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