Table of Conents
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SAFETY & CLINICAL MANUAL
For Temporary Staffing
And Students
Orientation and Annual Review
Rev. 09/08
Table of Contents
I. Introduction 5
II. Directions 5
III. Mission/Vision/Core Values 5
IV. General Safety 6
Safety 6
Environmental/Patient Safety 7
Domestic Violence information 7
Overhead Pages 8
Smoking Policy 9
Employee Health 9
V. Internal/external disasters (emergency operations) 9
Mass Casualty Plan 9
Evacuation Plan 11
Tornado/Severe Weather Plan 13
Earthquake Response 13
Bomb Threat Plan 14
Code Assist 15
Code Pink 15
Code Blue 15
Rapid Response Team 15
Utility and medical equipment emergency response 16
VI. Fire safety 17
Fire Prevention 17
Fire Procedures 18
Fire Emergency Response Team 18
Fire Extinguishers 19
VII. Electrical Safety 19
General 19
Safe Medical Devices Act 20
VIII. Back Safety 21
IX. Hazardous Materials Review 22
Hazard Communication 22
Hazardous Material Spills 22
Radiation Safety 23
Infectious Waste Review 23
X. Infection Control 24
Introduction 24
Bloodborne Pathogens Training 26
Tuberculosis 29
Reporting an Exposure Incident 30
Risk Management Laws 31
XI. Corporate Integrity 33
XII. Workplace Violence 33
XIII. Ethics 34
XIV. Additional Review Requirements for Patient Care Staff 34
Organ and Tissue Donation Information 34
Advance Directives 35
Restraints 36
COBRA/EMTALA 36
XV. Strength Through Diversity 38
XVI. Plan For Care 39
XVII. National Patient Safety Goals 43
XVIII. Information Management: Abbreviations 45
I. Introduction
This manual is intended to provide Cross-trained, Agency staff, and Allied Health students working at Saint Luke's South with a mechanism for meeting orientation requirements as stipulated by The Joint Commission and OSHA. This is a Training Manual - not a policy manual. Detailed information regarding relevant policies can be found on the I/SLS/Plan for Care. This training program is not meant to replace or supersede any area specific safety policies or training programs already in place. Other options regarding training delivery include the computer-based safety training program or area specific training programs.
All Cross-trained, Agency staff and students working at Saint Luke's South are to review this Safety/Clinical Training Manual each calendar year and to complete and pass the safety quiz.
II. Directions
Read the appropriate sections of this manual and complete the designated test questions located in Appendix A. PLEASE use a separate answer sheet. DO NOT MARK IN THIS MANUAL.
Return the answer sheets to the Agency Designated person for competency/education for grading and recording. It is the responsibility of the Cross-trainee’s primary facility (the Manager or Education Designated Member) and/or Agency staff to maintain written documentation of individual completion for their staff.
Students must return this information to the Clinical Education Manager prior to beginning their experience at the hospital.
This program is designed to help you review hospital-wide safety procedures and to help meet training requirements for The Joint Commission and OSHA. It consists of two parts: a review of general information and safety practices and a participant’s quiz to be completed by each area member. The review quiz will serve as documentation for The Joint Commission and OSHA safety review requirements.
This approach will provide a review of important information in an efficient and convenient manner. This program permits area members the freedom of scheduling the required review at a time that is convenient. It can be completed individually or as a group.
The educational process for an individual includes:
1. Read the manual
2. Answer the questions in the safety quiz.
3. Return the completed review answer sheet to the Agency Designated person or the Clinical Education Manager or Clinical Education Specialist for Competency/Education for grading and placement in employees file.
4. A score of 80% is required for passage. The date of completion will be documented.
The educational process for a group would include discussion of the general and area specific information instead of reading the information. The discussion can be lead by the Manager and/or designated staff member. Additional safety training will also be implemented to meet the specific needs of certain areas.
III. Mission/Vision/Core Values
The Mission, Vision and Core Values of Saint Luke’s South provide a framework for the prioritization of performance improvement activities.
Mission Statement:
Saint Luke’s South is a faith-based not-for-profit community hospital committed to the highest levels of excellence in providing health related services to our patients in a caring environment. As a member of Saint Luke’s Health System, we are committed to enhancing the physical, mental and spiritual health of the communities we serve.
Vision Statement:
The best place to get care, the best place to give care!
Core Values:
The Core Values exist to articulate the values and beliefs of the organization’s leadership and staff throughout the Saint Luke’s-Health System. These core values are also integrated into the performance management process and job description. The core values are described as follows:
❑ Quality /Excellence
❑ Stewardship
❑ Patient/Customer Focus
❑ Teamwork
❑ Learning and Innovation
Service in Action is always:
1. Greeting everyone with a smile.
2. Asking respectfully, “How may I assist you?”
3. Listening carefully.
4. Explaining next actions with expected timeline.
5. Providing quality, compassionate help.
6. Showing appreciation for the chance to serve.
Service Recovery In Action is always LAST:
L = Listening.
A = Apologizing.
S = Solving.
T = Thanking.
IV. General Safety
A. Safety
We are all responsible for Safety. Any employee observing a potentially hazardous safety condition or being informed of a potentially hazardous condition by a patient, visitor, or Medical Staff member shall take action to eliminate the hazard and/or report this information immediately to his/her Manager or the Hospital Safety Officer.
The Hospital’s Safety Officer is Gary Christian at 63477.
In order to make this policy truly effective, each employee is responsible for:
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Observing all applicable OSHA, EPA, Hospital, and department safety rules;
Wearing and using required safety equipment / personal protective equipment (PPE);
Performing work in a manner that will protect patients, visitors, other employees, and self;
Reminding fellow employees of safe work techniques in lieu of at risk behaviors; and
Being alert for unsafe conditions and if possible, correct them immediately or report them to your Manager / Safety Officer / or Security.
Violation of fire or safety rules or regulations, including the Occupational Safety and Health Act is subject to disciplinary action including possible discharge.
B. Environmental/Patient Safety
The primary responsibility of Saint Luke's South is to provide optimal care to our patients. Second only to this responsibility is Saint Luke's South’s commitment that it will furnish its personnel a place of employment that is free from recognized hazards that might cause serious injury or death. All reasonable methods, procedures and equipment necessary to achieve this end will be utilized.
All equipment and/or fixtures in need of repair shall be reported immediately to Facilities Management (ext. 22285) or Biomedical Engineering (ext. 22516). Avoid using these areas or equipment until repaired.
Patients should be immediately oriented to call lights, light switches and bed controls (where applicable). Beds should always be kept in low position (with the exception being in ICU units). Supplies, dirty equipment or any potentially dangerous item shall not be left within reach of the patient.
In transporting patients, the following general principles apply:
1. Never leave restless or confused patients unattended.
2. Patient’s arms are never to extend beyond side rails.
3. Side rails on carts are to be up.
4. Safety belts should always be worn.
5. Carts must be pushed from head with patient’s feet first.
6. Wheels must be locked when wheelchair or stretcher is stationary ( except when in storage.
7. Acutely ill patients and all ICU patients should be accompanied by a RN when transported to another unit or department.
8. When patients ambulate, keep walkways free of furniture; well fitting footwear is to be worn and if patient is unsteady, he/she should be assisted.
Patients should have ID bracelets on at all times. If patients have known allergies they will have the red bracelet marked with the appropriate allergy.
C. Domestic Violence information
• Domestic violence is a pattern of violent and coercive behavior where one person in an intimate relationship controls anther through force intimidation, or threat of violence.
• Can include: physical abuse, sexual abuse, verbal/emotional/mental abuse, and economic abuse.
• Anyone can be a victim and anyone can be an abuser.
• Abusers are often one person in public and another person at home.
• Domestic violence is the leading cause of injury to women between 15 and 44 in the United States which is more that car accidents, muggings and rapes combined.
• 1 in 4 women and 1 in14 men will experience domestic violence at some point in their lifetime.
• 1 in 6 pregnant women or 324,000 pregnant women a year are in a domestic violence relationship.
• Domestic Violence is the leading cause of traumatic death for pregnant women.
• There is a 75% risk that the victim will be killed when she tries to leave the relationship.
• One of the biggest reasons why someone stays in a domestic violence relationship is because they are told that it is there fault.
• Domestic Violence is a healthcare related issue.
• The Joint Commission has stated that domestic violence screening is mandatory.
• It has been recommended that all females 14 and older have to be screened no matter why they are at the hospital.
• Any male 14 and older with indicators for abuse have to been screened as well. Indicators include: same sex relationship, unusual bruising, history doesn’t match the injury.
• You must screen the patient in private and please make eye contact. Victims of abuse will not tell you in front of someone else. Keep in mind that DV is a very private matter that no one she knows may know about it.
• State: We at SLS are concerned about the violence that is impacting the health of many of our patients, so we routinely ask the following questions:
1. Are you being hit, kicked, punched, strangled, threatened or otherwise hurt by your partner or spouse?
2. Is your partner or spouse threatening you or otherwise making you feel afraid?
• If your patient says YES make an automatic referral to SAFEHOME. Call 913-262-2868 and tell the hotline who you are and where you are from. We will respond within 30min – 24 hours a day 7 days a week.
• Law: As a healthcare provider you can only mandatory report DV if there is a gun shot wound or a stab wound. Otherwise the patient has to give consent.
• Document everything. Her medical records may be used in the court system. Please write down what the patient states to you, what injuries they have, was SAFEHOME or the police involved. Where is the patient going when they leave the hospital? This will protect you and SLS from any legal action.
• Please call 913-432-9300 for any questions.
D. Overhead Pages
A variety of coded overhead page announcements are used at Saint Luke's South to indicate certain events which require prompt response by appropriate hospital personnel. The following coded announcements are currently in use at Saint Luke's South.
CODE BLUE: Medical Emergency. Code Blue team to area specified by operator.
CODE RED: A fire alarm has been received. It will be paged "Code Red", followed by the location. Except for designated personnel, all employees should avoid the area.
CODE PINK: An abduction of an infant from Maternity. Securityand designated departments will be dispatched to specific key areas. All personnel should be alert for persons with infants or suspicious bundles/packages large enough to conceal an infant, and always notify Security (ext. 63000) immediately.
CODE ADAM: A missing/abducted a child. Security and designated departments will be dispatched to specific key areas. Personnel should be alert for persons leaving with a child and notify Security (ext 63000) immediately.
CODE ASSIST: Security Emergency. Security will be dispatched to area specified by operator. All unnecessary personnel should avoid the area.
CODE BLACK: A bomb threat has been received. All personnel search work areas looking for “suspicious” items/devices not normally located there. Do not touch. Notify Security (63000). Any evacuations will be determined at the time of the event.
CODE WHITE: Hazmat Team activation.
CODE GRAY: Tornado Plan Activation. Move patients and visitors away from windows to center areas of the hospital.
E. Smoking Policy
Congruent with the mission and philosophy of the Saint Luke's Health System and grounded in the state law as well as accreditation standards, System facilities will be maintained as a smoke-free environment for the benefit of patients, visitors and staff.
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Accordingly, all buildings and grounds of Saint Luke’s South will be tobacco-free as a means of reducing:
- risks to the patients and staff associated with smoking,
- risks to other patients and staff associated with
passive smoke, and risks of fire.
F. Employee Health
Employee Health Services (EH) is available during the following hours:
Monday, Wednesday – Friday 7:30 a.m. - 4:00 p.m.
Tuesday, 7:00 a.m. – 3:30 p.m.
The Emergency Department is available for assistance only when EH is not open. Cross-trained personnel, temporary staffing agency and students are to report any work-related injury, illness or needlestick/exposure situations occurring at SLS to Employee Health at SLS and to the employee health department at their primary hospital or employer.
All work-related injuries must be reported to SLS EH within 24 hours of occurrence.
V. Internal/external disasters (emergency operations)
Emergency operations, including mass casualty response, fire plan, evacuation plan, tornado plan, earthquake response, and bomb threat plan are included in the Emergency Operations Plan manual. A summary is located in a Red-Emergency Preparedness Procedure tri-fold available in each work unit. Each employee should be aware of the location of this tri-fold.
The following summarizes the highlights of the major components of the Emergency Operations Plan.
A. Mass Casualty Plan
The Mass Casualty Plan is designed to efficiently handle a large influx of patients at one time by proper triage/treatment. In order to avoid a large amount of patients being transferred to one hospital and overloading their capabilities, the Kansas City Area Hospital Association has implemented the Hospital Emergency Administrative Radio (HEAR) System and EMSystem. These networks are designed to provide communication between area hospitals and emergency care providers at the disaster site in order to coordinate the disposition of disaster victims to hospitals.
When the hospital Communications Operator announces "THE MASS CASUALTY PLAN IS NOW IN EFFECT", all personnel will exercise their assignments outlined in the department specific responsibilities of the Mass Casualty Plan.
During a Mass Casualty event or drill, the following functional units are established:
NOTE: Due to the periodic changes in the locations for some of the functional units, please consult the Emergency Operations Plan manual for the most current locations.
1. Incident Command Center: (HR): Coordinates the Mass Casualty Plan. Staffed by On-Call Administrator and other select personnel. Maintains contact with all functional units. All requests for assistance or problems are referred to the Command Center.
2. Resource Pool: (Wellness Conference Room): Associates reporting to assist in the Mass Casualty will report here and be assigned as needed.
3. Triage Unit (Emergency Services Ambulance Entrance): Disaster victims are received, examined, and sorted on the basis of the severity of injuries, type of injury, need for life-saving first aid, likelihood of response to definitive treatment, etc. Here the patient is identified, and forwarded to the appropriate area for treatment.
4. Emergency Services Treatment Rooms (PACU and Short Stay will serve as over flow to this area): Used for treatment of all injuries. Cases will be moved to other functional areas as their conditions require.
5. Surgery Treatment Unit: These cases are seriously injured and require definitive surgical care STAT.
6. Pre-Op Holding Unit: These cases are seriously injured and require definitive surgical care as soon as possible.
7. Discharge Area: (Assessment Center): Discharge arrangements completed.
Family Waiting Area: Main Lobby. Personnel from Social Services and Spiritual Wellness will be available for assistance.
8. Body Holding Room: This area is set up to receive DOA's as well as those who expire during treatment.
9. Media/ Public Relations: South parking lot.
Departments which have responsibilities under the Mass Casualty Plan will have a separate section in the manual under the Departmental Duties section. All departments should report available personnel on duty to the Incident Command Center, ext. 67711. Available personnel should report to Human Resources for assignments as necessary. Remember, the "rule of thumb" for responding in the case of a disaster or mass casualty is:
( If you are at home ( stay there and wait to be called; or
( If you are at work ( available personnel report to the Wellness Conference Room for assignment.
B. Evacuation Plan
Saint Luke’s South’s Evacuation Plan is based on the principle of first securing horizontal (lateral) movement of patients from unsafe to safe areas on the same floor by making use of the fire/smoke doors in the corridors. It also provides for total and complete evacuation of all patients and personnel should such action be deemed necessary.
When a situation arises requiring evacuation of patients from threatened or affected areas, safety of lives is our primary concern.
In the event of an actual disaster, the Incident Command Center will be activated to concentrate appropriate personnel in one area with sufficient telephones, internal communications, fire alarm information, security camera monitors, and access to the H.E.A.R. Network. The Command Center will be located in Human Resources.
Except where otherwise noted in the plan, all evacuations, regardless of the type of emergency, should follow the basic procedures outlined below. However, since every emergency situation is unique, personnel at the scene should use their best judgment when making decisions and giving instructions.
General Procedures for Patient Care Areas and Hospital Complex:
If the area of the hospital being evacuated involves patients, the following general instructions apply.
1. Comply with instructions from administration and fire department. Only the Administrator on Call or designated member of the command center has the authority to implement an evacuation.
2. You will be directed as to where to evacuate patients from your unit. If the situation involves fire, evacuate patients beyond the first set of fire/smoke doors (door frames marked with a Black plates are smoke, Red plates are Fire) towards a stairwell. This area will serve as a staging area if further evacuation is warranted.
3. Remain with patients and render care to them as circumstances permit.
4. The patient’s chart should accompany each transferred patient.
5. If evacuation beyond the same floor is necessary, patients will be evacuated to an area of safety by whatever means are available (e.g., blankets, gurneys, stretchers, wheelchairs, sheets, mattresses, etc.). Downward evacuation is preferred.
a. Elevators within the building of fire origin should not be used for evacuation unless directed by the Fire Department. Evacuations should be by the enclosed stairwells.
b. Evacuation routes are posted in each area. Personnel should refer to these routes to determine the fastest and safest route available, except when specifically instructed to follow alternate routes by Fire Department, Police, or Administration., CEO, administrators or designee are responsible for prearranging evacuation assistance for any employee with disabilities which may affect their ability to evacuate.
6. Refer to the following guidelines for the evacuation/movement of patients:
Ambulatory Patients:
a. Provide for the patient's comfort and safety.
b. Assist ambulatory patients in forming a line and lead them to an area of safety.
c. People exiting the floor should stay to the outside of the stairwell (right side going down) so fire and rescue people can come up the interior.
d. Personnel should avoid stopping during the evacuation since this can block stairwells or doors while others are trying to exit.
e. Instruct patients to keep talking to a minimum so they can hear instructions from Fire Department officials.
Wheelchair/Stretcher Patients:
a. Use stretchers/wheelchairs/gurneys from the nursing units.
b. Use 1 and/or 2 person carries for bed patients. Blanket drag can also be used in extreme emergency.
c. Seriously ill patients can be transferred in their bed to a safe area. Provide portable oxygen if needed.
Nursery and Obstetrics:
a. Infants will be given to mothers if possible and evacuate the two together.
b. If a delivery is in progress, the physician in charge will assume responsibilities.
Surgery Departments:
a. Close doors to the department. Use wet towels, etc., around the openings to keep smoke out of the surgical suite and keep patients until safe to move.
b. The chief surgeon in each operating room will be responsible for taking the necessary measures for the safety of his/her patient. The surgical teams will remain under his/her control
Orthopedic Patients:
a. Patients will be evacuated in their own bed whenever possible. When carts or other means of evacuation are necessary, a physician will be consulted on the removal of traction equipment.
b. If elevators are designated safe, these patients will be evacuated by elevator. If not, consult with Fire/Rescue personnel who, in collaboration with nursing and other hospital personnel will assist in evacuation of these patients.
Restrained Patients:
a. Restrained patients require special attention. If the threat of violence is present, the patient should be restrained during evacuation. Guards for patients under legal restraints will follow the instructions of the nursing staff on the unit.
General Procedures:
Upon hearing an order for evacuation, proceed as follows:
1. INTERNAL EVACUATION OF AREA: Proceed in an orderly fashion:
• North end of building (Patient Information Center to ER) - proceed to Main Lobby
• South end of building (Patient Information Center to MOB) - proceed to Outpatient Rehab area.
2. TO EVACUATE BUILDING: Exit the building via the nearest and safest route, via stairwells. Do Not Use Elevators. Proceed in an orderly fashion to:
• North end of building (Patient Information Center to ER) - proceed to far side of parking lot outside Main Lobby
• South end of building (Patient Information Center to MOB) - proceed to Outpatient Rehab parking lot (lower level)
C. Tornado/Severe Weather Plan
A weather alert radio is located in the PBX/Security area. If the National Weather Service issues a severe weather watch or warning involving the Saint Luke's South’s area, the operator will notify the Administrator on Call, Safety Officer, and House Supervisor.
The PBX Operator will announce: Saint Luke’s South is under a (Severe Thunderstorm Watch, Severe thunderstorm Warning, Tornado Watch, Tornado Warning) until___. This will be repeated every 30 minutes while the severe weather alert remains in place.
If the National Weather Service alert is for “Southern Johnson County” the PBX operator will implement the Tornado Plan immediately.
Upon implementation of the Tornado Plan:
1. The PBX Operator will announce over the paging system "The Tornado Plan is now in effect" and repeat this announcement three times at two minute intervals.
2. Employees will proceed accordingly:
Non-Patient Areas:
1. Close all blinds and curtains;
2. Turn off nonessential power
3. Do not open any windows;
4. Close all doors;
5. Personnel are to move into corridor nearest the middle of the building;
6. If you are on an upper floor, attempt to move to a lower floor to enhance you protection. Do not use elevators.
Patient Care Areas:
1. Instruct patients and visitors to remain on unit;
2. Close all blinds and curtains;
3. Give patients extra blankets;
4. Move non-ambulatory beds to wall farthest from window;
5. Instruct ambulatory patients and visitors to move into corridor;
6. Close all doors to patient rooms, including fire doors;
7. Reassure patients; and
8. Await further instructions.
Earthquake Response
Upon detection of a tremor ( remain in place and remain calm. If indoors, watch for falling objects. Watch out for high storage areas, shelves and tall equipment which might topple. Stay away from windows and mirrors.
Perform first aid within your capability for the injured and remove others from areas of potential injury. Do not move people who are trapped or injured until help arrives unless the danger of further injury exists. Observe for potential fires and broken electrical wires and do not move people outside unless directed to do so.
IF IT BECOMES NECESSARY, THE MASS CASUALTY PLAN WILL BE IMPLEMENTED.
E. Bomb Threat Plan
Any bomb threat received by an employee, patient, visitor, medical staff member, volunteer, etc., will be taken seriously. The individual receiving such a bomb threat shall not attempt to judge or evaluate the validity or seriousness of the threat, but shall report all occurrences immediately.
I. The individual receiving such a bomb threat shall:
a. Get the attention of a coworker to notify PBX (63000) that a bomb threat has been received or notify PBX immediately after the call
b. Obtain as much information/details related to the bomb threat as possible- such as:
1. Ask specific location and time the bomb is set to go off?
2. Were there any identifiable background noises, conversations, etc?
3. Was the individual making the threat ( male, female, young, old; any accents, speech defects or anomalies, etc.?
4. How was the threat received - phone, note, etc.
5. If received by phone: could you tell if the call was an inside or outside call?
6. If the threat was written, save the written note, writing on the wall or mirror.
7. When was the threat received?
8. As nearly as possible, what was the exact wording of the threat?
9. Any other facts which will be helpful in dealing with the threat.
10. Your name, area and telephone number.
c. Notify his/her Manager/Supervisor and call 6-3000.
II. The Hospital Telephone Operator (PBX), upon receiving notification of a bomb threat, shall:
a. Notify Security, and the Administrator on Call.
b. When instructed by Administrator on Call alert hospital personnel by announcing three times over the P.A. system, “Attention Please, CODE BLACK”.
III. Hospital personnel, upon hearing the “Code Black“ page shall:
a. Search their work areas for anything (box, suitcase, attaché case, bag, etc.) which would normally not be there
b. Report any suspicious item/device to Security
c. Secure area; Do not touch
IV. Security shall:
a. Speak with the Incident Commander in an effort to assess the threat presented.
b. Respond to any area where associates have identified a suspicious item/device.
c. Relate information to 911 response personnel.
V. The authority to order an evacuation lies with:
a. The Incident Commander
b. The police or fire department official in charge of incident.
Code Assist
When Code Assist is paged, there is a serious security problem. All personnel, except those absolutely needed should stay away from the identified location until the Code Assist is canceled.
Code Pink
When Code Pink is announced overhead, it indicates an abduction of an infant from the Mother/Baby unit. Security will be dispatched to specific key areas. All hospital personnel should be alert for persons with infants or suspicious bundles/packages large enough to conceal an infant, and always notify Security (ext. 63000) immediately.
Associates from the following areas will be posted immediately to lock off the exterior exits:
• Pharmacy Medical Office Building Entrance
• Rehabilitation Outpatient Rehab Entrance
• Patient Information Center Front Main Entrance
Respiratory Therapy
• Emergency Room Ambulatory ED Entrance
Ambulance Entrance
• Facilities Management/Lab Outside Dock/Energy Center Entrance
• House Supervisor Exit in Surg/PACU near Anesthesia
• Radiology Exit Surgery at far SW corner
• Inpatient Rehab Fire exit on In-pat Rehab Unit
H. Code Blue
A Code Blue is called in response to a medical emergency where respirations and/or heartbeat have ceased. Code Blue will be called to the PBX operator (6-2222) from where the Code Blue occurs. The Code team will respond to all codes paged on Code beeper and overhead paging system activated by the PBX operator. PBX will also notify Security and the Chaplain.
All medical and surgical codes in the private physician offices will be handled by calling “911” for ambulance assistance.
The nurse taking care of the patient will assist in the Code as needed, provide patient history and will enter on STAR all patient charges for the Code Blue.
When a Code Blue occurs in areas, i.e. cafeteria, front lobby, where a crash cart does not exist: Code Blue staff will respond with the closest located crash cart.
RT will bring airway box on all shifts.
I. Rapid Response Team
In the event a patient exhibits signs and symptoms of physiological instability, clinical staff can activate the Rapid Response Team (RRT) to assist in the assessment and stabilization of the patient. The Rapid Response Team protocols may be initiated for any patient that a RRT event is activated. The patient’s attending physician should be called as soon as possible after an assessment by the Rapid Response Team members.
1. The Rapid Response Team will respond to all events activated and paged on the RRT pager. No overhead announcement will be made. RRT activations will not be paged or announced overhead as being cancelled. RRT members include:
• One Critical Care nurse
• Respiratory care practitioner(s)(RCP)
• House Supervisor
2. The RRT collaborates with staff member in assessing, intervening, and stabilizing the patient condition and organizing information to be communicated to the patient’s physician. Interventions may include laboratory workup, ECG, radiographs, IV therapy, and medication administration. The RRT members also take on the role of educator and support to the staff assembling the various pieces of clinical information. If the circumstances warrant, the RRT members will assist with the patient transfer to a higher level of care.
Activation Protocol
1. To activate the Rapid Response Team from any location in the hospital:
a. Dial 63000.
b. Please state clearly you want to activate the Rapid Response Team.
c. Give the operator the room number or location of the event.
2. The Rapid Response Team will be activated by the operator initiating an alphanumeric page on the assigned pagers, “Attention, Rapid Response Team, Room/Location _____”.
3. The Rapid Response Team members will respond to the event location in a timely manner.
See Rapid Response Team Policy.
J. Utility and medical equipment emergency response
The following table, from the Emergency Operations Plan, outlines the basic staff
response in the event of a medical equipment or utility system failure.
|Failure Of |Whom to Contact |Responsibility of User |
|Air Conditioning |Facilities Management (22285) |Use portable fans. |
|Electrical Power Failure; Emergency |Facilities Management (22285) |Ensure that life support systems are on emergency|
|Generators Work | |power (red outlets). Ventilate patients by hand |
| | |as necessary. Complete cases in progress. Use |
| | |flashlights. |
|Electrical Power Failure - Total |Facilities Management (22285) and Respiratory Care|Use flashlights; hand ventilates patients; |
| |Svcs |manually regulate IVs; don’t start new cases. |
| |816-440-6371 | |
| |Nursing | |
|Elevators Out of Service |Facilities Management (22285) |Review fire and evacuation plans; establish |
| | |services on first or second floor; use carry |
| | |teams to move critical patients and equipment to |
| | |other floors. |
|Failure Of |Whom to Contact |Responsibility of User |
|Elevator Stopped Between Floors |Facilities Management (22285) and Security |Keep voice contact with personnel still in |
| | |elevator and let them know help is on its way. |
|Fire Alarm System |Facilities Management (22285) and Security |Institute Fire Watch; minimize fire hazards; use |
| | |phone or runners to report fire. |
|Medical Gases |Facilities Management (22285) and Respiratory |Hand ventilates patients; transfer patients if |
| |Care Svcs 816-440-6371 |necessary; use portable O2 and other gases; call |
| | |for additional portable cylinders. |
|Medical Vacuum |Facilities Management (22285) and Respiratory |Call the Universal Resource Center for portable |
| |Care Svcs 816-440-6371and the Universal Resource |vacuum; obtain portable vacuum from crash cart; |
| |Center (67727) |finish cases in progress; don’t start new cases. |
|Natural Gas; Failure |Facilities Management (22285) |Open windows to ventilate; turn off gas |
| | |equipment; don’t use any spark-producing devices,|
| | |electric motors, switches, and such. |
|Nurse Call System |Facilities Management (22285) |Use bedside patient telephone if available; move |
| | |patients; use bells; detail a rover to check |
| | |patients. |
|Patient Care Equipment/ Systems |Biomedical Services (22516) |Replace and tag defective equipment. |
|Sewer Stoppage |Facilities Management (22285) |Do not flush toilets; do not use water. |
|Steam Failure |Facilities Management (22285) and Nutrition |Conserve sterile materials and all linens; |
| |Services (67310) |provide extra blankets; prepare cold meals. |
|Telephones |Operator (“0”) |See Operations Policy “Disaster Recovery |
| | |Procedure," phone failure. Use overhead paging, |
| | |pay phones, and runners as needed. |
|Water |Facilities Management (22285) |Institute Fire Watch; conserve water; use bottled|
| | |water for drinking; be sure to turn off water in |
| | |sinks. |
|Water, Non-Potable |Facilities Management (22285) and Nutrition |Use bottled water for drinking. Place |
|(Unfit for Drinking) |Services (67309) and ALL MANAGERS |“Non-Potable Water - Do Not Drink” signs at all |
| | |drinking fountains and wash basins. |
|Phone numbers: | | |
|Biomed |pager |
|Universal Resource Center |‘0 |
|Nutrition Services |“0” or 67000 |
| |x22285 |
VI. Fire safety
A. Fire Prevention
The best way to fight a fire is to prevent it in the first place. Follow good housekeeping practices including:
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Maintaining order and cleanliness in your work area.
Prevent blocked exits and propped-open doors
Keep exit corridors clear of equipment and material.
Do not store material within 18” of the ceiling in areas with fire sprinklers.
Do not use any electrical equipment that has frayed wires or smells hot when it is plugged in.
All employees should be aware of the following:
Location of telephone, fire reporting number (ext. 6-3000), fire alarm pull boxes, and fire extinguishers;
Types and proper use of the fire extinguishers in your area;
Location of fire doors for your area. These doors must always be kept clear and unobstructed.
Location of exits and exit stairwells
Location of oxygen shut-offs. Respiratory Therapy (RT) will respond to all Code Red’s. RT is responsible for shutting off or delegating the shutting off of the oxygen zone valves.
B. Fire Procedures
IN THE EVENT OF A FIRE - R.A.C.E
R - Rescue: Remove patients, visitors and staff from immediate danger. Evacuate if necessary.
A - Alarm: Turn in the alarm by pulling the alarm box in the area and then calling the hospital switchboard at ext. 6-3000.
C - Contain/Confine: Contain the fire by closing the door to the room or area involved. Assure all stairway doors are closed. Close all fire doors in the area.
E - Extinguish: If able, utilize fire extinguishers in the area to extinguish the fire. Do not attempt to extinguish the fire if doing so would put you in harms way.
THE NUMBER ONE PRIORITY IN ANY FIRE IS TO PROTECT LIFE! This includes not only the individual(s) in immediate danger, but also all patients, visitors, and hospital personnel. The first few minutes of a fire are the most important, and your correct response will prevent further spread or damage.
C. Fire Emergency Response Team
Upon announcement of a Code Red the following steps will be taken:
Saint Luke’s South Hospital Fire Emergency Response Team (Security, Facilities Management, Respiratory Therapy, House Supervisor, Administrator & the Safety Officer) will report to the area of the Code Red. Responsibilities include:
▪ Assist with evacuation as needed
▪ Attempt to extinguish the fire.
▪ Shut off utilities in affected area:
▪ RT to shut off zone oxygen valves
The overall authority and direction of this plan rests with the Chief Executive Officer at Saint Luke’s South. Authority to cancel the Code Red is given to Safety Officer, Security or Facilities Management designee.
Fire Extinguishers
There are three basic types of fire extinguishers in use at Saint Luke's South:
1. Multi-Purpose Dry Chemical extinguisher labeled ABC
2. The CO-2 (Carbon Dioxide) extinguisher labeled BC.
3. The Sterilized water mist extinguisher.
Multi-Purpose Dry Chemical Extinguisher - ABC Extinguisher
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puts out most types of fires - wood, paper, cloth, flammable liquids, and electrical fires. It discharges a yellowish to white cloud and does leave a residue. It works at a range of 10 to 20 feet and will completely discharge in 8 to 25 seconds, depending on the size. Alternate opening and releasing the control level on the extinguisher to conserve the length of time the extinguisher will operate. Never use water for electrical fires.
C0-2 (Carbon Dioxide BC Extinguisher)
will extinguish fires involving flammable liquids and electrical equipment. The carbon dioxide is basically an inert gas that discharges a cold white cloud which leaves no residue. It works at a range of approximately 4 to 8 feet and will discharge in 8 to 10 seconds. Alternate opening and releasing the control level on the extinguisher to conserve the length of time the extinguisher will operate. When operating, hold on to the plastic horn when aiming, and not the metal portion of the nozzle to avoid frostbite injury.
Sterilized water mist extinguisher.
Used in the OR in case of an electrical or any other type of fire during patient cases.
Procedures for Operating Fire Extinguishers
Although the majority of extinguishers work with these directions, there are exceptions. Know the correct operating instructions for extinguishers in your area. The following instructions follow the P.A.S.S. method (Pull, Aim, Squeeze, and Sweep).
PULL - Pull the pin. Some units require the releasing of a lock latch, pressing a puncture lever, or other motion.
AIM - Aim the extinguisher nozzle (horn on CO-2 or hose on Dry Chemical) at the base of the fire.
SQUEEZE - Squeeze or press the handle. Alternate opening and releasing the control level on the extinguisher to help conserve the length of time the extinguisher will operate.
SWEEP - Sweep from side to side at the base of the fire until it goes out. Shut off the extinguisher. Watch for reflash and reactivate the extinguisher if necessary.
Note: The fire hoses are available for fire fighter use only. Hospital employees are not to use the fire hoses.
VII. Electrical Safety
A. General
The following are danger signs to look for when examining electrical equipment in your department:
▪ Plug does not fit properly in outlet;
▪ Feels unusually warm to the touch;
▪ Smells as if burning;
▪ Makes noise or pops when turned off;
▪ Gives inconsistent readings;
▪ Knob or switch is loose or worn;
▪ Tingles when you touch it;
▪ Missing the third or grounding pin on the plug;
▪ Cord is frayed (most frequently occurs where cord comes out of the equipment).
If any of these are found,
1. Tag them immediately. DO NOT USE THE DEFECTIVE EQUIPMENT
2. Notify your Manager or supervisor
3. Notify Facilities Management (ext. 22285) or Biomedical Engineering (ext. 22516).
➢ Never roll electrical beds or equipment over power cords. Make sure long cords are rolled up or otherwise secured.
➢ Never pull out a plug by pulling on the cord; instead, grasp the plug and pull firmly.
➢ Never use a three-prong to two-prong adapter ("cheater plugs").
As a reminder, Hospital Policy and fire codes prohibits the use of portable heating devices, such as fuel-burning or electric space heaters anywhere in the Hospital. (This does not apply to physician-ordered treatment devices). Exception: Portable electric space heaters are allowed in non-sleeping and employee areas when approved by Facilities Management.
In addition, the Hospital requires all electrical equipment brought into Saint Luke's South to pass electrical safety criteria.
( The use of patient owned electrical devices, except those powered by batteries, is not permitted.
( For Hospital and/or staff owned electrical equipment, contact Biomedical Services or Facilities for the safety criteria or inspection.
Extension cords are the frequent cause of electrical faults, improper grounding, and accidents involving falls and fire. The use of extension cords can cause electrical hazards and increase the probability of sparks and/or electrical shock. In addition, use of extension cords may cause excessive voltage drop resulting in low efficiency, equipment malfunction or damage, and subsequent patient safety problems. For these reasons, the use of electrical extension cords is limited by Hospital Policy.
Safe Medical Devices Act
What is the Safe Medical Device Act?
Effective November 28, 1991 hospitals are required to report adverse events involving a medical device, which includes death and serious injury, to the Food and Drug Administration (FDA) and/or product manufacturer. The overall goal of the act is to help assure the medical devices are safe and effective.
What is a Medical Device?
An instrument apparatus, implement, machine, contrivance, implant, invitro reagent, or other similar or related article, including any component, part or accessory, which is:
0. recognized in then National Formulary, or the USP, or any supplement to them
1. intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals; or
2. intended to affect the structure or any function of man or other animal
3. and which does not achieve its primary intended purposes through chemical action within or on the body of man or other animal and which is not dependent upon being metabolized of the achievement of its primary intended purposes.
What is the Medical Device Reporting procedure at Saint Luke’s South?
What should I do if I become aware of a medical device that may have caused or contributed to the injury, or death, of a patient?
4. Any item that is identified as defective shall be removed from service
5. Complete a Medical Device form and a variance/ incident report
6. Report the event to your manager or supervisor.
7. Notify Risk Management immediately
8. Notify Bio-med immediately
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C. Cellular Phones
At Saint Luke’s South Hospital cellular phones may be used except in designated areas. In these areas the phones need to be switched off because even on stand-by they are still generating a signal which could affect medical devices.
VIII. Back Safety
A key principle in back protection is to maintain the curves of the spine in balanced alignment,
The good news is that back injuries can be prevented simply by following 5L’s when lifting or moving objects.
The Five L’s
Load
▪ Size up the load to be lifted. Do not attempt to lift alone if you have doubts- ask for help!
Lever
▪ Put your work at a comfortable height.
▪ Move in close to whatever is being lifted - do not reach.
▪ Hold the object close to you body- preferably at your waist.
Lungs
▪ Breathe! Take a deep breath before attempting to lift the object.
Legs
▪ Feet should be at least shoulder width apart to give adequate base of support (good balance).
▪ Keep your back straight and bend at the hips and knees
Lift
▪ Straighten your legs to lift not your back.
▪ Lift smoothly to avoid strain
▪ Shift the position of your feet- do not twist the trunk of your body when lifting and / or carrying with your feet positioned firmly on the floor.
▪ Push or roll an object whenever possible- it is safer!
IX. Hazardous Materials Review
A. Hazard Communication (Right to Know)
OSHA's Hazard Communication Standard (Right to Know) states that employees have the right to know about hazardous substances in their work environment. The Hazard Communication Program for Saint Luke's Hospital includes the following components:
1. Employee Training: Employees will learn how to handle chemicals safely, how to use protective equipment, and how and where to get more information on the hazards of the chemicals you work with. Phone number for MSDS is posted on all unit telephones. (1-800-451-8346)
2. Hazard Communication Plan: The written program for Saint Luke's South outlines the steps we have taken to inform you about hazardous chemicals. A copy of the program is available to each area on the I: drive / SLS/ New Plan for Care Manual.
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3. Material Safety Data Sheets (MSDS): The MSDS gives you detailed information on health risks and safe handling for every chemical you work with. A master collection of MSDSs for all hazardous chemicals used at Saint Luke's is available in the front area of the URC.
4. Warning Labels: Each hazardous chemical received by Saint Luke's South is required to be labeled by the chemical manufacturer. The warning label lists the chemical name, hazardous ingredients, and safety warnings on substances you handle. It also lists the chemical manufacturer's name. No further labeling is required unless the hazardous chemical is transferred to another container. If this happens, the new container must be labeled with the name of the material and any hazard characteristics.
B. Hazardous Material Spills
Under no circumstances is any employee to place himself or herself in any situation that may be life threatening or could lead to an injury or illness.
In the event of a hazardous material spill or release, the following guidelines should be followed:
1. Evacuate the area if warranted.
2. Notify Security (63000)/Facilities Management (22285), Safety Officer (63477).
3. Contain the spill if doing so will not result in further exposure. Security can assist
in securing the area until the spill is cleaned up.
4. Close doors to the area.
5. Complete the chemical Spill Investigation Incident Report and return to Safety Officer.
C. Radiation Safety
Radioactive materials and radiation-producing machines are used in the diagnosis and treatment of patients. In the Emergency Services Department, Radiology, Operating Rooms, and Patient Rooms, you may see the Radiation Symbol on or by a door or an “X-Ray” light over the door. Do not enter without first knocking or checking with the charge person.
1. Shipping Boxes containing radioactive materials carry warning labels.
Boxes that contain radioactive materials are safe for normal handling but should not be opened.
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Radiation Symbol
If the shipping package with the above Radiation Symbol Label is wet or appears to be damaged or is leaking, do not touch it. Immediately contact Nuclear Medicine (x67678) or the Nuclear Medicine Technologist on call. Someone will be sent to inspect and dispose of the package.
2. Trash Bags
Trash bags containing radioactive waste are labeled or have a warning tape attached. If the tape has been removed or marked over, the radiation has decayed to a safe level. These bags and cartons can be handled as routine trash.
3. Patients
When patients are being treated with radioactive materials, warning labels are placed on their hospital medical record / chart indicating when they are no longer radioactive.
D. Infectious Waste Review
"Infectious Waste" refers to that portion of medical waste that could transmit an infectious disease. For waste to be infectious, it must contain pathogens with sufficient virulence and quantity so that exposure to the waste by a susceptible host could result in an infectious disease. Infectious waste is also called medical waste, regulated waste, or red-bag waste.
Infectious waste includes the following general categories:
( Sharps
( Cultures and stocks of infectious agents
( Blood and blood products
( Pathology waste
( Isolation waste
Infectious waste must be segregated from other waste at the point of generation. Specifically, the following are categorized as Infectious Waste:
1. All discarded sharps including hypodermic needles, syringes and scalpel blades, broken glass, safety pins, disposable scissors, vacutainers, small glass slides and pipettes, suture needles, or other sharp items that have come into contact with material defined as infectious are also included.
2. Containers contaminated with blood or blood drainage:
a. Sealed collection units, such as Pleur-evacs, should not be emptied. Place in red-lined biohazard box.
b. Open containers, such as specimen cups, should be emptied by pouring accumulated liquids into the sanitary sewer system. Note: Empty urine cups, specimen containers, and urinary drainage bags are considered non-infectious waste, unless bloody drainage is visible on the container after emptying.
3. Items such as dressings, bandages, cotton balls, peripads, chux, etc., may be discarded into the regular trash. However, if these items are capable of releasing blood or other potentially infectious materials in a liquid or semi-liquid state if compressed, then these items are considered to be regulated (infectious) waste and must be discarded into a red biohazard bag.
4. Blood or blood products (bags and tubing).
5. Waste generated from the rooms of patients diagnosed with highly contagious diseases (anthrax, diphtheria, Lassa fever, plague, etc.).
6. Waste generated as a result of dialysis treatments.
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An infectious waste container, marked with the BIOHAZARD warning and lined with a red bag, will be kept in each nursing unit or area generating infectious waste. The container will be kept in the designated area such as dirty utility. When a box is full, tie the red bag shut and close the box. Sealed containers are taken to the Biohazard Room (Lower Level).
A copy of the Infectious Waste Management Plan can be found on I:/SLS/New Plan for Care Manual.
X. Infection Control
A. Introduction
The purpose of the Infection Control program is to contribute toward a high level of patient care by assisting to reduce the risk of hospital-acquired infections.
It is the responsibility of all hospital personnel with potential for contact with any body substance to take the necessary precautions in order to prevent contamination due to direct exposure.
Appropriate barrier precautions include use of gloves, masks, protective eyewear and gowns. Gloves should be worn for touching blood and body fluids, mucous membranes or broken skin of all patients; for handling items or surfaces soiled with blood or body fluids; and for performing procedures such as drawing blood or starting IV’s. Gloves are not a substitute for the quality and frequency of handwashing. Change gloves after contact with each patient and wash hands (bacteria multiply rapidly on gloved hands) or clean hands with the alcohol hand rinse.
Masks with protective eyewear should be worn during procedures that are likely to generate droplets of blood or other body fluids to prevent exposure of mucus membranes of the mouth, nose and eyes.
Gowns should be worn during procedures likely to generate splashes of blood or other body fluids.
In addition, protective devices are available to minimize the need for mouth-to-mouth resuscitation. An adult lifesaver filtered device isolation valve kit (pocket mask) is on each code cart on all nursing units and at each patient bedside.
|The single most important procedure for preventing Health Care Associated infections is |
|HANDWASHING! |
When routine handwashing is indicated during routine patient care, a vigorous rubbing together of all surfaces of lathered hands shall be done for at least 15 seconds, followed by thorough rinsing under a stream of water (use paper towel to turn off faucet).
Alcohol Hand sanitizers are available in all patient care areas. The CDC has recommended that alcohol hand sanitizers be used to clean hand when they are not visibly soiled with blood or body fluids. Artificial, gel nails, overlays, or long finger nails are not allowed by any staff members or students who have contact with patients or the patient environment.
Hand lotion is supplied in dispensers on all nursing care units. Please keep your skin healthy by using this hand lotion. Do not bring other non-approved hand lotions to the hospital as they may have ingredients that may inactivate the antimicrobial effect of the hand soap or alcohol hand cleaner.
DO NOT RECAP USED NEEDLES - Just activate safety device and place them in the sharps container. When the sharps container becomes 2/3 to 3/4 full, the liners need to be changed.
Saint Luke’s South Hospital is using Standard/Transmission Based Precautions (Refer to the I/SLS/Plan for Care Manual for the specific procedure. Standard Precautions replaces Universal Precautions and is used on all patients. Transmission-Based Precautions will include 1) Airborne, 2) Airborne AFB, 3) Droplet, 4) Contact, and 5) Special Contact. Each precaution has a color-coded card listing indications and instructions for use. Remember to use and observe appropriate door signs and isolation stickers. All isolation signs are posted below the patient’s room number.
The Infection Control Manual, available on the I/SLS/Plan for Care Manual / Infection Control, contains policies on Infection Control. It also contains an alphabetical listing of infectious diseases with their appropriate precautions for your easy reference,
The Infection Control Voice mail extension is 67685. Please feel free to call with questions and concerns or pager 816-440-7360 for more urgent concerns. .
B. Bloodborne Pathogens Training
1. Standard Precautions are designed to protect the health care worker from exposure to potentially infectious agents through the use of barriers such as gloves, gowns, masks, and protective eye wear.
2. HBV (hepatitis B Virus) causes “inflammation of the liver” leading to damage of the liver which may be severe, causing cirrhosis and almost certain death. This is the major blood borne hazard you face on the job. There is a vaccination against this disease, the Hepatitis B vaccine. Should you become infected:
5. you may suffer flu-like symptoms becoming so severe
you may require hospitalization
6. you may feel no symptoms at all
7. your blood, saliva and other body fluids may become infectious
8. you may transmit the virus to family, sex partners, and unborn children
3. HIV attacks the body’s immune system which may result in AIDS. There is NO
vaccine to prevent infection. A person with HIV:
9. may carry the virus without symptoms
10. will eventually develop AIDS
11. may suffer from flu-like symptoms, fever, diarrhea, fatigue
12. may develop AIDS related illness-neurological problems, cancer, and other opportunistic infections
4. HIV is transmitted primarily through sexual contact, but may also be transmitted through contact with blood and some body fluids. HIV is not transmitted by touching, feeding or working around patients who carry the disease.
HIV, HBV and other pathogens may be present in:
13. body fluids such as saliva, semen, vaginal secretions, CSF, synovial, pleural, peritoneal, pericardial and amniotic fluids or any other fluid contaminated with blood
14. saliva and blood contact during dental procedures
15. unfixed (not intact) tissue or organs
16. cell or tissue cultures that contain HIV/HBV
17. organ cultures or culture media
Transmission may occur through a variety of means including:
18. accidental injury by a contaminated sharp
19. open cuts, nicks, skin abrasions, dermatitis, acne or mucus membranes of mouth, eyes, and nose
20. indirect contact for example: touching a contaminated surface then transferring infectious material to mucous membranes
NOTE: HBV can survive on a surface dried and at room temperature for at least a week.
5. Exposure Control Plan
In order to limit exposure, the Exposure Control Plan was developed to reduce a significant risk of infection by monitoring or eliminating occupational exposure to blood and other potentially infectious materials. This plan in its entirety is located in the Plan for Care Manual on the I drive. One portion of the OSHA guidelines was to divide health care workers into three categories. They are as follows:
CATEGORY I: Tasks that involve exposure to body substances (caregivers).
CATEGORY II: Tasks that do not involve exposure to body substances but the potential is present because of conditions of employment (i.e., clerical support on nursing units).
CATEGORY III: Tasks that involve no exposure or potential exposure to body substances (i.e., administrative personnel).
Each patient room contains a puncture- proof “sharps” disposal container as well as glove dispenser. Each nursing unit has a “hazardous waste box” in the soiled utility room for disposal of contaminated equipment and other supplies.
If unanticipated exposure occurs, wash the exposed area immediately, apply appropriate barriers, clean up the body substance as necessary and proceed with patient care. Nursing personnel will clean up the initial spill, then contact a service coordinator for additional clean up as needed.
Refer to the I: Drive / SLS / Plan for Care Manual for additional information.
Methods of controlling exposure are divided into engineering and work practice controls and are defined as follows:
Engineering Controls act on the source of the hazard and eliminate or reduce employee exposure without reliance on the employee. These include:
21. ventilation systems including laboratory hoods
22. sharps containers (mounting containers upon request from nursing)
23. safety devices such as the Magellan safety needle, In-syte Autoguard IV catheter.
24. negative pressure isolation rooms
Work Practice Controls reduce the likelihood of exposure through alteration of the manner in which a task is performed. The protection they provide is based upon behavior of the employee. These include:
25. proper and frequent handwashing
26. use of gloves and other personal protective equipment
27. proper use and disposal of needles (Do not place any sharps in trash bags, leave in linen, lying on the floor, etc.).
NOTE: Contaminated needles shall not be recapped, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. If there is NO alternative to recapping it must be accompanied with a mechanical device using the syringe outer sheath with the one handed recapping technique.
28. avoid eating, drinking, applying cosmetic or lip balm and handling contact lenses in areas of potential exposure.
29. choose appropriate personal protective equipment for procedures.
30. label specimens and place in plastic bags, seal and apply BIOHAZARD sticker.
Personal Protective Equipment is specialized clothing or equipment provided to employees for protection against a hazard. For example, gloves, gowns, some lab coats, face shields, masks, goggles, and ventilation devices. These devices are readily accessible to all employees and will be cleaned, laundered and disposed of at no cost to the employee.
Should employee uniforms become soiled with potentially contaminated fluid, it must be laundered by the hospital to prevent migration of contaminants. Place soiled uniform in bag and label with your name and area. However, the hospital is not responsible for any loss or damage to an employee uniform if laundered within the institution.
Hazards of bloodborne pathogens must be communicated to all employees by use of the fluorescent BIOHAZARD sticker or color coded (red) trash can liners.
Needlestick Prevention
31. Do not recap needles. If, because of a special circumstance a needle must be recapped, use the one-handed scoop method.
32. Always activate the safety device on needles.
33. Never bend, break or otherwise manipulate needles/other sharps.
34. Always place needles/other sharps in approved, properly labeled sharps container.
Do not overfill sharps containers. Dispose of liners when they become two-thirds to three-fourths full, or if you consider the container to be unsafe. For example - a needle protruding from the container.
Use the proper size container for the items you are disposing.
Do not force needles/other sharps into containers. Never reach into a sharps container or use another item/object to push a needle/other sharp into the container or to “compact” what is in the container.
Keep fingers out of container.
Don’t allow patients and visitors to treat the sharps container as a waste receptacle or hanger for personal items.
Don’t place anything on top of a sharps disposal container such as glove boxes, tissue boxes or used syringes.
Please note that the sharps disposal containers are not intended for the disposal of any other materials such as adhesive tape, alcohol wipes, tubing or gloves. Using them for such items creates a hazard. For example, adhesive tape will cause needles /other sharps to lodge near the top of the container, creating an unsafe condition not only for you, but also for the next employee who may come in contact with the container.
35. Needles/other sharps should never be placed in a trash or linen receptacle, stuck into a mattress or towel or left on an instrument/procedure tray or on any surface area such as a counter or bedside stand. Doing so creates a hazard for other employees and sometimes patients. For example, an IV needle stuck in a towel creates an unsafe condition for you as well as the employee who is cleaning the room or handling the linen receptacle after you are finished.
36. Do not reach into a trash/linen bag. Look at trash/linen bags before handling them.
37. Get help when necessary to administer injections or infusion therapy.
38. When filling laboratory tubes from a syringe and needle, place tube in rack before filling. Do not hold tube in your hand to fill.
Tuberculosis
OSHA mandates that information related to the hazards and control of tuberculosis be reviewed annually.
1. Cause and Transmission of TB
39. TB is an infectious disease that spreads in the air when the bacilli, Mycobacterium tuberculosis are inhaled.
40. Bacilli are put into air when an infected person coughs, sneezes, laughs, or sings.
41. Bacilli can stay airborne for long periods of time with normal air currents.
2. TB Infection vs. TB Disease
a. TB infection-susceptible person had inhaled TB bacilli. Bacilli become encapsulated in person with healthy immune response. This limits further multiplication and spread.
42. Individuals infected with TB are usually not contagious
43. Bacilli are inactive and they are not contagious
44. About 10% of infected persons will develop clinically active disease at some time in their lives.
b. TB Disease-usually have one or more symptoms of TB
i. Symptoms
45. chronic cough
46. weight loss
47. hemoptysis
48. fatigue
49. decrease appetite
50. night sweats
51. weakness
52. fever
ii. Individuals are sick.
iii. Bacilli are active in the body and they are contagious.
iv. Health care personnel with active TB are excluded from work until treatment instituted and cough resolved or sputum free of bacilli on three consecutive smears.
v. All suspected or diagnosed cases of TB are to be reported to Infection Control Department so appropriate reporting and investigating can be performed. A sputum culture will be obtained. The sputum culture may be positive for AFB (acid fast bacilli), but the patient may or may not have TB. Other AFB strains such as M.avium or M.kansasii will show a positive smear but are not contagious and not the same as M.tuberculosis. It will then take another 3-6 weeks to culture out and positively identify the type of mycobacterium present.
3. Risk Factors for TB Development
( Being HIV (+) ( People from countries with high TB rates
( Being on steroids ( Alcohol & IV Drug Users
( Alcohol & IV Drug Users ( Chronic malnutrition
( Certain medical conditions (i.e., some diabetes)
( Close contact with untreated TB
4. Use of Source Control Methods
a. Having patient cover nose and mouth when coughing or sneezing.
b. Personal Protective Equipment
53. Special, properly fitting mask that can filter 1-5 micron TB bacilli (N-95 Mask). Temporary staff or students should contact Employee Health for Fit testing prior to donning a mask if one is required to be one to complete your assignment.
54. PAPR- Purified Air Powered Respirators for use when a staff member is unable to wear the N-95 Mask are available through Employee Health and the Safety Office
55. Use of gloves for draining TB accesses.
56. Limitations - be aware that all personal protective equipment has limitations. For example, wet or damaged masks may not be effective and neither would torn gloves be effective against preventing TB spread.
5. Engineering Controls in Work Area
a. Adequate ventilation to outside
b. Negative pressure rooms - opposite of normal patient room with positive pressure. Air flow in negative pressure rooms goes from hall to inside of room, this helps keep bacilli out of hallways. For negative pressure to be effective:
• Door must remain closed.
• AFB isolation sign (not respiratory) must be outside
patient rooms with specific instructions for persons entering room.
• Good handwashing still essential.
D. Reporting an Exposure Incident
1. Management of Accidental Exposures to Blood/Body Fluids
Definition of Exposure: Hazardous body fluids (HBF) include blood, bloody fluids, and other body fluids which are know or assumed to be associated with transmission to bloodborne pathogens.
Exposure Incident: A specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious materials that result from the performance of an employee’s duties.
Other Potentially Infectious Material:
a) Semen, vaginal secretions, cerebrospinal, synovial, pleural, pericardial or amniotic fluid; saliva in dental procedures; any body fluid that is visibly contaminated with blood; and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;
b) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and
c) HIV containing cell or tissue cultures, organ cultures and HIV or HBV containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.
Should exposure occur: Irrigate the area of exposure well, notify your immediate Supervisor, then report to Employee Health (if open) or report to the Emergency Room and notify Employee Health.
2. The post exposure evaluation will include:
a. Documentation of circumstances and route under which exposure occurred.
b. Identification and documentation of source individual.
c. Source individual blood shall be tested as soon as feasible if consent is obtained in order to determine HIV and HBV infectiousness.
d. If infection of source individual is already documented it need not be repeated.
e. Results of source individual tests shall be made available to the exposed employee in accordance with applicable laws and regulations.
f. Collection of employee’s blood for HBV and HIV serological status, unless employee waives testing.
g. If necessary post exposure prophylaxis including counseling.
h. Evaluation of reported illness.
E. Risk Management Laws
Clinical staff is quite literally the eyes and ears of the risk management program. No one area, individual, or group “does” risk management. Identifying and preventing loss exposures is the responsibility of all hospital employees, as well, as the medical staff.
In 1986 legislation was passed which specified that every hospital in the State of Kansas must have a written Risk Management Plan. This legislation is known as the Risk Management Laws. The hospital’s risk management plan is reviewed annually and submitted to the State of Kansas for approval.
A. What is the essence of the risk management laws?
Specifically, the law requires that each “reportable incident” be identified and investigated to determine whether or not specific acts meet expected standards of care.
B. Who is responsible to comply with the risk management laws?
Associates and agents of the hospital who are directly involved in the delivery of health care services, including but not limited to, registered and practical nurses, mental health care technicians, physical and occupational therapists and assistants, respiratory therapists, dentists, dental hygienists, and physicians.
C. As an associate of the hospital or as member of the medical staff, what do the risk management laws require of me?
The laws require you to report “…an act by a healthcare provider which
1. is or may be, below the applicable standard of care and has a reasonable probability of causing injury to a patient; or
2. may be grounds for disciplinary action by the appropriate licensing agency.”
Essentially, that means you report all “unusual incidents” or “unusual occurrences” that happen in the hospital and of which you have personal knowledge.
E. How do I make the “report”?
The “report” is made by completing the incident report in the risk management access database called RiskMaster located on an icon in Citrix. See below.
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Under risk management law, the “report” can be made to anyone of the following three persons:
1. The Risk Manager, or
2. The Chief Executive Officer, or
3. The President of the Medical Staff.
If you place the incident into the risk management access database, the “report” is deemed to have been made to the Risk Manager.
F. Is there penalty for not reporting?
Yes, the risk management laws contain a criminal penalty for willful and knowing failure to report; stating that such failure is a Class C misdemeanor. This means a fine of not more that $500. Incarceration of up to one month can be imposed.
G. When do I complete an incident report?
A variance / incident report must be filed under any of the following circumstances:
1. A disturbance occurs that may, or does, disrupt hospital functions or which may affect the standing of the healthcare facility in the community.
2. An undesirable event occurs which is inconsistent with normal patient care.
3. A significant violation of established policy and procedure occurs.
4. An unusual event occurs which does, or may result in, personal injury.
WHEN IN DOUBT, FILL IT OUT
Any event involving severe injury or voiced intent to seek legal counsel by a patient, visitor, or family member, requires immediate verbal communication to the risk manager, in addition to completion of a incident report.
XI. Corporate Integrity
The Saint Luke’s-Health System is committed to conducting all business in a legal and ethical manner and to abiding by all applicable laws. It is an expectation of the System that all employees conduct themselves in a manner consistent with that commitment. The System Corporate Integrity Plan has been created to assist in fulfilling that commitment.
No one expects all employees to be an authority in the law. The goal of the Plan is to provide fundamental information, which will prompt appropriate questioning and increase awareness of legal issues which may arise in a given situation. Commitment to compliance and ethical behavior will be recognized – unlawful or unethical behavior will not be tolerated. The Plan requires that any information regarding a known or suspected violation of the law be reported. It may be difficult to present certain concerns directly to a manager or supervisor; therefore, a hotline has been set up for reporting purposes. This hotline can be accessed by dialing 932-3053 or 1-888/860-6227 (a toll free number). The reporting individual may identify him/ herself or may remain anonymous. All calls will be investigated and resolved to the best of the System’s ability.
The compliance standards and procedures of the plan encompass the following areas: Fundamental Policy of Compliance, who is covered, responsibility of all employees, and additional responsibilities of managers and supervisors. Compliance program oversight involves the System Compliance Officer and Committee, as well as the board. Other key aspects reference due care in delegation, employee training, monitoring and auditing, enforcement and discipline, response and corrective action. Specific items detailed include billing practices, improper payments, contracts, antitrust, conflicts of interest, confidentiality of patient information, system proprietary information and property, proprietary information of others, advertising/ marketing, discrimination, Americans with Disabilities Act (ADA), sexual harassment, environmental compliance, OSHA, Emergency Medical Treatment and Active Labor Act (EMTALA), Safe Medical Devices Act, and political activity.
All employees receive a copy of the System Corporate Integrity Plan. The Plan is reviewed with each individual upon hire and annually thereafter. Signed acknowledgment of the Plan is maintained in the employee's file. Additional copies of the Plan are available from Human Resources.
XII. Workplace Violence
Saint Luke’s South’s objective is to provide a safe and secure environment for process owners, physicians, patients, visitors and the public.
Workplace violence is any act of physical or verbal aggression or threats of violence by an individual that occurs at the work site. The intended target may be an employee, patient, visitor or physician.
Policy
1. Any employee who initiates and/or participates in any act of occupational violence will be subject to disciplinary action up to and including termination and may also be mandated to the Saint Luke's Employee Assistance Plan (EAP).
2. Any employee who observes or receives a threat should report it immediately to their Manager and/or Human Resources. If neither are available, they should contact the Administrator on-call. All threats of violence should be reported to Security.
3. Incidents of violence in the workplace will be assessed by Human Resources and Security.
Procedure
Whenever an incident of violence in the workplace is reported the following procedure will be followed:
1. Notify Security immediately if there appears to be a potentially violent situation, or as soon as possible after the start of an act of violence.
2. Security will immediately respond and take appropriate action to prevent any further act of violence.
3. Security will follow the appropriate security protocol as outlined in the security manual for handling the situation.
4. Security will notify Human Resources, the Administrator on call and EAP (as appropriate) to notify them of the situation.
5. The associate who has initiated or participated in any act of occupational violence will automatically be suspended pending further investigation.
6. An incident report will be completed by Security. Security will review the report; send copies to Human Resources, Administration, the associate’s manager, Risk Management and EAP (as appropriate).
XIII. Ethics
Issues of Potential Ethical Concern:
1. SLS embraces the System policy on Cultural Values, Ethical Convictions, and Religious Beliefs as the framework for responding to issues of potential ethical conflict regarding patient care issues. The purpose of the policy is to manage situations in which personal cultural values and ethical/ religious beliefs of personnel are in conflict with patient care treatment choices. The associate must report, in writing, the basis of the conflict to the Manager. When possible, patients will be reassigned to accommodate the cultural values, ethics, or religious beliefs of staff members. However, nothing in the reassignment process shall result in a negative impact on patient care.
Ethics Committee:
2. The purpose of the Ethics Advisory Committee is to consider, through education, policy review and case consultation; ethical issues regarding the care of patients. Ethics Advisory Committee functions are detailed in operational policy - Ethics Committee.
The Committee serves those who need a place for discussion, support in facing choices, consultation and/ or assistance in resolving conflicts. The Ethics Committee is available to provide ethical consultations.
A consultation with the committee may be requested by a patient, his/her family, a patient’s friend or any health care provider directly involved with a patient by contacting the chaplain, a social worker, or Administration. While the committee does not have decision-making authority, it can make recommendations regarding the care of a patient.
XIV. Additional Review Requirements for Patient Care Staff
Organ and Tissue Donation Information
It is important to call the Midwest Transplant Network at 1-800-DONOR-91 (1-800-366-6791) to prescreen every patient that dies for donation options. This allows the requestor to know exactly what options, if any, to present to the family. It is preferable to call as soon as possible after cardiac death or diagnosis of brain death or unrecoverable severe brain injury.
If the patient is deemed eligible to donate by the Midwest Transplant Network, and there is no previous information that the patient would not wish to donate, the family must be approached. The approach must be facilitated by a Requestor trained by the Midwest Transplant Network, although the actual request may be assisted by another staff person. A list of trained Requestors is provided to each unit, and is available from the Spiritual Wellness office. In the event of brain death or severe brain injury and potential for donation of solid organs, screening and request will be made by a Coordinator from the Midwest Transplant Network, who will come to St. Luke’s South.
A Transplant Coordinator or Requestor will allow the family time to acknowledge their loss before approaching them about donation. It is important not to mention donation before death has occurred, whether it be brain death or cardiac death, or before a family has made a decision to withdraw life-sustaining support. Midwest Transplant Network personnel are available at any time for staff questions and support, as well as answer the family’s questions regarding donation options.
Offering the option of donation to a family provides them with the opportunity to make something positive come out of their tragedy, gives them back some control in a helpless situation, and allows them to carry out their loved-one’s last wishes. Many donor families express that donation helps them in their healing journey and gain some comfort in knowing that they were able to give such precious gifts of life.
Advance Directives
An Advance Directive is a term used for any document which allows the patient to communicate their health care treatment preferences when the patient is not able to make or communicate their decisions. The US Supreme Court decision clearly indicates that all people have a constitutional right to refuse any medical treatment, including life-prolonging procedures. Further, the Court’s decision affirms the right to name an agent to be a surrogate decision-maker for health care issues in the event decision-making capacity is lost.
The Advance Directive may include two parts:
1) A Health Care Treatment Directive and,
2) A Durable Power of Attorney for Health Care Decisions.
A patient may have either document or both.
The Health Care Treatment Directive is a signed, dated and witnessed document that allows you to state in advance your wishes regarding the use of life-prolonging procedures. It is similar to a living will, with which many people are familiar: however it is far more comprehensive than most living wills. Like the living will, the Health Care Treatment Directive has no effect until you can no longer make or communicate for yourself, and there is no expectation of recovery to an acceptable quality of life..
The Durable Power of Attorney for Health Care Decisions provides a way for you to appoint an agent to make health care decisions which you have not already covered in your Health Care Treatment Directive. This document goes into effect WHEN and ONLY WHEN you lack capacity to make or to communicate decisions for yourself. It is not restricted to use only when you are terminally ill.
At SLS it is the admitting RN’s responsibility to document the patients’ decision regarding Advance Directive (AD) on the electronic record within 24 hours of admission and prior to any procedure or surgery.
▪ If the patient has an AD, a copy of the current AD, dated and initialed by the patient, must be on the chart. The RN will assist the patient in retrieving the document whenever possible.
▪ If the patient can not or does not provide a copy of the AD, the patient must be offered an opportunity to complete a new AD.
▪ Kansas State law requires that the signature of a patient on an Advance Directive be witnessed by two witnesses or that it is notarized. If witnessed and not notarized, the witnesses must have no financial or personal stake in the patient’s death, and must not be involved in making treatment decisions or providing direct health care to the patient. Some IC’s are notaries; a list of current notaries is available on the I drive at SLS/Resource Notebook.
▪ If there are questions or concerns in educating patients and families about Advance Directives, a Social Work consult should be initiated. The Chaplain can also be consulted.
▪ For additional information, please refer to the Patient Care Policy.
▪ Forms for the Advance Directive and information for the patient and family in written form are available on each unit. A Spanish version is also available in both written form from the Spiritual Wellness office.
▪ SLS will honor the patient wishes in accordance with the laws of Kansas, so long as directions comply with state law. Any provider who will not honor the patient’s Health Care Treatment Directive is obligated to assist in arranging transfer to a provider who will honor the patients advance directive.
▪ If the patient is unable to communicate AD information on admission, the patient must be given the information and opportunity to complete an AD when they are able to communicate.
C. Restraints
POLICY STATEMENT - SUMMARY FOR COMPETENCY The St. Luke’s Health System supports the limitation of restraint use to clinically appropriate and adequately justified situations. Our goal is to reduce the use of restraint through preventative and alternative strategies that protect the patient’s health and safety and preserves his or her dignity, rights, and well being.
The System is committed to ensuring that Health Care Providers are adequately trained during orientation in the prevention and alternatives to restraint use, as well as the purpose and techniques for their appropriate use when clinically justified. Annual competency in the application and alternatives to restraint usage are required for all Health Care Providers who deliver direct patient care. The system is committed to moving toward a restraint free environment by identifying opportunities for growth and change in regard to the use of restraint through the performance improvement process.
Note: This is an abbreviated version of the Patient Care Policy and Protocols for Restraints. Please refer to the complete document for further information.
D. COBRA/EMTALA
▪ Consolidated Omnibus Budget Reconciliation Act was passed 1986 (COBRA)
▪ Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance
EMTALA- Emergency Medical Treatment and Labor Act- known as the patient anti-dumping law.
Patient “dumping” started to gain attention in 1961 when private hospitals began to send indigent patients to public (county) hospitals.
Who does EMTALA apply to?
Any Medicare-participating hospital with an “dedicated emergency department.”
Dedicated emergency department (DED) means:
▪ State licensure as an ED
▪ Held out to the public where care can provide on an urgent basis without appointment
▪ In previous year, 1/3 or outpatient appointments were unscheduled or without an appointment
SLS has 2 Dedication Emergency Departments (DED)
▪ ED
▪ Maternity Unit
DED’s must keep the following documents:
▪ Keep on log on all patient entering for treatment regardless of whether they are admitted
▪ Keep physician on-call list
Medical Screening Examination Definition
MSE: Means “medical screening examination” and refers to the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in Labor.
Such screening must be done within the facility’s capability and available personnel, including on-call physicians and other Qualified Medical Personnel (on OB, competent labor nurses have been approved by the medical staff to complete the MSE).
The medical screening examination is an on-going process and the medical records must reflect continued monitoring based on the patient’s needs and must continue until the patient is either stabilized or appropriately transferred.
Appropriate Transfers of Patients with Emergency Medical Conditions
An emergency medical condition is defined as “a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individuals health (or the health of the unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs”.
Screening of intoxicated individuals must be sufficient to r/o medical, toxic, psychiatric, and trauma causes for the apparent state.
A transfer can be properly authorized in 2 ways:
▪ The patient or legal rep. requests transfer.
o or
▪ the physician has certified that the medical benefits to be received at another Hospital outweigh the increased risks to the patient (and, as the case may be, to her unborn child); or if the physician is not present, the labor nurse can get it certified through consultation with the physician (This situation is based on the fact that the benefits of transfer outweigh the risks).
These things must occur in all transfers:
▪ Must be given a medical screening exam and stabilizing treatment must be given.
▪ Must have physician order to transfer.
▪ Patient must sign (certificate of transfer form)
▪ Risk and benefits of transfer must be explained.
▪ SLS must provide treatment within its capability to minimize the risks to the individual’s health and the health of the unborn child.
▪ Receiving facility and physician must agree to accept. Must have capability / capacity to accept.
▪ SLS must send copies of pertinent medical records to continue care.
▪ Transfer mode must be safe. – e.g. ambulance. If ambulance is refused- must have physician order.
***See Transfer packet for forms and checklist.
Patients MAY NOT be transferred for physician convenience or practice preferences.
▪ TRIAGE BY A NURSE DOES NOT MEET THE REQUIREMENT FOR A MEDICAL SCREENING EXAM.
▪ X-rays must be sent with the patient. ***See Transfer packet for forms and checklist.
▪ SLS (or its designated agent) must accept request for an in-coming transfer from another hospital’s Emergency Room department if the hospital has the specialized capabilities needed by the patient and transferring hospital is relatively less able to care for the patient.
▪ The hospital may decline if the patient can be adequately and completely cared for at the originating facility or when the hospital lacks the physical capacity to handle the patient.
▪ Emtala applies to 250 feet surrounding the facility.
Contact Risk Management for reporting known or suspected COBRA violations.
XV. STRENGTH THROUGH DIVERSITY: BUILDING EFFECTIVE WORK TEAMS
Strategies for the Workplace
Personal Dimensions
▪ Talk about diversity issues with others to raise their awareness and understanding.
▪ Learn about people different from yourself.
▪ Initiate steps to get to know as individuals people who are different from you.
▪ Be alert to what is taking place in the media and how it affects your cultural values.
▪ Value those who are different from you for their unique abilities and perspectives.
▪ Have personal dialogues with members of diverse groups in each others’ homes.
Interpersonal Dimensions
▪ Explore how you think about yourself and others.
▪ Learn how to speak and listen to people with different backgrounds.
▪ Think about the impact of your comments and actions before you speak or act.
▪ Refuse to use or listen to ethnic or sexual humor.
▪ Ask people who are using discriminatory language and behavior to stop doing so.
▪ Avoid using language that reinforces negative stereotypes.
▪ Include people who are different from you in the decision-making processes.
▪ Provide timely and honest feedback to others, even if it feels risky.
▪ Share the formal and informal rules of your group or organization with others.
▪ Respect different points of view.
▪ Talk straight – clearly, directly, honestly and respectfully.
▪ Welcome and become able to deal constructively with different opinions.
▪ Understand and accept other people’s frame of reference and values.
▪ Be flexible in your thinking.
▪ Speak out, raise issues and act on opportunities for change.
▪ Recognize that there is no “one right way”, that no one person can see it all.
▪ Remove barriers and blocks that limit the inclusion of all people’s talents.
▪ Continue to develop the skills to work effectively in a culturally diverse organization.
Organizational Dimensions
▪ Hold yourself accountable for creating a safe, respectful and trusting environment.
▪ Create an environment where dialogue and creativity flow freely.
▪ Recruit and refer qualified minority candidates to this organization.
Putting Diversity in the Proper ORDER
O – Observe the behavior.
What is not right about it?
What was the impact?
R – Reflect.
What could be done differently?
D - Develop a response.
What points do you want to make?
E – Engage.
Deliver your response to the individual(s) involved.
R – Review results.
Did the individual(s) understand your response?
Were you satisfied with the results?
XVI. Plan For Care - Policies/Procedures/Protocols At SLS
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All SLS policies, procedures and protocols are available via the computer on the I: drive The easiest way to access the I: drive is using the Plan for Care icon on Citrix.
Documents can be accessed directly by going to the folder where the document is located or by using the Plan for Care Search database. The database allows you to search for documents even if you do not know which folder the document is in or the exact name of the document.
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The database opens to a Main Switchboard. The Search button searches for key word(s) in title, file name, and cross reference fields.
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Clicking the Search button opens a dialog box where the user can enter a key word(s) to search for.
Tips for searching using key words:
▪ Keep key words as short and simple as possible
▪ Start with one or two word search when possible
▪ If search is unsuccessful, try simplifying search criteria, for example remove the “s” from the end of a word, try an abbreviation of the word, etc.
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The Search button returns a list of documents that contain the word(s) being searched for. Highlight the desired title on the list and double click to open the document.
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The Plan For Care Folder screen gives you information which includes:
Title: Title or subject as it appears on the document
File Name: File name of document as saved on I:drive
File Folder 1, 2, 3: Location of document on I:drive
Type: Policy, Procedure, Protocol
Most recent date: Most recent date policy was created, reviewed, or revised (from footer)
Review due date: Two years from most recent date
Responsible Party: Person(s) responsible for document maintenance, review
Cross reference: Other names, words by which document might be searched for
Related Documents: Other policies, procedures, or protocols
Archived Date: Date when document has been permanently archived
From the Plan For Care Folder screen the user can access the document directly by clicking the Link to Document on I:drive button, perform another search, or return to the Main Menu of the database.
The I:drive is a protected, read-only drive. Only specified staff have access to make changes in the I:drive. Questions regarding policies, procedures, protocols, or the Plan for Care Search should be referred to the Plan for Care Committee by Bart Carnoali, Quality and Outcomes Manager.
XVII. National Patient Safety Goals
The purpose of the National Patient Safety Goals (NPSG) is to promote specific improvements in problematic areas of patient safety. Complying with the NPSG is the responsibility of every SLS employee within his/her job responsibilities.
Goal 1 Improve the accuracy of patient identification.
▪ Use at least two patient identifiers (neither to be the patient’s room number) whenever administering medications or blood products, taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures.
Note: The 2 patient identifiers used by SLS are the patient’s name and date of birth. Ask the patient to tell you their name, their date of birth and compare that with your written information, such as the Medication Administration Record (MAR) or requisition.
Goal 2 Improve the effectiveness of communication among caregivers.
▪ For verbal or telephone orders or for telephonic recording of critical test results, the order or result must be written or entered into a computer, then verified by having the person receiving the order or test result “read-back” the complete order or test result and requesting confirmation of accuracy.
▪ Note: All test results that are reported by telephone are considered “critical” results for purposes of read-back.
▪ Standardize a list of abbreviations, acronyms, and symbols that are not to be used throughout the organization.
▪ Note: Refer to the yellow DO NOT USE List of Abbreviations which should be located in the front of every medical record.
▪ Measure and assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible caregiver, of critical test results and values.
▪ Implement a standardized approach to “hand-off” communications, including an opportunity to ask and respond to questions.
Note: SLS uses the Situation/Background/Assessment/Recommendation (SBAR) format for all “hand-off” communications. Unit or Department specific tools are designed to assist with this process. This applies to numerous types of patient hand-offs including nursing shift change, temporary responsibility for staff leaving the unit for a short time, hand-off from Emergency to the nursing unit, transfer from one unit to another, etc. Hand-off communication must include up-to-date information, an opportunity for questions, should limit interruptions, and include a verification of received information, such as a read-back, when appropriate.
Goal 3 Improve the safety of using medications.
▪ Standardize and limit the number of drug concentrations available in the organization.
▪ Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.
▪ Label all medications, medication containers (for example, syringes, medicine cups, basins) or other solutions on and off the sterile field.
Goal 7 Reduce the risk of health care-associated infections.
▪ Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
▪ Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.
Goal 8 Accurately and completely reconcile medications across the continuum of care.
▪ Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.
▪ A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.
Note: Refer to the Medication Reconciliation upon Admission, Transfer or Discharge Policy and the Medication History and Reconciliation Form.
Goal 9 Reduce the risk of patient harm resulting from falls.
▪ Implement a fall reduction program and evaluate the effectiveness of the program.
Note: Refer to the Care of the Patient at Risk for Fall or Injury Protocol.
Goal 13 Encourage patient’s active involvement in their own care as a patient safety strategy.
▪ Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.
Note: Refer to Patient’s Rights and Responsibilities, information available and provided to patient’s and family as part of the admission process.
Goal 15 The organization identifies safety risks inherent in its patient population
▪ The organization identifies patients at risk for suicide (patients being treated for emotional or behavioral disorders).
Note: Patient Assessment includes mental/emotional aspects of care. Plans for care are adapted to fit the individual need of the patient which includes suicide precautions if necessary.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery
▪ Preoperative verification process: to ensure that all relevant documents and studies are available prior to the start of the procedure and have been reviewed and are consistent with each other and with the patient and team’s understanding
▪ Marking the operative site: to unambiguously identify the intended site of insertion or incision
▪ “Time-out” immediately before starting the procedure: to conduct final verification of the correct patient, procedure, site, and as applicable, implants using active communication among all members of the surgical team
Note: The Universal Protocol applies any time an informed consent is obtained for a procedure, whether in the operating room, in an ancillary department, or in the patient’s room.
XVIII. Information Management: Abbreviations
SLS does not encourage the use of any abbreviations as this can lead to unsafe practice. However, the Saint Luke’s Health System has adopted Steadman’s Abbreviations as the reference tool for any abbreviations used. This tool can be found via the Citrix icon.
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The following is a list of dangerous abbreviations as defined by the Joint Commission on Accreditation of Healthcare Organizations and should not be use in the medical record by the Hospital or the Medical Staff. This list should be kept in the front on each medical record.
DO NOT USE List of Abbreviations
|Abbreviation |Potential Problem |Preferred Term |
|U (for unit) |Mistaken as zero, four or cc |Write “unit” |
| | | |
|IU (for International unit) |Mistaken as IV (intravenous) or 10 (ten) |Write “International unit” |
| | | |
|Q.D., Q.O.D. |Mistaken for each other. The period after the Q |Write “daily” and “every other day” |
|(Latin abbreviation for once daily and |can be mistaken for an “I” and the “O” can be | |
|every other day) |mistaken for an “I” | |
| | | |
|Trailing Zero (X.0 mg), |Decimal point is missed |Never write a zero by itself after a decimal point |
|Lack of Leading Zero (.X mg) | |(X mg), and always use a zero before a decimal |
| | |point (0.X mg) |
| | | |
|MS, MSO4 or MgSO4 |Confused for one another. |Write “morphine sulfate” or “magnesium sulfate” |
| |Can mean morphine sulfate or magnesium sulfate | |
If the above abbreviations are used in written physician orders, clarification of the order should be obtained before implementation of the orders whenever possible. The safety of the patient always comes first. If, in the judgment of the people providing care to the patient (e.g., the registered nurse and pharmacist), the order is clear and complete and the delay to obtain confirmation from the prescriber prior to execution of the order would place the patient at greater risk, then the order should be carried out and the confirmation obtained as soon as possible thereafter.
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