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2016MEMORIALHOSPITALMEDICALSTAFFANNUALEDUCATION
PAINMANAGEMENT
IMPAIREDPRACTITIONER
MHSBrespectspatients’rightstoeffectivepainmanagement.
Thetermimpairedisusedtodescribeapractitionerwhois
Painmanagementisamultidisciplinaryprocess,characterized
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Adheretohandhygiene;usesoap&wateroralcoholpreventedbyreasonofillnessorotherhealthproblems
bycontinualcoordinationandcommunicationoftheplanof
basedrubuponenteringandexitingpatientrooms.
fromperforminghisprofessionaldutiesattheexpected
caretowardstheimprovementofpatientoutcomes:increased
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Utilizestandardprecautionsforallpatients&any
levelofskillandcompetency.Impairmentalsoimpliesa
comfort,reducedsideeffects,andenhancedpatient
additionaltransmission-basedprecautions.(droplet,
decreasedabilityorwillingnesstoacknowledgetheproblem
satisfaction.
contact,airborne)guidelines.
ortoseekhelptorecover.Itplacesthepractitioneratrisk
Painisgenerallyassessedusinga0-10scale:
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Stayathomeifyouaresick.
andcreatesarisktopublichealthandsafety.Somesignsof
0=NoPain10=WorstPain
• Stayuptodateonallimmunizations.
impairmentaredeteriorationofhygieneorappearance,
Fornon-verbalpatients,apicturescale(Wong-Baker)is
Immunizations
personalityorbehaviorchanges,unpredictablebehavior,
availableshowingvariousfacesindicatingpainlevel.For
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Tdapneededforpertussispreventioninthoseinteracting
cognitivelyimpairedpatientsorpatientsunabletousenumeric unreliabilityorneglectingcommitments,excessiveordering
withchildren/newborns.
orfacesscale,painisassessedbyusinganon-verbalpainscale. ofdrugs,lackoforinappropriateresponsetopagesorcalls,
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Influenzavaccinationsmandatoryfor2016-2017
decreasingqualityofperformanceorpatientcare.
influenzaseason.
Painmedicationshouldbeorderedwithspecificdetails
PreventtheSpreadofMulti-drugresistantorganisms
regardingindicationsanddose.Rangeordersformedications
MHSBwillassisttheentryofasuspectedorconfirmed
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ContactPrecautionsforpatientswithknownorsuspected
shouldbeclarifiedinsuchawaythatnursingstaffis
impairedpractitionerintoevaluation,appropriate
MDRO,i.e.,MRSA,CRE,VREetc.
knowledgeableaboutwhichdosewithintherangeis
treatment,and/orrehabilitation.
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Gown&glovesrequired;handhygienebeforeandafter.
appropriate.Whenmultiplemedicationsareorderedforpain,
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Avoidtakingitemsintoroom,i.e.,(chart,electronics)etc.
specificguidelinesforwhichmedicationtogiveforeachtypeof INFECTIONCONTROL
PreventtheTransmissionofInfection
Disinfectitemsafterremovingfromanisolationroom,i.e.,
stethescope,otoscope,etc.
PreventionofCentral-lineassociatedbloodstreaminfections
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EducatepatientsaboutCLABSIprevention
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Usecentrallineinsertionchecklist
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Avoidfemoralandjugularsites
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Performhandhygiene,usefullbodydrape;wearmask,cap,
sterilegownandsterilegloves,useCHGskinprep
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Handhygiene&glovesbeforechangingdressingoraccessing
port---Scrubthehub15secondsbeforeallaccess
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Removeanyunnecessarycatheters
Preventionofsurgicalsiteinfections(SSI)
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EducatepatientsaboutSSIprevention
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Performpropersurgicalscrubonhands
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Useproperantibioticsforprophylaxisatrighttime
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Ifhairremovalneeded,useclippersinpre-oparea
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Ensurepropersurgicalsitescrub
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MinimizetrafficinORduringsurgery
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Donotflashsterilizeequipment
Preventionofcatheter-relatedurinarytractinfection
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Useapprovedindicationsforurinarycatheter
Ensureplanforcatheterremoval
Removeanyunnecessaryurinarycatheters
painshouldbeprovided.
Reference:MHSBMedicalStaffPolicyonPhysicianAssistance
RAPIDASSESSMENTTEAM(RAT)
TheRATisapatientsafetystrategythatcan“rescue”patients
whentheirconditionsdeteriorateandreducethenumberof
CodeBluesandtheinpatientmortalityrate.TheRATisateam
ofclinicianswhocometothebedsidetoassistwithassessment
andtreatmentofaninpatientthathashadanacutechangein
condition.TheRATcanbecalledatanytimeandconsistsof
thepatient’sprimarynurse,anICUnurse,arespiratory
therapist,andtheHouseResident.
ARapidResponsecanbeinitiatedbycalling44andrequestinga
RATteam.
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anytimeaclinicianisconcernedaboutasuddenorongoing
worseningofapatient’scondition,
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whenNarcanisbeingadministeredonanursingunit(the
RATmustbecalled).
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WhenapatientisexperiencingchestpaintheRATwillbe
calledaspartoftheinpatientSTEMIProtocol.
Reference:MHSBPolicyRapidassessmentTeam
DISRUPTIVEBEHAVIOR
Disruptiveconductbyamemberofthemedicalstaffis
behaviorwhichadverselyimpactsonthequalityofpatient
care,andincludesverbalorphysicalabuse,sexual
harassment,and/orthreateningorintimidatingbehavior
towardcolleagues,teammembers,orpatients/visitors.This
conductwillnotbetolerated.Anymedical/AHPstaff
member,teammember,oragentofthehospital,volunteer,
patient/visitormayfileacomplaintaboutapractitionerfor
disruptivebehavior.Noretaliationwillbetakenfor
reportingaconcerningoodfaith.Complaintsmaybe
referredtothePresidentoftheMedicalStafforVice
PresidentforMedicalAffairs(VPMA).Complaintsshouldbe
inwritingandwillbemaintainedbytheVPMA.
ReferencePolicy:MHSBMedication,OrderswithDoseRanges
Reference:MHSBMedicalStaffPolicyonDisruptiveConductand
theMedicalStaffCodeofProfessionalBehavior
2016MEMORIALHOSPITALMEDICALSTAFFANNUALEDUCATION
RESTRAINTandSECLUSION
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Arestraintisdefinedasanymanualmethod,physical,or
mechanicaldevice,material,orequipmentthatimmobilizesor
reducestheabilityofapatienttomovehisarms,legs,body,
orheadfreely.
Restraintdevicesmayonlybeusedafterlessrestrictive
alternativeshavebeentriedanddocumentedasunsuccessful.
2categoriesofrestraint:1)toprotectthephysicalsafetyof
thenon-violentornon-self-destructivepatient,and2)to
manageviolentorself-destructivebehavior.
Pronerestraintisnotpermitted.
MedicalStaffmusthaveaworkingknowledgeoftherestraint
andseclusionpolicy.
MedicalStaffmaynotbeinvolvedwithapplyingrestraintsor
seclusionwithoutpropertraining.
Restraintrequirementsfornon-violentornon-selfdestructivepatient:
o Atimed/datedorderforinitiationongreensticker
o Careplanmustbeupdatedtoincluderestraints
o Everycalendarday,thephysicianorLIPwillseeand
evaluatethepatientbeforewritinganeworderfor
restraints.Examinationofthepatientshouldbe
documentedinthemedicalrecord
Restraintrequirementsforviolentorself-destructive
behavior:
o Atimed/datedorderforinitiationondesignatedform
o Aface-to-faceevaluationwithinonehourof
implementation(physician,psychologist,LIP,on
designatedform)
o Careplanmustbeupdatedtoincluderestraints
o Durationoforders:≥age18–4hours;age9-17–2hours;
underage9–1hour
o Every24hoursaphysician,psychologist,orLIPwillseeand
evaluatethepatientbeforewritinganeworder.Examof
thepatientshouldbedocumentedinthemedicalrecord
ondesignatedform.
Restraintsshouldbediscontinuedwhenthepatientmeetsthe
criteriaoutlinedintheorder.TheRNwillterminatethe
restraintorseclusionanddocumenttherationaleinthe
medicalrecord.
Reference:MHSBRestraintandSeclusionPolicy
Documentation
ENVIRONMENTOFCARE
“CODE”Calls(Call44fromhospitalphoneor647-1000from
anyphone)
CodeRed:Fire,orSmoke–
“RACE”-Rescuepersons,pullAlarm&call44,Containfire;
ExtinguishifpossibleandEvacuateifnecessary.
“PASS”–Pullthepin,Aimatbaseoffire,Squeezethehandle,
Sweeptoextinguishfire.
CodeBlue: CardiopulmonaryArrest
PlainLanguageforallothereventssuchassystem/network
failures,weatherevents,andthefollowing:
MissingInfant,Child,orAdult(formerlyAmberAlert):monitor
immediateareaandexits,reportsuspiciouspeople.
SecurityAssistanceNeeded(formerlyCodeViolet):Disruptive
orCombativePerson.-Staybackunlessspecificallytrained.
SecurityAlert-ActiveShooter/ArmedIntruder(formerlyCode
Silver):Personwithweapon/hostage,activeshooter–Run,
Hide,orFight.Stayawayfromarea.
HazardousMaterialIncident(formerlyCodeOrange):
HazardousMaterialIncident/Spill-Evacuatearea,prevent
access,redirectcontaminatedpersonsoutsidetoECC.
SecurityAlert-BombThreat(formerlyCodeBlack):Remain
calm,reportdetails,avoidcellphoneuse.
WaterRescueEmergency(formerlyCodeWhite):WaterRescue
Emergency(EPWORTH)-call911.
EmergencyPlanActivation+Level(formerlyCodeYellow):
Internal/ExternalDisaster-IfLevel3orhigher,contactMedical
StaffOffice574-647-7920.Bepreparedtotriageinjured
personsifneeded.
SafetyDataSheet(SDS)Befamiliarwiththehazardsposedby
chemicalsusedinyourworkplace.SDSinformationisavailable
ontheintranetundergeneralinfo/SafetyDataSheet.
SafetyConcerns:ReportallSafetyConcernstotheSafetyand
JointCommissioncoordinatorat647-2290ortheSafetyHotline
at647-7233.
ABUSEANDNEGLECT
FALLS
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Alladultinpatientsandobservationpatientswillbe
screenedforfallriskuponadmissionusingtheJohns
HopkinsFallRiskAssessmenttool.Patientswillbe
reassessedeveryshiftandwheneverthereisasignificant
changeinthepatient’sconditionorafterafall.
Assessmentincludes7fallriskfactors:Age,FallHistory,
Elimination,Medications,PatientCareEquipment,Mobility
andCognition.
ThreeLevelsofFallRiskbasedonassessmentscore:
≤5=Low,6-13=Moderate,>13=High
Paralysisorcompletelyimmobilizedpatients=LowRisk
Seizurewithinlast6months,activealcoholwithdrawand
activebraininjurypatients=HighRisk
Interventionsarebasedonleveloffallrisk:
o Lowrisk:standardsafetyinterventions
o Moderate:Moderaterisksign,YellowWristBand,
Reorientconfusedpatientsasnecessary
o High:Highrisksign,YellowGown,Bed/ChairAlarm,
Gaitbeltorliftequipment,Caregiversremainwhile
toileting.
• Educationofpatientandfamilyonfallpreventionis
importantwithcorrespondingdocumentationinthe
chart.Apost-fallhuddlewilloccurwitheveryfall.
• Reportinganddocumentationofanypatientfallvia
MHSBIncidentReportingSystemisessential.
• AllPediatricinpatientsandoutpatientswillbe
screenedforfallriskuponadmissionusingtheHumpty
DumptyFallRiskAssessmenttool.Interventionswill
beinitiatedbasedonscoreandpatientneeds.
• Alladultproceduraloutpatientswillbescreenedfor
fallsbyutilizinga4questionform.Patientsthatscreen
positivewillbeidentifiedbyanappropriateband
and/oryellowsocks.
• Adultproceduralpatientsreceivingnarcotics,pain
medsoranesthesiaareautomaticallyafallrisk.
Reference:MHSBFallPreventionAssessmentand
InterventionsPolicy
REPORTINGCONCERNS
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AllEntriesintotherecordshouldbe:
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Signed
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Dated
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Timed
AllEntriesshouldbe:
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Legible
Allentriesshouldbe:
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Complete
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Needstotellthepatient’sstoryforall
caregirvers.
2016MEMORIALHOSPITALMEDICALSTAFFANNUALEDUCATION
Allin-andout-patientsshouldbeinformallyscreenedat
Healthcareworkersmayanonymouslyreport,withoutfear
admissionforsignsofabuseandneglect.
ofdisciplinaryaction,anyurgentpatientsafetyorquality
concern,aswellasanyimprovementideathroughthe
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Possibleindicatorsofabuse/neglectmayinclude:
MHSBIncidentReportingSystem.
o patientstatesthatabuse/neglectoccurred
ANTICOAGULATION
NationalPatientSafetyGoal#3:Reducethelikelihoodofpatient
harmassociatedwiththeuseofanticoagulanttherapy.This
pertainstopatientsonlong-termanticoagulanttherapywherethe
clinicalexpectationisthatthepatient’slabvaluesforcoagulation
willbeoutsidenormalvalues.Patienteducationisavital
componentofananticoagulationprogramincludingaface-to-face
interactionwiththeprofessionaltoexplainrisks,precautions,and
theimportanceofmonitoring.Alsokeywithanticoagulationisthe
useofapprovedprotocols,baselinelabs,andtheuseofresources
tomanagepotentialfoodanddruginteractions.
FIRESAFETY
Thehospitalminimizesthepotentialforharmfromfire,smoke,
andothercombustibles.MHSBisNONSmokingthroughoutthe
campus.Physiciansandotherprovidersshouldfollowtheacronym
RACEforfireresponse:Removepeoplefromimmediatedanger,
Activatethefirealarmandcall44,Containthefirebyclosing
doors,ExtinguishthefireifpracticalandEvacuateifnecessary.
FiresareannouncedasCodeRed.
Reference:MHSBFireSafetyPolicy
o repeatedand/orunexplainedtraumaticinjuries
o explanationofinjuriesisvagueorrefusestoexplain
o patientexhibitsfear,withdrawalorunnatural
complianceinpresenceofcaregiver
o suspiciousinjuries,“doctorhopping,”etc.
o unusualdelayinobtainingtreatmentforinjuries.
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Ifabuseand/orneglectissuspected,youshould:
o reportthisimmediatelytoCPSorAPS
o documentfindings,observationsandstatementsmade
bythepatientorfamily/caregiver(s)whichsupportthe
suspectedabuse/neglect
o arrangeforphotographsofinjuriesifappropriate.
Reference:MHSBAbuse,TreatmentandReportingPolicy
ORGANDONATION
MHSBworkswithIndianaOrganProcurementOrganizationas
wellastissueandeyebankstomaintainpotentialdonorswhile
thenecessarytestingandplacementofpotentialorganstakes
placeinordertomaximizetheviabilityofdonororgansfor
transplant.ThereisanOrganProcurementpolicyforMHSBon
theintranetunderpoliciesandprocedurestoassistwhenan
organprocurementispossible.Thenursingstaffandspiritual
careareavailabletoassistwiththefamiliesduringtherequest
fororgandonationandthroughouttheprocedures.Itisvitally
importantforphysicianstoattempttorequestdonation
wheneverappropriate.
Reference:MHSBOrganProcurementPolicy
ROLEOFLIPINEMERGENCYOPERATIONSPLAN
InthecaseofanactivationoftheEmergencyOperationsPlana
“CodeYellowactivationlevel1/2/3/4”willbeannounced
overheadandviatheLynxnotificationsystem.Whenthe
activationlevelreachesa3or4allavailablephysiciansareto
contacttheMedicalStaffOfficeat647-7920orinpersonto
notifythestaffofyouravailabilityandlocation.
Reference:MHSBDEOPpolicy
Concernsmayalsobereportedto:
RiskManagementat647-3632
SafetyHotlineat647-7233
IndianaStateDepartmentofHealth
2NorthMeridianStreetIndianapolis,IN46204
(317)233-1325.
TheJointCommission
DivisionofAccreditationOperations
OfficeofQualityMonitoring
OneRenaissanceBoulevard
OakbrookTerrace,IL60181
[email protected]
CULTUREOFSAFETY
Leaderscreateandmaintainacultureofsafetyandquality
throughoutthehospital.Safetyandqualitythriveinan
environmentthatsupportsteamworkandrespectforother
people,regardlessoftheirpositioninthehospital.Behavior
thatintimidatesothersandaffectsmoraleorstaffturnover
underminesacultureofsafetyandcanbeharmfulto
patientcare.Allmedicalstaffsignsandagreestoabideby
MemorialMedicalStaffCodeofConductatalltimes.Any
deviationsfromthatcodewillbeaddressedbytheMEC.
Reference:MHSBMedicalStaffCodeofConduct
ALTERNATEPROCEDUREDURINGDOWNTIMEFOREHR
Whentheelectronichealthrecordsystem(Cerner)is
interruptedMHSBgoesintoa“downtime”procedure.There
aredesignatedcomputersoneachunitthatmaintaina
“snapshot”ofthepatientsrecordtoreferencebackforlabs
andradiologyresultsetc.Anynewordersthatneedtobe
placedwillbedoneonpaperduringthedowntimeandthe
nursingstaffonallunitswillbeavailabletoassistyou.
Reference:MHSBPowerChartDowntimePolicy