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Clermont Hospital Medical and Allied Health Staff Orientation and Reference Manual Table of Contents Page 1 of 30 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……………………………………………... 3-4 4-5 5-6 6 6-7 7-9 9-10 10 10 10-12 12-13 13-14 14 14 14-16 16 16 16 16-18 18-20 20-21 21-23 23-25 25-26 26 26-27 26-27 Page 2 of 30 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. 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 Page 3 of 30 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. Page 4 of 30 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; Page 5 of 30 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. Page 6 of 30 Patients are surveyed on the following areas utilizing a Press Ganey survey tool. During this hospital stay how often did doctors treat you with: 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 Page 7 of 30 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 Page 8 of 30 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: Page 9 of 30 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. Page 10 of 30 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 Page 11 of 30 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. Page 12 of 30 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. Page 13 of 30 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. Page 14 of 30 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