Download Overview of the Environment of Care

Overview of the Environment of Care
At
Sacred Heart Hospital
Rev. 7/15
1
Identification
Student ID, Agency ID or SHH supplied ID badge must be
worn at all times, per Sacred Heart Hospital policy, preferably on
the upper right chest. Failure to follow this practice may result in
your being refused access to the hospital, or being sent home.
Parking at Sacred Heart
Parking is available in our Chew Street deck for agency and 5th Street decks for
students. All day shift students must use the top level of the 5th Street Deck. Evening
and weekend students may park in Chew Street Deck.
Agency and residents should park in the Chew Street parking deck.
Coupons for deck use are available through Human Resources or prior arrangement
with your institution.
Smoking
Sacred Heart hospital is a non smoking facility. There is no smoking
on Sacred Heart’s property. No smoking is permitted on parking
decks, outside hospital entryways, on the loading dock, nor any
where else on the Sacred Heart Campus. Please remember to pick
up your butts if you choose to smoking in the surrounding
community.
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Dress
Sacred Heart dress code is scrubs for clinical units and business
casual for non clinical areas.
For your safety: do not wear dangling jewelry. No more than 3
piercings per ear, and no other visible piercings.
No spiked heels
No denim clothing.
No strong scents
Body art should be covered
Direct patient care providers may not have false nails, wraps, or
acrylics.
Some departments may have more specific requirements. Please inquire in the
department where you will be working. If you are a student wear your student uniform.
Patient /Work Safety Considerations
Maintaining an environment that is conducive to the safe care of patients and the well
being of our staff is a core aim of Sacred Heart Healthcare System. The following
guidelines identify some basic common sense activities that should be a part of daily
practice:
 Wash your hands frequently – always before and after each patient contact. This
can be done using either soap and water or alcohol based hand gel and should take
as much time as it does to sing “Happy Birthday” or “Row, row, row your boat”.
 Clean up spills as soon as they occur.
 Use lifting/moving aids whenever possible.
 Use personal protective equipment as needed – they are provided at no cost to you.
 Make sure alarms on clinical equipment are audible to all caregivers.
 Always check name bracelets and verify the patient name and birthday or medical
record number before doing any procedure or giving medications. In addition, ask
patients to identify themselves to you.
 Prior to leaving a patient bedside, be sure that
Bed is in lowest position.
Call bell and personal necessities are within easy reach.
Overbed tables are near to the bed.
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 Adhere to all signage instructions, such as in construction areas.
 Be alert to people and happenings in your surroundings.
 Report any unsafe conditions to your supervisor.
Americans with Disabilities Act:
To comply with this act Sacred Heart offers services to those with communications
difficulties. We have a listing of in-house bilingual staff which is accessible on the
Intranet under General Information.
Additionally, we subscribe to a language line phone service which offers interpreters in
140 languages. Access to this feature is made through the telecommunications
operator which provides text messaging is available in Health Call, x5470
For medical interpretation Sacred Heart has tablets available at the switchboard for
video and audio certified interpreters.
This can be accessed by staff 24/7.
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Infection Control
The Infection Control Manual should be used as a reference for approved policies and
procedures.
How are infections spread? Basically, infections are spread through people and
through contaminated objects. People can harbor a variety of microorganisms (germs,
viruses) in blood and other body fluids such as saliva, sputum, and wound drainage, as
well as on the skin. Objects contaminated with infectious agents can be sources of
infection, whether through dirty laundry or contaminated food.
Why can infections occur in health-care facilities?
a.
Frequent contacts are made between people who have or can spread illness and people
who are at risk for infection.
b.
Large amounts of contaminated wastes, equipment and supplies must be
handled and processed.
c.
Microorganisms (bacteria, fungi, viruses, and parasites) can be present.
HANDWASHING - the single most important procedure that you can do to
prevent the spread of germs and viruses!
Perform hand hygiene: :
 before eating, drinking, smoking, applying makeup, handling contact
lenses, or using the bathroom
 after you eat, smoke, cough, sneeze, or use the toilet.
 after touching any blood, all body fluids, non-intact skin and mucous
membranes, contaminated surface.
 after gloves are removed.
 after every patient contact.
Use soap and water or alcohol-based gels.
Reduce your risk!
Use Standard Precautions - treat all blood and body fluids as if known to be infectious.
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Wear personal protective equipment (PPE) such as gloves, masks, gowns, goggles, and face
Shields when there is a possibility of a blood or body fluid splash. These are provided to you at your
work area.
The Hepatitis B Vaccine is effective in preventing HBV. If you are exposed
on the job through a needlestick or splash of blood or body fluids into the face or on
abraded skin, notify your immediate supervisor, wash the area thoroughly with soap
and water and go to the Emergency Department for treatment. You will receive
counseling and treatment consistent with all requirements of Act 148 which was
enacted to protect health care workers.
TUBERCULOSIS
How does TB Spread?
TB is spread when an infected person with active disease sneezes, coughs or
speaks. The tiny bacteria travel in the air currents and can be inhaled by anyone not
wearing respiratory protection. The TB bacteria can settle in the lungs and grow or
can spread to other parts of the body .
Passive TB Infection
In most people who breathe in the TB bacteria and become infected, the body is
able to fight the bacteria to stop them from growing. The bacteria become inactive, but
they remain alive in the body and can become active later. This is called TB infection.
People with TB infection:

have no symptoms

don't feel sick

can't spread TB to others

usually have a positive skin test reaction

can develop TB disease later in life if they do not receive preventative
therapy.
Active TB Disease
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TB bacteria become active if the immune system can't stop them from growing.
The active bacteria begin to multiply in the body and cause TB disease.
Those at high
risk include infants, young children, people infected with HIV, and those with weakened
immune systems.
Symptoms of active TB disease include:

a severe cough lasting more than two weeks

coughing up blood, called hemoptysis

weight loss

night sweats

weakness, chills, fever

Sputum for acid fast bacilli (AFB) is positive

chest x-ray may show active disease..
Patients with signs or symptoms suggestive of TB should be evaluated promptly to
minimize the amount of time they are in ambulatory care settings. Active TB disease is
treated with multidrug therapy including INH, rifampin, pyrazinamide, and ethambutol.
Passive TB Infection :
the TB has entered the body but is inactive.
no symptoms / skin test positive
Active TB Disease
TB is active and growing in the body
symptoms are present/ sputum positive (AFB)
the TB cannot spread to others.
TB can spread to others.
Meds are given to prevent active disease
Meds are given to cure active disease.
Preventing Occupational Exposure
OSHA requires health care workers with potential exposure to TB to be fit-tested with
an approved respirator. Respirators at Sacred Heart Hospital are OSHA approved
respirators that provide protection from aerosolized TB bacteria. This respirator must
be worn by anyone entering the isolation room, including visitors. A regular surgical
mask does not provide protection from TB. Fit testing is done by Employee Health,
the Respiratory department or specially trained staff on each patient care unit.
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Airborne Precautions are used for suspected/known pulmonary TB cases because
the disease is transmitted through the air. It is not spread by direct contact or touching
objects in the room. Private isolation rooms with negative airflow are used for patients
with TB. Isolation rooms with negative airflow for TB are located on 7 Tower, 6Tower,
ICU, Emergency Department. Staff must verify that the negative flow is turned on when
a patient is in airborne isolation. Doors must be kept closed at all times. The chart
must be tagged with the airborne isolation sticker, and an isolation sign is hung outside
the patient’s room. Patients with suspected or active TB must cover the mouth when
coughing and wear a surgical mask when being transported to prevent aerosolization of
the TB bacteria.
Tuberculin Skin Test -TST
The TST skin test is used to identify people who have been exposed to the bacteria
that cause TB. All health care workers are required to have the TST at least annually. .
Additional information can be found in the Infection Control Manual available on
all units.
You should always cover your mouth
when you cough.
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Waste Handling
Waste is collected in various receptacles. Sacred Heart recycles office paper and
aluminum cans.
CLEAR bags are used for non-infectious waste.
Paper bags are used in behavior health units for routine trash
Red bags and containers are used for infectious waste.
Yellow bags and containers are used only for chemotherapy waste.
You are to identify and segregate the various waste streams at their point of origin.
Sharps containers are used for disposal of needles and syringes, glass breakage and
any other potentially injurious objects.
WASTE HANDLING: SEGREGATE WASTE AT POINT OF ORIGIN
Does this waste contain any blood or body fluid?
If the answer is yes, put the waste in a Red bag (infectious waste stream).
If the answer is no, put the waste in a Clear bag (municipal waste stream).
NEVER place a RED Trash Bag INSIDE a Clear Trash Bag!
WHAT IS INFECTIOUS WASTE?
Infectious Waste is waste capable of producing a disease.
Types of infectious waste recognized by the institution are:
*
Contaminated Sharps
*
Pathology Waste
*
Human Blood and Blood Products
*
Isolation Waste
*
Body Fluid Waste
*
Laboratory Waste
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EXAMPLES OF DIFFERENT WASTE STREAMS:
Place in Red Bags
Place in Clear Bags
* Contaminated gloves, booties, caps, or
* Exterior wrappers from gloves,
other disposable personal protective
attire
culturettes, disposable O.R. packs, etc
* Vent tubings, ET tubes, suction catheters
* IV lines, bags with blood
* IV lines -- no blood
* Foley catheter tubing and bags with blood
* bedpans, urinals, emesis basins
* Wound dressings- dripping with blood
* Paper towels
* Laboratory waste
* Food waste
* Isolation waste
* Carbon paper
* Pathology waste
* Copy paper wrappers
* Pleurovacs and hemovacs
* Diapers, Chux with no blood
.
Place in Sharps Box
* Contaminated Sharps, lancets,
scalpels, scissors, broken glass,
IV catheters, scalpels
Blood tubes/used and unused
Place in Paper Recycling Bin*
* Copy/typing/colored paper
Place in Can Recycling Bin
* Soda cans
* Computer paper
* Juice cans
* Self-adhesive notes
* NCR Invoices
* Envelopes
* Brochures/pamphlets
* Newspapers
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* Any paper sources with patient medical information
* NOTE: Paper clips, rubber bands, staples, tape, tabs & spirals do not have to be removed.
PATIENT SAFETY
Incident Reports (Event Report Form)
A vital part of our compliance program
An incident is anything that occurs outside of general hospital procedures. Incidents can result
from a wide range of events. Some examples are:
Falls by patients or visitors
Inability to find personal possessions of patients, visitors, staff
Errors made by personnel
Accidental breakage of patient items
Unprofessional behaviors
Whenever an incident occurs, the person who witnessed the event should complete an Event
Report Form on line and forward to the department supervisor.
Back Safety/Ergonomics
You are at risk for back injury, regardless of the department you work in, your
position in the organization or the amount of physical work you perform Back injury not
only affects your ability to contribute to the workplace and properly perform your job but
also limits your ability to care for your family and enjoy leisure activities outside of work.
Following basic back care concepts on a daily basis will reduce your chance of
impairment. Successful injury prevention is the result of developing good lifting habits,
utilizing good posture and incorporating these skills into your day to day activities both at
work and home.
Key Concepts to Remember:
 Maintain the normal curves of your back.
 Maintain a wide, stable base of support while standing/lifting.
 Lift with your legs, not your back.
 Keep items close to you when lifting or carrying.
 Pivot your feet. Don’t twist your back.
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The following lifting/moving devices are available in the hospital to assist with
patient transfers: slide boards, Viking Total Lifts, Sit to Stand lifts.
SAFETY AND SECURITY
How We Help to Maintain a Secure Environment
 The attendant patrolled Chew Street deck is open 24 hours a day.
 An enclosed walkway connects the 2nd level of the Chew Street deck to the
hospital lobby. Direct access to the hospital from 5th Street Deck.
 Secured badge controlled hospital access after hours.
 The following areas are security sensitive and are locked units :ICU Pharmacy,
Birth Place, and Emergency Department, OABMC, EAC, and Adult Psychiatry.
Special policies are in place to govern clearance for access to these areas.
 A variety of engineered systems in place, such as camera surveillance,
intrusion alarms, escort services, protective glass.
 Special non-violent crisis intervention training (CAIR classes) provided.
 Security can be accessed immediately if an additional presence is needed
when the potential for a disruptive situation exists. Call at extension 3911.
Your Responsibilities: Follow these guidelines regarding your safety and
belongings:
1.
Wear appropriate agency identification at all times.
2.
Do not bring large amounts of cash, expensive jewelry, or other costly personal property
to work.
3.
Always keep handbags and other personal property should be kept in a secured locker or
closet. Bring a lock to secure items in a locker while on the premises
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4.
Be alert for any unauthorized or suspicious persons passing through your work area.
Contact the security department, to report any suspicious activity or persons.
5.
You may alert our Security to any Protection From Abuse orders.
6.
Report to your supervisor any unacceptable behaviors on the part of patients, guests, or
staff. Call a “Code Grey” whenever there is a clear and present danger of injury to
patients or staff.
7.
Report missing property to your supervisor immediately and complete an Incident report.
8.
Lock your car, whether parked at the hospital or at home. Windows should be closed.
Neither Sacred Heart nor the Parking facility is responsible for lost articles.
Options To Report Safety Concerns:

Tell your supervisor

Write it and drop into suggestion box outside the cafeteria.

Sacred Heart Intranet – “Feedback” option
Family Violence
Family violence is epidemic in the United States. It affects every age, race, socioeconomic group, and gender. Abuse is an issue of the abuser wanting power and
control over the victim. The abuse tries to gain power and control through emotional,
verbal, sexual, financial or physical abuse.
Sacred Heart Hospital has gathered a task force to look at policies and educate
the staff and community. All patients at Sacred Heart cared for by a licensed
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professional caregiver will be screened and assessed for family violence. We want to
make sure that the patient is safe. To ensure this we do the following:
 Identify the victims of family violence by screening the patient. Only screen when
the patient is alone.
“Are you safe at home?”
“Are you in a relationship where you feel threatened or afraid?”
 Provide health support
 Document the information in the medical record.
 Provide the patient with the appropriate referral to Social Service and/or Turning
Point.
 Report the suspected or actual abuse to the appropriate community agencies
according to law:
Children and Youth for children under 18 years of age.
Area Agency for Aging for persons over 60 years of age who are at risk.
Law enforcement agencies when permitted by PA law.
Family violence is a social problem and a medical problem where we can make an
impact on peoples’ lives. Ask the question, save a life.
Code Grey
Why used? To deal with disruptions occurring because of behavioral
disturbances on the part of patients or visitors. A Code Grey situation is any in which an
individual (patient, visitor, etc.) demonstrates a clear and present danger to self or
others.
What happens? Calling a
response team so that the
"Code Grey" activates a hospital based
situation can be brought under control.
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How is it activated? Dial "3333", and give your name and location and any
other pertinent information relating to the incident. The hospital operator will announce
"Code Grey and Location" 3 times. If a patient is involved, the nursing member calling
Code Grey will remain as primary communicator, unless this task is formally handed off
to a Code Grey responder.
Who may call a Code Grey? Any member of the hospital staff may institute the
Code Gray. If the occurrence is on a nursing unit, the charge nurse will coordinate team
efforts to maintain patient/staff/visitor safety until the arrival of our specially trained
response team.
To Deal with a Potentially Disruptive Person:
DO:
1. Assume the person has a real concern and has a reason to be upset – LISTEN to his concerns.
2. Try to understand the person's feelings.
3. Sit down, if possible. This is less threatening. Invite the other person to sit as well.
4. Invite the person to talk in an area that is more private, has less of an audience
5. Speak in a low, quiet but firm voice.
6. Apologize if you say or do something that inadvertently upsets the individual.
7. Offer some alternatives whenever possible.
8. Attempt to meet some of the more reasonable demands.
9. Suggest more appropriate ways to get needs met. Don't lecture.
10. Keep your hands open and visible to appear less threatening.
DO NOT:
1. Threaten the person or demand obedience.
2. Argue with the person about facts of the situation.
3. Tell the person he has no reason to be angry.
4. Ignore the person and talk to other staff as if he/she were not there.
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CAIR (Crisis Assessment, Intervention, Recovery) Classes: Sacred Heart offers training in
violence prevention and agitation defusion as well as self-prevention techniques for all staff.
Flyers are posted in all departments. Members of selected areas receive further education to
participate in our response team.
Infant/Child Abduction – Code Pink
The Birthplace is a secured unit. Staff in the Birthplace have special identification
badges to distinguish themselves to parents. We also have other security measures in
place, designed to prevent someone from abducting a child. All staff bear a
responsibility to help with measures to limit the possibility of an infant/child abduction.
You should always be alert to suspicious activities which could indicate someone who
may be considering an abduction. Report to security immediately, any person who is
displaying such behaviors.
Suspicious Activity
Repeat visitors with extreme interest in “babies”
Theft of staff identification
Extensive questions regarding infant-unit protocols
Persons carrying infants instead of using bassinet
Persons carrying bags, large packages, or loosely
wrapped bundles from the unit.
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CODE PINK signals an infant/ child abduction. Stop what you are doing, look at
your work area and halls and report anyone carrying a child or bag/package which could
hold a child. You may be assigned to monitor an exit door. No one should enter or leave
the building during a Code Pink situation. The number to call to report an abduction or
information related to an abduction is x3333.
Care of Inmates (Hospitalized Prisoners)
All inmates are accompanied by law enforcement agents who supervise them.
These agents are referred to as forensic staff. Forensic staff must receive information
regarding our policies and protocols. This informational booklet is on all units and can be
distributed to forensic officers. Any incidents related to forensic staff should be reported
to Security.
HAZARDOUS MATERIALS MANAGEMENT
Many kinds of hazardous materials are found in today's health care
settings. Sacred Heart complies with the Federal OSHA Communication
standard as well as the Pennsylvania Right-to-Know Act in informing employees
of their possible exposure to hazardous chemicals.
Know whether or not you work with hazardous chemicals.
Be educated about those hazardous materials to which you are exposed.
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Learn about the materials you work with.
Use hazardous materials in a safe and responsible manner.
Use PPE (Personal Protective Equipment) when indicated. PPE is provided at no
cost to you.
Know the location of emergency information.
At Sacred Heart our Hazardous Materials Management Program is coordinated
by Gina Hausman.
The program consists of:
 Hazardous Materials Warning Labels
 Material Safety Data Sheets
 Education Program during orientation and annually.
Types of Hazardous Materials
flammable liquids
corrosives
lab chemicals
cleaning agents, disinfectants
office chemicals
gases, such as in Operating rooms and
dental suites
hazardous drugs
Healthcare facilities use many different chemicals, which can enter your
body in different ways:
Ingestion – usually occurs when you eat, drink, or smoke around chemicals
Skin absorption – unprotected skin, especially when it’s cut, chapped, or
damaged can absorb chemicals
Injection – puncture wounds from needle sticks and other sharps injuries can
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inject toxins directly into the bloodstream.
Inhalation – toxic materials can be absorbed through the lungs.

Hazardous Material Identification Labels
Sacred Heart Hospital has initiated a system of chemical identification. All
containers should have a color coded “hazard triangle”. Number and letter codes
on the hazard triangle identify the degree of Health, Flammability, and Reactivity
Hazards for the product you are using as well as the safety measures you should
be taking. By consulting the Hazardous Material Identification Charts (a copy of
the chart is at the end of this section) on your unit you can be alerted to the
hazard potential of the product which you are using and the personal protective
equipment you should be wearing.
Material Safety Data Sheets
Material safety data sheets (MSDS) are received by the health system for all
hazardous materials it purchases. The Emergency Department maintains complete set
of all (Safety manual) for products utilized there. MSDS sheets are also available on line
through the intranet
Material safety data sheets provide valuable information about the product they
describe. They list the substance's chemical name, physical and chemical
characteristics, physical hazards, health hazards, reactivity, and any protective
equipment needed in order to clean up a spill of that substance. In case of an accidental
spill, the MSDS is the first reference that you will want to consult. Be sure to know their
location in your clinical area.
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Chemical spills
In the event of a minor spill (one which does not pose an immediate health threat),
you should consult the container for directions in cleaning it up or consult the MSDS. If
the spill is a major one or one which poses an immediate health threat:
1.
Remove anyone in immediate danger.
2.
Call 3333 - Code Orange.
3.
Secure the area by closing doors.
4.
Evacuate the area if necessary.
Calling a Code Orange will activate the spill response team who will then assess the
situation and determine appropriate follow-up and clean up action. An incident report is
completed for all spill events. A “Code Orange” is not initiated in situations of mercury
spill or spill/leakage of radioactive substances. Special policies cover these situations.
Mercury Spills
Sacred Heart Hospital is moving toward the elimination of all mercury in the health care
environment. However, some items containing mercury may still remain. Mercury spills
generally involve very small amounts of material, therefore a Code Orange need NOT be
called. The involved area should be isolated to prevent persons from touching or
pushing the mercury around with their feet. Unit personnel should obtain a mercury spill
kit from CSR and inform Housekeeping department who will clean up the spill. On night
shift, the supervisor will obtain the kit and take care of the spill. Any broken glass is
disposed of in sharps or other waste containers for glass.
Radiation Safety
Sacred Heart Hospital follows procedures according to the Nuclear Regulatory
Commission in managing its Radiation Safety program. The presence of equipment in
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the healthcare environment poses special hazards to those who use it and to other
health care workers. When portable x-ray equipment is being used in patient rooms, you
will be asked to leave the room, to minimize your exposure to external beams. Signs are
posted at all potential sites of exposure. Check with authorized personnel before
entering these rooms. Remember that time, distance, and shielding have the most
impact on one’s exposure. Minimize the length of time exposed; follow technician’s
instructions regarding where to stand when portable x-rays are being done, and if you
are a badged staff member, use the appropriate protective aprons provided.
MRI Safety
MRIs present special hazards in the hospital. The MRI is located in first floor radiology.
They operate with a very large magnet positioned beneath the unit. People entering the
room must be cleared by unit personnel. This even includes emergency responders.
Please adhere to all signage posted on doors. It is essential that no one enter the suite
with metal items. unsecured oxygen equipment, or other unapproved items.
EMERGENCY PREPAREDNESS MANAGEMENT
Emergency: an unplanned event caused by a fire, weather, utility failure, uncontrolled
chemical release or community event, such as a bus accident, which results in an
excessive number of injured patients.
Two types of disasters: External and Internal.
External disasters: events that occur outside the hospital and victims are brought to us
from the community.
Identified as Code Triage
Internal disasters: events that occur inside Sacred Heart facilities resulting in injury or
interruption of service.
Identified as Code Purple.
We are in the process of revising our emergency policies and procedures to be in
compliance with the guidelines of the National Incident Management System (NIMS).
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For all emergencies, Sacred Heart Hospital uses the Incident Command System
to manage our response. Under this system, an Incident Commander (IC) assumes the
leadership role to guide staff.
The hospital disaster plan is located in the Safety Manual on each unit. Unit
specific plans are at the same location. To keep employees apprised of the status of an
emergency event, the hospital has an Incident Command Notification Alert which is
activated on the Intranet Home page. Selected employees receive training in various
NIMS courses.
As part of our emergency preparedness plans, we participate with the Northeast
PA Emergency Response Group (NEPAERG) and have signed a mutual aid agreement
along with the other 17 hospitals in this group to assist each other with manpower,
supplies, and equipment as needed.
Bomb Threat (Code Black)

If you take a call warning of a bomb threat, use the laminated blue card, accessible
to unit phones, which gives guidelines and questions to ask of the caller. A paper copy
of this questionnaire is located in the BOMB THREAT manual in the Safety Manual.
Keep calm and direct energies to listening carefully to the characteristics of speech
and sound of the caller. Try to obtain information as per suggestions on the blue card.
 Immediately after the call, notify your department head who will proceed to call
security, the administrator or his designate. The announcement for a possible bomb
threat is “Code Black”.
Proper public safety officials will be notified. A search may be conducted. Evacuation
of patients may be necessary. The procedure for doing a search is detailed in the
hospital Safety Manual and is available in every department.
You may be asked to search your particular area for any strange or unusual items
or packages. If anything is observed, please report to ext. 3333. DO NOT
TOUCH.
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During a bomb threat situation, it is important to:

Avoid use of pagers, cell phones, and 2-way radios. Overhead paging and use of
telephones is acceptable.

If searching an area, DO NOT turn on any lights when entering a room. DO NOT turn
off any lights already on.
LIFE SAFETY MANAGEMENT – FIRE SAFETY
R.A.C.E. is our protocol to respond to a fire
situation.
R
Remove (Rescue) any person in
R
A
C
E
Rescue
Alarm
Contain/Clear
Extinguish/Evacuate
immediate danger and CLOSE the door.
A
Pull the alarm and dial 3333 to get the hospital operator. Inform the
operator of the EXACT location and type of fire. (out of hospital, call 9-911)
In the hospital, pulling the alarm activates the ringing of bells which signal
the building and floor of the alarm pulled. The first series of bells indicates
the building: 1= Pasteur wing; 2 = Masson wing; 3 = Trexler wing; 4 =
Tower wing; 5 = Service building; 6 = Butz wing. After a pause the second
series of bells indicates the floor of the designated building.
C
Contain the fire by closing all doors. Turn off fans. Clear halls.
E
Extinguish the fire using hand held fire extinguishers, or wet blankets, etc.,
if possible. Evacuate if necessary. In out-patient settings, evacuation is
your immediate priority before extinguishing the fire.
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Sacred Heart's fire extinguishers are
generally of the "ABC" type, good for all
fires. In addition, a few areas have CO2
extinguishers or halon extinguishers. To
P
A
S
S
Pull the pin
Aim the nozzle
Squeeze the handle
Sweep from side to side
use the extinguisher correctly, remember the "PASS" acronym:
P
PULL the pin. Pulling the pin breaks the nylon or plastic tie that prevents
accidental discharge.
A
AIM the extinguisher at the base of the fire.
S
SQUEEZE or press the handle. Shut off the extinguisher by releasing the handle.
S
Sweep from side to side at the base of the fire.
Remember to always keep your back to the door for easy evacuation when the
extinguisher is dry.
Evacuations
Detailed evacuation routes are posted at every elevator. In an emergency,
evacuations can be carried out either horizontally on the same floor, or vertically to either
the floor below or to the ground level for exit. In general, a horizontal evacuation is the
preferred alternative if it is at all possible. Patients can be moved from one area to
another by the following methods: ambulation, Stair chairs and evacuatiob
sleds,wheelchairs, litter, two-man lifts, pack-strap carry, dragging along floor
using sheets, blankets. Orders for evacuation are given by the CEO or his designee.
In ambulatory facilities, evacuation to outside the building is the rule.
NOTE regarding O2 shut-off valves: The Charge Nurse or his/her designee will be
responsible for turning off any O2 valves upon receipt of an order from the fire marshal.
This will be done only after provisions have been made to supply alternative oxygen to
those patients who require it.
NOTE: Smoke is the greatest hazard in any fire situation. The best air is near the floor.
When escaping a smoke filled area, it is best to crawl.
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Electrical Safety
The integrity of the electrical equipment used in our facilities is vital to the
prevention of injury to patients and staff. To ensure compliance with state and The Joint
Commission mandated codes, Sacred Heart contracts with an outside vendor for testing,
inspection, and repair of clinical electrical equipment. The Clinical Engineering
department is responsible for this function.
The procedure for new clinical electrical equipment:
1. All new patient electrical equipment is sent to Biomed for
clearance.
2. Clinical engineering affixes a “Safety” sticker to the item with
inspection date.
3. A sticker appropriate to the equipment is placed on all new,
rented, or loaned equipment.
The above label is available on the Intranet and must be completed and
attached to any equipment that fails. Three pronged plugs are required for optimal
electrical safety in patient care areas.
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1.
Any electrical equipment brought to the hospital by a patient MUST be
inspected by the Clinical Engineering department prior to it being used.
2.
Immediately disconnect equipment when there is fire, smoke, or shock.
These indicate faulty wiring and MUST be repaired. Tag it as defective and
report it as described above.
3.
In any PATIENT CARE vicinity, only electrical equipment with 3-prong
cords is permitted. Two prong appliances may be plugged in non-patient
care areas such as nursing stations, utility rooms, and staff areas. The
only exceptions are patient owned medical grade e CPAP or BIPAP units
Interim Life Safety Measures
The Joint Commission requires a program to compensate for life safety hazards
posed by construction activity. Construction activity generally involves alternate
pathways, increased dirt, presence of construction equipment and materials, and
increased levels of noise and vibration. Sacred Heart has a Safety sub-committee
dealing with Interim Life Safety Measures to study and provide for the necessary
protocols necessitated by each individual construction project. Some responsibilities
mandated by this program involve installing additional fire extinguishers, conducting twice
the normal number of fire drills, constructing a fire exit through the construction site, and
inspection of the construction site daily.
All staff are responsible for being aware of the interim life safety management
program. Staff working near the construction site are responsible for knowing the details
of the interim measures being utilized at that site.
Sacred Heart is responsible for assuring that there is an organization wide effort to
educate all staff on Interim Life Safety Measures implemented during construction.
Departments affected by construction activity will receive detailed training on the Interim
Life Safety program.
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MEDICAL EQUIPMENT MANAGEMENT
The Food and Drug Administration (FDA) requires that facilities that use medical
devices establish a program that requires us to report patient events to manufacturers
and the FDA involving devices and drugs. This allows the FDA to learn about any
medical product that has caused a serious illness, injury, or death and to take action to
track and/or recall the product for further action. The Sacred Heart Healthcare System
policy that addresses this is General Policy #444.
Definition of Medical Device - A medical device is any instrument, apparatus,
implant, machine, implement, contrivance, in-vitro reagent, or other similar or related
article or component which is used in the prevention, diagnosis, treatment, or care of
disease. It does not include medications and/or drugs.
How to report Safe Medical Device Act Events:

Remove and impound the entire medical device(including all accessories) from
service along with any packaging material. Do not dispose of the device
without authorization from your supervisor. Deliver device to the
Biomedical department for evaluation.

Complete a health system incident report via I.R.I.S. as soon as possible.
Incident report must include all manufacturer data: Serial number, Model
number, Lot number, Manufacturer name, Control number.

Discuss questions or concerns with your supervisor.
UTILITIES SYSTEMS MANAGEMENT
The Hospital depends on having electrical power, potable water, sewer, and
capable heating, ventilation, and air conditioning systems. In addition the hospital has
systems installed for central vacuum, medical gases, communications. In general, loss
of a major system in a Satellite office would necessitate the closing of operations and
cancellation of appointments until the system is repaired. In the hospital, loss or failure
of systems necessitates alternate plans to enable continued care for our patients.
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Sacred Heart has established plans to handle loss of utility systems. Red outlets
in patient rooms and other clinical area function in an emergency as they are hooked into
the generator system. Our generators are periodically checked by plant maintenance
personnel - notice of such tests is distributed prior to the event.
If you work in a patient care area, your department head should point out location
of oxygen valves, vacuum loss alarms, and other utility controls. You should report
any alarm conditions to Facilities Engineering. Flashlights (for use in electrical outage),
extension cords, and an emergency red cord phone and hand bells for patient use are
available in every unit. In a systems failure condition, staff will need to check patients
more frequently and possibly limit new admissions depending on the severity of the
condition.
.
In Conclusion
You play a vital part in the safe operation of our facility. Please help us to maintain
patient and staff safety by following our work rules as defined in our policies. You can
report unsafe conditions or make suggestions for improvements to our environment either
by speaking with your supervisor or completing a form at the suggestion box outside the
cafeteria, or online on our Intranet. We welcome your input.
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Key Names to Know:
Steven Lanshe, Esq
Tracy Burkhart
Corporate Responsibility Officer
610-776-4502
Privacy Officer
610-776-4981
Ralph Natale
Radiation Safety Officer
610-776-5117
Michele Coleman
James Zernhelt
Patient Safety Officer
610-776-4759
Hospital Safety Officer
610-776-4632
Director of Security
Kurt Braxmeier - Ext 4529, or page through Alpha paging or
operator
Infection Control and Prevention Nurse
Steve Schweon
Ext. 4712, or page through Alpha paging or operator
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SUMMARY OF CODES
DIAL 3333 for all Code Situations in the Hospital
CODE RED -
Fire Condition
CODE ORANGE
-
Chemical Spill
CODE PURPLE
-
Internal Disaster
CODE BLACK
-
Bomb Threat
CODE TRIAGE
-
External Disaster
CODE PINK
-
Infant/Child Abduction
CODE GRAY
-
Crisis Intervention
CODE BLUE
-
Cardiac/ Arrest
RRT
-
Medical Emergency
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