Download 2017 February Policies

PROCEDURE
TITLE: Code Adam – Infant/Child Abduction Plan
Issuing Department:
Emergency Management
Departments Involved:
Effective Date:
3/04
Review Dates:
07/08, 10/08, 10/15
Revision Dates:
05/09, 08/10, 01/11, 10/12, 12/16
This procedure rescinds any previous publication covering the same material
I. PURPOSE
To provide protection for all infant and pediatric patients during their hospital stay. This plan is
followed when it is suspected that an infant/child is missing from the hospital.
II. RESPONSIBILITY
It is the responsibility of ALL staff members to always be alert for persons in all areas who
exhibit unusual behavior and to be aware of patients who may be at risk due to family situations.
Unusual behavior can be described as: loitering at the Nursery excessively, inappropriate
questions about a baby or babies, following of nurses as babies are taken to their mothers, or
asking questions about staff procedures or security measures. During a CODE ADAM, it is the
responsibility of the hospital staff to stop and question anyone with children, bulky packages,
suitcases, baby in their arms, wearing a heavy coat or jacket, or anyone who may appear
suspicious.
III. ESSENTIAL POINTS
A. The OB Unit has specific security measures and procedures in place to assure that all infants
are protected. These are addressed in unit specific procedures.
B. In the event of an infant /child abduction, the National Center for Missing and Exploited
Children may be contacted to advise, provide technical assistance, network with other
agencies and organizations, assist in obtaining media coverage of the abduction, and
coordinate dissemination of the child’s photograph as mandated by federal law (42 USC
5771 and 42 USC 5780).
1. Call NCMEC at 1-800-843-5678 (1-800-THE-LOST). Staff will coordinate such
notification with law enforcement.
IV. PROCEDURE
A. CODE INITIATION/AUTHORITY
1. If abduction from OB unit:
a. Staff member will overhead page "Code Adam-location"
b. Upon hearing the overhead page, the switchboard operator will:
i. Repeat overhead page three times
ii. Call 9-1-1
iii. Wireless page Code Adam Team “Code Adam - location”
c. If infant security alarm is activated without overhead page, Switchboard Operator
will call OB unit to confirm.
i. If false alarm, Security is still dispatched to the unit to confirm.
ii. If confirmed or no response, the Switchboard Operator will overhead page
"Code Adam-location" three times
iii. Call 9-1-1.
iv. Wireless page Code Adam Team "Code Adam-location"
v. The Code Adam should be overhead paged every five minutes until the Code
Adam has been cleared.
d. UNIT ROLE:
i. Observe monitor for tag location and patient identification. If tag remains at
entry way – call Code Adam
ii. Search entire unit
iii. Unite all infants with their mothers, explain the situation and ask visitors to
remain in the room until released by Security or Law Enforcement.
iv. Notify lab to hold infant’s cord blood, if available.
v. Reset alarm so operator can reset board.
2. If abduction from any other unit:
a. Staff member will overhead page "Code Adam-location"
b. Upon hearing the overhead page, the switchboard operator will repeat overhead page
three times and call 9-1-1.
c. Operator will wireless page the Code Adam Team "Code Adam- location"
d. Operator will call affected unit to gather additional information of missing person
including:
i. Age
ii. Race
iii. Gender
iv. Name
v. General Description
e. The operator will then immediately overhead page, “Code Adam (with any
available description)”
f. Wireless page the Code Adam Team "Code Adam-description"
g. The Code Adam should be overhead paged every five minutes (with any description)
until the Code Adam has been cleared
h. UNIT ROLE
i. All available staff will search the department and adjacent public access areas.
ii. Secure the area where the infant / child was last seen.
iii. All staff and visitors on the unit at the time of the incident will remain on the
unit until released by security or law enforcement. No additional visitors will
be admitted.
3. DURING A CODE ADAM NO ONE WILL BE PERMITTED TO LEAVE OR
ENTER THE FACILITY UNTIL THE ALL CLEAR IS GIVEN WITH THE
EXCEPTION OF INCOMING STAFF AND LAW ENFORCEMENT.
B. RESPONDER ROLES:
1. Clinical Coordinator/Manager on Call
a. Responds to the page and assumes initial role of Incident Commander.
b. Notifies Administrator on Call who will then notify other members of
Administration of situation.
c. Assumes the Code Adam responsibilities of Building Services/Security position #2
(defined below in item 2. a.iii) in situations of single coverage.
2. Building Services/Security
a. Dual Coverage
i. Initiate emergency radio protocol
1)
Establish communication between Building Services/Security and the
unit using 2 way radios.
ii. Position #1
1)
Completes a sweep of all exits, grounds, and public access areas to
verify hospital lockdown.
2)
Report by radio to the unit all areas that have been secured.
3)
Relay description information of the abductor and child to employees
guarding exits.
4)
Reassign employees as needed to areas of needing coverage.
iii. Position #2
1)
Report to the department paging the CODE ADAM to secure the scene
and act as liaison to responding law enforcement.
2)
Complete the Code Adam Security Checklist located in Safety Corner
file pockets in all areas.
3)
1.
Gather information from the unit to complete the description
information on the front page and communicate by radio the
abductor and child information to Position #1.
2.
Check off location information on the back page of the form as it is
reported by Position #1 and advise what areas still need checked.
Brief law enforcement, who will assume responsibility for investigation.
b. Single Coverage
i. Same procedure as Dual Coverage except the role of Position #2 is performed
by the clinical supervisor.
3. Social Services
a. Respond, if on duty, or will be called in to provide support to the family
4. All Staff
a. INITIATE TOTAL LOCKDOWN
i. Staff report to the following areas to secure entrances / exits:
1)
Building Services / Security:
1.
Assign staff to go to parking lots.
2.
2)
Meet law enforcement and escort to area of concern.
All Other Staff
1.
Secure stairwells, elevators and exits in or near your area.
2.
Search all rooms and public access areas. Be alert for a person who
may be concealing an infant.
3.
ALL INDIVIDUALS SHOULD BE STOPPED AND
QUESTIONED. The recommended approach should be as follows:
a. Inform visitor(s) we have a missing child.
b. Ask the person “Is this your child?”
c. Check for ID band
d. Ask person to open any large bags or purses (if missing child is
an infant).
e. If the person has a child with them that is a toddler or older,
ask the child, “Who is the person with you?”
f. If the person has a child with them that is a toddler or older,
ask the child, “What is your name?”
g. Ask the person where they have been in the hospital. If they
stutter or can’t remember where they were, notify Security.
h. Try to recall as much as possible description/identifying marks
of suspicious persons.
4.
If abductor is identified:
a. Attempt to detain abductor and retrieve infant/child. At no
time should the staff member place themselves in danger.
b. If an employee feels threatened and is unable to detain, let the
person go and notify Security / Building Services immediately
with general description of abductor, vehicle and direction of
travel.
C. Recovery
1. False Alarm – infant / child found
a. Clinical Coordinator/ Manager on Call or Building Services/Security calls the
switchboard operator to announce “All Clear”. Notify Administrator on call of
situation and then AOC notifies Administration of situation.
b. All staff return to normal operations.
2. Infant / child found with potential abductor:
a. Immediately notify Building Services/Security and Clinical Coordinator/Manager on
Call.
3. If infant is not located:
a. Law enforcement assumes control of investigation.
D. Documentation / After Action Report:
1. Clinical Coordinator/Manager on Call will assure that documentation / after action report
is completed immediately following the event and sent to the Safety Officer/Emergency
Management Director and Director of Security.
2. Follow-up will be undertaken as soon as possible following the event.
3. The documentation / after action report summary will be reviewed by Emergency
Management Committee.
PROCEDURE
TITLE: Code Black – Bomb Threat
Issuing Department:
Emergency Management
Clinical Director Signature:
Departments Involved:
All Departments
Effective Date:
08/84
Review Dates:
03/04, 07/08, 02/10, 11/14, 11/15, 12/16
Revision Dates:
This procedure rescinds any previous publication covering the same material
I. PURPOSE
A. These special instructions pertaining to a bomb or incendiary threat to the hospital are
outlined for the following purposes:
1. To promote safety for staff and all others in the hospital.
2. To locate and facilitate the removal of the bomb by qualified personnel.
3. To make every effort to determine whether the threat is a hoax eliminating wasted time
searching for something which does not exist.
4. To prevent panic and confusion leading to possible injuries.
5. To avoid publicity leading to crank calls upsetting the routine of the hospital.
II. PROCEDURE
A. Bomb Threat – Call Information: When receiving a call expressing a threat that a bomb or
other device has been placed in the hospital, the person receiving the call will react as
follows:
1. When the threat has been conveyed by the caller:
a. Notify others around you of the call by holding up the fluorescent yellow “Bomb
Threat” sign.
b. Try to keep the caller talking, while placing a copy of the Bomb Threat Report
(located behind the fluorescent yellow “Bomb Threat” sheet that is posted in every
department) in front of you, asking the caller the questions shown on the Bomb
Threat Report.
c. Document the caller’s answers on the form as your discussion continues. Make any
other notes that seem important.
B. Notification:
1. Do not overhead page Code Black.
2. Notify the Switchboard Operator, indicating a “Code Black (location).”
3. Switchboard Operator will notify the following by:
a. Calling 9-1-1 and report Code Black at Pomerene Hospital.
b. Wireless paging the Code Black team. “Code Black (location).”
4. The Clinical Coordinator/Manager on Call becomes initial Incident Commander who
will:
a. Notify Administrator on Call, who will notify other Administrative team members
as deemed necessary.
b. Open Incident Command Center in the Human Resources Department.
c. The Incident Commander will assign two people to notify all departments of the
bomb threat. Departments located in outbuildings will be notified if threat is
relevant to a specific outbuilding.
5. Building Services/Security will:
a. Proceed to ED to meet law enforcement upon arrival.
b. Work with the law enforcement agencies to secure the hospital and assist in carrying
out a search program.
c. Provide hospital floor plans located in the Building Services Office.
C. Departmental Action:
1. Upon being alerted, Department Manager or designee, will immediately organize the
bomb search procedure for their area(s) utilizing all available staff and following the
instructions outlined below.
a. How to search an area:
i.
Areas should be searched from left to right and from top to bottom to ensure
no area is overlooked.
b. What to look for:
i.
Look for an object you cannot identify or account for, or which looks
suspicious, or something familiar located where it should not be present. (The
size or shape of a bomb or incendiary device can vary.)
c. Where to look:
i.
Nursing Areas: Total departmental area including patient rooms, equipment
and utility rooms, lounges, locker rooms, waiting areas, bathrooms, hallways,
and stairways.
ii.
Cardiology: Total departmental area including patient rooms, equipment and
utility rooms, lounges, waiting areas, bathrooms, hallways, and stairways.
iii.
Administration: Office areas, hallway, stairway to first floor.
iv.
Human Resources/Compliance: Office areas, public restrooms, South
Conference Room, supply closets, Auditorium (including silo stairs to third
floor), and stairway to first floor.
v.
Pharmacy: Departmental areas, hallway, stairs to first/third floor.
vi.
Laboratory: Departmental areas, morgue and storage area, and other
miscellaneous open rooms in the second floor Lab area
vii. Building Services: Departmental area, check elevators, communication
equipment rooms, and locations where considerable damage would result;
e.g., generators, electric circuit boxes, boiler room, roof, and any other
uncovered areas.
viii. Quality: Department area, assist Health Information.
ix.
Utilization Review: Departmental area, hallway.
x.
Health Information: Departmental area, adjoining doctors’ office/lounge.
xi.
Volunteer Services: Office area, gift shop.
xii. Dietary Services: Office areas, kitchen, dining rooms, storerooms, vending
area, hallway.
xiii. Respiratory Care: Departmental areas, office area, hallway, O2 storage area.
xiv. Social Services: Departmental area.
xv. Admitting: Departmental area, office and restroom.
xvi. Radiology (including 2nd floor areas): Departmental areas, including all exam
rooms, restrooms, dressing rooms, office areas, hallway, and main lobby.
xvii. Environmental Services: Department area, housekeeping supply closets in all
areas, lower level locker room areas, and restroom.
xviii.Materials Management: Departmental area, office areas, hallways, stairway.
2. If object of suspicious nature is found, contact the Incident Command Center
immediately at extension 1291 with a description of the suspicious object and the
location. DO NOT TOUCH OR MOVE ANY SUSPICIOUS OBJECT.
3. If nothing is found, contact the Incident Command Center to report the area as
searched and clear.
4. Available staff should report to the Employee Pool Room (ED waiting area).
D. Evacuation
1. All departments must be prepared to implement the Evacuation Plan, if directed by the
Incident Commander or law enforcement agencies.
2. When evacuating an area to try to search and take any personal items you brought in
with you. This will help to eliminate known items and assist law enforcement in their
search.
3. A distance considered safe for evacuation is approximately 300 feet in radius from the
suspected object plus the floor above and the floor below.
E. All Clear
The “ALL CLEAR” announcement will be made upon authorization by the Incident
Commander in consultation with the law enforcement agencies. The Incident
Commander will assign two people to notify all departments of the ALL CLEAR.
PROCEDURE
TITLE: Code Yellow – Disaster
Emergency Management
Issuing Department:
Clinical Director Signature:
Departments Involved:
All Departments
Effective Date:
Review Dates:
07/08
Revision Dates:
11/08, 07/09, 02/11, 11/14, 01/17
This procedure rescinds any previous publication covering the same material
III. GUIDELINES
A. Pomerene Hospital maintains an emergency response plan based on the Hospital Incident
Command System (HICS) which provides a clear chain of command that is responsible for
evaluation of any emergency situation, development and implementation of a plan to remedy
the situation and assignment of necessary resources.
B. Lines of Authority:
1. Hospital Coordination
a.
CEO or designee
b.
VP of Patient Services
c.
Safety Officer
d.
Clinical Supervisor
2. Medical Staff Coordination
a.
President of Medical staff or designee
b.
Emergency Department Medical Director or designee
IV. LOCATIONS
A. Major Trauma – ED
B. Trauma Overflow – PACU and Ambulatory Care
C. Incident Command Center – Human Resources
D. Labor Pool Room – Cardiology Waiting Room Area
E. Family Waiting – Auditorium
F. Discharge Area – Auditorium
G. Triage Area – Hallway East Door ED Entrance
V. PROCEDURE
A. Code Initiation / Authority and Notification
1. Communication to relevant personnel of important information regarding an actual or
potential hazard that may disrupt normal business operations. Such notification may
come from Public Health, police, EMS, local EMA, 911 or news media.
2. Information received by the switchboard or the Emergency Department regarding a
potential of actual disaster situation may come from 911 dispatch or the affected EMS,
fire, or law enforcement agency. All such notifications will be directed to the Clinical
Coordinator or designee.
B. Incident Command
1. Initial Decision Making Authority will generally be given to the Hospital
Administrator on call, Clinical Supervisor, Emergency Department physician and
nurse, Safety Officer, plus Building Services and Security.
a.
The Administrator on call will be notified and consider situation status:
i.
What happened?
ii.
What impact will this have on the facility?
iii.
Can that impact be managed through daily operations and management
practices? If not, initiate the Code Yellow, or other appropriate code.
C. Emergency Operations Plan Implementation / Authority
1. Code Yellow will be initiated by the Clinical Supervisor and/or ED charge staff.
a.
Internal Notification: The Clinical Supervisor / designee will:
i.
Advise switchboard operator to page “CODE YELLOW”
1)
b.
Such notification will be announced at satellite offices, as able.
On-duty staff will contact their Department Director or designee, who will direct
staff call-in as needed.
2. Appropriate response actions will based on available information. Initial decisions
include:
a.
Activation of the Incident Command Center.
b.
Revision of clinical care practices in the emergency department and other
operational areas in the hospital.
3. Administrator on call and Safety Officer report to the facility
a.
Alerts switchboard of arrival at facility
b.
Open Incident Command Center and requests meeting with inhouse charge staff,
i.e. Clinical Coordinator, Building Services, Security and nursing) to determine
situation / status, and assess safety of patients, staff, and visitors.
i.
Performs initial risk assessment
ii.
Activates command staff and assigns Section Chiefs, as appropriate
c.
Directs set-up of ICC in appropriate area.
d.
Advise switchboard operator to page ICC is now open and the location.
D. Responder Roles
1. Charge personnel, all areas:
a.
Determine needs on each clinical unit for staffing, current beds available, and
discharge options.
b.
Coordinate distribution of resources and services.
i.
c.
Report availability of resources using the Disaster Worksheet.
i.
d.
Clinical and Ancillary Services will send available staff to the Labor Pool.
Listen for announcement that ICC is open. Forward worksheet when
requested by runner or fax.
Department representative will report to the ICC only after an announcement has
been made requesting staff to report for a briefing.
i.
Be prepared to give an account of current departmental operations, including
all information on the Disaster Worksheet.
ii.
Retrieve vest and job action sheets ONLY IF YOU ARE ASSIGNED A
ROLE based on the incident assessment.
2. Personnel Distribution
a.
All available employees initially report to the Labor Pool for potential assignment:
i.
Those not currently needed will sign in and return to their home unit and be
counted as ‘available’ on the disaster worksheet.
ii.
Department Directors will assure additional staff has been called in to fill
positions vacated by staff assigned to disaster support, as needed.
b.
Physicians called in will report to the ED Physician for assignment.
c.
Building Services/Security will determine the scope of the incident and provide for
controlled lockdown, traffic control, and support area security.
E. Disaster Patient Care Areas
1. Emergency Department Treatment Areas:
a.
Triage - Hallway East Door ED Entrance
b.
Immediate Care - ED
c.
Delayed Care - PACU/Ambulatory Care
d.
Minor Care - Ambulatory Care
2. Job Action Sheet Assignment will address the activation, staffing, and process for
support function areas.
F. Expansion of Space
1. Additional patients may be placed in stretchers and wheelchairs delivered from other
departments.
2. TEMPS beds are available from Emergency Preparedness room.
3. Surge Capacity: Additional needs beyond the ED:
a.
Refer to Patient Surge Plan (located on hospital intranet under Administration
Policies and Procedures).
G. Disaster Support Functions
1. Hospital Command Center: Staffing
a.
Incident Commander: Organizes and directs ICC with strategic direction for
hospital incident management and support.
b.
Operations Chief: Organize, assign, and supervise Staging, Medical Care,
Infrastructure, Security, Hazardous Materials, and Business Continuity Branch.
c.
Logistics Chief: Organizes and directs those operations associated with
maintenance of the physical environment and the provision of human resources,
material, and services to support the incident activities.
d.
Planning Chief: Oversees all incident-related data gathering and analysis
regarding incident operations and assigned resources, develop alternatives for
tactical operations, conduct planning meetings, and prepare the Incident Action
Plan (IAP) for each operational period.
e.
Finance: Monitors the utilization of financial assets and the accounting for
financial expenditures. Supervises the documentation of expenditures and cost
reimbursement activities.
2. Hospital Command Center Setup
a.
The CEO, Senior Administrative Team, and Medical Staff President (if needed)
will alert the switchboard operator they are in the building, then proceed to the
ICC.
b.
Site of the ICC may be changed depending on current conditions and/or needs of
the situation. Once open, the location will be announced by overhead page and a
facility briefing is requested.
c.
Management briefing includes an assessment of the situation and determines the
appropriate level of response. At this time assignments will be made based on
HICS positions.
d.
The following support areas will be implemented as needed.
i.
ii.
iii.
Family Waiting Area
1)
Social Services will set up the Family Waiting Area in the
Auditorium.
1)
Coordination of family notification and discharge will be from this
area.
Media Center
1)
Public Relations will set up a Media Center in the lower level
Business Office across street from hospital.
1)
Public Information Officer will supervise the area and have the
availability of Security Services if needed.
Labor Pool
1)
Staff will be assigned per ICC
H. Communication Resources
1. Internal Communication
a.
Phone System
b.
i.
Prior to ICC activation, calls from first responders will be sent to the ED.
ii.
When ICC is activated, general phone calls regarding the incident will be
directed to the Public Information Officer. Advise switchboard operator
when assigned.
iii.
Clinical calls regarding patients and their location will be directed to the
Patient Tracking area. Advise switchboard operator when assigned. Outside
general phone calls will be directed to Social Services in the Family Waiting
Area. Advise switchboard operator when assigned.
2-Way Radios
i.
Each 24-hour clinical unit has access to a 2-way radio that will be used for
communication with the Clinical Coordinator, Security, and/or the
switchboard operator.
ii.
Additional 2-way radios are available through Safety Officer and Security.
c.
Cell phones may be used in the ICC.
d.
Runners may be used for internal communication.
2. External Communication
a.
Outside Agencies: ICC maintains contact lists for outside agencies.
b.
MARCS (multi-agency response communication system) radios are maintained in
the South Conference Room and in the ED.
c.
A HAM Radio is kept in the EMS Room by ED along with directions for
implementation.
d.
ED maintains a radio dedicated to local and county emergency services channels.
e.
E-mail and internet resources are available through internal and external means.
I. Records
1. CODE YELLOW chart packets are kept in a box in the EMS room by the ED and are
maintained by registration.
2. Computer registration will be done when time and resources permit.
3. Completed records will follow usual hospital procedures.
J. Managing Resources and Assets
1. Supplies
a.
All requests for in-house supplies will be channeled through Materials
Management.
b.
Requests for medical equipment not available in-house will be sent to the ICC.
Procurement will be coordinated by Biomed.
2. Staffing: Requests for personnel will be sent to the Labor Pool.
K. Traffic Control and Security
1. Security services will coordinate access and egress from the hospital, including parking
lots.
L. Patient Considerations
1. Inpatients and observation patients being discharged will follow routine discharge
procedures.
2. Outpatients may be rescheduled at the discretion of the department director using
established procedures.
M. Visiting hours, meetings, and clinics may be canceled on the direction of Incident
Command.
N. Additional Considerations
1. Surgical Services will adjust scheduled surgical cases as needed.
2. Food Services will provide routine dietary services as well as emergency food service
to personnel and volunteers.
3. Chaplains will be utilized as needed with primary focus in the family waiting area.
The Hospital Chaplain or Social Services is responsible for contacting additional
chaplains. A list of chaplains is available.
O. Licensed/Non-licensed Volunteers
1. Disaster responsibilities are assigned to volunteers only when the emergency
operations plan has been activated and the organization is unable to meet immediate
patient needs.
a.
Holmes County Health Dept is responsible for coordination and verification of all
Licensed and Non-licensed independent practitioners.
b.
Medical Staff will be credentialed through the Medical Staff Credentials
Coordinator or designee in coordination with the Medical Staff President or
designee. Credentialing will be accomplished according to the Pomerene Medical
Staff Bylaws.
c.
The President of the Medical Staff or designee will determine the number of
additional practitioners needed.
d.
Licensed nursing staff will be credentialed through HR.
2. Identification: Volunteer practitioners will be identified by photo ID badge from their
home facility. Pomerene Hospital will issue emergency ID badges following
credentialing, as needed.
3. Assignments
a.
Physician: Disaster responsibilities will be assigned by the Medical Staff Unit
Leader or designee consistent with the hospital’s needs and skills of the volunteer.
b.
Nursing: Disaster responsibilities will be assigned by the Nursing Staff Unit
Leader or designee consistent with the hospital’s needs and skills of the volunteer.
c.
Ancillary: The labor pool will make similar assignments for other LIP or non-LIP
volunteers.
4. Supervision: Every effort will be made to partner each volunteer practitioner with an
on staff supervising practitioner.
P. Termination of Code Yellow Status
1. The ICC will determine when the situation stabilizes to the point that the ICC can be
closed. The switchboard operator will be instructed to page the ‘all clear’ upon their
direction.
Q. Recovery Following All Clear
1. When notified by ICC the switchboard operator will page: “Attention all personnel,
CODE YELLOW all clear” and repeat 3 times.
2. All on-duty personnel will assist in restoring their respective work areas to normal
operations.
3. Patient care areas used as disaster response areas will be re-stocked and returned to
previous capacity.
4. Job Action Sheets will direct the appropriate personnel to begin business recovery
procedures.
5. Critical Incident Stress Debriefing will be coordinated by Social Services using internal
or external resources.
R. Documentation / Critique
1. All implementations will be reviewed in a timely manner.
2. All informal debriefing will be done at the time of the incident. A formal critique will
be scheduled shortly after the incident as necessary.
3. The Clinical Supervisor will assure that the initial critique form is completed
immediately following the event and sent to the Emergency Management Director.
4. All reports will be reviewed by Emergency Management and Environment of Care
Committee.
VI. OBJECTIVE
A. To provide a consistent method for responding to disasters, both internal and external, and
methods to reduce the impact (mitigation), manage the hazard (preparedness), control
negative effects (response), and restore essential services to normal operations (recovery).
B. To provide a mechanism to respond effectively to a variety of emergency situations.
C. To ensure the continued operations under emergency conditions.
D. To ensure that employees are aware of their individual and departmental roles in the
emergency.
E. To ensure the safety and security of patients, visitors, and employees during an emergency.
VII. DEFINITIONS
A. CODE YELLOW: Activated when house wide response is necessary due to the scope and
resources needed to respond effectively to an event that disrupts or threatens to disrupt
normal operations. Code Yellow will require activation of Incident Commander as well as
support functions.
B. DISASTER: Any event either within or outside the facility that disrupts the system’s ability
to provide care and treatment or endangers the well being and safety of patients, visitors,
staff, and property.
C. HOSPITAL INCIDENT COMMAND SYSTEM (HICS): The Hospital Incident Command
System (HICS) is a management system based on National Incident Management System
(NIMS) that consists of a flexible organization structure and time-proven management
principles. The system includes defined responsibilities and reporting channels and uses
common language to promote internal and external communication and integration with
community responders.
D. INCIDENT COMMAND CENTER (ICC): An identified area where administrative staff
will meet to coordinate response activities, resources, and information during an emergency
or disaster.
E. INCIDENT COMMAND SYSTEM (ICS): Identifies chain of command through an
organizational chart and corresponding Job Action Sheets.
F. NATIONAL INCIDENT MANAGEMENT SYSTEM (NIMS): A federally mandated
system designed to provide a consistent nationwide approach to prepare for, respond to, and
recover from domestic incidents, regardless of cause, size or complexity.
VIII. BACKGROUND / REFERENCES
A. The plan is influenced by various regulatory standards, including but not limited to:
1. Accrediting Agency
2. Emergency Medical Treatment and Active Labor Act (EMTALA)
3. OSHA
4. NFPA
5. Hospital Incident Command System: Job Action Sheets
PROCEDURE
T120.00
TITLE: Safe Injection Practices
General Nursing
Issuing Department:
Clinical Director Signature:
Departments Involved:
Effective Date:
12/16
Review Dates:
Revision Dates:
This procedure rescinds any previous publication covering the same material
I. PURPOSE
Safe injection practices help prevent the transmission of bloodborne infections from patient to
patient.
II. POLICY
All members of the healthcare team will comply with current recommendations for safe
injection practices.
III. PROCEDURE
A. Aseptic Technique: Use aseptic technique to avoid contamination of sterile injection
equipment.
1. Perform hand hygiene before any handling, accessing, preparing or administering
medications.
2. Disinfect the rubber stopper of medication vials and the neck of glass ampules with
sterile 70% alcohol before inserting a needle or breaking the ampule.
3. Needles, cannulas, and syringes are sterile, singe use items. Never reuse for another
patient or to access a medication or solution that might be used for a subsequent
patient.
4. Use aseptic technique in all aspects of parenteral medication preparation,
administration, medication vial use, injection, and point-of-care testing.
5. Use a mask to contain respiratory droplets when preparing and injecting solution into
an intra-capsular space (joint), the spine and during lumbar puncture.
6. Store, access and prepare medications and supplies in a clean area on a clean surface.
7. Avoid having nonsterile contact with sterile areas of devices, containers and drugs.
8. Following an emergency event, discard all opened or needle-punctured vials of sterile
parenteral products, IV solutions, and single-use containers, such as bags, bottles,
syringes.
9. Never store needles and syringes unwrapped because sterility cannot be ensured. Keep
bulk unwrapped syringes in the original package (e.g., intradermal syringes).
10. Place only pre-filled flush syringes (e.g., saline, heparin) that are terminally sterilized
by the manufacturer after packaging onto a sterile field immediately after opening.
11. Use needle free systems for all aspects of parenteral medication administration and
transfer of solutions between containers.
12. Disinfect catheter hubs, needleless connectors, and injection ports before accessing.
Use either an antiseptic containing port protector cap or vigorously apply 15 seconds of
mechanical friction with sterile 70% isopropyl alcohol pad.
B. Transporting Medications
1. Never transport medication filled syringes/needles in pockets or clothing.
C. IV Solutions
1. Use an IV solution (e.g. bag, bottle) for only one patient, and then discard.
2. Use needleless spiking devices to remove fluid from IV bottles/bags and vials and use
for only one patient.
3. Never use a container of IV solution (e.g. bag, bottle) to obtain flush solutions for more
than one patient.
4. Never use infusion supplies, such as needles, syringes, and administration sets, for
more than one patient.
5. Use needle free systems for all aspects of parenteral medication administration and
transfer of solutions between containers.
D. Flushing
1. Use single-use containers for flush solutions, whenever possible.
2. If a multi-dose vial must be used, use it for only one patient and then discard it. Use a
new, unused sterile needle and new, unused sterile syringe for each entry into the vial.
a. Multi-use vials are dated when they are first opened and discarded within 28 days
unless the manufacturer specifies a different (shorter or longer) date for the vial.
E. Syringes and Needles
1. Needles, cannulas and syringes are sterile, single-use items. They should never be
reused for another patient or to access a medication or solution that might be used for a
subsequent patient.
2. Remove needle, cannula, syringe and/or accessory items from sterile packaging
immediately before use.
3. Do not use prefilled syringes to further dilute medication for administration. This is an
unsafe practice due to potential for contamination, dosing errors, drug diversion and
needle stick injuries.
a. For drugs that require further dilution prior to administration, pharmacy personnel
should prepare and dispense the diluted formulation in syringes or mini-bags
whenever possible or dispense single-use vials of the drug and diluent together.
4. Do not prepare medication in one syringe to transfer to another syringe (e.g. RN draws
up solution into a syringe then transfers the solution to a syringe that has the plunger
removed or injects it into the bevel of the syringe).
5. Never withdraw medication from a manufacturer prefilled syringe barrel (carpuject
style syringe barrel).
6. Never use a syringe for more than one patient even if the needle has been changed
between patients.
7. Use a new sterile syringe and a new sterile needle for each entry into a vial or IV bag.
8. Utilize sharps safety devices (needles/syringes) to administer injections whenever
possible.
9. Discard syringes, needles, and cannulas in an approved sharps container/receptacle
immediately after use and at the point of use.
10. Draw up medication into a syringe as close to administration time as possible.
a. Inject within one hour (or as soon as possible) after drawing up the medication.
11. Label all syringes containing medication if not immediately administered.
a. Include patient identification information, names and amounts of all ingredients
(including strength and concentration), and the name or initials of the person who
prepared the medication, the date and time the medication was prepared, and
beyond use date and time.
F.
Medication Vials
1. Always follow the manufacturer’s instructions for storage and use.
2. Check the manufacturer’s expiration date on all medication vials prior to use.
3. Inspect vials and discard if sterility is known or suspected to be compromised.
4. Examine vials for particular matter, discoloration, or turbidity; if present, do not use
and return to pharmacy.
5. Read the vial label carefully. Vial size does not indicate whether or not a vial is single
use or multi-dose.
6. Store vials with the same colored labels and/or same medications with different
dosages separately.
7. Always use a new sterile syringe and new needle/cannula when entering any vial.
Never enter a vial with a syringe or needle/cannula that has been previously used.
8. Use single-use or single-dose vials or ampules whenever possible and discard after use
on one patient.
9. Use multi-dose medication vials for one patient whenever possible.
10. Store and access multi-dose vials away from the immediate patient care environment
and always use a sterile syringe and needle/cannula each time the vial is accessed.
11. Never leave a needle in the septum of a medication vial for multiple medication draws.
a. This provides a direct route for microorganisms to enter the vial and contaminate
the fluid.
12. Never use a de-capping device to remove the top from a vial (e.g. to pour medications).
13. Draw solutions through the diaphragm with a sterile syringe and sterile transfer device
or needle using aseptic technique.
14. Use needleless transfer devices when reconstituting drugs. Discard transfer device
with the vial at the end of the transfer.
15. Use a filter needle or filtered transfer device to draw medications from an ampule into
a syringe to prevent glass shard and/or potential microbial contamination.
16. Never pool or combine leftover contents of vials for later use.
17. Discard any vial that has been placed on a known or visibly contaminated surface or a
used procedure tray.
18. Label a multi-dose vial with a beyond-use-date when first accessing it. The beyonduse-date after initially entering a multi-dose vial is 28 days, unless otherwise specified
by the manufacturer. The beyond-use-date must never be after the manufacturer
specified expiration date.
19. Check bot the beyond-use-date and the manufacturer’s expiration date prior to using an
opened mult-dose vial.
20. Discard any vials that were used to draw two or more medications into a single syringe.
21. Discard the multi-dose vial with a needleless vial access device after use with a patient.
22. Do not administer medications from single-dose vials or ampules to multiple patients
or combine leftover contents for later use.
23. If multi-dose vials must be used, both the needle or cannula and syringe used to access
the multi-dose vial must be sterile.
a. Date multi-dose vials when they are first opened. Multi-use vials are dated when
they are first opened and discarded within 28 days unless the manufacturer
specifies a different (shorter or longer) date for the vial.
G. IV Injectables in the Operating Room
1. Whenever possible, prepare injections that require compounding (e.g. two or more
medications combined) such as those designed to reduce post op bleeding and pain,
and/or administered into intra-articular space during orthopedic surgical procedures) in
a pharmacy environment instead of in the operating room.
2. When a single medication needs to be reconstituted outside the pharmacy prepare
according to manufacturer’s instructions and just prior to administration.
3. Multi-dose medication vials used for more than one patient should be stored and
labeled appropriately and should not enter the immediate patient care area (e.g.
operating room, anesthesia carts).
a. If multi-dose vials enter the immediate patient care area, they must be dedicated for
single patient use and discarded immediately after use.
4. Never use a de-capping device to remove the top from a vial to pour the contents onto
the sterile field (e.g. into a sterile basin) as vials are not designed for aseptic pouring.
5. Use a commercially available sterile transfer device (e.g. vial spike, filter straw, plastic
cannula) to aseptically transfer medications/solutions to the sterile field.
a. The circulator should hold the vial so a designated scrub person can withdraw the
medication or solution using a sterile syringe and needleless adapter. Remove the
vial and transfer device after each use and they are not intended for multiple uses.
6. When utilizing sequential dosing for one patient (e.g. anesthesia), draw the entire
contents of a vial into a sterile syringe and use the same syringe for the sequential
doses in only that patient never leaving the syringe unattended OR obtain sequential
doses individually from the same vial using a new needle/cannula/syringe each time
the vial is accessed for a dose. The vial should then be discarded when empty or no
later than the end of the case.
7. Save and isolate all medication containers and delivery devices until the case is
completed and the patient leaves the room as this is important evidence should an
adverse event/error be identified.
IV. REFERENCES
A. CMS-CoPs
B. CDC Safe Injection Practices
C. APIC 2016 Position Paper
D. ASC Safe Injection Practice
PROCEDURE
GL 960.20
TITLE: Laboratory Orders
Issuing Department:
Clinical Director:
Departments Involved:
Effective Date:
Laboratory
Review Dates:
Revision Dates:
5/10, 5/13, 03/16
7/06, 4/07, 12/09, 5/10, 5/11, 11/16
6/05
I. PURPOSE
The laboratory performs testing upon the written or electronic request of authorized
individuals. In most instances, the authorized individual is a physician/Advanced Practice
Practitioner.
II. REQUISITIONS
A. Requisitions and report forms shall contain such information as to make the chain of
responsibility of personnel clear and to make all significant dates and times known.
B. Laboratory test orders must contain the following information:
1. Patient's full name and date of birth
2. Patient’s sex
3. Contact information of the authorized person requesting the test, and if
different, the individual responsible for using the test results, in order to report
routine and critical results.
4. Authorized requestor’s signature (may be electronic)
5. Name of the test(s) ordered
6. Any special handling required
7. Date and time (where pertinent) to the test being ordered and the date and time
of collection
8. The specimen source, when pertinent to the test being ordered
9. Date and time when delivered to laboratory if applicable
10. Diagnosis or Diagnosis Code (ICD10)
C. Laboratory Test orders must be legible. Illegibility is determined when two laboratory
personnel cannot decipher the order information.
D. If any of the above criteria are not met, the Laboratory will contact the authorized
requester for the missing information. This information must be obtained before the
sample is collected and processed except for “Life Threatening” situations.
III. ROUTINE ORDERS
A. Routine morning lab work is printed from CPSI by the third shift phlebotomist and
organized for collection.
B. Timed orders are placed in the acrylic file above the desk in the office area such that
patient information cannot be read.
IV. STAT ORDERS
A. Individuals receiving STAT orders must page the phlebotomist. If a phlebotomist is
unavailable, technical staff shall be asked to perform the venipuncture.
B. It is imperative that communication between the physician / nursing unit and the
laboratory does not break down. Orders must be followed through by every individual
involved.
C. STAT blood work is to be completed within 1 hour. Certain testing may not be ordered
STAT. Refer to the lab reference manual for information on which tests can be ordered
STAT.
D. When a STAT test has been ordered ordering personnel are required to page the
phlebotomist.
E. Results of STAT testing automatically print at the nursing station upon verification in
the laboratory.
F. Results of STAT testing for non-inpatients will be called to the ordering physician or
other responsible caregiver upon completion.
V. VERBAL ORDERS
A. All verbal orders are to be read back to the requesting individual for verification of
accuracy and are to be followed up with a written or electronic order within 30 days.
B. Verbal orders should be recorded on form LAB 1017.
C. The laboratory should request written authorization (paper or electronic) within 48 hours.
The authorization should be received within 30 days. All attempts to obtain authorization
should be documented.
VI. STANDING ORDERS
A. Standing orders faxed from physician offices to the main lab should be faxed to both the
Berlin and Millersburg Medical Building locations.
B. Standing orders are stored electronically in the patient’s account.
C. When the patient arrives, the order should be pulled from the file and printed. The copy is
to be sent to the Laboratory with the patient’s samples.
D. If there is no order in the file, call the physician/practitioner’s office and request that the
order be faxed.
Check the date of the standing order. Do not collect blood from patients with orders
that are older than 1 year. A new order must be requested from the ordering physician
by the Laboratory or phlebotomist.
Standing Order Flow
Patient arrives
with order in hand
Order faxed to lab
Order faxed to
Berlin and Multi
Order placed in
standing order file
Order
photocopied and
scanned into
account
Copy of order
kept with bloodwork
PROCEDURE
AC18.00
TITLE: Discharge Criteria
Issuing Department:
Ambulatory Care
Departments Involved:
04/86
Effective Date:
Review Dates:
03/00, 03/03, 12/09, 02/10, 05/11, 09/14, 1/17
Revision Dates:
This procedure rescinds any previous publication covering the same material
IX. STATEMENT
Discharge criteria should be evaluated and assessed using the parameters below. A physician
order is required for discharge and a post-anesthesia assessment must be completed by the
Anesthesia provider prior to discharge.
X. DISCHARGE CRITERIA (to include but not limited to):
A. Airway and respiratory/ventilation status
B. Vital signs
C. Temperature/thermoregulation
D. Level of consciousness
E. Pain level
1. Patient has adequate pain control with medication by mouth (PO)
F. Sedation level
G. Comfort level
H. Able to ambulate.
I. Ability to swallow
J. Presence of nausea/vomiting
K. Skin color and condition
L. Condition of dressing/surgical or procedural site
M. Urinary status
N. Child-parent/significant other interactions
O. Patient and home care providers knowledge of discharge instructions
P. Verbal and written discharge instructions given to patient/accompany responsible
individual
Q. All patients who receive anesthesia other than local anesthesia on an ambulatory basis will
be accompanied on discharge by a responsible adult / driver.
R. Provide additional resources to contact if any problems arise
S. Tolerates clear fluid for minimal amount of one-half (1/2) hour without emesis prior to
discharge, if ordered.
T. Verbal and written medication instructions
1. Prescriptions
2. Over-the-counter medications
3. Resuming home medication plan
U. Order for discharge received from physician.
XI. REFERENCES
A. AORN 2016 Guidelines
B. ASPAN2017-2018 Guidelines
PROCEDURE
AC21.00
TITLE: Colonoscopy, Setting Up for and Assisting with
Ambulatory Care
Issuing Department:
Clinical Director Signature:
Departments Involved:
Effective Date:
03/87
Review Dates:
06/05
Revision Dates:
06/02, 10/07, 01/11, 01/14, 01/17
This procedure rescinds any previous publication covering the same material
V. PURPOSE
To outline procedure for setting up equipment and assisting the physician with colonoscopy
procedures.
VI. PROCEDURE
A. Provide the following equipment and supplies:
1.
Medicines for sedation as ordered by the examining physician
2.
Light source and monitors
3.
Suction and irrigation for colonscope
4.
Suction with yankauer tip
5.
Colonoscope
6.
Clean 4 x 4’s
7.
Water Based Lubricant
8.
Alcohol sponges
9.
1 pair sterile gloves and 1 unsterile glove for physician
10.
Pitcher 2/3 full with H2O
11.
Biopsy forceps
12.
Specimen container with 10% formalin
13.
Electrocautery (have available, not set-up)
14.
Snare
15.
Gown for physician
16.
Procedure Flow Sheet
17.
O2 with nasal cannula
18.
Surgical permit
19.
Ambu bag
20.
Crash Cart
B. Explain the procedure to the patient
C. Monitor vital signs including the following:
1.
Blood pressure
2.
Cardiac monitor
3.
ETCO2
4.
Pulse oximetry
D. Document and print cardiac rhythm strip
E. Position patient on left side with knees bent
F. Apply nasal O2
G. Assist physician during the procedure as requested
H. If polypectomy is performed using cautery / snare:
1.
Apply grounding pad to patient
2.
Prepare snare
I. The RN monitors the following:
1.
Vital signs
2.
Level of consciousness
3.
Response to medicines and procedure
J. Properly preserve and label all specimens obtained
K. Deliver specimens to laboratory and sign log book
L. Print vital signs
VII. DOCUMENTATION
A. Procedure
B. Time
C. Medication given
D. All specimens obtained
E. Vital signs
F. Patient’s tolerance
G. Patient’s response
VIII. CARE AND CLEAUP
In accordance with established procedure. See AC24.00 Endoscopes; Cleaning of.
IX. REFERENCE
A. Olympus Reprocessing Manual.
B. Pomerene Hospital procedure AC24.00
C. Pomerene Hospital procedure AS402.00
PROCEDURE
OR314.00
TITLE: Monitoring Patient Receiving Local Anesthesia
Surgical Services
Issuing Department:
Clinical Director Signature:
Departments Involved:
Effective Date:
10/86
Review Dates:
05/02, 05/05, 12/13
Revision Dates:
08/03, 10/07, 12/10, 1/17
This procedure rescinds any previous publication covering the same material
I. PURPOSE
To provide guidelines for patient monitoring of all procedures requiring the use of local
anesthesia by non-anesthesia personnel.
II. OVERVIEW
Patients requiring local anesthesia and who meet the criteria for patient selection will be
monitored by an RN trained in basic EKG/arrhythmia, with current ACLS certification, in
addition to a technician or nurse assisting the physician.
III. EQUIPMENT AVAILABLE
A. Supplemental oxygen
B. Suction equipment
C. Emergency crash cart with defibrillator
D. Cardiac monitor
E. Pulse oximeter
F. Blood pressure monitor
IV. PROCEDURE
A. Pre-procedure Assessment
1. The pre-operative assessment will include:
a. age
b. height, weight, and body mass index (BMI)
c. current medications and use of alternative complementary therapies
d. allergies and sensitivities
e. NPO status
f. Medical history
g. Laboratory results
h. Diagnostic test results
i. Baseline cardiac status (eg, heart rate blood pressure)
j. Baseline respiratory status (rate, rhythm, pulse ox)
k. Baseline skin condition for integrity (eg., rash, breaks, ecchymosis)
l. Baseline neurological status (level of consciousness)
m. Sensory impairments (eg, visual, auditory)
n. Level of pain
o. Perceptions of surgery
p. Need for intravenous access
q. Anxiety level
r. Vital signs, including temperature
2. Any concerns that have been identified in the pre-operative assessment should be
addressed with the provider.
B. Intra-procedure Monitoring:
1. Patient is continually reassessed throughout the procedure.
2. Vital signs (EKG, oxygen saturation, heart rate and blood pressure, and respiratory rate)
are recorded every five minutes. Level of Consciousness is recorded every 15 minutes.
3. Verbal reassurance is given to the patient frequently throughout the procedure.
4. Untoward reactions or sudden/significant changes in monitoring parameters should be
immediately reported to the physician.
C. Post-procedure Monitoring and Discharge Criteria:
1. All outpatients who receive sedation for any procedure must be observed and monitored
for a minimum of one hour prior to being discharged home.
2. Vital signs (heart rate, respiratory rate, pulse oximetry and blood pressure) are
recorded at 15, 30 and 60 minutes.
D. Documentation:
1. All nursing care must be documented on the Intraoperative Record.
2. Document the local anesthetic administered, including the:
a. Medication
b. Strength
c. Total amount administered
d. Route
e. Time
f. Expiration date
g. Lot number
h. Response
i. Adverse reactions
E. Local anesthetic systemic toxicity (LAST): an uncommon potentially fatal, toxic reaction
that occurs when the threshold blood levels of a local anesthetic are exceeded by an
inadvertent, intravascular injection or slow systemic absorption of a large, extravascular
volume of local anesthetic.
F. Symptoms of local anesthetic systemic toxicity (LAST)
1. Metallic taste
2. Numbness of the tongue and lips
3. Auditory changes (tinnitus)
4. Light-headedness
5. Dysarthria (eg. Slurred speech)
6. Shivering
7. Tremors
8. Confusion
9. Agitation
10. Syncope
11. Seizures
12. Coma
13. Tachycardia/hypertension (initially)
14. Bradycardia/hypotension (with increased toxicity)
15. Ventricular arrhythmias
16. Asystole
17. Respiratory arrest
G. If LAST occurs:
1. Call a rapid response or activate a code
2. Maintain the airway
3. Oxygenate
4. Assist with basic life support or advanced cardiac life support
5. Be prepared to assist with administration of 20% lipid emulsion therapy
H. Signs and symptoms of an allergic reaction include:
1. Anxiety
2. Bronchospasm
3. Dizziness
4. Dyspnea
5. Erythema
6. Edema
7. Heart arrhythmias (tachycardia, bradycardia)
8. Hypotension
9. Nausea
10. Pallor
11. Palpitations
12. Pruritus
13. Rash
14. Syncope
15. urticaria
V. REFERENCE
AORN 2016 Guidelines
PROCEDURE
PACU103.00
TITLE: Post-Anesthesia Recovery Score
PACU
Issuing Department:
Departments Involved:
Effective Date:
02/00
Review Dates:
05/06, 04/09, 06/12
Revision Dates:
03/03, 10/12, 7/16, 1/17
This procedure rescinds any previous publication covering the same material
I. PURPOSE
To establish cohesiveness and uniformity in the interpretation of discharge criteria for
postoperative patients.
II. STATEMENT
The patient is evaluated using the Post-Anesthesia Recovery Score scoring system prior to
discharge from Phase I and Phase 2 of PACU.
III. PROCEDURE
A. The PACU scoring graph is located on the Postanesthesia Care Unit Record.
1. Each parameter is rated on a scale of 0-2.
a. Activity-able to move voluntarily or on command
i. Moves 4 extremeties-2
ii. Moves 2 extremeties-1
iii. Moves 0 extremeties-0
b. Respiration: To evaluate respiratory effectiveness.
Able to deep breath and cough-2
i. Dypnea, shallow, or limited breathing-1
ii. Apneic-0
c. Circulation: A measurement of cardiovascular hemostasis and a comparison with
previous blood pressures.
i. B/P and HR +/- 20 mm/Hg Pre-sedation-2
ii. B/P and HR +/- 20-50 mm/HG Pre-sedation-1
iii. B/P and HR +/- 50 mm/HG Pre-sedation-0
d. Consciousness
i. Fully awake-2
ii. Arousable on calling, mostly sleeping-1
iii. Not responding or only responds to painful stimuli-0
e. Oxygen Saturation
i. Able to maintain oxygen saturation > 92%-2
ii. Needs supplementary oxygen to maintain oxygen saturation >90%-1
iii. Oxygen saturation < 90% even with supplementary oxygen-0
B. A score of 8 or greater, or a return to a pre-sedation baseline must be achieved before
discharge from Phase I PACU.
C. A score of 9 or greater, or a return to a pre-sedation baseline must be achieved before
discharge from Phase II PACU.
D. Post Anesthesia Recovery Score is required before discharge from any area, except on
written orders from a provider.
E. Some patients will be unable to score 8 or greater due to pre-sedation deficits. These
patients must return to their baseline before being discharged.
F. A score of 0 in any category excludes eligibility for discharge unless approved by a
provider.
PROCEDURE
PACU104.00
TITLE: Discharge from Phase I PACU
Issuing Department:
PACU
Departments Involved:
Effective Date:
02/00
Review Dates:
12/06, 12/00, 03/03
Revision Dates:
12/09, 10/12, 08/14, 12/14,1/17
This procedure rescinds any previous publication covering the same material
XII. PURPOSE
To ensure that patients are appropriately and adequately recovered from effects of anesthesia
prior to return to Phase II recovery unit.
I. PROCEDURE
A. Assess, and document the patient’s status for discharge from Phase I recovery area:
1. Airway and respiratory/ventilation status
2. Cardiac and hemodynamic status
3. Thermoregulation
4. Level of consciousness
5. Pain level
6. Sedation level
7. Comfort level
8. Sensory/motor function
9. Condition of dressings and/or surgical site
10. Patency of tubes, catheters, drains, intravenous lines
11. Skin color and condition
12. Intake and output
13. Medication management
14. Emotional status
15. Child-parent/significant other interactions
16. Notification of patient care unit for admitted patients for hand off report of significant
events and pertinent patient information from the operating room and Phase I
Recovery.
17. Post-Anesthesia Discharge Score see below:
B. Patients are discharged from the Phase I PACU when they have achieved a score of 8 or
greater or a return to baseline on the Post Anesthesia Recovery Scoring System. A score of
0 in any category excludes eligibility for discharge unless approved by a physician. Some
patients will be unable to score an 8 due to pre-sedation deficits. These patients must return
to their baseline prior to discharge.
Post-Anesthesia Recovery Scoring System
ACTIVITY (able to 4 extremities
move voluntarily or 2 extremities
on command)
0 extremities
Able to deep breath and cough freely
RESPIRATION
Dyspnea or limited breathing
Apneic
BP and HR +/- 20% of pre-sedation level
CIRCULATION
BP and HR +/- 20% to 50% of pre-sedation level
NP and HR +/- 50% of pre-sedation level
Fully awake
CONSCIOUSNESS Arousable on calling mostly sleeping
Not responding or only responds to painful stimuli
Able to maintain oxygen saturation > 92% on room air
OXYGEN
Needs oxygen inhalation to maintain saturation > 90%
SATURATION
Oxygen saturation < 90%, even with supplemental oxygen
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
C. Patients receiving monitored anesthesia care (MAC) may be discharged directly to Phase II
recovery area, per the discretion of the anesthesia provider.
D. Inpatients must be monitored in Phase I recovery area for 1 hour prior to transfer back to
Nursing Unit.
E. Before the patient is transferred to the nursing unit, the receiving unit is called by phone
and notified of the transfer; report will be given according to hand off communication
procedure / current protocol.
III. REFERENCE
A. American Society of Anesthesiologists Standards.
B. AORN 2016 Guidelines
C. ASPAN 2017-2018 Guidelines
PROCEDURE
PACU 105.00
TITLE: Criteria for Notifying Anesthesiologist
PACU
Issuing Department:
Clinical Director Signature:
Departments Involved:
Effective Date:
02/00
Review Dates:
01/07, 10/07
Revision Dates:
01/01, 01/04, 02/11, 03/14, 1/17
This procedure rescinds any previous publication covering the same material
I. PURPOSE
To outline the criteria for notification of the attending anesthesiologist for patients in the
PACU.
II. PROCEDURE
A. The attending anesthesiologist will be notified of the following occurrences:
1. Pulse rate of less than 40 or greater than 120 per minute.
2. Any arrhythmia or irregular pulse.
3. Systolic blood pressure less than 90mmHg for two consecutive blood pressures.
4. Systolic blood pressure greater than 160mmHg for two consecutive blood pressures.
5. Respirations less than 10 per minute and/or difficulty breathing.
6. REMINDER: DO NOT administer the pain medication ordered in the postoperative
orders by the surgeon, unless specifically written to do so. Use pain medication orders
specific to PACU.
7. ETCO2 reading < 35mm.
8. Uncontrolled pain and/or nausea/vomiting.
III. RESPONSIBILITY
PACU personnel are responsible for proper assessment and documentation of each patient and
the notification of the anesthesiologist and/or surgeon when necessary.
IV. REFERENCES
A. AORN 2016 Guidelines, ASPAN 2017 Guidelines
PROCEDURE
PACU504.00
TITLE: Emergency Equipment
PACU
Issuing Department:
Clinical Director Signature:
Departments Involved:
Effective Date:
02/00
Review Dates:
10/04, 10/07
Revision Dates:
10/01, 12/10, 12/13, 04/16, 1/17
This procedure rescinds any previous publication covering the same material
I. PURPOSE
To have emergency equipment available and in good working condition for use in an
emergency.
II. PROCEDURE
A. Each Phase I bedside unit will have the following equipment available:
1. Various types of artificial airways
2. Constant intermittent suction and suction equipment
3. Oxygen tubing, masks, cannulas and pulse oximeter
4. ECG Monitor
5. Blood Pressure monitoring device
B. An emergency crash cart containing medications and endotracheal intubation tray is located
in the PACU and outside the Endoscopy suite.
1. A defibrillator with adult/pediatric pads and cardiac pacing capabilities.
C. Bag-valve masks of appropriate sizes are available on the emergency crash cart.
D. Equipment will be available to assess:
1. Hemodynamic/cardiovascular status
2. Point of care testing (blood glucose, lab draws)
3. Arterial blood gases
4. End tidal CO2
5. Presence of residual never blockade (peripheral nerve stimulators)
6. Portable ultrasound, dopplers
7. Bladder scanner
8. Temperature monitoring device
a. Warming unit to rewarm patient will be available if needed.
9. Malignant Hyperthermia cart (located outside of PACU in hallway)
10. At least one ventilator will be available for use in PACU.
11. Supplies needed to insert aterial line, and central venous lines.
12. Infusion pumps and intravenous supplies
13. Other supplies immediately available if needed:
a. Dressings
b. Facial tissues
c. Gloves
d. Bedpans and urinals
e. Syringes, needles, and protective devices
f. Emesis basins/bags
g. Patient linens
h. Blankets
i. Alcohol swabs/pads
j. Ice bags
k. Tongue blades
l. Irrigation trays
m. Urinary catherization supplies
n. Personal protective equipment
o. Nasogastric tube supplies
p. Access to latex-free supplies and equipment
14. Equipment to safely transport a patient from Phase I Level of Care to inpatient unit:
a. Portable oxygen
b. Cardiac monitoring equipment
c. Pulse oximetry and capnography
III. RESPONSIBILITY
A. Ambulatory staff will be assigned to Phase I Recovery and will be responsible for
maintaining and stocking supplies and equipment.
B. Checking the emergency crash cart daily and testing emergency equipment.
IV. REFERENCES
ASPAN 2017-2018