Download Clermont Hospital

Clermont Hospital
Medical and Allied Health Staff
Orientation and
Reference Manual
Table of Contents
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TOPIC
PAGE
Welcome to Mercy Health – Clermont Hospital………………………………………..
Medical Staff Overview…………………………………………………………………
Bylaws, R&R……………………………………………………………………………
Physician Response Time……………………………………………………………….
Patient Experience……………………………………………………………………….
Medical Records – Completion Tips……………………………………………………
Disruptive Behavior……………………………………………………………………..
Impairment……………………………………………………………………………....
Incident Reporting/SafeCARE…………………………………………………………..
Quality Initiatives………………………………………………………………………..
MEWS, Rapid Response, Code Blue, Clinical Administrator…………………………..
CarePATH (EPIC)………………………………………………………………………
Antimicrobial Stewardship
Dictation Instructions……………………………………………………………………
Translators, Interpreters…………………………………………………………………
Patient Complaints………………………………………………………………………
Pharmacy, Anticoagulation Clinic………………………………………………………
Employee Health………………………………………………………………………...
Infection Control………………………………………………………………………...
Laboratory……………………………………………………………………………….
Pain Management………………………………………………………………………..
Spiritual Care, Advance Directives, Ethics……………………………………………...
Behavioral Health Institute……………………………………………………………...
Physical Environment, Emergency Management, Emergency Codes…………………..
Reporting to Joint Commission………………………………………………………….
Contact Information – Nursing Units……………………………………………………
Contact Information – Management Team……………………………………………...
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Medical Staff Reference
Welcome to the Mercy Health – Clermont Hospital Medical Staff!
Clermont Hospital was established in 1973 and since that time, has served as Clermont
County’s leading healthcare provider, offering advanced, convenient medical care. Clermont
Hospital features one of the region's newest and largest intensive care units, one of the region's
first dedicated wound care centers, 24/7 emergency care and inpatient/outpatient surgery. The
Eastgate Surgery Center also provides eastside residents a convenient option for top-notch
surgery and other healthcare services. Formerly known as the Surgery Center of Cincinnati,
Mercy Health – Eastgate Surgery Center provides outpatient surgery and a wide range of
specialists that treat health conditions including orthopaedics, pain management, podiatry,
gastrointestinal and urology.
Mt. Orab Medical Center features 24-hour emergency medical care, comprehensive imaging
and diagnostic services and Laboratory Services. Imaging and diagnostic services at Mt. Orab
Medical Center include: CT Scanning, general X-ray, Electrocardiogram (EKG) and lab
services.
Mercy Hospital Clermont opened in 1973 and is licensed for 160 beds. You are joining a staff of
over 669 Physicians and Allied Health Professionals and a hospital with 810 employees. Mercy
Clermont is a 7-Time Reuters Top 100 hospital. The main hospital number is (513) 732-8200.
Below is a list of specialized offerings provided by Mercy Health – Clermont Hospital to help
you be well.
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24-Hour Emergency Care
Adult Behavioral Health Services
Outpatient Diabetes Services and Education
Cancer Care/Oncology
Cardiology
Critical Care
Lung/Pulmonary Services
Lung Specialists
Medical Imaging Centers
Orthopaedic Care/Joint Replacement
Palliative Care
Primary and Specialty Care
Sports Medicine
Rehabilitation and Therapy (Outpatient)
Women's Center
Wound Care Center
Mercy Hospital Clermont
Acute Admissions
Behavior Med Admissions
Inpatient Surgeries
Outpatient Surgeries
ER Visits – Clermont
ER Visits – Mt. Orab
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2016
5,693
1,512
738
7,813
36,675
20,290
OUR MISSION | What we do
Mercy extends the healing ministry of Jesus by improving the health of our communities
with emphasis on the people who are poor and under-served.
OUR VALUES | The principles that guide our behavior
Excellence, Compassion, Human Dignity, Sacredness of Life, Justice, and Service
STANDARDS OF BEHAVIOR | How we, as employees, behave to deliver on the
Mission, Values and Promise
Compassion: We seek to understand, listen and explain.
Advocate: We are the voice for the vulnerable.
Respect: We demonstrate the highest regard for and welcome all people.
Excellence: We commit to the highest standard of quality care, joyful service, and
teamwork.
OUR PROMISE | How we want patients, residents, guests, and community to feel each
and every time they have an experience with us.
We promise to make each and every patient’s life better – mind, body and spirit.
We enjoy being of service to our patients, residents, guests, community, and one
another.
We make healthcare easy so our patients can enjoy their lives.
THE MEDICAL STAFF
2016 – 2017 Medical Staff Officers
Chief of Staff: Larry Graham, M.D.
Chief Elect: Stephen Meyers, M.D.
Immediate Past Chief of Staff: Param Hariharan, M.D.
MEC Members at Large: David Beck, M.D. and Anil Kakumanu, M.D.
Chair, Department of Emergency Medicine: Janice Jones, M.D.
Chair, Department of Medicine: Samir Ataya, M.D.
Chair, Department of Psychiatry: Larry Graham, M.D.
Chair, Department of Surgery: Brian Shiff, M.D.
2016 – 2017 Committee Chairs
Acute Care – Brent Kinder, M.D.
Advisory (Peer Review) – Anil Kakumanu, M.D.
Cancer – Benjamin Herms, M.D.
Cardiology Division – Stephen Meyers, M.D.
Credentials – Ruth Ann Cooper, M.D.
Ethics Committee – Peter Ruehlman, M.D.
Medical Executive – Larry Graham, M.D.
Quality Council – Stephen Meyers, M.D.
General Medical Staff Meetings on the 2nd Tuesday in April and October at 6 p.m.
Department and Sections meet at the direction of the Department/Section Chair.
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Medical Staff Social Events
Annual Seafood Fest held in April or May of each year.
Annual Anderson-Clermont Medical Staff Outing held in the fall of each year.
Annual Anderson-Clermont Medical Staff Holiday Party held on the 1st first Friday in
December.
Medical Staff Services
Michelle Arnold
(513) 732-8327
[email protected]
Michelle Arnold is the Manager of Medical Staff Services at Mercy Clermont. Please
direct any questions you may have related to credentialing, privileging, Medical Staff
Committees,
Medical Staff Governance, Bylaws, Rules and Regulations, Call
Schedules, Medical Staff Social Events, etc. to this office. An updated event and
meeting calendar and any announcements are located in the physician lounge. A
monthly Medical Staff meeting calendar and Newsletter are also distributed via email so
it is important to ensure that your current email address is on file in the Medical Staff
Office.
Physician Parking Available
Convenient physician-only parking is available. As you enter the main Hospital drive,
turn left and follow the roadway to the north side of the hospital - the parking spaces will
be just to the left of the Physician Pavilion entrance. Enter door # 21 to the Physician
Lounge.
Medical Staff Members Photo Identification Badge
Obtain a photo identification badge from the Medical Staff Office PH: 732-8327 or Plant
Operations PH: 732-8571 during business hours. Your badge must be worn at all times
in the hospital. The badge contains a chip that allows entrance to the physician lounge
and the external door after hours.
Medical Staff Bylaws and Rules & Regulations
Current documents can be found on the
Clermont
intranet
site
and
at
https://www.mercy.com/en/cincinnati/about-us/medical-staff-services .
3.3. Responsibilities of Medical Staff Membership
By applying for and holding Medical Staff Membership, each Member agrees to:
3.3.1. provide continuous care to his or her patients at a generally recognized
professional level of quality and efficiency, if clinical privileges are held;
3.3.2. enforce and comply with these Bylaws, the Rules and Regulations and all
other rules, policies and regulations of the Medical Staff and of the Hospital
and Mercy;
3.3.3. abide by commonly accepted standards of professional ethics and while
practicing at the hospital abide by the Ethical Directives for Catholic Health
Care services;
3.3.4. provide where appropriate, emergency care and other professional
services to patients;
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3.3.5. participate in performance improvement and peer review activities;
3.3.6. discharge in a responsible and cooperative manner such reasonable
responsibilities and assignments as a Member may assume or receive by
virtue of Medical Staff membership in the applicable Medical Staff category,
including committee, Department leadership and officer assignments;
3.3.7. work cooperatively with Members, non-Member healthcare providers,
Hospital administration, Mercy and others so as to ensure the efficient
operation of the Hospital and the provision of quality healthcare to the patient
population;
3.3.8. provide accurate information relating to his or her qualifications for Medical
Staff Membership and Clinical Privileges (including but not limited to
information that might result in automatic termination) and promptly provide
updated information with regard to revocation or suspension of professional
license/imposition of terms of probation or limitation of practice by any state
licensing agency; loss of staff membership or loss or restriction of privileges
at any hospital or other health care institution; cancellation or restriction of
professional liability insurance coverage; revocation, suspension or voluntary
relinquishment of Drug Enforcement Agency (DEA) registration number; the
commencement of a formal investigation; the filing of charges by the
Inspector General, Department of Health and Human Services;
3.3.9. make timely payment of dues and assessments as may be levied from
time to time;
3.3.10. discharge such other Medical Staff obligations as may be lawfully
established
from time to time by the Medical Staff or MEC;
3.3.11. provide accurate, timely information on changes of address, contact
numbers and coverage arrangements;
3.3.12. comply with rules, regulations and policies related to medical records;
Physician Response Time
In accordance with the Medical Staff Rules & Regulations, R.III.3.6 The on-call
physician is responsible for accepting any patient who has been referred from the
Emergency Department for one office visit or until the patient can be safely and legally
discharged to the care of another source, regardless of the patient’s financial status.
Follow-up must be provided within a clinically appropriate time for the specific condition,
but in all cases within two weeks.
Patient Experience
Mercy Health Clermont Hospital is committed to exceeding our patients’ expectations
with regards to their experience while they are in our facility. Management and staff
goals include specific patient experience targets. The Medical Staff, in particular, has
also made this a priority.
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Patients are surveyed on the following areas utilizing a Press Ganey survey tool.
During this hospital stay how often did doctors treat you with:
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Courtesy and respect?
Listen carefully to you?
Explain things in a way you could understand?
Below are key things to remember in every patient interaction:
What makes a good communication?
 Informative in a way the patient can understand
 Empathetic
 Respectful
 Calming
 Setting expectations
 Good listener
What makes a good listener?
 Sits down
 Keeps hand off of door knob
 Puts phone on vibrate and does not answer it when with a patient
 Makes good eye contact/good tone of voice
 Has good body language
 Empathetic
 Doesn’t judge
 Doesn’t interrupt
 Asks open ended questions
 Re-states for clarity
 Undivided attention
Medical Record Completion – Tips
For assistance with medical record completion, please contact Stacy Finkbeiner, Chart
Completion Specialist at 513.624.3643.
Please refer to the Medical Staff Rules & Regulations for a complete listing of
requirements.
History & Physical
R.V.2.1 General Statements referencing History and Physical Exams reside in section
18 of the Mercy Health Bylaws.
R.V.2.2 The appropriately privileged Practitioner must authenticate, at a minimum, the
following information in the chart of both inpatients and non-inpatients, including medical
observation patients:
R.V.2.2.1 History of present illness/reason for procedure;
R.V.2.2.2 Summary of relevant past medical and surgical history, including
current medications; allergies; previous procedures; other previous significant
medical history; and
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R.V.2.2.3 Physical examination of vital signs; airway and lungs; heart; and
examination of involved area.
R.V.2.2.4 Diagnosis/ assessment and treatment plan.
R.V.2.3 Inpatient Care: An appropriately privileged Practitioner shall perform and
document a history and physical examination within 24 hours of admission (in the case
of a newborn, within 24 hours of delivery).
R.V.2.4 Non-Inpatient Care: A history and physical by an appropriately privileged
Practitioner is required for non-inpatients undergoing all surgical procedures, and any
procedure where Minimal Sedation, Moderate Sedation/Analgesia/Conscious Sedation,
Deep Sedation/Analgesia or Anesthesia is used.
R.V.2.4.1 A surgical procedure means” An invasive operative procedure in which
skin or mucus membranes and connective tissue is incised or the procedure is
carried out using an instrument that is introduced through a natural body orifice. It
includes minimally invasive procedures involving biopsies, use of laser, or
placement of probes or catheters requiring the entry into a body cavity through a
needle o trocar. Surgeries include a
range of procedures from minimally invasive dermatological procedures (biopsy,
excision, and deep cryotherapy for malignant lesions) to vaginal birth or
Caesarian delivery to extensive multiorgan transplantation. It does not include
use of such things as otoscopes and drawing blood.
R.V.2.4.2 Minimal Sedation, Moderate Sedation/ Analgesia/ Conscious Sedation,
Deep Sedation/ Analgesia, Anesthesia is defined in the “Moderate Sedation –
Management Of The Patient by Non-Anesthesia Personnel” Policy.
R.V.2.5 When the History and Physical has been dictated but not transcribed and
placed in the record, a note prepared by an appropriately privileged practitioner should
be placed in the health record containing pertinent findings, assessment and plan.
R.V.2.6 If an appropriately privileged Practitioner, has performed a history and physical
examination within 30 days of admission, a durable, legible copy of this report may be
used in the patient’s medical record.
R.V.2.7 Should a History and Physical examination be performed by a practitioner who
does not have privileges at the facility at which the services are being performed, then a
provider who has privileges at the facility must authenticate/ co-sign.
R.V.5 Operative or other high-risk procedure records
R.V.5.1 Except in emergencies, a History & Physical examination, the
pre-operative diagnosis, appropriate consents, appropriate laboratory and
radiology reports, and consultations, when requested, must be recorded on
the patient’s medical record prior to any surgical procedure. In the case of
an emergency, where any or all of the above entries have not been made in
the medical record, the operating surgeon shall make a note setting forth a
pre-operative diagnosis and a statement that delay would have been
detrimental to the patient. If a History and Physical was not performed
prior to emergency surgery, then a History and Physical must be
performed within 24 hours of admission.
R.V.5.2 A full operative or other high-risk procedure report is prepared
upon completion of the operative or other high-risk procedure and before
the patient is transferred to the next level of care. If the Practitioner
performing the operation or high-risk procedure accompanies the patient
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from the operating room to the next unit or area of care, the report can be
entered or dictated in the new unit or area of care.
The full report includes, at a minimum:
 the name of the Practitioner who performed the procedure
 his/her assistants,
 the name of procedure performed
 a description of the procedure
 findings of procedure,
 any estimated blood loss,
 any specimens removed,
 the postoperative diagnosis
 and any unanticipated events or complications (including blood transfusion
reactions) and the management of those events.
R.V.5.3 When a full operative or other high-risk procedure report cannot
be immediately accessible in the patient’s medical record after the
operation or procedure, a progress note (Brief Op-note) is entered into the
medical record before the patient is transferred to the next level of care
and is accessible in the record for the next health care provider.
This brief op-note includes:
 the name(s) of the primary surgeon(s)
 names of assistant(s),
 procedures performed
 a description of each finding,
 estimated blood loss,
 specimens removed,
 postoperative diagnosis.
Discharge Summary:
R.V.7.1 For patient stays under 48 hours, the final progress notes may serve as
the discharge summary and must contain the outcome of the hospitalization, the
case disposition and any provisions for follow-up care.
R.V.7.2 For patient stays greater than 48 hours, a discharge summary shall be
prepared. In all such instances, the content of the health record shall be sufficient
to justify the diagnosis and warrant the treatment and end result. All summaries
shall be authenticated by the responsible Practitioner. The discharge summary
must include:
R.V.7.2.1 final diagnosis(es), which shall be recorded in full, without the
use of abbreviations or symbols, and dated and signed by the responsible
Practitioner. If the final diagnosis is a malignancy, clinical staging must be
included;
R.V.7.2.2 the reason for hospitalization;
R.V.7.2.3 significant findings;
R.V.7.2.4 procedures performed and treatment rendered;
R.V.7.2.5 the patient’s condition at discharge; and
R.V.7.2.6 specific instructions given to the patient or family, if any.
R.V.7.3 A discharge summary shall be prepared for a patient who expires.
The discharge summary must include:
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R.V.7.3.1 final diagnosis(es), which shall be recorded in full, without
the use of abbreviations or symbols, and dated and signed by the
responsible Practitioner. If the final diagnosis is a malignancy,
clinical staging must be included;
R.V.7.3.2 the reason for hospitalization;
R.V.7.3.3 significant findings;
R.V.7.3.4 procedures performed and treatment rendered
Disruptive & Inappropriate Behavior
A Member who engages in conduct disruptive to the operations of the hospital is subject
to counseling and action under the Rules & Regulations and the Practitioner
Effectiveness Committee Policy (PEC). The PEC serves as a guideline to assist the
Medical Staff in addressing Practitioners who exhibit disruptive, inappropriate or
unprofessional behavior that, whether by pattern of behavior or individual incident, has
the potential for causing imminent harm to individuals. The process shall refer to
Practitioner Effectiveness Policy, Attachment “A” of this document. Please refer to the
Medical Staff Rules & Regulations for details.
R.XI. Managing Physician Health and Impairment
R.XI.1 When a Practitioner with Clinical Privileges shall make statements, engage in or
exhibit acts, demeanor or professional conduct, or raises concerns about his/her health
or
well-being, and the same is, or is reasonably likely to be, detrimental to patient safety or
to the delivery of quality patient care, or is reasonably likely to be disruptive to Hospital
operations, the matter shall be referred to the Physician Effectiveness Committee.
Actions taken will be in accordance with the Physician Effectiveness Committee policy.
Notwithstanding the guidelines set forth in this policy, the commencement of an
investigation or corrective action against a Practitioner shall not preclude the summary
suspension of the Physician’s Privileges in accordance with Article XIII of the Medical
Staff Bylaws. The intent of any immediate action taken and of the Physician
Effectiveness Policy is to protect patients from harm. Issues involving quality of care
will be referred to the Medical Staff Peer Review Committee.
R.XI.2 Definitions
R.XI.2.1 “Impairment” as used in this rule shall mean a condition which is, or may
adversely affect patient care at the Hospital, including, but not limited to,
physical or mental conditions; psychiatric disorders; emotional disorders;
behavioral disorders; deterioration through the aging process or loss of
motor or perceptive skill; or habitual or excessive use or abuse of drugs,
including alcohol or impairment from the habitual or overuse of drugs or
alcohol.
Please refer to the Medical Staff Rules & Regulations for specifics on managing
physician health and impairment, including self-referral and the Medical Staff process
for assessment and treatment of Member health issues.
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Incident Reporting For Physicians Available Through SafeCare
SafeCARE is an electronic safety event reporting system available on all hospital
computers. Use the system to enter actual safety events, near misses, and
professional conduct concerns. To enter a report, select “SafeCARE” from the “Quick
Links” drop-down menu on the MHP Intranet. Enter the issue, complete all mandatory
fields, and include a brief narrative. Either the applicable department manager or risk
management will address the issue and follow up with you. Remember to specify the
patient name and medical record number, location or department, and your contact
information. (Reports can also be entered anonymously.)
Michelle Williamson, Director of Risk Management
Anderson Office: 513-624-4059
Clermont Office: 513-735-1531
Core Quality Initiatives
Below is what is included in the 2017 Quality Harm Composite, which is the primary
focus of our Quality work in 2017 in addition to the continued focus on reducing all
cause, inpatient readmissions within 30 days of hospital discharge.
Patient Safety Indicators [PSI] AHRQ
EXP 01 Complications of Anesthesia
EXP 02 OB Trauma / Cesarean Delivery
PSI 2- Death Low-Mort DRG
PSI 3- Pressure Ulcer Stage 3 or 4
PSI 4- Surgical Patients Expired
PSI 5- Retained Foreign Obj after Surg
PSI 6 - Iatrogenic Pneumothorax
PSI 7- Central Venous Cath Blood Stream
Inf
PSI 8 - Hip Fx
PSI 9 - Postop Hemorrhage or Hematoma
PSI 10- Postop Phys & Metab
Derangement
PSI 11 - Resp Failure1
PSI 11- Postop Vent Requirement
PSI 12 - Peri op PE/DVT
PSI 13- Postop Sepsis
PSI 14- Postop Wound Dehiscence
PSI 15 - Puncture/Laceration
PSI 16 - Transfusion Rx
PSI 17 - Birth Trauma - Injury to Neonate
PSI 18 - OB Trauma - Vag Del w
instrument
PSI 19 - OB Trauma - Vag Del wo
instrument
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Hospital Acquired Conditions [HAC]
CMS
Catheter Associated UTI
Air Embolism
Blood Incompatibility
Foreign Body Left During Procedure
Infection from Central Venous Catheter
Hospital Acquired Injuries
Mediastinitis after CABG
Pressure Ulcers NPOA, Stage III and IV
DVT/PE, Orthopedic
Surgical Site Infections, Orthopedic
Surgical Site Infections, Bariatric
Poor Glycemic Control
Surgical Site Infections, CIED
Iatrogenic PTX with Venous Cath
Hospital Acquired Infections-NHSN
[CDC]
BJ – Bone and joint infection
BSI – Bloodstream infection
CNS – Central nervous system
CVS – Cardiovascular system infection
EENT – Eye, ear, nose, throat, or mouth
infection
GI – Gastrointestinal system infection
LRI – Lower respiratory infection, other
than PNA
PNEU - Pneumonia
REPR – Reproductive tract infection
SSI – Surgical site infection
SST – Skin and soft tissue infection
SYS – Systemic infection
UTI - Urinary tract infection
VAE – Ventilator-associated event
Modified Early Warning System (MEWS) -- Early Detection of Patient Deterioration
A nurse may call and mention the MEWS score, which is a scoring system that
identifies high risk patients. The score is calculated based on heart rate, blood
pressure, respiratory rate, temperature, and neurologic status. The score is calculated
in Epic to enable nurses to identify patients who are deteriorating and who need urgent
intervention and may call for a Rapid Response Team. The Clinical Administrator
evaluates all elevated MEWS > 4 or if scores a 3 three times in a row.
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Rapid Response Team
The Operator overhead pages “Rapid Response Team” and location three times.
Respondents include the Clinical Administrator who leads, the Clinical Coordinator, and
Respiratory therapist. Others like radiology or EKG tech may be called as needed. This
is intended for “pre-codes” or significant change in status requiring an immediate
evaluation. Staff, patients, family members or visitors can activate the Rapid Response
Team by calling the emergency number at x88456.
Code Blue
Codes should be called to the emergency # at 88456. The operator overhead pages
"Code Blue" and location three times. The Clinical Administrator assumes the
leadership role and follows ACLS protocol until a physician is present. Primary
responders to code blue in addition to the clinical are the Hospitalist or Specialist in
house during the day and the Emergency Department doctor at night and off hours, ED
Charge RN, Respiratory Therapist, and EKG tech. Secondary responders to code blue
are radiology, pharmacy and phlebotomist from laboratory. Code blue occurring in the
Emergency Department are handled by ED staff; MD, RN, and Respiratory Therapist
and pharmacy. The Clinical Administrator audits all codes and the Acute Care
Committee routinely reviews code blues. Now that we have a nocturnist, the ED MD
does not typically respond to inpatient codes at night, nor the ED charge nurse. The
charge nurse of the all inpatient units does respond to codes though on the inpatient
side. For codes in the ED, pharmacy does not respond unless requested now, or if it is
a pediatric code-they must always respond to those.
The Clinical Administrator (CA)
Shifts: 6a-6p and 6p-6a. They cover the hospital 24/7.
Location: their office is located on the second floor, East end, Room 201. In the old ICU
next to the staffing office.
Contact Information: Phone: 735-7683.
Primary responsibilities: The CA is primarily responsible for throughput. They work
closely with the physicians to make appropriate bed placement for each patient. They
do all patient bed placement using EPIC and Awarix tracking board, working with the
transfer center and shift leads closely on each unit. When unable to be done by
Transfer Center, they quick register direct admit patients in EPIC so physicians can
perform order entry. They manage all staffing and adjust staffing levels every 4 hours
based on the hospital needs. They are the primary nursing responder to all in-house
codes, Rapid Responses and Code Blue’s. They are all critical care trained and can
manage patients anywhere in the hospital if needed. They are responsible for updating
GCHC with bed availability, and during disaster situations. They are responsible for
initiating the chain of command when there is an issue that needs administrative
assistance. They are trained in hazmat, evacuation and disaster management and lead
the Emergency Operations until a higher administrator arrives. Night shift CA’s do an inhouse restraint log and all are responsible for locating any equipment or supplies that
might be needed through the house during ancillary departments off hours. They start
IV’s at all hours and several are ultrasound guided IV therapy trained. They complete a
CA report three times a day that is sent to administration electronically. They also
follow-up on all elevated MEWS, Troponins, and Lactic acid scores in-house.
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CarePATH (Epic) Electronic Medical Records and Physician Order Entry
The hospital provides a fully electronic environment for physicians including the Epic
electronic medical records, physician-order entry, digital radiology and remote access.
All physicians are required to attend EPIC physician training prior to caring for patients.
You will receive your log-in at that time. There is a monthly Epic class schedule.
Register at [email protected]. Epic may be used for all documentation and
is fast and easy with customization; dictation is still permitted.
The Physician CarePATH Support line is available 24/7
at the Doc Help Line: 981-5050
Epic Access From Home or Office
The website for OUTSIDE the hospital is Angie McCloud https://chpEconnect.healthpartners.org Best to use Windows Explorer or Firefox. Only works with Firefox on the
Mac (not Safari). Does NOT work on an iPad.
You will need to download Citrix the first time you use this site. Click Accept. This may
take some time. Enter your Epic Username and password to enter the Citrix site. Very
important – Scroll down to MSWO in the third box. Citrix will load. This takes a minute.
Be patient. You will need to download Citrix the first time you do, call 981-5050 for
guidance and help.
Click on the Epic Hyperspace PRD South Central icon. At the Epic Hyperspace log-in
screen put in your username and password, just like in the hospital.
Three Methods for Order Authentication
The Ohio Board of Pharmacy requires a secondary authentication for any medication
orders. That’s why we must use the RF-ID “tap” to sign orders or the challenge
questions or RSA token outside the hospital. Away from the hospital, the RSA token is
used as secondary authentication when ordering any medication. This must be
activated and a PIN number specified before use. Call 981-5050 to set up an RSA
token. Otherwise, challenge questions work in all three cases.
Epic Challenge Questions
To meet Board of Pharmacy requirements, set a total of 15 “challenge questions” under
the EPIC tab and remember that no two answers can be the same, answers must be at
least three characters, and case sensitive. The Ohio Board of Pharmacy requires a
pool of 15 questions. You answer two questions with each order.
Antimicrobial Stewardship
A Joint Commission standard effective Jan 1, 2017 requires hospitals to have
antimicrobial stewardship as an organizational priority including a multi-disciplinary
team. Epic CarePATH pharmacy intervention triggers have been in place since fall 2015
for the Cincinnati Mercy Health hospitals. – most common triggers were de-escalation
and duration of therapy.
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One estimate shows almost half of antimicrobials prescribed in U.S. hospitals are either
unnecessary or inappropriate. Antimicrobial resistance is a serious public health
concern. The rise in resistant microorganisms and the slow development of new
antimicrobial drugs has prompted the Joint Commission to require antibiotic stewardship
programs. Hospital based “Antibiotic Stewardship Programs” can optimize the treatment
of infections and reduce adverse events associated with antibiotic use
Dictation Instructions
If in-house, dial 76370; outside dial 981-6370.
Enter last 5-digits of Medical License number, followed by # sign.
To create a dictation, press 1.
Enter 2-digit worktype, then # key.
01 H&P
02 H&P Pre-op
03 Consult
04 Operative Note
05 Discharge Summary
07 Emergency Department admission (or 01 for H&P)
08 Emergency Department note
14 Letter or memo
Enter patient location: 2 = Clermont
Enter 10-digit account number, then # key.
A job number will be provided at this point; write it down and enter into an Epic note.
Ready to dictate. Press 2 to begin recording. Press 8 to end the report and start
another OR hang up to disconnect.
Begin dictation with:
 Patient name
 Patient account number
 Date (admission, discharge, surgery, etc.)
Any problems with dictation or transcription, call regional transcription at 981-6495 or
after hours call the IT Service Desk at 800-498-1408. You may pick up a dictation
pocket card from transcription services or from the Medical Staff Office.
Translators Available, call the Operator
In accordance with CLAS Standards and Title VI, patients who are identified as Limited
English
Proficient (LEP) will be provided access to qualified interpreters to aid in facilitating
communication related to patient needs at all times. LEP patients are those do not
speak English as their primary language and who have a limited ability to read, write,
speak or understand English. The professional responsible for the patient’s care or
designee will coordinate the use of a dual headset phone whenever one is available. If a
dual headset phone is not available a speaker phone or regular phone may be used.
Dual headset phones are provided to patients at no cost. Whenever a dual headset
phone is available, it would be advisable to keep it by the patient’s bedside until the
patient is discharged. Dual handsets for Cyracom interpreter services are available in
most patient care areas. These phones are bright blue in color and can be used to
direct dial the Cyracom Interpreter Services. Extra phones are kept in a centralized
location at each site. Contact the facility Security Services to obtain if one is not
available.
Page 15 of 30
Bilingual employees cannot be used as staff interpreters unless they have undergone
the process to become a qualified interpreter. Services of a qualified foreign language
interpreter must be offered, at no additional cost, to all patients and/or relatives
identified as Limited English Proficient. To preserve patient confidentiality, family and
friends should not be asked to interpret for a patient unless there is an emergency
situation (until an interpreter can be arranged and arrives), or the patient expressly
requests to use that person. Document this in the medical record.
TO ARRANGE FOR AN INTERPRETER/TRANSLATION:
For on-site interpretation please contact:
Affordable Languages
513.745.0888
1.866.745.9888
Available 24 hours a day
For on-line scheduling:
www.affordablelanguages.com
*contact vendor to obtain password
Vocalink:
1.937.223.1415
Available 24 hours a day
For on-line scheduling:
www.vocalink.net
*contact vendor to obtain password
For phone interpretation services:
Use the blue Cyracom Dual Handset phones to direct dial the interpreter services.
Over the phone Interpreters, dial “O” for the operator
Pacific Interpreters is the preferred vendor. Language Line and Vocalink are used as a
back up service for rare languages.
Sign Language Interpreters
MHF contracts with Affordable Language Services – who
specialize in medical translation. They are used by Cincinnati Children's Medical Center.
They are certified and trained on medical terminology with and required continuing
education.
For complete details regarding Limited English Proficiency, please access the
“Effective Communication with Patients that are Deaf and Hard of Hearing or have
Limited English Proficiency (LEP)” Policy via the below link:
https://secure.compliance360.com/Common/ViewUploadedFile.aspx?PD=PbRt%2bA78
MS4MiN6IgIG4jo5ylyq4cv3huMCfaSSwdBauIk%2fqTDIRJtDt6OVzEN2fEdKnihLA2a%2
f2FQsIvjrQRcJo6V1Jkdll8ntirzwQwWyKkmLGPa4x0fqgUXqOhXUUnfXymFfFTDrUeW3
pDy2Hdhj7ZUBtFEZYOpY2YWuwxDpP2dXUQxmrs%2btHv2tL2%2bkzStRxBMcihgct65
JfWz7C7KxH2Q0n%2bbFptToM9q2ND6%2bhIpEYd%2fklUw%3d%3d
Page 16 of 30
For complete details regarding Interpreter Services, please access the “Access to
Interpreter/Translator Services” Policy via the link below:
https://secure.compliance360.com/Common/ViewUploadedFile.aspx?PD=PbRt%2bA78
MS4pRdcSCijXpZG%2fsNrMjDczFladu6pz0WyzQUIORKvYlMKwtjLrktUp0Uzavb7TNW
D6R9jq4UGyQBqzBmWMSDajMD%2byy3cg92nP2fT4akKF4Ckw0i8pGFPEWMaQXc5j
dP8u9LDvXQWZYeAMXe4MFluSptBVKKc2XjEQ0xIwE8RP2LMj%2fqT2bHaCd78SR6r
4nw%2fYg7lZRKgYk5tsu6NpEFcfjtUN%2fdhOXnSDuPGcLpyvTA%3d%3d
When Patients Complain -- We Want to Know
If you have a patient with a complaint or issue with care during their hospital stay notify
the charge nurse, clinical administrator or department manager so that the issue can be
handled immediately. If you have a patient with a complaint (grievance) regarding an
ED visit, outpatient visit or procedure, or about their hospital stay after they are
discharged, please refer them to our Patient Representative at 735-7792. We want to
know when patients have a bad experience, we want to improve.
Department of Pharmacy
The Pharmacy is open 24/7. The Pharmacy phone number is (513) 732-8291.
Bill Carroll, Director
Connie Holmes, Clinical
Donna Branham, Lead
Anticoagulation Clinic
We also offer an on-site pharmacist-managed anti-coagulation clinic available by
physician referral. In order to refer a patient to the clinic, the physician must complete
the required information and sign both the referral form and the collaborative care
agreement. The form can then be scanned to the pharmacy or faxed to the clinic (513)
732-8766 (fax), or a call can be placed to the Clinic Line at (513) 732-8719. If an
inpatient is referred to the clinic, the physician should check the correct box indicating
whether or not he/she wants anticoagulation therapy management by the clinic
personnel to begin immediately or upon discharge from the hospital. Every attempt will
be made to visit inpatients to establish a clinic appointment; otherwise patients will be
contacted at home by telephone.
Location: 3020 Hospital Drive, Suite 100, Batavia, Ohio 45103
Employee Health
Annette Ellerhorst is our Employee Health Nurse. Currently the EH office is open MonFri, 7am-3:30pm. The office is located on the first floor of the Hospital, the last door on
the right down the administration hallway (past Radiology). The office number is 7357779.
Respirator Fit Testing – Annual fit testing for N-95 respirators is done through
Employee Health. Fit testing is recommended for any healthcare provider that has
contact with patients in airborne precautions. If you are not fit tested, for your safety you
should wear a PAPR when entering a patient’s room in airborne precautions. Contact
Employee Health or Infection Control for any questions.
Hepatitis B Vaccine – Is offered to all medical staff free of charge through the
Employee Health Department (Ext. 87779).
Page 17 of 30
Tetanus, diphtheria and pertussis (Tdap) vaccine – Is recommended for all
healthcare workers. Tdap is available free of charge through the Employee Health
Department to employed healthcare providers. (Ext. 87779).
Influenza vaccines - Flu vaccines are available through Employee Health free of
charge for any provider with privileges. Flu vaccines are mandatory for all Mercy
employed healthcare providers. For NHSN reporting requirements we do ask that nonemployed healthcare providers provide us with information
Bloodborne Pathogen Exposure
If you are exposed, use the digital pager 1-855-343-5076 and enter your 10-digit call
back number when prompted. The BBP hotline is staffed 24/7 by an Employee Health
nurse who will order labs on both the source patient and the physician involved free of
charge (Note-if labs are ordered by the healthcare provider involved through CarePath
(Epic) on the source- charges will be incurred by the patient) Labs include Rapid HIV,
Hep C and Hep B antigen on source and HIV, Hep C and Hep B antibody on healthcare
provider involved. This hotline is also used for any other communicable disease
exposure that can be treated with prophylaxis, for example meningitis.
Needle/sharps disposal
Physicians/LIPs are required to properly dispose of their own used needles and sharps
during procedures. Safety sharps are to be used in place of non-safe sharps whenever
available and feasible.
Infection Control
Mary Barnett is our Infection Preventionist. Her phone number is 732-8498.
Hand Hygiene
All staff, including physicians, is expected to perform hand hygiene with soap & water or
the alcohol hand hygiene product before and after touching patients, before touching
clean equipment and after touching soiled equipment. We instruct our patients to
observe their healthcare providers performing hand hygiene – they are watching what
we do.
Isolation
Patients in isolation have yellow carts outside their door and signs on the door way. All
staff, including physicians, is expected to follow the directions on the card for the
personal protective equipment (PPE) that should be worn. Discard PPE and wash your
hands upon leaving the room. PPE should not be worn out into the hallway. Again, our
patients are watching if we are consistent.
Page 18 of 30
Categories of isolation are:
 Droplet – Some examples are Invasive Haemophilus influenzae type b disease,
Neisseria meningitidis, diphtheria, pertussis, and influenza.
A surgical mask must be worn before entering these patients’ rooms.
 Airborne – Some examples are for Measles, Varicella (including disseminated
zoster) & Tuberculosis
These patients need to be placed in a negative pressure (airborne isolation) room as
soon as possible. An N-95 particulate mask or a Power Air Purifying Respirator (PAPR)
must be worn before entering these patients’ rooms. Fit-testing for N-95 masks and/or
instructions on PAPR use is available through the Employee Health Department
(Ext. 87779).
 Contact – Examples are any known/suspected infection/colonization with an
MDRO, persons with uncontained drainage or a condition that promotes heavy
environmental contamination.
The minimum PPE is gloves to enter the room. Wear a gown if you are against the bed
or environmental objects in the room.
 Contact Alert (for C diff) - This is for suspect/known C diff patients.
Gloves and gowns should be worn into the room.
PPE should be discarded inside the patient room followed by hand hygiene. No PPE should be
worn outside the patients’ room.
There is an INFECTION field in the top EPIC header that may be populated with an MDRO.
The history should show the date and source of the MDRO.
Keep yours items clean
All staff is encouraged to use the hydrogen peroxide wipes to frequently clean off
personal stethoscopes and personal items such as keyboards and phones. For items
used in a Contact Plus isolation room (used for C Diff) use the Clorox wipes.
Device-Related Infections
Device related infections are a big focus of our program. Please assess the need for
urinary catheters and central lines on a daily basis and discontinue if no longer
necessary. If the device is still needed, please document the reason why.
Prevention of central line associated blood stream infections (CLABSIs)
We follow the Institute for Healthcare Improvement’s (IHI’s) Central Line Bundle:
1. Hand hygiene prior to insertion or manipulation of catheter
2. Maximal barrier precautions in preparation for line insertion. Person inserting the
line and those assisting are to wear a cap, mask, sterile gown and gloves. Cover
the patient from head to toe with a sterile drape.
3. Chlorhexidine skin antisepsis (with Chloraprep) prior to insertion and during
dressing changes.
Page 19 of 30
4. Optimal catheter site selection, with Subclavian vein as the preferred site for nontunneled catheters in adults. We discourage use of the femoral vein unless
absolutely necessary.
5. Daily review of central line necessity with prompt removal of unnecessary lines.
Some other initiates which we follow at MCH to prevent CLABSIs include:



Use of Biopatch: Chlorhexidine gluconate (CHG) – impregnated dressing on
insertion site
Use of SwabCap on central and PICC lines: alcohol impregnated cap to ensure
proper disinfection of ports prior to accessing
“Scrub the Hub” for 10 – 15 seconds with alcohol prep pad prior to access of IV
ports
Antibiograms
Hospital-specific antibiograms are available on the MHPnet. Click on “Clinical
Resources” on the left hand side. The antibiogram is the top tile on the right.
Mercy Health Clermont Clinical Laboratory
Manager: Joyce Day-Schamer (732-8236) [email protected]
Laboratory Main Phone: 732-8233 available 24/7 for questions
Hematology, Coagulation and Urines : 732-8607
Chemistry: 732-8608
Blood Bank: 732-8606
Microbiology: Mercy Core Lab at 215-0020
Pathology/Histology: 732-8237
Pathologist on site 8 am – 4 pm, Mon-Fri
After hours, call the main number at 732-8233 to contact the on-call
pathologist.
Medical Director: Dr. Carl Buckner, office: 732-8309
Email: [email protected]
Turn-around Times
 Stats: 30 minutes
 Routine samples which have been ordered for first morning draw are collected
starting at 4:00 a.m. and should be completed by 7:00 a.m. All other routines will
be completed within regular business hours.
 Arterial Blood Gases: 15 minutes
 Type & Screen: 1 hour (15 minutes for O-neg emergency need, 2 units always
available)
 Histology samples: 24-48 hours
Referral Tests
 Many less commonly ordered tests are sent to one of the referral laboratories
utilized by MHP.
 Most are sent to ARUP, located in Utah. Specimens are sent daily and most
results are back within 48 hours.
 If you need information on a particular test please visit the ARUP website at
www.aruplab.com or call the main lab number (732-8233) for assistance.
Page 20 of 30

Infrequently ordered tests which need a "stat" turn-around time will be sent to a
local laboratory that performs those tests.
Add-on Tests
Please call the lab before adding on a test to a sample previously sent to the lab to
ensure the amount of sample and age are within limits for the new test being added.
Then in EPIC go to: (utilize tip sheets)
1.
2.
3.
4.
Order Entry for the patient.
In the "New Order" box type the test to be added-on and hit ENTER.
Click on the desired test to highlight and then click "ACCEPT".
The test will display in a blue box - click on the "priority (ie routine) listed in the
blue box.
5. At "Priority" box click on the magnifying glass, choose add-on, and ACCEPT.
6. Choose "ACCEPT" again to place the order.
Blood Bank Available Products:
 Packed Red Blood Cells
 Fresh Frozen Plasma
 Apheresis Platelets (considered a therapeutic dose that is equivalent to 6-8
random donor platelets) *This must be ordered, not stocked.*
 Cryoprecipitate
Ordering Blood Products: EPIC ordering for blood products is a multi-step process.
 Order a "Type and Screen" if one has not been ordered within the last 3 days.
Type and Screen tests on in-patients expire after 3 days and need to be reordered as necessary.
 Order "PREPARE.” This is what was traditionally known and ordered as a crossmatch. This section gives options for number of units, special instructions (i.e.
irradiated).
 Order "TRANSFUSE". This section gives options for duration, special needs (i.e.
blood warmer), and pre-medication notes.
 The PREPARE and TRANSFUSE are set up together as a single order screen,
but these components can be ordered separately by unselecting one part or the
other.
 Order blood products in EPIC under "GEN BLOOD".
Pain Management
Review of Pain Assessment and Management in EPIC
Review nurse’s documentation of patient’s pain assessment/management on Doc
Flowsheet in EPIC. This information is pulled into a report in Patient Summary called
Pain Monitoring.
Managing Pain
Upon Admission or After Procedure: MDs/PAs/NPs need to REORDER:
- long acting opioid pain meds for chronic pain (e.g., Oxycontin, Oramorph, Methadone,
etc.); and
- adjunct pain meds (e.g., Cymbalta, Pregabalin, Gabapentin, etc.).
Patient Controlled Analgesia (PCA) & Chronic Pain Med Administration:
Page 21 of 30
Patients appropriate for patient controlled analgesia (PCA) must be mentally alert and
have the cognitive, emotional and physical abilities to understand the operation of the
PCA and be able to safely manage his/her own pain.
Upon ordering PCA, following parameters must be specified:
 Loading bolus: Initial analgesia dose
 PCA dose (“bolus” dose): The patient controlled dose delivered on patient
demand
 Continuous (“basal” rate): Low-dose, continuous infusion rate; only for opioid
tolerant patients
 One-hour limit: The maximum amount of analgesia the patient can receive in
one hour
 Lockout interval: The time period during which patient cannot activate the pump –
i.e., a 10-min lockout interval would prevent the patient from receiving a bolus
more frequently than every 10 minutes.
- Other systemic narcotics should be limited while on PCA.
- In order for the patient to receive their chronic pain narcotic with the PCA, the MD, who
has ordered the PCA, needs to approve (in verbal or written format) the chronic pain
med to be given. When the Attending MD or the Resident MD is placing the order for
the chronic pain narcotic, he/she needs to add in the Administration Instructions: “OK to
give chronic pain opioid med with PCA per Dr. _____________.”
*Equianalgesic doses are drug and route conversions approximately equal to a single morphine 10mg IV or 30mg PO dose. This table is a
guideline only. The equianalgesic dose is not the usual starting dose. Dosing must be individualized and titrated according to the patient’s
age, condition, response, and clinical situation.
*To account for incomplete cross-tolerance when converting to a new opioid, start with 50-75% of the equianalgesic dose and the new
opioid and titrate to effectiveness.
*Duration: the shorter time generally refers to parenteral administration of opioids; the longer time generally refers to oral administration of
immediate-release opioids.
*NR = not recommended at that dose
Page 22 of 30
Spiritual Care Services
Mercy Hospital Clermont provides chaplaincy services 24/7 and may be contacted by
calling the operator. The Chaplains are certified through professional chaplaincy
associations and represent multi-faith backgrounds and approaches. Chaplains are
available to all of our patients and their families who need spiritual and/or emotional
support; chaplains are members of the inter-disciplinary team; chaplains assess for
spiritual needs without disrespecting anyone’s beliefs, values or faith background;
chaplains support a holistic approach to patient care recognizing that attention to
spiritual and emotional needs are important elements in healing; chaplains provide
assistance with advance directives and end-of-life discussions with the patient and
family members. Chaplains are also available to all hospital staff for spiritual and
emotional support.
Advance Directive Information and the Chaplaincy Role
Chaplains receive referrals for advance directive information. Health Care power of
Attorney (HCPOA) and Living Will (LW) information is offered to all patients admitted to
our facility. The HCPOA lets the patient name who they would want to make their
health care decisions if they are unable to do so. The LW directs the physician on a
patient’s wishes for end-of-life care. The HCPOA goes into effect if the patient is
temporarily or permanently unable to speak for him/herself. The LW is activated only
after two physicians determine and document the patient has a terminal condition
(defined in the document) or is permanently unconscious with little hope of regaining
consciousness. The LW is not a DNR order. A DNR order must be written by a
physician. While chaplains are available to discuss end-of life issues related to a
patient’s journey with illness, meaning and hope, they do not discuss DNR orders.
Code status discussions are done by clinical staff as they require the patient to
understand how their medical condition affects their goals. If a patient expresses
specific end-of-life wishes to the chaplain, he/she will document them in the medical
record. The LW takes precedence over the HCPOA.
Mercy belongs to the US Living Will Registry and offers registration free to any patient
and their families. This is a national database that stores the ADs electronically so that
caregivers have access to them wherever the patient is. Chaplains are available to
assist patients complete this process.
Ethics
Ethical concerns are handled with a multidisciplinary approach. Patients (or their
decision makers) are given all the information and support they need to make decisions.
The patient’s physician should be advised of patient concerns. The Ethics Committee is
a consultative resource for patients, families, physicians and staff. Chaplains are also
available to support patients and their medical team in difficult discussions. Spiritual
Care is represented on the hospital ethics committee.
How do I request an ethics consult?


CALL THE HOSPITAL OPERATOR, providing your name, location, and contact
information. Note: Please tell the operator you are calling from Mercy Health
Clermont so the correct consultants respond.
Appropriately document the consultation request in the electronic medical record.
Example: “Called the operator for an ethics consultation at 1:32 p.m. – Signed
Steven J. Squires”
Page 23 of 30

OB ethics questions, which may happen infrequently at Mercy Health Clermont,
follow a different process, going to a Chaplain and/or the Mission leader and the
regional director of ethics.
What should I expect in the consultation process?



The chaplain-on-call will call you back to get more information about your concern.
If your concerns are unresolved after this conversation, the chaplain will call the
ethics consultant on call. He or she will gather information, determine next steps
and establish expectations.
Ethics will review the consult process and incorporate your feedback after the
consult.
The following are realistic and unrealistic expectations of and reasons for
requesting ethics…
Credentialed Medical Staff Required to Follow Ethical and Religious Directives
(ERD)
Catholic health care is premised on the human dignity of all persons and the
sacredness of human life. Our Bylaws require that all Medical Staff abide by the Ethical
and Religious Directives (ERDs) for Catholic Health Care Services. Compliance with
these ERDs is a condition for medical staff privileges.
When you accept hospital privileges, you are agreeing to practice in a manner
consistent with the ERDs when rounding and performing procedures at any Mercy
facility. “Consistent” neither implies nor suggests that the physician personally
espouses the Directives or adheres to the Catholic faith. “Consistent” does imply that
the physician will participate in the healing mission of the hospital and will not provide a
limited set of prohibited services – direct abortion, direct sterilization, active euthanasia
or some means of contraception.
A full copy of the ERDs is available at http://www.usccb.org/issues-and-action/human-lifeand-dignity/health-care/upload/Ethical-Religious-Directives-Catholic-Health-Care-Services-fifthedition-2009.pdf.
Page 24 of 30
Behavioral Health Institute
The President and CEO of Catholic Health Partners (CHP), John Starcher, with the
support of the Board of Directors, made a bold commitment to address the needs of the
mentally ill, an underserved population. Donna Markham, OP, PhD was invited to join
CHP with the mandate to effect the transformation of the delivery of behavioral health
services to serve the health of the population encompassed by the regions of CHP. This
includes initiating evidence-based treatment procedures in acute care, partial
hospitalization and intensive outpatient services. It also involved embedding behavioral
health clinicians in primary care physician practices.
Rather than treating mentally ill persons as pariahs who are kept out of sight and out of
proximity to our healthcare facilities, CHP committed to a comprehensive plan that
involves capital improvements, staff training and development, the initiation of treatment
outcome measures and the expansion of services designed to assist patients in their
process of healing. The focus is on expanding acute care services, ambulatory services,
and broadening clinical integration as well as supporting the ministry’s response to the
opiate epidemic.
Capacity in the Behavioral Health Unit after July 2104 will be 24 inpatient and we
anticipate a capacity for 30 outpatients by January 2015.
Behavioral Health Adult Admission Criteria
1. The patient will have a primary diagnosis recognized by the current edition of the
Diagnostic and Statistical Manual and:
2. The patient will have at least one of the following criteria:
a. Demonstrates a danger to self, others, or property.
b. Manifests major impairment in activities of daily living and in occupational
functioning as outlined in the current edition of the Diagnostic and
Statistical Manual.
c. Demonstrates continued decline in functioning manifested by impairment
in ability to provide for his/her basic physical needs.
d. Condition prevents him/her from benefiting from less intensive levels of
care requiring 24-hour nursing/medical assessment, intervention and
monitoring.
e. The patient has not responded to treatment at a lesser level of care and is
exhibiting an acute exacerbation of severe symptoms and/or significant
decrease of functioning.
f. The patient exhibits acute psychotic thought processes with acute, marked
social and/or occupational dysfunction of such severity that his/her health
and safety are at imminent risk.
3. The patient is able to participate in and benefit from therapeutic processes and
milieu.
4. There is reasonable expectation that there can be improvement, control or
stabilization of the presenting symptoms
5. There is a degree of medical stability that does not require ongoing, significant
active or invasive medical treatment for management.
6. The person is age 18 or over
Page 25 of 30
Behavioral Health Adult Exclusion Criteria
Patients admitted to the Behavioral Health Unit will not be admitted if the following are
present:
The following are guidelines to be used when assessing patients for appropriateness on
the Adult Behavioral Health Unit. Patients assessed for the Adult Behavioral Health unit
who fall within the exclusionary guidelines will be discussed with the BHI Director of
Nursing and BHI Medical Director if needed to accommodate an individual’s treatment
needs.
1. The person has significant physical illness, injury or condition that requires active
or invasive medical treatment. The most common medical conditions excluded
from inpatient behavioral health include, but are not limited to, the following:
a. The patient is unconscious.
b. Head trauma requiring extensive neurological workup and assessment.
c. Unstable cardiac conditions, whether drug induced or otherwise, requiring
telemetry.
d. Hemo-dynamically unstable
e. Septicemia.
f. Patients who require intensive medical/surgical intervention and/or acute
med/surg nursing care as the primary focus of treatment.
g. Requires blood or blood product transfusion.
h. Insulin drip.
i. The patient is acute and receiving continuous oxygen at the bedside.
j. The patient is acute and receiving continuous IV fluids.
k. The patient is unable to take nourishment by mouth.
l. The patient is required to use a Bi-Pap or C-Pap without physician
clearance.
m. The patient has a medical reason that causes him/her to be unable to
participate in treatment.
n. The patient has a fracture that requires the use of assistive devices such
as lift equipment or total care.
o. The patient is post-operative 24-48 hours or less.
p. Bariatric patients as defined by ability to properly care for individual with
safety equipment
q. The patient requires isolation for MRSA, VRE or C-Diff.
r. The patient requires a negative pressure wound device.
s. The patient is in need of primary detox, and thus will be assessed for
medical placement.
2. The patient is under a criminal court order for treatment and does not meet
medical necessity.
3. The patient is in need of a forensic treatment setting.
4. Cases in which the patient has a recent history of sexual crimes or is a registered
sex offender will be reviewed with the psychiatry medical director prior to
acceptance.
5. The patient is actually in need of a long-term treatment setting and does not meet
medical necessity.
6. The patient's sole diagnosis is/are: substance abuse, substance dependence,
dementia, developmental delay, malingering, and/or antisocial personality
disorder.
7. The patient presents for admission as an alternative to incarceration, placement
in a residential home or intermediate care facility and whose behavior could be
better treated in another setting until placement can be arranged
Page 26 of 30
8. Cannot refuse admission due to an absence of resources (i.e., being homeless,
evicted or unable to return to place of residence).
For complete details, please access the “Admission, Disposition, Exclusionary,
Discharge Criteria for Acute and Sub-Acute Programs” Policy via the below link:
https://secure.compliance360.com/Common/ViewUploadedFile.aspx?PD=PbRt%2bA78
MS7O4C08uG%2bLGRNF0rG%2f7w0Rdz2R6xuYk%2bm0WYmoX6RhZR2b8JfYbDs1
yR6Ak46D72jugWkSX5UtG5sn4oASloMOv3Xtg2IIktVRZLS1uvbtt6o%2b4EaSKj42eT5
R1k5sFm9uUQnIQaiw0ntczgBMJl6sYduRZRx3d87vlsq1F2KbH12gDAxbcVy94QCAt8A
rtjXtXaWYz05OkIjJWWPIcegSNKN9TYGQ%2bxliGHYUC63iAQ%3d%3d
Physical Environment
Environment of Care/Safety Information
Dial #88456 to report all emergencies.
Fire Safety Plan
Remember R A C E when responding to a fire.
R = Rescue patients and visitors
A = Sound the Alarm pull the fire alarm and dialing #88456
C = Confine or contain the fire
E = Extinguish the fire
Remember PASS when using Fire Extinguishers.
P = Pull the pin
A = Aim at base of fire
S = Squeeze the lever below the handle
S = Sweep from side to side
Hazardous Materials Management
Various hazardous materials are used throughout the hospital. These could pose a
threat if a spill or release should occur. MSDS (Material Safety Data Sheets) are found
on the intranet. The MSDS gives detailed information on a specific chemical product,
including the chemical ingredients, potential hazards, and safety precautions. Call
Safety/Security at #83911 to report a spill. Do NOT attempt to clean up a spill unless
you or the personnel involved are properly trained to do so.
Emergency (Disaster) Management
This Emergency Preparedness Plan is designed to manage the hospital’s resources,
such as, space, supplies, communications, and personnel, during such emergencies.
Emergency Operations Center (Incident Command) is located across from the
Emergency Department conference room. Physicians should report to the Emergency
Operations Center (Incident Command), for assignment. The Medical House Physician
will take charge of the assignment of physicians until relieved by the Medical Staff
Operations Chief on-call.
Page 27 of 30
Reporting to Joint Commission
Any individual who provides care, treatment or services at Mercy Health Clermont
Hospital who has concerns about the safety or quality of care provided may file a report
with The Joint Commission by calling 1-800-994-6610. No disciplinary or punitive action
will occur because of reporting of safety or quality of care concerns.
Page 28 of 30
MANAGEMENT TEAM CONTACT LIST
Last Name
First Name
Title
Department
Phone MHC
Armold
Michelle
Coordinator
Medical Staff
732-8327
Barnett
Mary
Preventionist
Infection Control
732-8498
Barton
Kathy
Supervisor
HIM Operations
735-1739
Bauer
Bonna
Manager
732-8570
Beckman
Carrie
East Market Director
Plant Operations & Security
Support/Ancillary Svs,
Anderson Emergency
Services
Beeler
Sarah
Sr. Admin Assistant
Administration
735-7842
Boggs
Kristin
East Market Director
Quality/Case Mgmt
735-7599
Cantrell
Raymond
Administrator
Eastgate Surgery Center
947-1130
Carroll
Bill
East Market Director
Pharmacy
732-8670
Colwell
Dan
Manager
735-7747
Countryman
Tonya
Manager
Admitting/Patient Access
OR/PACU/S/PAT/Sterile
Proc
Day-Schamer
Joyce
Manager
Laboratory
732-8236
DePuccio
Lena
Manager
2 West
732-8759
Dorward
Susan
Foundation
952-4026
Edrington
Kathi
Director
Site Administrator
MHA / CNO East
Market
Administration
624-4505
Ellerhorst
Annette
RN
Employee Health Srvs.
735-7779
Feagins, MD
Stephen
VP Medical Affairs
Administration
624-3281
Fedders
Neil
East Market Director
Operations-Anderson/ Pt
Experience-East Market
624-4586
Fisher
Tom
East Market Director
Supply Chain
233-6738
Flannery
Michele
East Market Mgr
Rehab Services
732-8209
Gamble
Kim
Manager
ICU
735-8643
Gilkerson
Eric
Supervisor
Admitting/Patient Access
735-1723
Glover
Brittany
Manager
Imaging
735-1510
Graham
Jeff
President/CEO East
Market
Administration
732-8252
Grooms
Molly
Patient Care Services
732-8308
Haggard
Terri
East Market Director
Eastmarket
Supervisor
Clinical Documentation
732-8331
Igo
Michelle
Manager
Emergency Dept
James
Kenneth
President, Clermont
Hospital
Administration
732-8590
Jones
Megan
Director
Behavioral Health
732-8558
Kang, PsyD
Navdeep
Director
Behavioral Health
732-8629
Kellenberger
Shonda
PCU
735-1508
Kelly
Kim
Manager
East Market
Supervisor
Telecommunications
233-6735
Laudermilk
Ashley
Manager
Emergency Dept
732-8349
Overbeck
Kendra
Director
Marketing
952-4711
Palmer
Sheila
East Market Director
Cardiovascular Services
233-6522
Richter
Jim
East Market Director
Mission
735-7777
Rutledge
Kenneth
Manager
Clinical Engineering
688-3948
Page 29 of 30
735-7626
735-8980
513-981-4745
Scheffter
Cathy
Supervisor
Rehab Services
732-8207
Schlinkert
Allison
East Market Manager
Staff Development / Magnet
624-4559
Schneider
Del
East Market Director
Periop Services
732-8369
Schultz
Julie
Director
Wound Care
735-8924
Shelley
Kristin
East Market Director
Patient Care Services
624-4963
Siemer
Theresa
Supervisor
Imaging
831-4425
Smith
Krista
Manager
Respiratory Therapy Dept.
732-8761
Taylor
Tracy
Director
Volunteer Srvs / Gift Shop
513-732-8582
Thomas
Laura
Market CFO
Administration
735-7548
Underwood
Geoff
Manager
Non Invasive Cardiology
924-8595
VACANT
East Market Director
Human Resources
732-8321
VACANT
Manager
732-8298
Vickers
Deb
Manager
Quality Clermont
Specialized Srvs.
Radiation Onc. & Cancer
Reg.
Voorhees
Chip
Director
Food & Nutrition Srvs.
732-8299
Walker
Nissa
Director
Medical Staff
624-4391
Warren
Rhiana
HR Business Partner
Human Resources
732-8272
Weber
Ben
Manager
Med Surg (C3)
624-4959
Westendorf
Robyn
Lead RN Spec.
Case Mgmt
732-8403
Whitt
Michele
Manager
Environmental Srvs
732-8574
Williamson
Michelle
Director
Risk Management
735-1531
Medical Staff Reference Updated:
October 25, 2011; March 5, 2014; March 27, 2017
Page 30 of 30
732-8547