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PLAN FOR PROVISION OF CARE

Scope of Service

Barrett Hospital and HealthCare

Planning and Providing Care

Purpose:

The care of patients at Barrett Hospital and Healthcare is planned to ensure that care is appropriate to the patient’s needs and severity of illness, impairment or disability.

Care is provided through a multidisciplinary approach and is individualized to each patient. Planning for care can occur in a variety of ways, including but not limited to multidisciplinary care planning conferences, consultations, and both formal and informal communication. Each patient’s care is based on identified patient care needs and patient care standards and is communicated to all members of the healthcare team.

Scope of Service

The following paragraphs describe the clinical scope of service, the general staffing plan, and the provision of clinical service.

Anesthesia Services:

Two full time Certified Registered Nurse Anesthetists provide general, regional and Monitored Anesthesia Care for surgical procedures. Anesthesia providers are available five days per week from 7:00 AM to 5:00 PM and on-call for the remainder of time.

Cardiopulmonary Services:

Respiratory therapists provide the following services to all age groups: electrocardiograms, cardiac stress testing, Holter monitoring, thirty day cardiac event monitoring, and testing for peripheral arterial disease. Respiratory treatments include, but are not limited, to the following: nebulizer and inhaler treatments, CPAP and BIPAP treatments, incentive spirometry, ventilator management, pulmonary function testing, and smoking cessation. The respiratory therapists are NRP certified, BLS and ACLS certified. The respiratory therapists attend all c-section deliveries. Respiratory therapists are staffed seven days per week from 0700 to 1900 and on-call the remainder of time.

Cardiac Rehabilitation Services:

The Cardiac Rehab Medical Director oversees the BHH Cardiac Rehab program. The Cardiac Rehabilitation Medical Director or physician designee shall be immediately available when high-risk patients are participating in scheduled exercise sessions. The referring physician or physician designee shall provide direct supervision for their individual patients, remaining immediately available and accessible at all times when the referred patient is participating in Cardiac Rehab. The Medical Director and all supervising physicians will have expertise in the management of individuals with cardiac pathophysiology, BLS and ACLS training, and be licensed to practice medicine in the state in which the Cardiac Rehabilitation is offered. A registered nurse, certified in BLS and ACLS, coordinates the cardiac rehabilitation education and rehabilitation program. The RN has specialized training in the care of the cardiac patient either through self study or through an approved program. The department is staffed to supervise 3 outpatients at one time. Staffing will depend on the risk level of patients served on a particular day. Cardiac rehab is provided Monday through Friday, as needed and per patient need.

The American Heart Association, the American College of Sports Medicine (ACSM), and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) are references used in the formulation and review of policies, procedures and standards of practice in Cardiac Rehabilitation, as well as collaborative input from the knowledge and expertise of the Cardiac Rehabilitation staff.

The patient population served by Cardiac Rehabilitation consists of the adult and geriatric population who has cardiopulmonary disease. Cardiac Rehabilitation provides a safe and comfortable environment for patients with cardiovascular disease requiring interventions to prevent complications and to provide restorative health needs to restore an optimum level of wellness for the patient.

The patient’s physical, psychological and social needs are assessed prior to beginning the Cardiac Rehab Program. Reassessments are performed throughout the patient’s Cardiac Rehab Program. An individualized treatment plan (ITP) is established by the referring physician or Medical Director, in coordination with the CR nursing staff, reviewed, revised, and signed every thirty days. Modifications of the ITP are based on the reassessment of the patient. The scope of services includes exercise prescriptions with cardiac monitoring via telemetry, education/counseling for cardiac risk factors, lifestyle modifications to include smoking cessation, weight management, lipid management, control of blood pressure, stress management, behavior change, and others.

Clinic Services

Barrett Hospital & HealthCare Clinic department provides physician services to patients of Barrett Hospital. The department provides inpatient and outpatient call and medical care coverage. The employees of the department provide medical care to inpatient care, outpatient care, office care, home health care and nursing home care. This is a clinic department with office hours 0800 to 1700 PM Monday through Friday. The physician employees of this department provide rotational call coverage for Internal Medicine, Family Practice, Obstetrics and General Call 24 hours a day.

Diagnostic Imaging:

The Diagnostic Imaging department is staffed 0700 to 0130 Monday through Friday and 0700 to 2300 Saturday and Sunday with an on-call service for off hours. Every radiology services technologist is accredited through the American Registry of Radiology Technology (ARRT), and licensed by the State of Montana. There is a radiologist available for interpretation and consultation M-F and Teleradiology Services 24/7 as needed.

Radiology Imaging Services is comprised of CR imaging, fluoroscopy, Mammography and Bone Densitometry. In addition, advanced modalities in Sonography, Computerized Tomography, Magnetic Resonance and Nuclear Medicine are provided and a dual monitor C-arm is available for surgical orthopedic procedures. The multislice CT scanner is adjacent to the ED and the 1.5T 8-channel MRI mobile unit is located directly outside the ED entrance. CT and CR imaging are available 24/7, all other modalities must be scheduled 0700 to 1700 M-F. All imaging studies, with the exception of Mammography, are imported into our web based PACs for easy access and distribution.

Emergency Services:

The Emergency Department is staffed 24 hours per day/7 days per week by either a physician or PA/NP with training in emergency medicine. A registered nurse is staffed from 6:00 AM through 12:00 midnight seven days per week, when possible. In the hours a dedicated nurse is not assigned to the ED, the charge nurse is responsible for the department. Emergency Department registered nurses have the following specialized training: BLS, ACLS, TNCC, NRP, and PALS. Emergency Department Technicians are staffed from 10:00 AM to 10:00 PM, when possible. ED technicians are trained on the job and are required to complete a skills competency list. The ED technician is required to have EMT certification which may be obtained after hire. The RN supervises the ED technician and only delegates those tasks for which the ED technician has an approved, signed competency.

A registered nurse is designated the Trauma Coordinator to organize services and systems needed for a multidisciplinary approach to trauma care. Activities of the coordinator include clinical oversight, education, performance improvement, trauma registry, and participation in the state trauma system. The Trauma Coordinator works cooperatively with the Trauma Medical Director and Administration.

The ED has a designated Trauma Medical Director who serves as the trauma director with clinical oversight for patient treatment, development of protocols, performance improvement and correcting deficiencies. The medical providers are either a MD or a PA/NP with experience in emergency care. ED staff is required to have ACLS certification and are competent in caring for patients with traumatic injuries. The department highly encourages additional education such as: PALS, ATLS, and TNCC (or equivalent) or 8 hours of trauma education annually.

The ED serves approximately 4000 adult and pediatric patients annually. The Emergency Department is open 24 hours per day/7 days per week. Patients are treated for illnesses and injuries ranging from minor cuts and abrasions to major trauma requiring stabilization and transport to a higher level of care. All patients presenting to the ED have an appropriate medical screening examination. The ED provider and team determine the need for transport to a higher level of care. The scope of services is too broad to list in this limited document. Any patient presenting to the hospital for treatment is evaluated and treated. The Emergency Department operates as a “Trauma Receiving Facility” and adheres to trauma policies and procedures approved by the Medical Staff. In the event of a trauma or disaster, the trauma team is organized and directed by the ED medical provider. The provider is responsible for the overall provision of care for the trauma patient from resuscitation through discharge.

BHH offers the following specialty services: internal medicine, family practice, radiology, general surgery, orthopedic surgery and anesthesia. The ED providers are aware of availability through call schedules and a physician status report. Call coverage for internal medicine and family practice is available 24/7. Availability of other specialties is variable due to single provider status.

Intensive Care Services: (ICU and CCU)

The ICU is staffed on an as needed basis by a registered nurse with BLS and ACLS certification. The two bed unit is used for cardiac monitoring, central venous pressure monitoring, invasive line monitoring and ventilator management. In addition, the unit has resuscitation equipment and a separate automated medication dispensing unit.

The ICU serves approximately 50 adult and pediatric patients annually. The attending physician, in consultation with the charge nurse, is responsible for determining the level of support needed and the capability of the institution on a case by case basis. If both beds are full, the admitting physician speaks directly with the attending physicians to determine degree of priority. In the event that there is a disagreement, the Chief of Staff will be contacted to determine the priority. Situations warranting a higher level of care may include, but are not limited to: ventilator support greater than 3 days, ICU pediatric care for greater than 3 days, severe staffing shortages, or services requiring physician specialties not provided in the community

The ICU is open 24 hours per day/7 days per week and is staffed by qualified physicians who are approved for hospital privileges. Registered nurses working in the ICU are required to maintain skill level and certification. The ICU nurse and/or Charge Nurse may utilize personnel from within the facility to assist with the care of patients. Additionally, cardiopulmonary, pharmacy and radiology staff are available to provide the respective services. During the off shift hours, the following services are available via the call system: social services, radiology, lab, nursing, cardiopulmonary, anesthesia and administration.

Home Health and Hospice:

Barrett Hospital and HealthCare’s Home Health department provides home health care for eligible patients in the patient’s home. Medicare patients must be home bound and their physician needs to order the service. Services available are skilled nursing, home health aide, physical and occupational therapy as well as social service. These services are intermittent services. The Home Health department office is open 5 days a week from 8am to 4:30p.m. Home Health staff is available 24 hours a day.

Barrett Hospital and HealthCare Hospice is available for terminal patients. This service is a home based service. This service is provided per the IDG team and Plan of Care. There are 4 levels of hospice care which are routine, inpatient general care, respite care, and 24 hour continuous care. The Hospice department office is open 5 days a week from 8am to 4:30p.m. Hospice staff is available 24 hours a day.

Labor and Delivery: Women’s Services

(Obstetrics and Nursery)

The Labor and Delivery department (L&D) is a two unit suite allowing for ante partum, delivery and postpartum care within the suite. The L&D has direct access to the operating room for cesarean deliveries. The department also has a newborn nursery with capability for stabilization of critical newborns, as well as extended monitoring of stable newborns. The unit also houses a waiting area and a separate nurses’ station.

The department averages 80 deliveries annually. The department handles vaginal and cesarean deliveries. Deliveries are performed by a qualified physician, credentialed through the medical staff. A registered nurse is present during labor, delivery and post-delivery. During the latent phase of labor, a registered nurse may monitor two patients. During the second stage and active stage of labor, one registered nurse attends one patient. Registered nurses working in these areas will have current NRP and ACLS certification. The hospital routinely provides additional education of the STABLE course to physicians and nurses. Only a physician, anesthesiologist, or CRNA is permitted to initiate/re-dose intrathecal or epidural anesthesia/analgesia and to initiate or continue general or regional anesthesia/analgesia. During delivery, one RN is present to attend to the maternal care and one RN is present to attend to immediate newborn care.

All pregnant patients presenting to the L&D area will have a medical screening examination and appropriate treatment, as needed. If the patient condition falls outside of critical access hospital capabilities (< 34 weeks gestation, non-emergent VBAC, known congenital malformations or significant maternal complications), transfer to a tertiary facility is expected. However, if the patient is not stable for transport (> 4 cm dilated) and imminent delivery is expected, respiratory therapy will be present for the delivery. During any emergency cesarean or VBAC, the on-call surgery crew will be called to provide support. Staffing for cesarean sections includes: surgeon, first assist, anesthesia, scrub tech, circulator, baby nurse and respiratory therapist. For routine deliveries, the family practice physician will provide delivery room assessment and management; and will manage the care of the newborn independently. Criteria for consultation or transfer to a tertiary facility includes, but is not limited to:

1. Meconium stained fluid with changes in fetal heart monitoring.

2. Respiratory depression and other common effects of maternal anesthesia, medications, or substance use/abuse based upon the assessment of the attending physician.

3. Anticipation of a complicated delivery based upon recommendation of the attending physician and initial assessment

4. Newborn cyanosis, respiratory distress or heart murmur, cardiorespiratory depression or abnormal blood gases as determined by the attending physician.

5. High risk congenital malformations

6. Newborns requiring neonatal intensive care

7. Newborns requiring special care beyond 24 hours post delivery

Laboratory Services:

The lab is staffed with medical technologists from 0600 to 2400, seven days per week and has a call tech for off hours. The laboratory offers a comprehensive menu of “rapid response” tests performed 24/7 to support Emergency Services. Routine and emergency lab specimens are tested for chemistry, immunology, hematology, serology and microbiology. Through its affiliation with ARUP Laboratory, BHH also provides an extensive menu of esoteric tests, including cytogenetics and molecular biology. The lab is affiliated with Mountain West Pathology in Helena, Montana for anatomic pathology.

The blood bank is affiliated with the American Red Cross and has six units of O negative blood available for trauma.

Medical/Surgical Services:

The medical/surgical unit has capacity for 14 beds and is open 24/7. ICU beds can be utilized as overflow medical/surgical rooms or for outpatient treatments when needed. The medical/surgical unit has the capability for telemetry monitoring, pulse oximetry, vital sign monitoring, automated medication dispensing, IV therapy and other monitoring.

Approximately, 1000 adult and pediatric patients are served on the med/surg inpatient unit. Inpatient admissions may include: pneumonia, abdominal pain, changes in mental status, total joint replacement surgery, and general surgery. Outpatient treatments and observation admissions may include: chest pain, outpatient medications, transfusions, and dressing changes. Swing bed patients can be cared for in the same unit and include continued need for IV therapy, rehabilitation and wound care. Patients with complex, rapidly changing conditions are either transferred to the ICU or to another facility for services unavailable at BHH.

The med/surg unit is staffed with qualified registered nurses, licensed practical nurses, nursing assistants and health unit coordinators. A registered nurse is on duty and in charge of the departments at all times. A staffing matrix allows for the charge nurse and another nurse to be on duty regardless of census or patient acuity. A typical shift includes the charge nurse, two staff nurses, one nursing assistant, and one health unit coordinator. Additionally, there is a nurse available on-call for the night shift and on weekends. Patient assignments are made by the charge nurses based on staff competency and patient acuity.

Nutrition Services:

Nutrition Services has a stock supply of food and beverages to last one week, in the event of a disaster. Food service is provided to patients, staff, doctors and guests. Food is available for after hour’s emergencies.

The kitchen is staffed from 0600 to 1900 with cooks and dietary aides. The Registered Dietician (RD) is licensed in the state of Montana and has graduated from an accredited program. The RD completes nutritional consults and develops plans of care for inpatients upon order of the attending physician. Patients identified to be at high risk receive a nutritional consult. High risk patients may include patients with diabetes, cancer or those with wounds. The RD also provides nutritional counseling to outpatients and is a key member of the diabetic program. The Nutrition Services manager is a certified dietary manager and is certified in food safety.

Perioperative Services:

The surgery department consists of two operating suites, one endoscopy suite and a two bed post-anesthesia care unit with three day surgery recovery bays. Sterile processing is housed within the suite. The following equipment is available: fluid warmers, endoscopic equipment, arthroscopic equipment, airway management equipment, traction tongs, burr-hole drills, resuscitation equipment, cardiac monitors, CO2 monitors, pulse oximetry, and malignant hyperthermia therapy. Surgeries are done for both elective and emergent cases. Common outpatient procedures include endoscopy, ophthalmic, breast, abdominal, orthopedic and urologic. Select procedures are performed on pediatric patients including tonsillectomy and/or adenoidectomy, podiatric, gynecologic and hernia surgery.

Surgery procedures are scheduled Monday through Friday. Emergent cases are covered by the use of on-call staff. Surgery is staffed by qualified registered nurses, certified nurse anesthetists, surgical technicians and sterile supply technicians. All RN and CRNA staff is ACLS certified. Surgeons are credentialed through the medical staff credentialing process.

Pharmacy Services:

The pharmacy is staffed daily from 0800 to 1800 seven days per week with a pharmacist. The pharmacy provides a full range of services, including but not limited to: preparation and monitoring of automated dispensing devices, IV admixture preparation, patient education, nursing education, control of all scheduled medications, and requisition/purchasing of all medications and intravenous fluids. All TPN and lipids are mixed and monitored by pharmacy services. When available, the pharmacist will advise on medication administration and dosing during emergencies. On off hours, the staff may consult by telephone or with another designated facility pharmacy.

Anticoagulation services are available. Services are flexible according to patient volume. Services are referral related.

Rehabilitation Services:

Therapy Services includes Physical, Occupational and Speech Therapy for inpatients, outpatients and emergency patients. The department also offers School System Physical Therapy, Home Health Physical and Occupational Therapy services and an aquatic Physical Therapy program through the community pool at the YMCA.

The majority of patients served have orthopedic related problems. Also treated are those patients with traumatic brain injury, cerebral palsy, arthritis, CVA wound care, and vertigo. The department is open Monday through Friday from 0730 to 1700. Weekend therapy is available for inpatients and second day post-op orthopedic patients. Employees include four Physical Therapists, one Occupational Therapist, one contracted Speech Therapist and an Administrative assistant.

Social Services:

Social Services and Discharge Planning are provided for patients throughout the facility. Comprehensive care is provided in the Inpatient Unit, Crisis Intervention is provided in the Emergency Department, and Case Management is available in the outpatient setting with referral.

Provided services include:

1. Crisis intervention and support -- Supportive counseling during hospitalization is directed toward helping patients and families cope with the psychological and emotional impact of crisis and illness and may include referrals to State Crisis Response Team or other mental health resources. Also helps patients adapt to chronic illness and deal with Medical fears, Anxiety, Stress, Depression, Family conflict, Non-adherence, Bereavement, and Advance directives. Provides for emergency housing, food, clothing, and transportation needs.

2. Referral to community resources/ Case Management -- When services are needed outside of the hospital, social services staff use their extensive knowledge of community resources to link patients and families with the appropriate community agency. Typically, referrals are made for Home Oxygen therapy, Home Health/Hospice care, In Home Services for help with cooking, laundry and other daily needs, Durable Medical Equipment, Meals on Wheels, Life Line, and financial assistance in the form of Medicaid or SS Disability applications or indigent drug program supplies.

3. Discharge planning -- Social services staff help patients and families prepare for a smooth transition from the hospital to home or other setting. Social services staff coordinate efforts with other hospital staff, community agencies and other facilities. Additional services include patient advocacy and patient/family conferences.

Social Services is staffed with 1 full time Master Level Clinical Social Worker (MSW), with backup provided by a Bachelor’s prepared UR/QA Assistant, a Registered Nurse, and 1 per diem Bachelor Level Social Worker (BSW) to assist in covering on-call hours.

The hours of operation are as follows: in-house Monday through Friday 8:00am to 5:00pm and on call after weekday in-house hours and on weekends for Crisis Intervention.

Other Contracted Services:

The following services are furnished under contract or other service agreement: (may not be all inclusive)

1. Pathology

2. Blood Bank

3. Organ procurement

4. Radiologist Services

5. Speech Therapy

6. MRI

7. Polysomnography

8. Echocardiography Interpretation Services

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