LearnShare LMS
|Part 1 – All Employees |Page |
|Introduction: How to Prepare for Annual Mandatory Competency Testing |1 |
|Section 1: Hospital Safety and Security |2 |
|Section 2: Violence Free Workplace |8 |
|Section 3: Security and Confidentiality of Data |8 |
|Section 4: Ethics Advisory Committee |10 |
|Section 5: Reporting Abuse and/or Neglect |10 |
|Section 6: Magnetic Resonance Imaging (MRI) Safety |11 |
|Section 7: Occupational Health and Safety |11 |
|Section 8: SBAR Communication |12 |
|Section 9: Cultural Diversity in Healthcare |13 |
|Section 10: Bariatric Sensitivity |14 |
|Section 11: Infection Control – for ALL Employees |14 |
|Section 12: Incident Reporting |16 |
|Section 13: Drug Diversion |16 |
|Section 14: Complaints and Grievance Process |17 |
|Section 15: Patient Advocate Description |18 |
|Section 16: Environmental and Patient Safety at Sibley |19 |
|Part 2 – Staff With Direct Patient Contact | |
|Section 17: Infection Control for Patient Care Providers |20 |
|Section 18: Management of Patients at Risk for a Fall |23 |
|Section 19: Assisting the Rapid Response Team |24 |
|Section 20: Code Blue and Code Cart Review |24 |
|Section 21: Restraint Safety |27 |
|Section 22: Pharmaceutical Waste Disposal |29 |
|Section 23: Pressure Ulcer Prevention |31 |
Introduction: How to Prepare for Annual Mandatory Competency Testing
What is annual education testing?
Although CPR is now required every two years, annual education testing is due every year for all employees.
Formerly known as “Education Day,” employees are required to complete the on-line education test annually. The timeframe for completion is 30 days prior to or by the end of the month of your annual evaluation due date. After reviewing the material in this study guide you will need to take the appropriate tests in My Learning.
The following are completed every TWO years, in a classroom setting by employees who require the skill for their roles:
• CPR/AED competencies-includes maneuvers & CPR test.
• Code Cart competency
When are the CPR/Competency sessions held?
CPR/AED/ Code Cart competencies are held on the following days:
• Basic Life Support – two sessions a month on the third Wednesday of every month at 7:30am and 12:30 pm.
• Heartsaver – one session a month on the second Wednesday of every month alternating between 7:30am and 12:30 pm sessions.
• Evening sessions are held two to three times per year from 6:00pm to 10:00pm.
Basic Life Support (BLS) covers infant, child, and adult CPR. BLS is required for all nurses and most employees who are licensed or registered. Heartsaver covers CPR for the adult victim and is required for unlicensed caregivers such as certified nursing assistants and clinical associates, transporters, Admissions and Safety and Security personnel. For employees that take Heartsaver and work in WIS or the ED, the infant portion of CPR will be covered at the end of the class.
If you are not sure if you need BLS or Heartsaver please check with your supervisor or the Department of Education, Training, and Research at 202-537-4058.
The American Heart Association (AHA) standards mandate that CPR maneuvers be taught by integrating the use of a video with practice. Employees must watch the video and participate in the required practice sessions in order to receive an AHA card. It is for this reason that anyone arriving after the video has started will not be admitted to the class.
To prepare for the CPR class, obtain a CPR book from your manager. If your manager does not have a CPR book, call the Department of Education, Training, and Research at 202-537-4058 to borrow one.
How do I register for CPR and/or annual education testing?
Registration is required for both the annual education test(s) and CPR. Registration must be completed online and can be accessed on My Learning by typing CPR into the search box
If you only need to take the annual education testing you should register for the annual education test on My Learning. You can type SMH Annual Exposure Test or SMH Annual Non-exposure Test in the search box.
How do I prepare for the mandatory annual education tests?
From the Sibley intranet enter the search term “Annual Education Study Guide”. You may also search “CPR 2010 Guidelines” to review any changes in CPR training.
How do I take my tests?
The Annual Exposure and Annual Non-exposure test are located in the Sibley catalog on My Learning. You can type in SMH Annual Exposure Test or SMH Annual Non-exposure Test in the search box to access the test. No need to call Education and Training to load your test. Once completed print your certificate and send them to HR.
SECTION 1 – HOSPITAL SAFETY AND SECURITY
Hospital Security
In order to maintain a safe and secure workplace, everyone must be alert and aware of their surroundings. All employees are responsible for hospital security and security is “MY JOB.”
M - Maintain a good security attitude
Y - Your involvement
J – Joint efforts produce positive results
O – Observe and report suspicious activity
B – Believe your involvement makes a difference
Basic hospital security involves:
• Reporting any suspicious persons or activities to Safety and Security at 202-537-4674.
• Protecting people and property entrusted to your care
• Controlling access to sensitive areas such as Nursery, Health Information Management, Cashier, Pharmacy, Information Technology, etc.
• Wearing hospital identification badge at all times
|Type |Description |Number |
|Code Red |Fire |4600 |
|Code Blue |Cardiac Arrest |4555 |
|Code Purple |Neonatal Code Blue | |
|Code Pink |Infant Abduction | |
|Code Yellow |Accident/Incident | |
|Code Orange |Hostage Situation | |
|Code Stork |Precipitous Delivery | |
|Code Silver |Active Shooter | |
|Code Strong |Violent Patient | |
|Code 100 |Internal/External Disaster | |
|Rapid Response |Stroke Response | |
|Neonatal Rapid Response |Bomb Threat | |
|RACE |Rescue/Alarm/Contain/Extinguish/Evacuate | |
|PASS |Pull/Squeeze/Aim/Sweep | |
|Command Center |4497 |
Under OSHA regulations only trained employees are permitted to use a fire extinguisher, the hospital Fire Response team members are the only trained and authorized employees to use fire extinguishers.
Emergency Numbers
The number for Code Red remains the same- 4600- to comply with a DC Fire Department requirement for standardizing the number used to report a fire across all DC hospitals.
Code Red remains 4600
All other codes now use 4555.
Initiating an Emergency Response
When calling a code you must give the operator the following information:
• The type of code or emergency
• The building
• The location
• Your name
For Example:
1. “Code Blue main hospital, sixth floor west wing. This is Suzy Smith calling.”
2. “Code Yellow, Medical Building, 1st floor main lobby by the gift shop. This is Suzy Smith calling.”
3. Rapid Response Team, Renaissance building, 1st floor, outpatient therapy by the pool. This is Suzy Smith calling.”
It is important to specify the building since the team may respond to codes in the Renaissance building, the main hospital or the Medical Building. When the emergency is not on a patient care unit, such as outpatient physical therapy, or the infusion center in the Medical Building, it is important to give a clear description of the location. Do NOT give a patient’s room number when initiating an emergency response.
Special information for Certain Codes
Rapid Response Team (RRT)
A Rapid Response is activated when a patient’s condition has deteriorated but he/she is still responsive. The response team, which consists of critical care nurses and a physician, is available to offer clinical expertise and assistance in an emergent, non-code situation.
Code Blue Team
A Code Blue is initiated when a person becomes unresponsive. This team consists of critical care nurses, physicians, respiratory therapists, and other staff trained in Advanced Cardiopulmonary Life Support (ACLS).
Stroke Response Team
A Stroke Response is activated when signs of a stroke are seen. The team consists of critical care nurses, a physician, and a respiratory therapist. Act FAST when you observe the following:
FACE - Facial droop, uneven Smile
ARM - Arm numbness, arm weakness
SPEECH - Slurred speech, difficulty speaking or understanding
TIME - Call x4555 state Stroke Response Team
Code Yellow
A Code Yellow called for an accident or incident on hospital grounds but outside of the main hospital building, such as in the parking lot or on the sidewalk. The Code Yellow team will also respond to emergencies on the ground floor of the Medical Building because there are Sibley departments located there, such as outpatient imaging and outpatient surgery.
If you are in one of the hospital parking garages, go to an emergency call box (there are several on each level), push the call button and tell Security there is a Code Yellow and give the location. Security will activate the team.
Code Silver
A Code Silver is activated when there is an active or potential shooting situation on the hospital campus. The first employee who can safely do so, should call 911 and notify Safety and Security, 202-537x4674 of a Code Silver.
If you are in the area of a code silver and it is safe to do so, leave the area immediately. Proceed to a secure location and call 911 and hospital Safety and Security at 202-537-4674.
If you can’t get out, follow the Protect in Place recommendations
• Barricade yourself in a room where you can lock the door and/or push heavy objects in front of the entrance to block anyone from coming into the room
• Close blinds or cover windows
• Turn cell phones to silent or vibrate
• Stay in place until instructed by a police officer or member of Safety and Security that Protect in Place is over
Once law enforcement agencies respond they assume command over the incident. If you encounter law enforcement during a Code Silver, you should
• Ensure that your ID badge is prominently displayed
• Listen to police instructions
• Keep your hands raised, empty and visible at all times
• Do not attempt to carry items with you
Patient care during Code Silver:
• Warn other staff, visitors and patients to take immediate shelter.
• Attempts to rescue patients should only be made if it can be done without endangering persons in the immediate area.
• Only attempt patient care activities if they are immediately life-saving
• Treat any injured person as best you can. Use basic first aid.
Recovery Actions for a Code Silver occur after a shooting situation is controlled:
• Hospital staff, visitors and patients need to stay away from the area of the incident.
• Communications will announce that the “protect in place” is all clear. They will then announce that a Code 100 is in effect.
• Identified employees will report to the Command Center for law enforcement interviews
• Mental health professionals will be available to support employees.
Code Stork
Code Stork is implemented when a pregnant woman is giving birth outside of the Labor and Delivery unit. An employee should remain with the mother until the team arrives.
Code Purple
A Code Purple is called when an infant becomes unresponsive. Code Blue Team members trained in neonatal resuscitation and Special Care Nursery nurses will respond.
Bomb Threat
If you receive a phone call with a bomb threat:
• Remain calm and take the call seriously
• Listen for background noises
• Try to determine the callers age, race, and sex
• Listen for the tone of voice or any accent
• Note the time and length of the call
• Ask these questions
o When is the bomb going to explode?
o Where is the bomb?
o What does it look like?
o What type of bomb is it?
Family Activated Rapid Response Team
GOALS:
o To Empower Patients and Families to access care and provide the ability to communicate their needs
o To improve satisfaction, decrease anxiety and increase safety for patients and families
BACKGROUND:
First started in 2005, it was begun in response to a highly publicized sentinel event in which a deteriorating child experienced critical delays in care despite her family's concerns
It also addresses a 2009 Joint Commission National Patient Safety Goal where hospitals encourage the patient and family to seek assistance when the patient’s condition worsens
Studies have shown very few “false alarms” from the families
Rapid Response phone number x7000
Upon admission, the patients and families will be informed of the program. Signage with the phone number will be in each patient room
Scripting for the nursing staff to communicate with patient and family during admission and room orientation
I want to share information with you about a service “Family activated rapid response”
The Rapid Response Team is a group of highly trained hospital staff that can be called if it appears that your or your loved one is getting sicker very quickly. The team works with your caregivers as an expert set of eyes and ears to address your concerns.
The RRT is not intended to replace the excellent staff on this unit. But when you notice a serious medical change, you can call the team.
To call the team, you just dial x7000 on the hospital phone system. It’s like calling 911 from home for an emergency. We also have the phone # posted on this sign in your room.
Do you have any questions?
Emergency Operations Plan or Code 100
A Code 100 will be announced overhead when the Emergency Preparedness Plan is put into effect. The Emergency Preparedness Plan, also known as the Disaster Plan, will be implemented in the event of an emergency situation resulting in the potential for a large influx of victims to the hospital or when adverse weather conditions could affect hospital operations. A Command Center is established by Administration. A supervisor or charge person will direct staff to their appropriate roles. Each department should refer to their department-specific Code 100 response plan.
To access emergency management information while at work, go to the new Sibley intranet and search for Code 100. If you are at home when a Code 100 is announced, go to the Sibley webpage at to find information.
• Click on “Employees” in the top right corner of the page
• Sign in using the id and password you use to log into the main computer system at work.
• Click on the “Emergency Management” tab under “Quick Links” on the left side of the screen
When you report to work during weather emergencies you should bring an overnight bag with you with extra clothes, toiletries, and medications with you in the event you have to shelter in place. Shelter in Place is used for emergency situations where it is safest to remain where you are rather than to try to go home.
Fire Safety
If you discover a fire, no matter how small, activate the fire alarm by calling 4600 to report a Code Red. Remember to give the building, location, and your name. All employees are responsible for knowing the location of fire extinguishers, fire alarms, and oxygen cut off valves for their work area.
If you discover a fire, remember RACE:
R = RESCUE anyone in immediate danger
A = ACTIVATE the alarm and call 4600
C = CONTAIN the fire and smoke
E = EXTINGUISH the fire, if it can be done safely, or EVACUATE
Under OSHA regulations only trained employees are permitted to use a fire extinguisher, the hospital Fire Response team members are the only trained and authorized employees to use fire extinguishers.
For proper use of fire extinguisher, remember PASS:
P = PULL the pin
A = AIM at base of the fire
S = SQUEEZE handle
S = SWEEP at base of the fire
Hazardous Materials Program
Material Safety Data Sheets (MSDS) sheets contain information about safe handling and use, health hazards and precautions to follow when using the chemical. MSDS information for chemicals used in the hospital can be found on the Sibley intranet. To locate the MSDS for a specific chemical search the Intranet and scroll down to “Material Safety Data Sheets” and click on Chemwatch and Chemwatch Quick Search Guide and search for the chemical. From that website you can enter the name of the specific chemical and obtain all of the information on the chemical.
If a chemical spill occurs you should:
• Contain the spill by dropping paper towels or some other absorbent material on top of the spill
• limit access to the area
• Ask all people who are not essential to leave the area
• Close windows and doors to prevent fumes from spreading
• Locate the Material Safety Data Sheet (MSDS) and follow the clean-up instructions
If a very large chemical spill occurs you should:
• Notify Environmental Services at 202-537-4775
• Provide the name of the chemical and any other important information about the spill so EVS can bring the appropriate equipment.
Chemotherapy is considered a chemical and there will be an MSDS for each drug however Environmental Services staff are not trained to deal with chemotherapy spills. It is nursing’s responsibility to deal with chemotherapy spills. If a chemotherapy spill occurs outside of a patient care area, notify the nursing unit from which the patient came. See Section 21 on page 28 for more detail on chemotherapy waste management.
If there is a blood and body fluid spill you should:
• Contain the spill by dropping paper towels or some other absorbent material on the spill.
• Use personal protection equipment as necessary such as gloves, goggles, mask and/or gown.
• Decontaminate area with appropriate disinfectant (bleach)
• Dispose of contaminated supplies in red bag
• For large spills, call Environmental Services for assistance at ext. 4775.
An Occurrence report must be completed any time there is a spill, no matter how small.
Reporting Utility, Telephone and Computer System Failure:
To report a utility failure, call Plant Operations (Maintenance) ext. 4068. They are open 24 hours a day, seven days a week. Utility failures include:
• Electricity and emergency power outage
• Medical gas and vacuum system malfunctions
• Heating, air conditioning or refrigeration problems
• Water, plumbing and sewage problems
• Elevator malfunctions
• Pneumatic tube system problem
Report phone and computer problems to the Information Technology Help Desk at x4584. The help desk is available 24 hours a day, seven days a week.
Safe Medical Devices Act (SMDA)
This act puts medical devices under the jurisdiction of the Food and Drug Administration (FDA) an requires facilities using medical devices to report adverse events where a medical device cannot be ruled out as a cause or contributing factor of an injury to a patient, visitor or staff member. There are over 15,000 generic categories of what constitutes a medical device but generally anything that is not a drug or biologic such as tissue, blood and blood products, vaccines etc., it is most likely a medical device. If there is any question, treat it as a medical device and send it to Biomedical and they will make the determination.
If you think a medical device has malfunctioned in any way, even if no harm occurred, you should:
• Remove the device from use.
• Do as little as possible to the device. Do not remove any tubing or change any settings. Leave it in the condition is was when the incident took place. This helps Biomedical discover what happened. They will submit a report to the manufacturer of the device and to the FDA as needed.
• Notify Biomedical at 202-537-7676 M-F 0700-1630. After hours, or on weekends or holidays contact the Patient Care Coordinator who will notify the on-call Biomedical engineer.
• Notify your immediate supervisor
• Complete an occurrence report. This must be completed as accurately and clearly as possible because this helps Biomedical determine if FDA reporting is necessary.
SECTION 2 – VIOLENCE FREE WORKPLACE
Sibley Hospital has zero tolerance for workplace violence, threats and related actions.
This prohibition against threats and acts of violence applies to all persons, including, but not limited to, hospital staff, contract and temporary staff, patients and visitors. Employees shall not engage in violence, threats of violence, intimidating behavior, or unwanted touching on the premises of Sibley Hospital. Any situation that appears to be escalating towards the potential for violence should be taken seriously and reported immediately to Safety & Security, your supervisor and/or Human Resources.
Management is committed to and is accountable for endorsing and being visibly involved in safety and violence prevention and for providing the resources to deal effectively with workplace violence.
The Safety & Security Department, Human Resources, Employee Assistance Program and the services of the hospital are available to assist in the implementation of this policy.
SECTION 3 – SECURITY AND CONFIDENTIALITY OF HOSPITAL DATA
Computer users should be familiar with the hospital policy #03-24-01, Computer, Email and Internet Use.
Users expressly waive any right of privacy in anything they create, store, send or receive on a hospital computer or through the Internet while on a hospital computer.
The computer system belongs to the hospital and may be used only for business purposes. Email and internet access is given to users only to assist them in the performance of their jobs. Users understand that Sibley Memorial Hospital may use human or automated means to monitor use of its computer resources and that Information System’s personnel have access to any material in the computer system.
Prohibited Activities
The following activities are specifically prohibited by policy
• Viewing, storing or sending inappropriate or unlawful materials
• Dissemination of ads, political material, commercial or personal advertisements or solicitations.
• Wasting computer resources on mass mailings, chain letters, chat rooms, radio broadcasts, games or ‘surfing the web.’
• Misuse of software: Users cannot copy software, install unapproved software, modify, revise, transform, recast or adapt any software.
• Communication of trade secrets by sending, transmitting or otherwise disseminating hospital data is strictly prohibited unless authorized by the Chief Operating Officer or a designee.
Computer Security
Users are responsible for safeguarding their passwords. To create a strong password, eight characters should be used in a combination of upper and lower case letters, numbers and special characters such as ! @ # $. Protect your user code and password. Do not share these with anyone. Users are responsible for all transactions made using their passwords and no user may access the computer system with another user’s password. Passwords do not imply privacy. Sibley Memorial Hospital has global passwords that permit it access to all material stored on the hospital computer system.
The goal of Sibley's information security program is to protect the confidentiality, integrity, and availability of data. Users may not alter or copy a file belonging to another user without first obtaining permission from the owner of the file.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
HIPAA is a federal law instituted to protect the privacy and confidentiality of patient information. Violations of this law can result in fines and/or jail terms up to ten years. Practical privacy tips include:
• Don’t leave confidential hospital documents lying around.
• Don’t discuss patients or employees in public places.
• Make sure confidential faxes are going to the correct place.
• Do not leave a computer with patient information displayed on the screen.
HIPAA refers to Protected Health Information (PHI). This includes all information about patients, whether written on paper, saved in a computer or spoken aloud. This includes anything with patient identifiers such as specimen labels, forms, pictures, etc. and these items must not be thrown away in the regular trash. Trash is NOT private. If you see patient information in an open trash container, tell a supervisor. Do not send it to the IT department. Trash containing confidential information should be placed in the locked shredder bin until it can be destroyed or put directly into a paper shredder.
If you receive a call from a family member of a patient you must be sure you have the patient’s permission to disclose the information. If you receive a call about a patient about a patient from any media outlet do not confirm the patient is in the hospital and refer the caller to Public Relations at 202-537-4700.
Electronic protected health information, or EPHI, is patient information that is created, received, stored or maintained, processed and/or transmitted in electronic media. Electronic media includes computers, laptops, disks, memory sticks, PDAs, servers, networks, dial-up modems, E-mail, web-sites, etc.
If you reveal EPHI to someone who does not need to know it, you have violated a patient’s confidentiality and you have broken the law. Follow the “need to know rule” which is - If you don’t need to know it in order to do your job, don’t look at it or don’t ask about it. No employee, including doctors and nurses, has the right to look at information that does not pertain to their work.
Reporting HIPAA Violations
All employees are responsible for promptly reporting actual or suspected wrong doing. Employees will not be subject to any punishment, retaliation, reprisal, or harassment for a good faith report of a suspected violation of the program. Employees may contact their Supervisor or Director, or the Corporate Compliance Officer at 202-370-6557. There is also an anonymous privacy hotline available: 202-243-2260. Confidentiality of the person reporting the violation will be maintained; informing only those involved who have a need to know of the violation.
SECTION 4 – ETHICS ADVISORY COMMITTEE
The Ethics Advisory Committee can assist staff, patients, family members and physicians to clarify options involving ethical dilemmas. Ethical issues may include concerns about pain management, conflicts about resuscitation, level of care or treatment issues, or patient decision-making capacity.
Anyone may request an Ethics Advisory Committee consultation. The Ethics Committee contact person can be reached by dialing “0” and asking the operator to page the Ethics Consultant on-call to your extension.
SECTION 5 – REPORTING ABUSE AND/OR NEGLECT
All employees need to be aware of the signs and symptoms of abuse and/or neglect of both children and adults. Some common signs of abuse or neglect are listed below but for a comprehensive list of signs and symptoms of abuse, see policy #02-31-23 on the Sibley Intranet.
Report any cases of suspected abuse and/or neglect to the Case Coordination Department at 202-537-4004 Monday through Friday from 0800 - 1630 on normal business days. If it is outside of these times notify the Patient Care Services Coordinator by calling the page operator at x4111 and ask to have the Nursing Coordinator paged to your number.
Examples of Child Abuse
• Bruises, superficial welts, scratches or abrasions, especially those with a pattern or are in various stages of healing; minor burns, blisters, abrasions confined to a small area on an arm or leg
• Behavior such as embarrassment about symptoms, evasiveness, poor eye contact and denial about the cause of the injury
• Extensive cuts requiring stitches
• Internal injuries
• Sexual abuse: bruises around breast or genital area, unexplained venereal disease or infections, unexplained vaginal or rectal bleeding
• Parent has exaggerated and/or falsified medical symptoms for the child which results in unnecessary medical tests performed on the child.
Examples of Child Neglect
• Parent/guardian not seeking recommended medical care for the child
• Locking a child outside, especially when inappropriately dressed for the weather
• Driving while intoxicated with a child in the vehicle
• Locking a child in a closet
• Forcing a child to eat a non-food item such as soap or a cigarette.
Examples of Adult Abuse/Neglect
• Physical abuse: bruises, black eyes, lacerations, rope marks, bone fractures, open wounds, untreated injuries, sudden change in behavior, caregiver's refusal to allow visitors to see the adult alone.
• Sexual abuse: bruises around breast or genital area, unexplained venereal disease or infections, unexplained vaginal or rectal bleeding
• Emotional/Psychological abuse: extreme withdrawal and non-communication or non-responsiveness, unusual behavior including embarrassment about symptoms, evasiveness, poor eye contact and denial about the cause of the injury
• Neglect: dehydration, malnutrition, untreated bedsores, poor personal hygiene, unattended health problems, hazardous, unsanitary, unclean or unsafe living conditions
• Abandonment
• Self-neglect
SECTION 6 – MAGNETIC RESONANCE IMAGING (MRI) SAFETY
Sibley has three MRI scanners – two are located on the ground floor of the hospital in the Imaging
Services Department and the third MRI is located in the Medical Building on the ground floor.
The powerful magnetic field is always on and attracts certain metal objects. The magnetic field is strong enough to turn any ferrous (magnetically attracted) object into a projectile, including objects like scissors, floor buffer, stretcher, or wheelchair. Many items may be hazardous or may interfere with an MRI exam therefore no one is to enter the scan rooms without checking with a technologist.
All patients, visitors and employees must be screened before entering the MRI suite. Nurses must complete the Patient Assessment for MRI Exam form (02-163 nm) prior to the patient leaving the unit for an MRI. An order for an MRI will be generated by the physician in the EPIC system.
Patients with implants such as pacemakers, implanted defibrillators, Acticoat dressing, or any other implanted devices can be seriously or fatally injured if an MRI exam is performed without proper evaluation. If any implantable devices are identified, the nurse MUST contact the MRI technologist for further instructions and evaluation.
Code Blue emergency situations are never conducted in the scan room. They are conducted in an anteroom just outside the scan room.
Questions about an MRI exam should be addressed to the MRI section of the Imaging Services Department (Radiology) at 202-537-4956.
SECTION 7 – Occupational Health and Safety
Occupational Health and Safety has many other functions in addition to performing annual physicals for those departments who need them. They also see employees for work related injuries, return to work
clearance after an injury or illness. They also give limited immunizations.
Direct patient caregivers employees are required to have an annual physical exam, which includes a test for tuberculosis, known as a tuberculin skin testing. Some additional departments are required to have an annual tuberculin skin only. Each department is assigned a month and year in which to complete this requirement and your manager will have a list of appointments available for your department. There may be some limited appointments available in the evening but you will have to contact Occupational Health and Safety directly to see when they are offered. Private physicians can complete your yearly physical, but must do so within the required time frame. Forms can be obtained from Occupational Health and Safety and on the Sibley Intranet.
When to be Seen in Occupational Health and Safety
Other than your physical, you should be seen in Occupational Health and Safety when one of the following occurs. You must call Occupational Health and Safety at 202-537-4265 before coming.
• Job related injury or illness
• Exposure to blood, body fluids, chemicals or tuberculosis
• Possible latex allergy
• Returning to work after an injury/illness/leave of absence (see details under “Return to Work” criteria)
• Possible infectious or communicable disease, e.g. rashes, sore throat, productive cough, diarrhea, food borne illness, purulent drainage from a wound, hepatitis or any other blood borne illness.
Job Related Injuries
During the day shift, Monday to Friday
• Report the injury or exposure to your supervisor.
• Complete an Employee Confidential Occurrence Report
• Call Occupational Health and Safety at x4265 to be seen. They will give you a statement of work status to be given to your supervisor.
All Other Shifts
• Report the injury to the supervisor on duty. If no supervisor is available page the Patient Care Coordinator. They will arrange for you to be seen by a physician, if needed.
• Complete an Employee Confidential Occurrence Report
Blood and Body fluid Exposure
• Immediately wash the exposed area
• Report the injury or exposure to your supervisor or the Patient Care Coordinator or to the 24/7 ID specialists at 410-283-2325 if it is on the off shift
• Complete an Employee Confidential Occurrence Report
• Rapid HIV testing should be done on the patient. For reasons of confidentiality, test results do not get reported on the chart or in the computer
• If chemoprophylaxis is indicated, it should be started within 1 - 2 hours after exposure
Return to Work Criteria After an Illness or Injury
Even if you are cleared by your private physician you must be seen in Occupational Health and Safety for clearance to return to work when any of the following apply.
• If you have been on medical leave for three or more days
• If you have had a communicable or infectious disease, regardless of number of days you have been absent from work
• For any injury, surgery or illness that may affect your job performance. In this case clearance by private physician is mandatory
To be Cleared by Occupational Health
• Make an appointment to be seen prior to your return date
• You must be cleared for full duty – no restrictions or light duty
• Employee will not be able to work until cleared by Occupational Health and Safety
• If injury is non-work related, an employee who is unable to return to full duty will be referred to Human Resources and his/her supervisor.
• If injury or illness is work-related, employee will be referred to the Worker’s Compensation office.
Immunizations Offered by Occupational Health and Safety
The following immunizations are available to all hospital employees. Call 202-537-4265 to set up an appointment to receive an immunization.
Hepatitis B – highly recommended for employees who have possible exposure to blood borne pathogens
• Flu
• Chickenpox (Varicella)
• Tetanus
• Measles (MMR) – recommended if you were born in 1957 or later: need a second dose to complete series
• Pneumonia Vaccine (pneumococcal)
SECTION 8 – SBAR COMMUNICATION
SBAR stands for Situation, Background, Assessment, Recommendation/Request and is a communication tool that provides a quick, concise explanation of the purpose of the conversation, a background and assessment of the condition and a recommendation for the next action. The JCAHO recommends that healthcare providers establish a standardized communication system and Sibley Hospital has selected SBAR as the format for communicating pertinent information between healthcare practitioners, hospital departments, etc. SBAR can also be used to communicate any kind of critical information between departments.
SBAR is needed because the healthcare workforce is very diverse, both culturally and in age, which can lead to misunderstandings. Poor communication or lack of communication accounts for 90% of sentinel events or errors. We need to ensure we are communicating clearly to our internal and external customers and the SBAR format will help us share our information in an organized, accurate and concise format.
Situation - Background – Assessment – Recommendation/Request
S – Situation - Describe/explain the situation, problem or concern. Briefly state the problem but be specific.
B – Background - Provide pertinent history or background relevant to the situation. Report your observations.
A – Assessment - Describe the severity of the problem; say what you think the problem is.
R - Recommendation/ Request - Explain what you would like to be done or request suggestions
SECTION 9 – CULTURAL DIVERSITY IN HEALTHCARE
Whenever a group of people spend a period of time together, a culture is formed. Culture is a pattern of values and beliefs reflected in our outer behaviors. Culture is formed by where you were born, family values, religious beliefs, race, gender, socioeconomic factors, education and personality. In many cultures, communication is more than just words; it involves the whole context of the encounter -the status of the individuals, the setting, body language, voice tones and phrasing all contribute to the subtleties of what is communicated.
To improve communication with patients and visitors
• Use open-ended questions which require more than a yes or no response
• Avoid slang expressions and speak in simple and correct English
• Look for nonverbal clues of confusion.
• Take time to learn about each patient
• Avoid stereotyping
• Ask about accepted ways to show respect – how to address patients
• Consider privacy needs
Other Factors That May Affect Care
• Age – be aware of age specific traits and that people from different generations may view the same action very differently
• Gender – culture may prohibit touching by opposite sex
• Sexual orientation – do not assume orientation
• Socioeconomic status – can affect relationships, access to care
• Physical/mental disability – special communication needs, may be reluctant to discuss
• Disability: keep in mind that a person who is disabled may not consider it a disability
• Unfamiliarity with the US health care system or American behaviors
SECTION 10 – BARIATRIC SENSITIVITY
Obesity is the second leading cause of preventable, premature deaths after smoking. Obesity is a chronic illness, the same as diabetes or COPD, and there are multiple causes of obesity including genetics, hormones, environmental, and neurological causes. Currently, surgery is the most effective treatment for the severely obese patient.
It has been said that obese persons are the last acceptable targets of discrimination. It is not uncommon for overweight individuals to experience psychological stress, reduced income, and workplace discrimination. No one laughs at other chronic illnesses. Obesity can be just as deadly.
As a Sibley employee you may come into contact with an obese patient and are therefore considered part of the Bariatric Team. To better understand the struggles and fears of obese persons and to give better care to the obese patient, be familiar with some of the types of bias and discrimination that obese persons endure.
• Obese persons are often blamed for their own condition and are not afforded the same consideration as others who suffer with a disability.
• Obese individuals often experience problems in public settings, because of inadequate seat size and inadequate features such as seat belts.
• Society sees the obese person as a second class citizen. They are often called “lazy,” “dirty,” and “ugly.”
• Obese individuals often experience discrimination from licensed healthcare professionals. Anti-fat attitudes among healthcare professionals affect clinical judgments and deter obese persons from seeking care.
• Obese people often shy away from doctors and hospitals because they are afraid of being embarrassed, chided or humiliated by medical workers or their surroundings.
• Eighty percent of obesity surgery patients report being treated disrespectfully by medical professionals. Unsolicited or inappropriate comments from healthcare staff will spoil the experience for the patient.
• Comments such as “big,” “hefty,” “portly” or “plump” may be offered as compliments, but can be perceived negatively by the patient.
Many patients feel that their decision to have weight loss, or bariatric, surgery is highly personal and do not always tell visitors, or even family members, exactly what kind of surgery they have undergone. For the staff to automatically assume that the patient’s family and friends are aware of the surgery may result in issues around confidentiality and could potentially humiliate and embarrass the patient. Train yourself to be sensitive by being a good role model. Do not tolerate behind-the-back whispers and jokes about obesity, even in private, avoid labeling of the patient by staff, and assume a non-defensive postures by using reflective listening, having a calm manner, being open and friendly, and respectful.
Be aware of the bariatric patient’s special needs, such as larger gowns and robes, equipment sturdiness and weight limits, distance and accessibility, and temperature. A dedicated staff can make the bariatric surgery experience less stressful and more rewarding for the patient. Understanding the challenges of bariatric patients is the key to providing them safe and effective care.
SECTION 11 – INFECTION CONTROL PROGRAM – For ALL Employees:
Sibley Memorial Hospital (SMH) has established a comprehensive Infection Prevention program that encompasses all patients, staff, visitors and volunteers.
Infection Prevention and Occupation Health work as a team to promote health and safety for patients and staff.
All Infection Prevention policies and procedures are accessible on the intranet. Please use the policy manual index to quickly locate the policy you would like to access.
Infection Prevention and Control Basics:
• Infection prevention is everyone’s responsibility
• Despite emerging technologies hand hygiene remains the single most important prevention tool we can employ
• Isolation precautions are used to reduce transmission of microorganisms in healthcare and residential settings. These measures are designed to protect patients/residents, staff, and visitors from contact with infectious agents. There are two categories of isolation precautions: standard precautions and transmission-based precautions.
• Transmission precautions are used in addition to standard precautions when warranted. Equipment and other patient care items that are not dedicated to a single patient must be cleaned and / or disinfected between patients.
Hand Hygiene:
SMH offers two options for hand hygiene – soap and water or alcohol hand sanitizer. Hand hygiene must be performed when entering and exiting a patient’s room, or in cases of semiprivate rooms, when moving between one patient to the next using the curtain as the defined point of entry. Additional hand hygiene is required when donning or removing gloves, moving from a dirty procedure to a clean procedure and when Personal Protective Equipment (PPE) has been removed.
Soap and water is the preferred method of hand hygiene when hands are visibly soiled and / or when providing care to a patient on enteric contact precautions. Enteric precautions are usually employed for patients experiencing infectious diarrhea (Clostridium difficile, norovirus, etc).
Alcohol hand sanitizer is appropriate except in above situations. Apply the product, cover entire hand surface and continue to rub into the hand surface until dried.
Standard Precautions: Standard precautions are basic infection prevention practices intended to prevent transmission of infectious diseases from one person to another. These precautions apply to very patient every time. Gloves and gowns are worn if contact with body fluids is anticipated. Appropriate cleaning and disinfection of the environment and equipment occurs. Hand hygiene and cough etiquette are practiced.
Transmission Precautions: These precautions are in addition to standard precautions and are based on how an organism is transferred to others or the environment. Three categories make up these precautions – Contact, Droplet and Airborne. Patients placed on transmission precautions will have signage posted on their doors providing instructions to those entering the room what personnel protective equipment (PPE) is required. Communication of transmission precautions is key when moving a patient from one location to another to ensure no lapse in prevention occurs.
Cough Etiquette: Cough etiquette is a simple means to limit dispersal of infectious droplets into the environment thus limiting the transmission of viruses and disease. The important components of cough etiquette are covering the mouth or nose while coughing or sneezing with your elbow or tissue, appropriate disposal of used tissue into trash and performance of hand hygiene afterwards. SMH has cough etiquette stations located through the institution to promote this important prevention method. A procedure mask can be used by a visitor if a cough is present and a visit is required.
Contact Precautions: – hand hygiene and gown and glove to enter room, mask if splashing is anticipate. Commonly used for MRSA, VRE, CRE, MDRO’s. Hand hygiene upon removal of PPE. A lavender contact precaution sign indicates enteric contact precautions and soap and water MUST be used for exiting hand hygiene.
Droplet Precaution: – Hand hygiene to enter and exit room; private room surgical mask to enter. Commonly used for influenza and meningitis.
Airborne Precaution: – Hand hygiene to enter and exit; private room with negative ventilation (AII rooms). The air enters this room but does not directly recirculate back into the hospital ventilation. Commonly used for tuberculosis (suspected or confirmed) and varicella (chickenpox). N-95 mask is the only certified respirator that has to be used when entering AII rooms.
Section 12 – INCIDENT REPORTING
Sibley began using a new event reporting system called HERO: Hopkins Event Reporting Online on December 14, 2015
HERO is a real-time web based event reporting system that allows Sibley to capture information through a standard taxonomy that includes adverse events, near misses and unsafe conditions involving patients, visitors and staff. Events are entered by Front Line Reporters (anyone!) working at Sibley and are reviewed in the Risk Management Department and Leadership of the area in which the event occurred. Events can be entered anonymously but the reporter is encouraged to identify themselves to aide in the investigative process.
How to Complete a HERO Report
HERO can be accessed from any hospital computer by clicking on the HERO Icon on the desktop. Any system questions can be forwarded to the system administrator in the Risk Management Department.
Section 13- Drug Diversion
Drug diversion is the transfer of drugs from a licit to an illicit channel of distribution or use.
• May be for personal use (frequent)
• Self or other
• May be for sale (rare)
Drug Diversion is a felony
Drug diversion typically begin with diversion of small quantities of a particular drug using methods they consider harmless to patients, i.e. stealing “only” waste
• Failure to waste
• Delaying waste to facilitate substitution
• Deliberately removing larger quantities to necessitate waste
• Premature replacement of drips and PCAs
• Theft from sharps containers
Commonly Diverted medications:
• Primarily opioids but also steroids, anti-retrovirals, and steroids
• Often a primary opioid of choice with an additional benzodiazepine
• As addiction progresses, drugs used to treat opioid side effects may also be diverted (GI discomfort; additional benzodiazepines)
Signs and Symptoms to be aware of:
• Staff who disappear to breakrooms or restrooms for extended periods
• Staff who appear drowsy, or nod off
• Staff who come in early for shifts or consistently stay late
• Staff who come in on their day off, without being asked
• Staff who consistently seek out the same person to witness waste
• Staff who consistently offer to medicate your patients for you
• Staff who frequently call in
• Staff who exhibit changes in behavior
• Unsecured medications
Reporting suspected impairment or diversion
What to do
• Alert your Manager
• Contact the Nursing Coordinator
• Contact your director, the Director of Pharmacy, or the Director of Professional Practice
• Understand that drug diversion threatens your career, as well as the health and safety of your patients, colleagues and yourself.
• Get engaged with drug diversion prevention strategies: If you see something, say something!
• Policies are in place to keep patients and staff safe– it is your responsibility to know and follow them for every patient, every time.
What NOT to do:
• Keep silent
• Discuss among peers
• Rationalize away your concerns
Surveillance at Sibley
The hospital is required to monitor and institute controls to detect and prevent drug diversion
• Sibley Proactive Diversion Committee
• Routine audits/reports about Pyxis removals
• Analysis of clinician wasting practices
• Interview by Senior Hopkins Detective when significant amounts of medication are not accounted for in the record
Best Practices
• Never carry CS in your pockets or leave them unattended
• Always administer medication within 30 minutes of removal from Pyxis (required by policy)
• Do waste at time of removal whenever possible
• Always return or waste medication within 45 minutes of removal from Pyxis (required by policy)
• Minimize over rides for controlled substances
• Always ensure that you obtain an order for medication you administer (required by law & policy)
• Do not witness your own waste in Pyxis: If you pulled it, log in as person wasting, not the person witnessing
Hospital Policies
• Hospital Policy 03-11-01 Controlled Substance Management
• Hospital Policy 03-11-06 Automated Dispensing Machines Management
• HR Policy 03-21-43 Substance Free Work Place
Section 14 – COMPLAINT AND GRIEVANCE PROCESS (Summarized from Hospital Policy 03-25-21)
Problems, questions or complaints should be handled by the staff within the department in the simplest and most direct way appropriate to the situation. If necessary, the department head should be notified and an attempt made to provide reasonable resolution. The patient advocate can be contacted to assist in resolving an issue.
Complaint: A complaint is defined as occurring at the time of the incident and generally takes verbal form.
Grievance: A grievance is a written complaint or verbal complaint** that has not been resolved by the staff that is then present at the time it is initially made; or requires additional review for further action. A grievance may concern the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the centers for Medicare and Medicaid Services (CMS), Hospital Conditions of participation (COP), or a Medicare beneficiary billing complaint.
Staff present: Any hospital staff present at the time of the complaint or who can quickly be at the patient’s location (i.e. nursing, administration, patient care coordinators, patient advocates, etc.) to resolve the patient’s complaint.
Patient Representative: A person who has the authority under applicable law to make decisions related to health care on behalf of an adult or emancipated minor.
Director of Volunteer Service and Guest Relations/Patient Advocate: The Sibley official who manages the reporting and tracking of grievances. (EXT. 4267)
The Process
• Problems, questions or complaints should be handled by the staff present and in the simplest and most direct way that is appropriate to the situation.
• If necessary, the Manager or Director of the department will be notified and be accountable for responding to the complainant and attempt to provide a reasonable resolution.
• If the complaint is resolved by staff present, or by the manager or director, no further action is necessary.
• If the complaint is NOT resolved, the complaint becomes a grievance and must be handled according to the following:
• The Director or Nurse Manager of the Department/Unit involved will review the issues and document the review in RL Solutions Database.
• If the issue is not resolved at this point, the Director/Nurse Manager will contact the Patient Advocate to intervene and help with the resolution.
• All grievances must be responded to in writing within 21 days of initial notification either with a resolution to the concern or to state that an investigation (7 days) is in process.
• At this point, the Director and Patient Advocate can make a decision regarding Service Recovery and how it will be implemented.
Section 15 – PATIENT ADVOCATE
What is a Patient Advocate?
The Patient Advocate is a resource for:
• Patients
• Families
• Staff
• Physicians
As part of our mission to provide quality health services to all, the Patient advocate acts as a liaison between:
• Patient/family/appropriate others and
• Hospital staff and departments
The Patient Advocate is here to help. At the patient’s and /or staff‘s request, the Patient Advocate will become involved and focus on:
• Improving communication
• Accessing information
• Addressing concerns, and
• Resolving difficulties
The Patient Advocate will address concerns and forward suggestions in order to ensure optimal care for our patients and family members.
Why is a Patient Advocate Needed?
Hospitalization and illness can be very stressful and disruptive for the patient/family/other(s). There are times when a patient may need to speak to someone other than clinical staff. It is normal for a patient to experience emotions that make it difficult for them to address their needs and concerns.
The Director of Volunteer Service and Guest Relations/Patient Advocate is the Sibley official who manages the reporting and tracking of grievances.
Section 15 – Environmental and Patient Safety at Sibley
Sibley Memorial Hospital is committed to excellence, and a very important part of that is ensuring the safety of our patients, visitors and staff at Sibley.
Please be aware of your surroundings, looking for possible environmental hazards such as spills, trip hazards and clutter that could create an unsafe environment. When you see these hazards, take the initiative to fix the problem so we protect everyone in our community.
All patients at Sibley are assessed daily for their risk of falling. Nationally, up to 20% of all patients in the hospital falls at least once in their hospitalization. Our patients identified as high risk for falling are identified with a yellow fall risk armband and wear yellow treaded socks. These visual triggers are intended to identify these vulnerable patients to everyone in the hospital community. All employees should intervene if they see a patient wearing a yellow armband attempting to get out of a chair by themselves. Simply assist them back to the chair, tell them you will be getting a staff member to assist them safely to their intended location. As a hospital community, safety is our number one priority.
EMPLOYEES NOT EXPOSED TO BLOOD OR BODY FLUIDS WHILE PERFORMING THEIR JOBS OR THOSE NOT PERFORMING DIRECT PATIENT CARE STOP HERE.
READ THIS SECTION ONLY IF YOU COULD POSSIBLY BE EXPOSED TO BLOOD OR BODY FLUIDS ON YOUR JOB AND/OR YOU ARE AN EMPLOYEE PERFORMING DIRECT PATIENT CARE.
Section 17 – INFECTION CONTROL FOR PATIENT CARE PROVIDERS
All previously discussed infection prevention methods in Section 11 apply in addition to the following:
Hospital Acquired Infections (HAI):
In recent years strides have been made in the prevention of hospital acquired infections (HAI). In the US approximately 2 million HAI’s are reported and result in an estimated 100,000 deaths.
Sibley’s Infection Prevention Team performs surveillance for HAI’s in several targeted areas:
• Central line associated bloodstream infections (CLABSI)
• Catheter associated urinary tract infections (CAUTI)
• Surgical site infections (SSI) – targeted procedures
• Ventilator associated events (VAE)
• Multi-drug resistant organisms (MDRO) surveillance
HAI’s that occur in the above categories must be reported to the National Healthcare Safety Network (NHSN) by the hospital. In an effort to prevent HAI’s from occurring and improve patient outcomes Sibley has taken a proactive approach.
CLABSI (Central Line Associated Blood Stream Infection)
• Hand hygiene prior to insertion and line care
• Use of central line insertion checklist
• Use of all inclusive kit or cart
• Maximum barrier protection during insertion process – full sterile body drape full patient; all staff involved in process should wear capes, mask, sterile gown and gloves
• Chlorhexidine skin prep
• To minimize contamination, utilize alcohol-impregnated port protectors for every line and IV tubing port
• For each assess of the line, scrub the hub with alcohol for 15 seconds
• Optimal site selection – avoiding femoral site when possible
• Daily review of medical necessity of line with prompt removal when deemed not medically necessary
CAUTI (Catheter Associated Urinary Tract Infection)
• Hand hygiene prior to insertion and catheter care
• Aseptic insertion technique
• Daily review of medical necessity of catheter with prompt removal when deemed not medically necessary or if an external catheter can be substituted
• Secure catheter to leg
• Specimen collection done in an aseptic manner to avoid contamination of closed system
• Drainage tubing and bag positioned to avoid kinks in tubing and so bag is hung below the level of the bladder
SSI (Surgical Site Infection)
• Appropriate hand hygiene (OR hand scrub prior to the case vs. hand hygiene post operatively)
• Preoperative skin scrub
• Hair removal by clippers only
• Appropriate selection of prophylactic antibiotic for case and administration of antibiotic within 60 minutes of initial incision; discontinuation of prophylactic antibiotics within 24 hours of surgery
• Minimize OR traffic especially once packs are open and when case has begun
• Appropriate OR surgical attire both within the OR and upon leaving the OR suite
• All PPE, including shoe covers and mask, should be removed before leaving the OR area
VAP (Ventilator Acquired Pneumonia)
• Hand hygiene prior to oral care, specimen collection, tube manipulation
• HOB elevated to 30 degrees or higher
• Appropriate oral care
• Deep vein thrombosis prophylaxis
• Peptic ulcer prophylaxis
• Appropriate specimen collection to avoid the introduction of bacteria
• Daily assessment of readiness to extubate
The Comprehensive Unit-based Safety Program (CUSP)
CUSP recognizes the central importance of culture in sustaining patient safety improvements. A unit’s safety culture can reliably predict a wide range of complications and infections, as well as operational outcomes such as nurse turnover. Because culture is local, it must be targeted at the unit level, with support at the organizational level. Sibley has instituted various CUSP teams to improve outcomes for patients with medically necessary devices by using the evidence based steps outlined above. Infection Prevention is a team member in these multidisciplinary teams addressing HAIs.
General Infection Prevention Principles
Cleaning and Disinfection of Equipment: Any item that is not designated by the manufacturer as “single use only” or dedicated to a single patient must be cleaned and disinfected prior to its use on another patient. Patient care items such as blood pressure cuffs, IV poles, Dinamaps, bladder scanners, glucometers, etc) can be cleaned and disinfected by:
• Hand hygiene
• Don clean gloves
• Clean off any organic material prior to disinfection
• Use germicidal wipes to wipe down equipment, allowing for the equipment to remain wet for the contact time designated by the manufacture to kill the targeted organisms. Contact time can be found on the germicidal products label. For contamination with Clostridium difficile, bleach wipes must be used for cleaning the room and equipment.
• Allow to dry
• Green tag clean equipment
• Place in designated clean equipment area on unit or department
Sharps Safety
Every day, more than 1,000 healthcare workers in the hospital setting are injured with a needle or other sharp device. Most healthcare workers are at risk for blood borne pathogen exposure.
What are your chances of infection from a contaminated sharps injury?
Hepatitis B: 1 in 5 (if you’re not vaccinated)
Hepatitis C: 1 in 50
HIV: 1 in 300
Examples of High-risk situations:
During patient care:
• Inserting or withdrawing a needle
• Inserting needles into IV lines
• Handling or passing sharps
Immediately after sharp use:
• Recapping a used needle
• Transferring or processing specimens
During and after sharp disposal:
• Disposing of sharps into proper containers
• Cleaning up after a procedure
• Sharps left on floors and tables, or found in linen, beds, or waste containers
In hospitals, 80% (4 in 5) of sharps injuries are due to the use of:
• Hypodermic needles/syringes
• Suture needles
• Winged-steel (butterfly-type) needles
• Blood collection needles
• Scalpels
• IV stylets
WHAT YOU CAN DO TO HELP PREVENT AN INJURY.
A FACILITY’S “CULTURE OF SAFETY” IS IMPORTANT FOR SHARPS INJURY PREVENTION
Be Prepared
• Organize your work area with appropriate sharps disposal containers within reach
• Work in well-lit areas
• Receive training on how to use sharps safety devices
• Before handling sharps, assess any hazards–get help if needed
Be Aware
• Keep the exposed sharp in view
• Be aware of people around you
• Stop if you feel rushed or distracted
• Focus on your task
• Avoid hand-passing sharps and use verbal alerts when moving sharps
• Watch for sharps in linen, beds, on the floor, or in waste containers
Dispose of Sharps with Care
• Be responsible for the device you use
• Activate safety features after use
• Dispose of devices in rigid sharps containers; do not overfill containers
• Keep fingers away from the opening of sharps containers
Remember many questions can be answered through the Infection Prevention policies found on the SMH intranet however a member of the Infection Prevention Team can be contacted at extensions 4393, 4266 and 5865.
SECTION 18 – MANAGEMENT OF PATIENTS AT RISK FOR A FALL
Assessing and Preventing Falls
As a result of falls, patients may suffer severe injury and potentially life threatening outcomes. Falls are more commonly related to age and functional ability and are influenced by disease status, physical strength, coordination and level of alertness. Injuries resulting from falls are the second leading cause of death for people aged 79 and older. While it is unreasonable to think that all patient falls are avoidable, the incidence and severity of injuries resulting from falls can be reduced. The key lies in the identification of fall risks early on, and the use of targeted interventions that can minimize many of the injuries resulting from falls.
Sibley’s protocol, Management of the Patient at Risk to Fall defines a fall as: “An event which results in the patient or a body part of the patient coming to rest inadvertently on the ground or other surface lower than the patient”. Therefore, even those patients who you may assist to the floor are considered to have fallen and an occurrence report is filed in HERO.
To access the fall protocol, log onto the Sibley Intranet and type in the word “fall”.
Upon admission the nurse completes a “Fall Risk Assessment” which assigns a patient as at a low, moderate, or high risk of falling. Once the assessment is completed, the patient’s risk is determined to be low, moderate, or high. Risk levels are based on a numerical score tabulated from the number of risk factors a patient is assessed to have (i.e. a history of falls).In each category there are fall risk reduction strategies and the nurse selects and implements the appropriate interventions. If the patient is in the high risk category the nurse must choose strategies from the basic safety interventions and the high risk fall options. For a complete list of fall prevention strategies refer to the protocol.
For patients assessed as being high risk the nurse will place a yellow armband and yellow socks on the patient.
Reassessments are important because a patient’s condition can change at any time. All patients are reassessed for their potential to fall at the following times during their hospitalization.
• Daily - on the day shift
• After they have fallen
• If they are transferred from one level of care to another
• With any change in medical, or mental status
Communication about fall-risk among care-givers
Trip Ticket in Epic is used to communicate important safety information among care-givers in different departments. This form is completed by the nurse on the patient’s unit prior to the patient leaving the unit for a test/procedure in another department. The receiving department should check this form for information related to the patient’s fall risk – for example, the patient’s orientation, any language barriers, ability to ambulate, isolation precautions, etc. When a patient who has been identified as being at a high risk for a fall goes to another department for a test or procedure the receiving department is responsible for ensuring the patient’s safety by implementing measures to minimize the patient’s fall risk, such as providing a call light or keeping the patient in an area where they can be easily observed.
Patients who have fallen during their hospital admission
Patients who experience a fall during the current hospitalization do not require a fall assessment score and are automatically a high fall risk for the remainder of the hospitalization
Evaluate need for following:
• Move the patient to room with best visual access to nursing station*
• Apply appropriate restraint if other interventions have proven unsuccessful
• Do not use the overbed table in front of a chair as a safety device*
• PT consult if patient has a mobility impairment, decreased strength, decreased balance and/or decreased endurance
• Pharmacy review for potential medication changes
• If restraints are not an option, encourage the patient’s family to obtain a safety sitter or family member to sit with the patient. Provide families with a list of agencies to use.
After any fall, staff members will meet briefly (huddle) to discuss the details of the fall, reassess the patient’s risk level , and re-establish the necessary precautions to ensure safety
Post Fall Huddle should occur within 15 minutes of a fall
Once a patient has fallen the “falling man” sign should be placed on the door jamb
SECTION 19 – ASSISTING THE RAPID RESPONSE TEAM
A rapid response may be called by any staff member or by a family member using the Family Activated Rapid Response Team phone number.
The Rapid Response Team (RRT) consists of critical care nurses, a physician, and a respiratory therapist. This team will respond when a person has a sudden or unexpected deterioration in condition and the person is still responsive. The RRT members will be able to offer clinical expertise and assistance in an emergent, non-code situation. When a rapid response is activated and the patient continues to deteriorate, the RRT members may decide to activate a code blue.
To activate a Rapid Response call 4555 and state the following:
• Rapid Response
• Your name
• Building
• Location without patient room number
When the RRT arrives, the caregivers should assist RRT members in the following ways:
• Give report to the team using SBAR, including the patient’s signs & symptoms, pertinent history, vital signs, assessment findings, medications given, and other actions taken up to that point.
• Remain in the room to answer any additional questions from the RRT members.
• Obtain supplies and equipment and, if necessary, arrange for blood samples to be delivered to the Lab, etc.
• Initiate the RRT record until the team arrives. When the telemetry RN arrives, she/he will complete the record.
• Ensure that the RRT members sign the completed form. Place the form in the appropriate location in the patient’s record.
Some paper charting will continue at Sibley, including Rapid Response events. Blank copies of the RRT record can be found in the envelope with the Code Blue Forms and are also available on the intranet.
Following a Rapid Response, the original copy of the paper document remains in the patient’s chart. A copy of the Rapid Response record (while Sibley still uses paper) and a post code improvement summary sheet must be completed and returned to the ICU nurse manager for quality monitoring.
SECTION 20 – CODE BLUE AND CODE CART REVIEW
The Code Blue team consists of critical care nurses, a physician, a respiratory therapist, and a pharmacist.
For any person found unresponsive with questionable breathing and/or pulse including a patient, visitor, or employee:
• One person should initiate CPR immediately and send another to call the code and get help.
• If you are alone and no one is within shouting distance you should call the code and get help then return to the victim and initiate CPR immediately.
To activate a Code Blue call 4555 and state the following:
• Code Blue
• Your name
• Building
• Location without patient room number
While waiting for the Code Blue team to arrive, staff should:
• Take the code cart into the room. Unlock and open the cart.
• Turn the defibrillator on and access the AED function. Apply the pads to the patient’s chest and follow the prompts from the AED.
• Have oxygen and suction set-up and available in the room.
• Have the patient’s record and MAR open, ready to give information to code team.
• Be prepared to give the patient’s history and precipitating events.
• Review the patient’s code status.
• Continue CPR until the patient no longer needs CPR or the physician running the code has called a stop
• Be familiar with the Code cart.
o Although the code team usually accesses supplies in the code cart, nurses that are not part of the Code Blue Team should also know what drugs are commonly used in a code, the drawer in which they are located and how to assemble the syringes. Practice assembling the syringes is available during CPR training.
o During CPR class, clinical staff from PCS, Imaging and Rehab will be encouraged to go through a code cart to identify medications and equipment. They will be required to identify and locate the ambu bag, intubation tray, oxygen tank, and defibrillator on the code cart and demonstrate how to use the AED function of the defibrillator. If there is a code cart and a defibrillator in your department, professional staff should know how to:
▪ Activate the AED function
▪ Attach the pads to the patient’s bare chest
▪ Activate the paper recorder
▪ Replace the EKG grid paper and know where the supply of EKG grid paper is located
As part of the hospital’s quality control program the code cart and AED must be checked every day.
Checking the Code Cart:
• Follow the instructions on the Daily Emergency Cart Checklist
• Make sure the paper in the defibrillator contains EKG grid lines. (The paper used in the ICU monitors does not have grid lines and the AED cannot print strips on this paper.)
• The black cable MUST be unplugged from the test-load device after quality control testing is complete. Then, the cable will be ready and available to be connected to the hands-free pads
An ‘hour glass’ symbol should be present in the small window located in the upper right corner of the AED machine. A red “X” indicates a problem.
To troubleshoot:
• Check to see if the defibrillator is plugged in. If not, it may need to be plugged in to charge the battery.
• If the defibrillator is already plugged in, check the battery (on the back) and make sure it is pushed securely in place.
• If the red “X” continues, call the Biomedical Engineering Department.
|Code drugs |Location |Use |Special Considerations |
| | | | |
|Amiodarone (Cordarone) |Drawer #1 |Antiarrhythmic |NOT prepackaged – comes in a glass vial & needs to be drawn up in a|
| | | |syringe |
| | | |. |
| | |Sympathomimetic | |
|Epinephrine Bolus |Drawer #1 |used in treatment of V-fib, |Prepackaged syringe – flip off yellow caps, screw the plunger into |
| | |pulseless V-tach, PEA, |the syringe barrel |
| | |asystole | |
| | | | |
|Vasopressin |Drawer #1 |Used in treatment of V-fib, |NOT prepackaged – comes in a glass vial and needs to be drawn up |
| | |asystole, or PEA (pulseless |into a syringe |
| | |electrical activity) | |
| | | |Prepackaged syringe – flip off yellow (or purple) caps, screw |
|Atropine Bolus |Drawer #1 |Anticholinergic |plunger into syringe barrel, has a yellow/green cap over the needle|
| | |(increases heart rate in |guard-the yellow part of the cap unscrews to allow luer-lock access|
| | |certain |OR the entire cap can be pulled off to expose a needle. |
| | |bradyarrhythmias) | |
| | | | |
|Lidocaine Bolus (Xylocaine) |Drawer #1 |Antiarrhythmic |Prepackaged syringe – plunger needs to be screwed into the syringe |
| | | |barrel AND a needleless lever lock also needs to be added. |
| | | | |
|Lidocaine Drip |Drawer #5 |Antiarrhythmic |Prepackaged IV solution – need to add tubing and then prime the |
| | | |tubing and add a needleless lever lock. |
| | | | |
|Dopamine Drip |Drawer #5 |Used to maintain BP and to |Prepackaged IV solution – bag is packaged in a protective silver |
| | |treat selective |cover, remove cover, add tubing, prime tubing, add a needleless |
| | |bradyarrhythmias |lever lock. Use a pump to run the solution. |
Applying AED pads and monitor leads:
After the Code
Following a code, drugs and equipment must be accounted for and replaced.
• Complete the Medication Checklist by writing in the amount/number of each medication used. Place the checklist and the entire white medication drawer #1 in a large plastic bag and take it to Pharmacy. The Checklist and the plastic bag can be found under the medication tray in drawer one.
• Complete a Miscellaneous Charge Slip with a patient label and affix it to the cart.
• Call the Sterile Processing Department to arrange for a new code cart to be delivered.
• Be sure the Post Code Performance Improvement Summary Sheet and the Code Blue Record are completed after every code. Although there is a place for electronic charting of code blue events in EPIC, Sibley will continue to use paper documentation for these events. A copy of the Code Blue Record and a Post Code Improvement Summary Sheet can be found in an envelope on the Code Cart. The Code Blue Record Form must be placed in the patient record. A copy of the Code Blue Record Form and the Post Code Performance Improvement Summary Sheet should be sent to the Critical Care Educator in the Education, Training and Research Department for quality monitoring.
SECTION 21– RESTRAINT SAFETY
Sibley’s policy, Restraint and Seclusion of Patients, establishes guidelines for the safe, effective use of restraints. These guidelines are designed to ensure that restraints and/or seclusion are used safely and appropriately while maintaining the patient’s dignity, rights and well-being.
To review the full policy, go to the Sibley Intranet, click on Hospital Policies and Procedures, and search for policy #01-31-12. A summary of the main points of this policy is contained in this section.
The decision to use a restraint or to seclude a patient is not driven by diagnosis, but by an assessment of patient behaviors and implementation of an individualized plan of care which addresses the behaviors.
There are two standards regarding when restraints can be used, for promoting non-violent (med/surg healing) and for violent or self-destructive behavior. Non-violent medical-surgical healing covers patients who are at risk for harming themselves due to cognitive impairment demonstrated by an inability to follow instructions or to participate in their plan of care. Self-destructive or violent behavior covers secluding patients for the management of behavior that is an immediate threat to the patient, staff, or other’s physical safety.
Trip Ticket form in Epic is used to communicate important safety information among care-givers. This form is completed by the nurse on the patient’s unit prior to the patient leaving the unit for a test/procedure in another department. Receiving departments should check this form for information related to the reason for a patient’s restraints – for example, the patient’s orientation, any language barriers, ability to ambulate, precautions, isolation, pain medication given, and whether or not the patient is a fall-risk.
Types of Restraints
• Vest Restraint: a cloth vest that when applied restricts the patient’s movement – they are unable to turn or position themselves without help.
• Wrist Restraint: soft cloth restraint which is applied to the wrist(s) & prevents reaching.
• Hand Mitt: soft cloth mitt that prevents patient from grabbing, grasping, or scratching.
Guidelines for Physician Orders
Restraint Orders for Promotion of Medical-Surgical Healing
• An order must be obtained within 8 hours of restraint application.
• The MD must sign the order within one calendar day
• No order for restraints can exceed one calendar day. Continued use of restraints beyond the calendar day will require a new order and a face-to-face evaluation by the patient’s primary physician.
• No standing orders or PRN orders are permitted.
Restraint Orders for Violent or Self-destructive Behaviors
• A face-to-face evaluation by the MD or LIP is required within one hour of restraint or seclusion initiation.
• For patients over 18 years of age the restraint order must be renewed every four hours. Different parameters apply for patients under 18 years of age.
• The patient must be re-evaluated by the MD or LIP in a face-to-face visit every 8 hours. The maximum amount of time that a patient is continuously restrained or secluded may not exceed 24 hours.
• No standing orders or PRN orders are
Guidelines for Monitoring
Restraint Orders for Promotion of Medical-Surgical Healing
• Patients in restraints must be monitored at least every two hours and PRN if indicated. Monitoring must be done by direct observation of and interaction with the patient to include:
• That the patient’s rights, dignity and safety are maintained.
• Physical wellbeing is maintained which includes toileting, hydration, feeding, repositioning, skin condition, circulation, and safe application of the restraint.
• The patient’s emotional wellbeing
• If the behavior or activity that precipitated the use of restraints is still present. If it is not then restraints must be discontinued.
Restraint Orders for Violent or Self-destructive Behaviors
•Patients in restraints must be monitored at least every 15 minutes
•Monitoring must be done by direct observation of and interaction with the patient to include:
• That the patient’s rights, dignity, and safety are maintained
• Physical wellbeing is maintained which includes toileting, hydration, feeding, repositioning, skin condition, circulation, and, safe application of the restraint
• The patient’s emotional well being
• If the behavior or activity that precipitated the use of restraints is still present. If it is not then restraints must be discontinued
• Whether the patient’s condition has changed to require less restrictive interventions or removal of the restraint or seclusion
Guidelines for Documentation
Restraint Orders for Promotion of non-violent Medical-Surgical Healing
• Documentation must include
• Assessment of the patient before the use of restraints
• Alternatives to restraints
• Order obtained
• Date, time, and type of restraint applied
• Ongoing monitoring and assessment
• Findings from monitoring checks
• Care needs addressed
• Time of discontinuation of restraints
• Discontinuation of restraint order when the criteria for release have been met
Restraint Orders for Violent or Self-destructive Behaviors
Staff evaluation and monitoring observations will be entered into the Close Observation Record as required.
SECTION 22 – PHARMACEUTICAL WASTE DISPOSAL
Improper disposal of pharmaceutical waste has resulted in contamination of drinking water and mutations in both amphibians and fish. Examples of pharmaceutical waste include partial IV medicated drips, partially used vials of medications, partially used syringes, and opened but non-administered medications.
Pharmaceutical waste is divided into four categories based on how they are disposed. The person giving the medication has to select the correct bin based on the following criteria.
BLACK BIN: Hazardous drugs with more than trace amounts remaining
Examples:
• Partial vials
• Partial syringes
• Unused pills
• Sponges soaked in liquid meds
• Topical ointments
• Free liquid and loose pills MUST be contained in a securely sealed ziplock bag before being placed in the black bin
• NO SHARPS
YELLOW BIN
• Trace Hazardous Drugs
• Chemotherapy waste
• Empty packages that read “Handling/Disposal Special Precautions Necessary” See list below*
|Arsenic trioxide |Becaplermin 0.01% gel |
|Benzocaine 20% oral |Benzocaine 20% topical |
|Candida skin test |Chloraseptic |
|Chromium |Crotalodae immune fab |
|Cyanide antidote |Flurbiprofen 0.03% opth |
|Hydrochloric acid |Influenza virus vaccine |
|Insulin (aspart,detemir,glargine,lispro,NPH,R, 70/30) |Multivitamin |
|Nicotine |Oxymetazolone 0.05% Nasal spray |
|Phenol |Phentermine |
|Physostigmine |Pol/Neo/Gram Opth Solution |
|Poly/Neo/HC Otic Solution |Poly/Neo/HC Otic Suspension |
|Selenium |Silver antimicrobial dressing |
|Silver antimicrobial gel |Silver antimicrobial pad |
|Silver nitrate |Sulfacet/prednisolone opth |
|Tetanus/Dipth toxiod adsorbed |Trace Elements |
|Trifluridine |Trypan blue 0.06% Opth |
|Warfarin |Witch Hazel pads |
RED BIOHAZARDS SHARPS CONTAINER
• Empty syringes, with or without needles
• Guide wires from IV access equipment
• Phlebotomy waste tubes
• Empty broken glass medication vials.
NARCOTICS
Sibley follows Drug Enforcement Agency (DEA) regulations for the wasting of Controlled Substances.
Controlled Substances not used in patient care must be witness wasted and non-retrievable.
This includes withdrawing the entire volume of a vial, wasting any excess volume (as witnessed by a colleague) into the green cactus bin, administering the ordered dose and disposing of the empty vial in the regular trash.
Excess drugs from a PCA cassette should be measured out and poured into the cactus bin and not down the drain.
It is against DC DOH regulations to waste narcotics down the drain
Fines for pouring narcotics down the drain begin at $1,000 per incident
Wasted narcotics should not be squirted in the trash.
REGULAR TRASH
• Empty containers. This includes vials, IV bags, and medication wrappers (except medications listed above)
• Standard IV fluids may be disposed of down the drain and then have the empty bag discarded in the regular trash. Standard IV fluids are any fluids that do not have medications added by the pharmacy. Some examples of standard IV fluids would be D5W, lactated ringers, potassium, and electrolytes.
Chemotherapy Spills
• It is the patient care staff’s responsibility to contain the chemo spill, including clean up. Housekeeping staff are not trained to clean up chemo spills.
• The Chemotherapy Drug Spill Kit must be used to clean up a chemo drug spill. The kits are available from the Pharmacy.
• Any time a chemo spill occurs an occurrence report must be completed.
A chemotherapy spill can happen anywhere. For example, IV tubing could become separated from the IV solution containing chemotherapy, or the IV bag could get knocked off the IV pole, drop to the floor and break. If a chemo spill occurs outside of a patient care unit, contact the nurse on the patient’s unit immediately. If the spill involves a carpet, Housekeeping can be called to clean the carpet AFTER the chemo spill is cleaned up.
If a chemotherapy drug spill occurs, refer to nursing protocol Management of the Patient Receiving Cytotoxic Agents on the Sibley Intranet.
If there is direct skin contact with cytotoxic agents, immediately remove the involved gloves or gown and discard in a hazardous waste container. Wash the affected skin area with detergent soap and water. Do not use germicidal soap.
If eyes are exposed, immediately flood the affected eye with water or saline for 15 minutes.
If clothing has been exposed, change the contaminated clothing as soon as it is feasible and place clothing in a plastic bag. Clothing may be washed in normal fashion after 48 hours.
Employees exposed to cytotoxic agents should report to employee health or to the administrative coordinator (after hours) for guidance and direction.
Patients or visitors exposed to cytotoxic agents should have their healthcare provider informed, and the nurse manager or patient care coordinator, and/or clinical coordinator should also be informed.
SECTION 23 – PRESSURE ULCER PREVENTION
A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Pressure ulcers are staged according to the extent of observable tissue damage as defined by the NPUAP (National Pressure Ulcer Advisory Panel 2007) using Stages I-IV, Deep Tissue Injuries and Unstageable classifications.
Once staged, pressure ulcers cannot be reverse staged.
Pressure ulcers develop when the compression of soft tissue interferes with its’ blood supply, leading to vascular insufficiency, tissue anoxia, and cell death. Pressure ulcers usually occur over bony prominences such as the coccyx, ischial tuberosities, heels and trochanters where there is less tissue to compress. Other factors such as incontinence, poor nutrition, friction and shear, and immobility can also contribute to tissue break down. Pressure ulcers can develop within 24 hours of the insult or take as long as five days before presenting.
Pressure ulcers can be a common and costly problem in acute care populations resulting in pain and suffering, increased time in the hospital and risk of associated morbidity. The District of Columbia requires hospitals to report to the Department of Health any “Stage III or IV pressure ulcer acquired after admission to the healthcare facility” (D.C. Code § 7-161 et al.)
Pressure ulcers that are present on admission must be documented in the medical record within 24 hours after admission or they are considered by CMS to be hospital acquired and Sibley will not receive payment to care for this ulcer.
Risk Assessment
All in-patients are to be assessed for their relative skin breakdown risk using the “Braden Scale for Predicting Pressure Sore Risk” upon admission, daily (on the day shift), when a patient transfers from one level of care to another level of care (i.e. ICU to Med Surgical unit) and/or whenever the patient’s skin condition changes.
Braden Score:
19-23 - Not at Risk
15-18 - At risk
13-14 - Moderate Risk
10-12 - High Risk
9 or below – Very high risk
Based on the Braden score, Pressure Ulcer Prevention Interventions are put in place by the staff and include but are not limited to:
1. Using pressure redistribution surfaces
2. Suspending of heels off of the bed or any contact surface
3. Repositioning of patients
4. Managing incontinence
5. Using Moisture Barrier Cream
6. Obtaining nutritional support consultation
If the patient has or develops a pressure ulcer, pressure ulcer treatment options are put into place by using the NonPrescriber Initiated Pressure Ulcer Order Set found in the Electronic Health Record. This order set does not need to be signed by a physician before treatment can be initiated.
An occurance report must be filed for any pressure ulcer that is determined to be present on admission or any pressure ulcers that are determined to be hospital acquired.
The Sibley Wound Ostomy nurses are available to assist the staff with pressure ulcer management.
A “Wound/Ostomy Evaluate and Treat” order must be entered in the EHR to trigger a wound/ostomy consult. In addition, it is mandatory that a wound nurse be consulted for all Stage III, IV, and Unstageable pressure ulcers and Deep Tissue Injuries (DTI).
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Sibley Memorial Hospital
Johns Hopkins Medicine
Department of Education, Training & Research
ANNUAL EDUCATION
STUDY PACKET
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For updates or changes to the Annual Education Study packet please contact the
Department of Education, Training & Research
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In a Code Blue the AED pads can defibrillate, pace, and monitor
Color coded monitor leads are sometimes used in a rapid response. They are placed as shown below
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[pic]
WHITE
BLACK
RED
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