. 3. Provide work policies & procedures for safe work practices. 4. Provide engineering controls and personal protective equipment to protect employees. 5. Monitor the compliance with use of the above. 6. Monitor the environment. Provide material safety data sheets. 7. Monitor accidents and incidents. вЂў Employees are responsible to: 1. Understand and comply with hospital polices and procedures related to hazardous material safety. 2. Use the Haz-mat spill kits when handling hazardous substances. 3. Use the Personal protective equipment provided when handling hazardous substances. 4. Report unsafe or hazardous situations. 5. Report and document accidents, incidents, exposures and spills. 6. Understand where to find and how to read Material Safety Data Sheets (MSDS). IX. Electrical Safety вЂў Personnel are responsible for knowing how to operate each piece of electrical equipment before using it. 6 вЂў вЂў вЂў вЂў вЂў вЂў X. All equipment in patient care areas must be approved by the Engineering Department of the hospital. Check power plugs and cords before turning on equipment. Any damaged equipment should not be used, tagged with the facility form, and sent for repair. If any electrical equipment вЂњlooks, smells, or sounds strangeвЂќ, disconnect the plug from power source, tag with facility form and notify engineering. Patients are not allowed to use their own electrical appliances unless battery operated. The first step to take in the event of an electrical fire or electrical shock is to disconnect the power to the equipment. Never handle electrical equipment while in contact with potential grounds water faucets, sinks, or wet areas. Fires This fire plan is based on the acronym RACE, which is easy to remember: RвЂ“ Remove AвЂ“ Activate Alarm CвЂ“ Confine the Fire EвЂ“ Extinguish or Evacuate the area if not safe (behind smoke barriers) For use of the fire extinguisher use the acronym PASS: PвЂ“ Pull the Pin AвЂ“ Aim SвЂ“ Squeeze SвЂ“ Sweep вЂў вЂў вЂў вЂў вЂў вЂў Do no use elevators in the event of fire. Keep hallways clear (place equipment only on one side of the hallway) Do not block exits, fire alarms or prop doors open Do not store supplies or boxes on the floor Keep items on top shelves at least 18 inches from the ceiling. Fires are classified according to the material that is burning. Fire extinguishers are coded to reflect the type of fire they can put out. The classifications are: Class A: Ordinary combustible material, such as paper, cloth, wood and some plastics. Class B: Liquids, oil and gases. Class C: Electrical, such as live energized electrical equipment. Class ABC: Extinguishes all types of fires *It is required to know the location of the closest fire extinguisher, fire alarm pull, and exits in your work area. 7 XI. Life Safety Measures вЂў вЂў In the event you are directed to conduct a partial or total building evacuation know where your designated evacuation location is on the exterior of the building. The priority of patient evacuation is as follows: 1. Any in immediate danger. 2. Ambulatory patients. 3. Semi-ambulatory patients. 4. Non-ambulatory patients. Disaster Manuals are located in each work area for reference. 8 Code What it Means What to do Considerations CODE RED Fire, Smoke or Rescue those in immediate danger Alarm the Alarm & Pull Alarm Contain the Fire, Close Doors Extinguish the Fire, if safe to do so If not responding, close doors, assume the responsibilities of those that responded, remain alert listen for more information. If not responding, take over the responsibilities of the personnel that responded to the Code Burning Smell CODE BLUE Adult Emergency Assess the Patient, call for help, initiate CPR CODE WHITE Pediatric Emergency Under 18 yrs of age Assess the Patient, call for help, initiate CPR CODE PINK Infant Abduction less than 1 month of age Personnel go to nearest point of entry & stop all traffic. Maintain at least one person per door, age of missing infant will be announced CODE PURPLE Infant/Child Abduction Personnel go to nearest point of entry & stop all traffic. Maintain at least one person per door, age of missing child will be announced CODE YELLOW Bomb Threat Keep caller on phone, obtain information about bomb location, description, when it will go off, why it was placed, listen for background noises All personnel follow directions of the lead person in charge until All Clear is announced CODE GRAY Combative Person If not responding, take over the responsibilities of the personnel that responded to the Code Security All staff trained in AB508 report to location paged, assist with de-escalation or with restraint if necessary CODE ORANGE Haz Mat Spill /Release Contain Spill Wear personal protective equipment Seek medical treatment if necessary CODE SILVER Person with Weapon / Hostage RAPID RESPONSE Patient with Deteriorating condition CODE TRIAGE I & II Internal or External Disaster Secure yourself & others, Dial 5555 give location, hostages, suspects & weapon DO NOT RESPOND Call 5555, and state Rapid Response Team to Room---Know the criteria for activation Use SBAR To communicate patientвЂ™s condition to the team Department Directors report to Command Center, get briefing & report unit status (census / staff on duty), personnel without assigned duties & If not responding, take over the responsibilities of the personnel that responded to the Code If not responding, take over the responsibilities of the personnel that responded to the Code If not responding, take over the responsibilities of the personnel that responded to the Code All personnel follow directions of the lead person in charge until All Clear is announced All personnel remain in secured area until Police evacuation. Do not enter effected location Do Not leave the room when team arrives Be a resource and have patients вЂ� chart ready for the team If not responding, take over the responsibilities of the personnel that responded to the Code 9 employees off duty report to personnel pool Code AMI Code Stroke Code Census Condition Help Patients with Acute Myocardial infarction Patient with possible stroke diagnosis coming to ER ER Full, Beds Needed Alerts Cath Lab, EKG, HS If not responding, take over the responsibilities of the personnel that responded to the Code CT Scan Alert, May initiate ROBOT CN to coordinate Department Directors report or call in to ED to see what help is needed , including through put If not responding, take over the responsibilities of the personnel that responded to the Code Family to activate if it is medical emergency Patient or family calls 4357 (HELP) Rapid Response Team Responds to the room after operator calls it Do Not leave the room when team arrives Be a resource and have patients вЂ� chart ready for the team 10 XII. Guidelines for Infection Control вЂў These guidelines are intended to protect patients and healthcare providers from potential exposure to communicable disease. The Infection Control Manual provides extensive additional information. вЂў TWO BASIC TEIRS OR PRECAUTIONS: Вѕ Standard Вѕ Transmission Based вЂў STANDARD PRECAUTIONS are designed to reduce the transmission of blood borne pathogens. вЂў STANDARD PRECAUTIONS apply to: Blood, all body fluids, secretions and excretions (except sweat), regardless of whether or not they contain visible blood. Exposure is through: Вѕ Non-intact skin Вѕ Mucus membranes вЂў Вѕ Вѕ Вѕ TRANSMISSION BASED PRECAUTIONS apply to: Airborne Droplet Contact OVERVIEW OF ISOLATION GUIDELINES Precautions When Used Standard Some Examples of Disease All patients All patients All blood, body fluids, secretions, excretions (except sweat) and contaminated items.Non-intact skin mucous membranes Airborne Instructions Use barrier precautions as needed to prevent contact with blood, body fluids, excretions, secretions, and contaminated items. Wash hands before and after contact or glove use. Wash hands and change gloves between patients. Take care to prevent injuries when using sharps. Dispose of properly. Transmission Based Precautions In Addition To Standard Precautions Private room, negative air pressure, door closed. N95 Measles, Respirator, mask on patient Spread by droplet nuclei particle Chicken Pox, during transport. Tuberculosis Droplet Spread by droplets Meningitis, Diphtheria, Myocoplasma Pneumonia, Influenza, Mumps, Rubella Private room if possible, wear mask, within 3 feet of patient, limit transport, surgical mask on patient during transport. 11 Contact Spread by contact with intact skin or surfaces XIII. Resistant bacteria like MRSA, VRE, Herpes simplex, highly contagious skin infections , C. difficile (infectious diarrhea) Private room, wear gloves. Avoid contamination of hands. Wear gown. Limit transport. Dedicate use of patient care equipment to a single patient. Safety/Risk Management/Occurrence Reporting вЂў Report the following to your department resource: 1. Defective or damaged equipment. 2. Injuries to self, staff, visitors, patients. 3. вЂњSentinel EventвЂќ Any unexpected occurrence involving death or serious physical or psychological injury. 4. вЂњNear MissвЂќ defined as any process variation which did not affect the outcome, but for which a recurrence caries a serious adverse outcome. вЂњA close call.вЂќ 5. Hazardous Condition-Any set of circumstances which significantly increases the likelihood of a serious adverse outcome. XIV. Core Measures The Joint Commission (TJC) requires accredited hospitals to collect and submit performance data. This requirement was established to improve the safety and quality of care and to support performance improvement in hospitals. The Core Measure initiative allows JCAHO to review data trends and to work with hospitals as they use the information to improve patient care. At FVRH we have chosen as our Core Measures: 1. Acute Myocardial Infarction 2. Community Acquired Pneumonia 3. Congestive Heart Failure 4. Coronary Artery Bypass Graft 5. Surgical Site Infection Prevention Patients with a вЂњcore measureвЂќ diagnosis have clinical pathways and protocols. Your department resource will provide you with specific information and criteria. AMI : Acute Myocardial Infarction 9 ASA within 24 hours: From arrival at facility door to Aspirin administration 9 EKG within 10 minutes: From arrival at facility door to EKG interpretation by MD 9 Door to Balloon within 90 minutes: From arrival at facility door to device deployment 12 9 LDL Assessment: Anytime during hospitalization 9 DC Medications: Prescribe Beta-Blocker, ASA, ACEI or ARB for LVSD, and lipid lowering agent for LDL>100. 9 Smoking Cessation: Counseling & resources if smoked cigarette within 12 months of admit 9 Patient Education: Cardiac risk factor reduction and monitored Cardiac CAP: Community Acquire Pneumonia 9 Chest X-Ray: Pneumonia confirmed by chest x-ray interpretation 9 Blood Culture: IF ORDERED: Draw Blood Cultures prior to 1st dose of antibiotic medication 9 Blood Culture: To be drawn within 24 hrs when pt. admitted or transferred to ICU within 24 hrs of hospital arrival. 9 Antibiotics: Prescribe per ISDA guidelines. IV ABX converted to oral med when tolerating Pos 9 Pneumonia Vaccination & Flu Immunization: Educate & administer unless contraindicated CHF: Congestive Heart Failure 9 LVEF Assessment: Before arrival, at hospital, or planned for after discharge 9 DC Medications: Prescribe ACEI/ARB at discharge from the hospital if LVEF is less than 40%. 9 Smoking Cessation: Counseling & resources if smoked cigarette within 12 months of admit 9 Patient Education: Discharge Instructions в™ҐActivity Level в™ҐDiet в™ҐDischarge medications в™ҐWeight monitoring в™ҐFollow-up appointmentIncluding date and time of first appointment в™ҐWhat to do if symptoms worsen CABG: Coronary Artery Bypass Graft 9 Pre-induction heart rate<=80 9 Peri-operative use of aspirin 48hrs pre-op to 48hrs post-op 9 Pre-operative glucose=140mg/dl 9 ACC/AHA Appropriateness Class Documented 9 Beta Blockers Used within 24 hours prior to surgery 9 Post-operative extubation in<=12 hours 9 Post-operative ICU/CCU stay of <=36 hours 9 Aspirin, Beta Blockers, Ace/ARB for LVSD, and lipid lowering agents prescribed at discharge 13 SCIP: Surgical Care Improvement Program 9 Antibiotic received within 1hour of incision 9 Discontinuations of all Antibiotics within 24 hours post operatively, unless there is documentation of infection. 48 hrs for cardiac. 9 Glucose level < 200 in cardiac patients. 9 Hair removal NO RAZORS 9 Normothermia immediately post-op 9 If on a beta blocker, given within 24hrs. Pre-op and given by the end of POD 2. 9 VTE prevention ordered and implemented within 24hrs. 9 Urinary Catheter removal by the end of POD 2 XV. National Patient Safety Goals 2012 NPSG 1 - Improve the accuracy of patient identification 01.01.01 - Use at least two patient identifiers (neither to be patient's room number) - Prior to specimen collection, medication administration, transfusion or treatment. We utilize the patientвЂ™s name and the patientвЂ™s DOB (both of which are located on the patient identification band). At FV, the third Identifier is the MR # which is used for infants or if patientвЂ™s name and DOB are the same. Use two identifiers when administrating medications, blood components, collecting blood and other specimens, and when providing treatments or procedures 01.03.01 - Eliminate Transfusion errors related to patient misidentification - before initiating blood/blood components for transfusion, the patient is matched to the blood/blood components; match the blood or blood component to the order, match the patient to the blood or blood component; use a two-person bedside verification process One of the two-person verification team must be qualified to perform the transfusion (i.e., a Registered Nurse) The second person on the verification team must be qualified to participate in the process (i.e., Registered Nurse or Licensed Vocational Nurse or MD) Also at FV, one of the people verifying must be RN on the staff, two registry personnel cannot verify the process. NPSG 2 вЂ“ Improve the effectiveness of communication among caregivers 02.03.01 - Report critical results of tests and diagnostic procedures on a timely basis The objective is to provide the responsible caregiver these results within an established timeframe. FVRH has established a 60 minute timeframe. Report critical results of tests and diagnostic procedures in a timely basis. 14 NPSG 3 - Improve the safety of using medications 3.04.01 - Label all medications, medication containers (For example: syringes, medicine cups, basins) or other solutions on and off the sterile field 3.05.01 - Reduce the likelihood of patient harm associated with the use of anticoagulation therapy; use only oral unit-dose products, prefilled syringes or premixed infusion bags; before starting warfarin assess baseline coagulation status Program is implemented house wide at FV. Accomplished through patient and family education, dietary interactions, and accurate and timely lab results. NPSG 7 - Reduce the risk of health care вЂ“associated infections 07.01.01 - Comply with the current CDC hand Hygiene guidelines. At FV we follow CDC guidelines, there are set goals for improving the compliance with the hand hygiene guidelines. Audits are done monthly. Staff teaching is done during orientation and annual reorientation at minimum Good hand hygiene: Not visibly soiled, waterless hand rubs. Visibly soiled, soap & water. C. Diff requires soap and water hand hygiene. No artificial nails will be worn by anyone providing direct patient care. NPSG 7 - Reduce the risk of health care вЂ“associated infections 07.03.01 - Implementation of guidelines to prevent multi-drug resistant organisms; see Guidelines for Infection Control 07.04.01 - Implement evidence based practices to prevent of central line associated bloodstream infections Implement evidenced-based medicine (EBM) practices to prevent central line-associated bloodstream infections. Central line Bundle is implemented at FV 07.05.01 - Prevention of surgical site infections - Implement evidencedbased medicine (EBM) practices for preventing surgical site infection вЂ“ refer to SCIPS protocol 07.06.01- Implement evidence based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI) Implement evidenced-based medicine (EBM) practices, CAUTI bundle is implemented at FV NPSG 15 - The hospital identifies safety risk inherent in its patient population 15.01.01 - Identification of patients that are likely to harm themselves, suicide risk. We provide one-on-one supervision and referral to these individuals as necessary. UNIVERSAL PROTOCOL - Eliminate wrong site, wrong patient, and wrong procedure/ surgery. UP 01.01.01 - Conduct a pre procedure verification process Pre-op verification process / checklist, availability of appropriate documents. Consent is completed & signed, risk/ benefits/ alternatives 15 are explained, H&P and Pre op VS are done, and all documents/special equipment/implants are available. UP 01.02.01 - Mark the procedure site Marking the surgical site, which involves the patient. Required for all cases, вЂњYESвЂќ is marked with a permanent marker in an area that will be visible after draping. UP 01.03.01 - A time-out is performed before the procedure Conduct a вЂњtime-outвЂќ immediately before starting the procedure FVRH NPSG Requirement Implementation of applicable NPSGвЂ™s and associated requirements by competent and practitioners sites Staff is informed about NPSGвЂ™s during general orientation and ongoing Nursing orientation and department specific orientation also includes info about NPSGвЂ™s All department directors quiz staff on rounds about NPSGвЂ™s Staff is reeducated on NPSGs during safety fair and on going education XVI. Sentinel Event Any serious occurrence or unanticipated event that causes serious physical or psychological injury, death, or the risk thereof is termed a sentinel event. An occurrence that may be a sentinel event should be reported to your manager/director immediately as well as to the Administrative Supervisor. When notified, the Risk Manager and Administration will take further action which may include performing a root cause analysis, mandatory reporting to the State of California, and a corrective plan of action. XVII. Patient Rights A copy of these rights and responsibilities is given to all patients and posted in the facility. This information is also included in patient handbook that patient receives at admission. These rights include: 9 9 9 9 9 9 9 9 9 9 9 Access to Care Hospital Charges Advance Directives Hospital Rules and Regulations Communication Identity Complaints & Conflict Resolution Information Consent Pain Management Consultation 16 9 9 9 9 9 9 9 9 Personal Safety Dying/Grieving Process Privacy and confidentiality Ethical Issues Refusal or Acceptance of Treatment Experimental Drugs/Devices/Clinical Respect and Dignity Trials Transfer and Continuity of Care Patient responsibilities: 9 9 9 9 9 Provide accurate, complete information Follow treatment plan; comply with instructions Accept responsibility if treatment refused Financial obligations Follow hospital rules; be considerate of others Patients have the right to register complaints without fear of retribution, to have their complaints investigated and resolved, and be provided with timely follow up. Furthermore, a patient complaint will not compromise continued care or access to care in the future. Additionally, patients and employees alike have the right to report concerns they may have about safety or quality of care provided in the hospital and may report these concerns to the Joint Commission. The hospital will take no disciplinary action if an employee or patient reports safety or quality of care concerns to the Joint Commission See the Administration Manual for the complete policy and procedure titled: Patient Rights and Responsibility XVIII. Patient Satisfaction/Customer Service It is the goal of FVRH that every patient and customer is completely satisfied with the care and services provided. Our customers include patients, visitors, employees, and medical staff. It is our policy to follow up on patient concerns. If you should hear a patient or family member voice a concern while at FVRH, please notify your department resource immediately so the appropriate action can be take. Our approach to customer service is as follows: AIDET Acknowledge our Customers Make eye contact Smile Stop what you are doing so your customer knows he/she is important 17 Introduce Yourself Offer greeting State your name State your department Explain how you will be serving them Duration Explain how long before the treatment, procedure, test, process starts. Explain how long the activity will last. If applicable, explain the post-activity report process. Explanation Explain the treatment, procedure, test or process. Explain who is involved providing their care/service. If a clinical procedure, explain if the test will cause pain or discomfort, or if post procedure instructions are necessary. Solicit and/or offer to answer any questions, concerns. Service Recovery (ACT) Correcting and recovering when we have failed in service A: Acknowledge and/or apologize C: Correct the problem(s) ASAP T: Thank the customer for raising the issue. XIX. Population Specific Issues Healthcare providers are required to relate to their patients in age/populationappropriate ways. This is based on criteria identified for each unit and position description. XX. Forensic Services Non-employee personnel and/or contract staff receive orientation to the facility as appropriate to their role. XVIII. End of Life Issues All disciplines must comply with procedures to ensure respectful, responsive care of the dying patient. XIX. Organ/Tissue Donation All deaths are reportable for possible donation to вЂњONE LEGACYвЂќ .See hospital policy for specifics. 18 XX. Cultural Diversity FVRH recognizes the diverse cultural make-up of our local population, and seeks to accommodate each patient's cultural needs XXI. HIPAA/Patient Confidentiality All patients are entitled to have their protected medical information remain private. To accomplish this: вЂў Health information is shared on a need-to-know basis according to hospital policy. All paperwork containing patient information will be placed in the designated bins for proper disposal. IV bags have a perforated label that must be removed prior to disposal. вЂў Patient information is not shared with anyone who is not directly involved in the care of the patient. This includes family members not authorized by the patient to receive that information, other staff, and visitors. Please do not hesitate to question anyone attempting to access patient information, reading the patient's paper chart, or attempting to access an electronic record. Report anyone who is attempting to gain information to your department resource immediately. вЂў Family members and visitors are not authorized to be in the nurses' stations. вЂў No photographs may be taken in the hospital unless associated with medical/surgical related documentation (a signed Consent for Photography must be obtained). вЂў Employees, Contracted Staff, or Volunteers may not use cellular telephones to text or otherwise relay protected health information or the personal identification of patients to anyone whether they are involved with the patientвЂ™s care or not. вЂў Some patients may choose not to release their name on the general census. These patients are referred to as вЂњno informationвЂќ. The charts are labeled вЂњNo InfoвЂќ, and вЂњNo InfoвЂќ is placed on the census board instead of their name. The designation вЂњoccupiedвЂќ also delineates patients for which no information is provided outside of direct care providers. At no time should information be shared with visitors or over the phone for either of these patient categories. XXII. Moderate Sedation FVRH provides specific policies for the monitoring of patients receiving moderate sedation by the professional registered nurse and medical staff 19 during diagnostic and therapeutic procedures. Policies are available on the nursing unit and clinical department. XXIII. Pain Management All patients are entitled to pain management. Please let your department resource know immediately if your patient's pain is not well controlled. A variety of 0-10 pain scales are used based on the patient's age and cognitive status. Non-pharmaceutical pain management measures such as distraction, music, and relaxation techniques are used in addition to ordered medications. Reassessment of pain after intervention is required and must be documented. XXIV. Restraints FVRH promotes the minimal use of restraints. Restraint may be the most appropriate means of preventing patient injury. Restraints are only applied after all other alternatives have been attempted and found unsuccessful. Protocols for restraints are not used: each patient is individually assessed for the need for restraints. When restraints are applied, hospital policy and the manufacturerвЂ™s directions must be followed. Non-Violent / Non-Behavioral restraints must be renewed every 24 hours by the MD. Written orders for Violent / Behavioral restraints are limited to 4 hours for adults 18 or older; 2 hours for children 9-17; or 1 hour for children under age 9. The restrained patient must be assessed, monitored and reassessed as per hospital policy. Documentation of restraints is to be done on the Restraint Flow Sheet. Refer to the Administration Manual for the Restraint and Seclusion policy. XXV. Fall Prevention FVRH has a fall prevention program to promote patient safety. Patients are assessed using the Morse Fall Risk Scale on admission for the adult population and the Graf вЂ“ PIF Scale for the pediatric population. Yellow nonskid socks, yellow вЂњFall RiskвЂќ wristbands are placed on patients identified as вЂњAt RiskвЂќ. A magnetic вЂњSAFEвЂќ sign is placed on the doorframe of the patientвЂ™s room and yellow вЂњFall PreventionвЂќ stickers are placed on the patientвЂ™s chart and kardex. The Fall Prevention Policy details the Morse Fall Risk Scale and the Graf вЂ“ PIF for assessment and requirements for reassessment. XXVI. Abuse All healthcare workers are mandated reporters of domestic violence, child abuse , elder and dependent abuse. See hospital policy for specific criteria. 20 XXVII. Recognition of Impairment Impaired and disruptive behavior of a licensed independent practitioner can impact the safety and care of patients, endanger the physical safety of hospital employees and may create a working environment that is hostile and unproductive. FVRH has program to identify and manage physician impairment. Please report symptoms of both impairment and disruption to your department supervisor. XXVIII. Team Dynamics The medical, nursing, and ancillary professional staff of FVRH function collaboratively as part of a multidisciplinary team united in a purpose to achieve positive patient outcomes. XXIX. Chain of Command Each unit/department has a charge nurse or supervisor who is responsible for the function of the unit during their shift. The Administrative person on call and nursing supervisor is available at all times including nights and weekends. Unit managers have 24-hour responsibility for the unit. Unit directors answer to the Chief Nursing Officer. Issues related to medical staff are reported to the charge nurse or department supervisor for follow-up through the chain of command. XXX. Central Supply Items Chargeable central supply items have a sticker attached. Remove the sticker and place on the patient's central supply card. XXXI. Verbal/Telephone Order Read Back Verbal and telephone orders will be written on the вЂњPhysicianвЂ™s OrdersвЂќ form. Orders will be read back to the physician and noted as such on the physician orders form by placing a check- mark in the box next to вЂњVerbal Order Read Back.вЂќ It is the policy of the facility to discourage verbal orders unless it is under an emergency situation or the physician is surgically scrubbed in and unable to write orders. A nurse may not accept verbal orders for chemotherapy. XXXII. Medication Administration All licensed staff are required to follow the "Five Rights" of medication administration Two identifiers are used prior to administering medication: patient name, DOB Only approved abbreviations may be used. Refer to hospital policy. 21 MEDICATION SHORTAGES How are staffвЂ™ notified of medications shortages or outages? The Pharmacy Department sends a notice to all affected areas each time a shortage or outage occurs. The notice provides instructions as to alternative medications available. Lists of shortages are available on the Pharmacy website. USE OF INVESTIGATIONAL MEDICATIONS How are investigational medications managed? The hospitalвЂ™s Protocol Review Committee approves all investigational medications for use in the facility. A copy of the investigational protocol governing the medication is placed in the patientвЂ™s medical record. StaffвЂ™ is oriented to any requirements regarding the medication. STORING OF MEDICATIONS How do you assure that medications are appropriately stored? We have developed specific policies to assure that medications are appropriately stored. These policies require that: вЂў вЂў Internal and external medications are stored in separate locations. Medications requiring refrigeration are stored in refrigerators. The temperature is monitored each day to assure that proper temperature is maintained. вЂў Medications are protected from light as required. вЂў Medications are made available in the most вЂњready to useвЂќ form as possible. вЂў Medications are provided in unit dose form whenever possible вЂў Pharmacy staff makes routine inspections of medication storage areas to assure compliance with policy. o вЂњLook-alikeвЂќ and вЂњsound alikeвЂќ medications are stored with special precautions o Outdated medications are returned to Pharmacy for appropriate disposal SECURITY OF MEDICATIONS How do you keep medications secured? We have developed specific policies to assure that medications are appropriately secured. These policies require that: вЂў вЂў Medication rooms and carts are locked. Only authorized licensed staff are permitted access to medication storage areas 22 вЂў вЂў вЂў Emergency medication carts and tackle boxes are checked regularly. Tags are controlled only by Pharmacy staff No medications are kept on top of medication carts or in patient rooms. Staff is not allowed access into the main Pharmacy CONTROL OF CONTROLLED SUBSTANCES How do you keep controlled substances secure and reconciled? We have developed specific policies to assure that controlled substances are appropriately controlled. These policies require that: вЂў вЂў вЂў вЂў All controlled substances are stored in Pyxis. Only licensed authorized staff will have access to controlled substances Discrepancies of controlled substances are reconciled each shift. If a discrepancy is noted, the Charge Nurse must be notified immediately. Any wastage of controlled substances is witnessed by two licensed personnel HIGH RISK MEDICATIONS What steps do you take to protect patients from risks of errors in care when dealing with high -risk medications? We have taken steps to manage high-risk medications such as: вЂў вЂў вЂў Specific policies have been developed to manage high-risk medications such as insulin, heparin, and chemotherapy. Special warning labels and precautionary statements are placed on high -risk medications and look alike sound alike medications. These are also identified on the Pyxis machine. Special precautions have been taken to reduce the risk of administration errors such as requiring two licensed nurses to verify identified high risk medications. MEDICATION ERRORS & ADVERSE DRUG REACTIONS How do you spot a potential adverse drug reaction? The following strategies have been developed to spot potential adverse drug reactions вЂў Pay particular attention to the first time a patient receives a medication. вЂў Monitor for allergic reactions such as fever, rash, anaphylaxis. вЂў Monitor for hypersensitivity to a drug such as changes in vital signs, acute or severe manifestations of side effects. вЂў Look for drug intolerance вЂ“ a lowered threshold to the normal pharmacological effect of the drug. вЂў Look for idiosyncratic reactions вЂ“ an uncommon response by a patient to a drug given at normal doses. 23 вЂў Chart notation should be made. What do you do if you suspect an adverse drug reaction or a medication error? Staff should take the following actions when there is a suspected adverse drug reaction or medication error: вЂў вЂў вЂў вЂў Support the patient. Assess the patient for untoward effects. Notify the patientвЂ™s Physician for orders and treatment. Notify the charge nurse and/or clinical Manager and Pharmacy Charge nurse will complete eSRM a вЂњSuspected Adverse Drug Reaction ReportвЂќ form and forward it to Pharmacy. If a medication error occurred, complete an Occurrence Report or Medication Error Report form. Document the pertinent facts in the patientвЂ™s medical record. CONCENTRATED ELECTROLYTES Is there any concentrated Potassium or hypertonic saline stored in the various patient care areas? NoвЂ¦concentrated Potassium and hypertonic saline are stored under the control of Pharmacy. They are not stored in patient care areas. MEDICATION ADMINISTRATION How do you assure that you administer medications to a patient safely and effectively? We have developed specific policies to guide staff in administering medication. Key steps to safely administering medication include: вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Wash your hands. Correctly identify the patient using two patient identifiers. Using the patientвЂ™s armband and the medication administration record Verify that you have the correct medication / dose / route against both the drug label and the medication order. Check the expiration date on the drug to make sure it is still good. Do not use if the drug has expired. As appropriate, visualize the medication for stability (i.e., color, clarity, presence of particulate matter). Does not use if the medication appears compromise. Check the patientвЂ™s medical record to make sure there are no contra-indications to giving the medication. Verify that you are giving the medication at the proper time. Advise the patient of the purpose of the medication, and, as appropriate, of any potential adverse reactions or side effects. 24 вЂў If you have any questions or concerns regarding the medication, discuss them in advance with the Physician or call the Pharmacist for assistance. Remember Five Rights: Right Drug, Right Dosage, Right Route, Right Time & Right Patient 6th Right- Right Documentation FIRST DOSE REVIEW BY PHARMACY How do you process a new medication order? Our policy requires that Pharmacy review all new medication orders before staff may give the first dose. That means that staff cannot take the medication from Pyxis until Pharmacy has reviewed the order. There are some exceptions: вЂў вЂў The Physician is in control of the medication process such as in Surgery, ED, invasive procedures, etc. There is a clinical emergency and there is no time for Pharmacy to review the order (i.e. Code Blue, impending cardiovascular or respiratory failure, etc) ADMIXTURE OUTSIDE OF PHARMACY Can Nursing admix IVвЂ™s outside of Pharmacy? Only under emergency conditions. Otherwise, all IV admixtures are done in Pharmacy. If Nursing must admix a medication, special training and precautions are taken. XXXIII. Documentation Initial Assessment A complete assessment by a registered nurse shall be conducted on every patient as follows: вЂў Critical Care: An initial physical assessment shall be done within 15 minutes of the patient's arrival to the unit. вЂў Emergency Room: -Per ED triage policy вЂў Medical/Surgical/Telemetry--Within eight hours of admission вЂў The Admission Data Base will be completed within 24 hour. Each nursing unit individualizes documentation. Please check with your department resource that will show you the forms to use for your assignment. In patient assessment, nursing flow sheets, outcome notes, interdisciplinary 25 plan of care, patient and family education form, and belonging list are some of the forms that get initiated as part of initial assessment. Ask your resource on the floor to share these forms with you. Reassessment Patients are reassessed every shift or more frequently as their condition dictates Nursing flow sheetвЂ”initiated upon patient admission and every shift there after Interdisciplinary Plan of CareвЂ” вЂў Initiated by the RN after completion of the admission assessment. All entries on the Interdisciplinary Plan of Care will be initialed on the page where documentation occurs and signature recorded at the end of the document. The Interdisciplinary Plan of Care is individualized and based upon actual or potential problems, anticipated length of stay, assessed needs, policies, patient care standards, cultural issues, available resources and will be consistent with other therapies and/or disciplines. вЂў The Interdisciplinary Plan of Care will be reviewed every shift and updated as patient progress indicates. Outcome NotesвЂ” вЂў Enter problem number from Plan of Care that is being addressed, enter date, record time of documentation, enter discipline completing the entry from the Key at bottom of page, enter assessment/data/observation information in the "assessment" column, and enter interventions completed in appropriate column. Patient and Family educationвЂ” вЂў The RN admitting the patient is responsible for coordinating the education assessment, formulation of the plan, referral to other disciplines and completing the initial "Core Education." вЂў Educational needs and barriers to leaning will be assessed upon entry into the clinical setting. вЂў Educational interventions and response are documented on the Patient/Family Education Record by all disciplines throughout the hospitalization. XXXIV. Performance Improvement FVRH is committed to continuously improving performance and patient care outcomes. The medical staff, employees and contracted services participate in identifying opportunities to improve, data collection, multidisciplinary teams and implement actions to sustain improvements. The methodology selected by FVRH to analyze and improve 26 care/services and processes/outcomes is called the PDSA P- Plan the Improvement D- Do the Improvement S- Study the results A- Act to hold the gains How to Report an Event вЂў вЂў вЂў To report an event, contact your immediate charge nurse/supervisor. They will facilitate completion of an occurrence report. All Tenet Hospitals utilize an on-line incident reporting system that employees access through eTenet. As a contract employee you donвЂ™t have access to this system This report is limited to factual statements that document the occurrence, any interventions taken and shall not admit to or attempt to assign blame, liability or causation What is a Reportable Event? Вѕ This occurrence isnвЂ™t consistent with the routine operation of the hospital or routine care of a patient/s. Even the potential for accident, injury, illness or property damage is considered a reportable event. Вѕ An unintended event or act of omission or commission that departs from or fails to achieve what was intended is considered reportable. Вѕ Errors may or may not result in negative consequences. This includes a system &/or an individual error of judgment or inaction. These are reportable. REMEMBER: Any Hospital Staff, who witnesses, discovers or has direct involvement/knowledge of a reportable event, shall complete an occurrence report before the end of their shift. Examples of Reportable Events include (but are not limited to): Patient falls Property (loss of or damage to) Adverse drug events - medication errors Equipment failure or malfunction Adverse drug reaction (allergic reaction) All stages of Hospital acquired pressure ulcers Stage III and above decubitus ulcers Why Report Potential/Actual Occurrences? вЂў Supports a culture of shared accountability for identification of events that may impact hospital & patient safety 27 вЂў вЂў вЂў Integrates risk reduction strategies into the hospitalвЂ™s performance improvement, peer review, credentialing & liability prevention activities Supports compliance with requirements of federal/state law and standards of accrediting organizations Establishes process to ensure documentation and investigation is conducted appropriate to the type/level of severity of reportable events XXXVI . PRESENT ON ADMISSION (POA) FACT SHEET вЂњHow to Complete a POA FormвЂќ What is a Present on Admission (POA) Form? Beginning October 01, 2008, the federal government and 3rd party payers will no longer pay for certain hospital acquired conditions (HAC). Because of this new ruling, weвЂ™re highlighting certain conditions as especially important to assess upon your patientвЂ™s admission to the hospital. Documentation is an extremely important part of this process! Hospital вЂ“ Acquired Conditions selected for 2008 Stage III & IV Pressure ulcers Catheter-associated urinary tract infections (UTI) Retained foreign object Mediastinitis after CABG (Coronary Artery Bypass Graft surgery) Air embolism Blood incompatibility Manifestations of poor glycemic control Surgical site infections following certain ele procedures: (Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma o Orthopedic procedures involving Secondary Diabetes with repair/replacement/fusion of join Ketoacidosis, Secondary Diabetes shoulder, elbow, neck with Hyperosmolarity & spine Bariatric surgery for obesity (Laparoscopic Gastric Bypass, Gastroenterostomy, Laparoscopic Gastric Restrictive Surgery) Deep Vein Thrombosis (DVT)/Pulmonary Blood Incompatibility Embolism (PE) following total hip/knee replacement How is it determined that conditions are вЂњPresent on AdmissionвЂќ? If they meet any of the following criteria: вЂў Present at the time the order for patient admission occurs вЂў Conditions originate in the ED, observation, or outpatient surgery вЂў Conditions that were clearly present but not diagnosed until after the admission took place are considered present on admission If a submitted claim contains one of these conditions acquired during the hospital stay, that claimвЂ™s processed as if the diagnosis was NOT present on admission. This may result in 28 a DROP in severity tier & decreased reimbursement. How to complete a POA form (2 main sections completed by the nurse & physician) NURSE: FV policy requires two nurses to complete POA form. This is considered вЂњFour eye checkвЂќ. One of the nurse must be FV staff nurse. Two registry staff cannot perform the assessment or documentation together. Skin Assessment (If youвЂ™re unable/unsure how to assess, stage & document your findings, please check with your supervisor) вЂў Note all stages of pressure ulcers on the form вЂў At FV, we also require that all patients that meet the вЂњHigh RiskвЂќ criteria will also have pictures taken regardless of skin breakdown or intact skin. вЂў Two Nurses will also take picture of Cocyx/sacral area and both heels of intact or impaired if patient meets high risk criteria. вЂў High Risk Criteria for obtaining photographs in this policy is defined as - Any transfers from: acute hospitals; long term acute facilities; Skilled Nursing facilities or boarding care; any patient with Braden score of 12 or under; patient that is diagnosed as malnourished/anorexic ; and patient with impaired mobility. вЂў Nurses will take the picture(s) to include scale and patient identifier, and will mount picture(s) on the Photographic Wound Documentation form (FVH-8740-04(12-07). This form will be signed by the same two nurses to ensure assessment for POA indicators and photographs were taken by two nurses together. This process will be the considered 4 eye check. вЂў If skin integrity is impaired, nurse will document the wound location on the form and will obtain Physician orders to initiate wound care consult. Pbar number for the consult will also be documented on the space provided on this form. The charge nurse or nurse helping you take pictures will help you put the order in the PBAR for wound care consult вЂў This form will be placed under the Physician progress note section. вЂў вЂњHigh Risk Criteria for Pressure Ulcer Prevention Protocols to included patients: 75 years of age or greater, Peripheral vascular disease, Myocardial infarction, Stroke, Multiple trauma, Musculoskeletal disorders, GI bleed, Spinal cord injury, Neurological and/or chronic medical conditions (e.g., Guillain BarreвЂ™, multiple sclerosis), Unstable and/or chronic medical conditions (e.g., diabetes, renal disease, cancer, COPD, CHF, dementia), History of previous pressure ulcer, Obesity, and Anasarca. If patient meets this criterion pressure ulcer prevention protocols must be initiated, even if there is no skin breakdown. вЂў This process will be validated by POA audits and visual checks during multidisciplinary rounds вЂў Note any area of surgical site infection вЂ“ surrounding skin, wound site, drainage вЂў Use 1 line per breakdown area Genitourinary Assessment вЂў Document if a catheter is present on admission. вЂў If so, indicate date of insertion and locale of insertion. (In the field, nursing home, ED, home, etc) Central Line 29 вЂў Document if a catheter is present; state the type of device & date of insertion Surgery вЂў Document the date if patient had one of the following surgeries with the last 6 months: CABG; Orthopedic; Bariatric Surgery Once you complete the admission assessment: вЂў If none of the previously noted indicators are present, check all appropriate boxes labeled вЂњIndicator NOT presentвЂќ вЂў If no indicators are identified, the process stops here. Make sure the form is complete, properly dated/timed, and signed. PHYSICIAN: Place signed & completed form in the вЂњProgress NoteвЂќ section of the medical record. вЂњFlagвЂќ the form for physician attention. XXXVI Wound Care Policy & Procedure Wound Care and Skin Care Guidelines, Management & Documentation- PCSW-4.0 1 POA information is as above 2 Updated, photograph each wound upon discovery and weekly on Wednesday, at the time of transfer, and at the time of discharge.. Photographs should also be obtained if the condition of the wound deteriorates 3 Charge Nurse is responsible for checking the camera and delete pictures that are no longer needed every day. Compliance officer will audit the process during Environment of Care (EOC) rounds. 4 Document skin assessment on admission and every shift on Patient Care Flow Sheet (TRC1024). Four eye check process will be followed at the bedside shift report to perform skin assessment for all patients. Two nurses performing the visual check will initial on the skin assessment section on the nursing flow sheet (TRC 1024). 5 Document reassessment of each wound weekly (every Wednesday) and upon transfer or discharge of patient. Reassessment of the wound should also be documented if the condition of the wound deteriorates. 6 Document on the Pressure Ulcer Prevention Protocol form, and update it every shift and as needed. Place the form under Wound Care Tab. Document asterisk (*) interventions on the Treatment Administration Record (TAR) every shift, if initiated. 7 Patients with existing wounds or with a Braden Scale score of 18 or less, get R.D. Nutritional Assessment for wound care initiated by entering the consult request in the PBAR system. 8 Patients with existing wounds or with a Braden Scale score of 18 or less, get PT functional screen initiated, if patient has impaired mobility. Enter the request using the PBAR system. 9 Ensure that visual cues are in place (door frame magnet, census board magnet, and chart stickers). Follow the auditory cues to observe the turn schedule (Addendum E). 30 10 11 12 13 14 15 16 17 18 Use вЂњHelp Us Protect Your SkinвЂќ brochure for education (Addendum F). Nursing must notify central supply of the patient transfer using PBAR for bed management The Primary Care Nurse is responsible for entering an eSRM for any & all skin breakdown & for any advancement in pressure ulcers. The Primary Care Nurse is responsible for notifying the patientвЂ™s physician for any skin breakdown, any advanced stages, infection, and/or a Braden Scale score of 12 and below to obtain a Wound Care Consult. The Wound Care Nurse will make recommendations only, does not follow the wound care management of the patient. It is the nurses ultimate responsibility to manage the wound care with the collaboration of Wound Care Team, Nutrition, Physical Therapy, & Physician The Primary Care Nurse is responsible to Notify Wound Care Nurse for any new onset of skin breakdown and/or advanced wound changes. When in doubt just do it The Primary Care Nurse is responsible for initiating a Dietitian consult for any patient with existing wounds or with a Braden Scale score of 18 or less. The Primary Care Nurse is responsible for initiating a Physical Therapy Functional Screen for any patient with impaired mobility on the Braden subscale The Primary Care Nurse is responsible for initiating the Pressure Ulcer Prevention Protocol for patients with a Braden Score of 18 or less and/or patients with existing skin breakdown. Ensure Audio & Visual cues are in place The Primary Care Nurse, along with the Charge Nurse can determine need for a support surface bed. Complete & fax the Support Surface Rental Requisition form as appropriate. A PhysicianвЂ™s order is required. Any delays, notify RNC/Director as soon as possible. Wound Care Documentation Вѓ Вѓ Вѓ Вѓ Вѓ Вѓ Photograph each wound upon discovery and weekly on Wednesdays, if the wound condition changes , and upon discharge or transfer of the patient Document new & existing skin breakdown/wounds on Wound Assessment & Progress Record. Reassessment is weekly (Wednesdays) and with any changes, and upon discharge and transfer. Only use one form per wound. Document skin assessment every shift on Patient Care Flow sheet under the SKIN/MUCOUS MEMBRANES section. Document Braden Risk Assessment score on admission and every shift on Patient Care Flow sheet. During bedside shift report, all RNs are to assess patientвЂ™s skin and both nurses are to document their initials on the Patient Care Flow Sheet under the SKIN/MUCOUS MEMBRANES section. This applies to all patients. 31 For complete information review the Policy: Wound Care and Skin Care Guidelines, Management & Documentation- PCS-W-4.0 Thank you for completing this self study module Please refer any questions/clarifications you might have to your resource. Complete the certificate on the first page and return it to the designated person Do not hesitate to call education department if you need additional information on any of the topics covered in this packet.