Download Student Orientation: Part 1 (ppt)

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Monroe County Hospital
NEW EMPLOYEE ORIENTATION
REVISED AUGUST 2016
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MCH Personnel Policies
MANAGED BY:
DEBRA K. FLOWERS, PHR, SHRM-CP
DIRECTOR, HUMAN RESOURCES
EXTENSION 209
Annual Policy Review

Each employee should be familiar with all policies and
procedures.

Policies and any related forms are posted on the internal
(intranet) web site for your convenience:


Type in mch in the address line – nothing else

Click on Policy Central

Click on Administrative

Click on Human Resources
This is short review; please go to the web site to review the
complete policy.
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Annual Updates

Annual recertification/updates are mandatory for all
employees. Requirements include:

PPD Skin Test (or chest screen questionnaire if history of positive
skin test).

Flu vaccine.

Passing score on annual update chapters (via the web) (100%
or higher).


All updates and vaccinations are due between September 1st and
September 30th of each year.
Any required license renewal to include CPR and ACLS.
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Anti-Harassment &
Complaint Procedures

MCH prohibits harassment, including sexual harassment, of any
kind, and will take appropriate and immediate action in
response to complaints or knowledge of violations.

Complaint Procedures:

Discuss concerns with immediate supervisor, Human Resources, or
any member of management.

Prompt reporting of any incident is encouraged so that rapid and
constructive action can be taken.

Investigation will be conducted including interviewing appropriate
personnel.

Confidentiality will be maintained.

Retaliation is prohibited.
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Attendance

It is essential that all employees work the hours they are
scheduled to work.

MCH requires employees to provide adequate notice, as well
as justifiable reason, for absenteeism and tardiness.

Excessive absenteeism and/or tardiness can result in
disciplinary action, up to and including, termination.
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Confidentiality


It is the responsibility of all employees to safeguard MCH information.

Never share patient information with strangers or anyone without prior consent
from the patient.

Never discuss confidential patient information where others can overhear your
conversation.

Never reveal any information to the media or other public source; refer
questions to your supervisor.
Safeguarding patient information is every employee’s obligation.
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Equal Employment Opportunity

Monroe County Hospital provides equipment employment opportunities
to all employees and applicants for employment without regard to race,
color, religion, gender, sexual orientation, gender identity, national origin,
age, disability, genetic information, martial status, amnesty, or status as a
covered veteran in accordance with applicable federal, state, and local
laws.

MCH will provide promotion and advancement in a non-discriminatory
fashion.

MCH will not permit employees to engage in discriminatory practices.
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Family Medical Leave Act (FLMA)

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MCH provides 12 weeks of unpaid leave to eligible employees each calendar
year.

Applies to employees who have worked one year and for at least 1250 hours over the
previous 12 months.

Leave is granted for birth of child, serious health condition of employee or
family member.

Employee is required to complete FMLA documentation and provide
certification from attending physician.

Return to work authorization is required prior to employee’s return to duties.

Contact Human Resources, ext 209, with any questions regarding eligibility.
Paid Days Off (PDO)

All full-time employees are eligible for PDO.

PDO days are days off which include vacation, holidays, bereavement
leave, and short term illness.

Holidays are: New Year’s Day, Memorial Day, Independence Day, Labor
Day, Thanksgiving Day, Christmas Day

Employees start to accrue PDO on date of hire, but cannot use it until
they have satisfactorily completed the 90-day introductory period.

Employees are paid PDO upon proper resignation; if terminated PDO
will be forfeit.
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Performance Evaluations

Evaluations are done during the month of October for all employees.

Salary increases are neither automatic nor periodic. Salary is reviewed
and increases are based on performance and overall fiscal goals of
MCH.

Performance evaluations are a permanent part of an employee’s
personnel file.

Employees are required to complete a self-evaluation as part of the
evaluation process with your supervisor.
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Progressive Discipline


All employees are expected to abide by the general rules of good
conduct. Should it become necessary for disciplinary action the following is
usually taken:

Oral/Verbal Warning

Written Warning

Suspension

Termination
If the severity of the infraction is sufficiently serious, one or more of these
steps may be bypassed.
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Safety
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
All employees are required to report any incident or accident or any unsafe
practice.

Follow these guidelines:

Notify your supervisor

Complete the Accident Report Form and Lab Request Form.

Escort employee to ER to be examined by ER doctor.

Escort employee to lab for drug screen/alcohol test.

Return to work, if released by ER physician.

Forward Accident Report Form to HR.
Tobacco Free Facility

No smoking or other tobacco products are permitted on or in hospital
property or in personal vehicles parked in hospital parking lots.

Failure to comply with this regulation may result in disciplinary action, up to
and including termination.
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Substance Abuse

It is a violation of MCH policy to use, possess, sell, trade, offer for sell, or offer
to buy illegal drugs or otherwise engage in the illegal use of drugs on or off
the job.

It is a violation for employees to report to work under the influence of illegal
drugs or impaired by alcohol.

It is a violation for employees to use prescription drugs illegally.
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Termination/Resignation

An employee desiring to terminate employment with MCH is asked to
give a minimum 2 weeks notice; managers are asked to give 30 days
notice.

If an employee is retiring they are asked to provide a 30 day notice.

If employee provides proper notice, accrued PDO will be paid based
on the terms of the PDO policy.

All terminations will be treated in a confidential and professional
manner.

If an employee is terminated, all PDO is forfeit.
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Test
1.
2.
Where can you find personnel policies:
1.
In your supervisors office.
2.
In your employee handbook.
3.
Posted on the intranet (internal web page).
What are the guidelines for an accident/injury?
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The Core Values
MANAGED BY:
CHIEF EXECUTIVE OFFICER
EXTENSION 214
Guiding Statements

Mission Statement:


We will be the hospital of choice in our service area and will be guided by
our core values of caring, quality, integrity, and respect to those we serve
and to our employees, medical staff, volunteers, and partners.
Vision Statement:

To be an independent community hospital that is an asset to its community
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Mission Statement

Our mission is to provide compassionate
community healthcare that meets the public’s
expectations.
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Core Values

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We are deeply committed to practice a certain set of Core Values in everything we do. These values
guide our daily life and define, in a simple way, the basic way we look at our ministry to the public
and to each other.

The Value of Caring – this is the thread that runs through our hearts. It is the guiding driver of living that we come to work
to do. Caring is a part of us, and this action is practiced not just with patients, but with families, visitors, and each other.
The Value of The Person – this simply means that we treat everyone as equals, and that we do not discriminate or judge,
no matter how difficult or trying situations can get. We cannot afford to be prejudiced and biased and still maintain the
public’s trust.
The Value of Quality – this value states that we will do the very best we can. It is the principle this country was founded on,
is the underlying meaning of the American work ethic, and it’s just the right thing to do.
The Value of Integrity – this value means that we will always do what we say we are going to do. It means conducting
business with the utmost honesty. In addition, it means that we will follow the rules, procedures, laws and regulations that
we create and that others impose on our industry.
Core Values

The Value of Caring – the common thread that runs through our hearts.

The Value of the Person – we are all equal in God’s sight.

The Value of Quality – we always do the very best we can.

The Value of Integrity – we will always do what we said we would do.
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Core Value Test
1.
2.
What core value is the first and most important?
1.
Person
2.
Caring
3.
Integrity
4.
Quality
Why are Core Values so important?
1.
Because my grandmother has those values.
2.
Because we act the way we think and believe.
3.
I’ll get 10% off at eh grocery store if I rattle them off to the cashier.
4.
Because I’ll look foolish if I don’t know them.
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Quality Management
MANAGED BY:
TABITHA KENT BA OM (R)(RT)(MR)
DIRECTOR, QUALITY MANAGEMENT
EXTENSION 215
Quality Improvement

A continual, hospital-wide process that involves each of us!!!
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Quality Improvement (QI) in
Healthcare

The purpose of QI is meant to enhance the safety, efficiency,
and effectiveness in all businesses from healthcare processes
and the performance of delivering products to our customers.

Improvement is achieved using various methods, both
qualitative and quantitative.

With so many changes in healthcare reimbursement, there is
now a requirement for new and enhanced methods that
provide better outcomes, better customer/patient experience,
and better costs.
( Reference: Lean 6 Sigma) ; (Dr. Donald Berwick)
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Center for Medicare & Medicaid
Services (CMS)
Previous
Reimbursement
Method
New
Reimbursement
Method

Reimbursement driven
by VOLUME

Reimbursement driven by
OUTCOMES

Driven by the number of
patients serviced

Driven by quality of care
for patients receive and
their outcomes
$ ↔ Volume
$ ↔ Quality
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Quality Improvement (QI)

When a system remains unchanged over time and no enhancements are
made, it cannot generate better results than the ones already created.

Bringing a change into the system can facilitate the achievement of a
new performance level for the system.

In order to obtain consistent, high quality, the most important things to be
cultivated are teamwork and effective communication.

At MCH, we use the PDSA Methodology for Performance Improvement.
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Continual Process
Improvement
Achieved through
the use of the PDSA
Cycle

P- plan

D- do

S- study

A- act
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
Quality
Measures
Externally
reported quality
measures are
reported in the
Hospital Quality
Star Ratings
Hospital-Specific
Report (HSR).
Star rating report includes:

Patient’s experience in
the hospital

Imaging Efficiency

Outcomes:


Mortality

Readmission

Safety
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Processes of:

Timeliness of care

Effectiveness of
care
We are a
Hospital.


Each department is
responsible for:

monitoring any critical
processes within the
department

mandated monitoring set
forth by regulatory
agencies

setting goals, reporting,
and tracking pertinent
data internally on the
quality dashboard on a
monthly or quarterly basis.
When setting department
goals use the “S.M.A.R.T.”
way.

This brings structure and
track- ability into your
goals;

Brings goal closer to
reality.
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Process Improvement
Complaint and Grievance Reporting Process

Complaint and Grievance
policy and form are located
on the MCH Intranet in Policy
Central under Administration.

This process is for patients
and/or their representative
voice, as well as for visitors.

Complaints are resolved
within 24 hours; Written
complaints are considered
grievances.

Grievances are a formal or
informal written or verbal
complaint that is made to
the hospital by a patient or
the patient’s representative.

All complaints/grievances will
be forwarded to Director of
Quality Management.

The investigation of the
complaint/grievance shall be
conducted by the Director of
Quality Management and will
involve the necessary parties to
include : the manager (s), staff,
and medical staff of the
involved areas.

This process is confidential.

Employee complaint and
grievances are referred to and
handled in the Human
Resource department.
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Process Improvement
Occurrence Reporting Process



Occurrence Reporting
policy and form are
located on the MCH
intranet in Policy Central
under Administration and in
each department.
Report initiated by the
person most
knowledgeable about the
occurrence.
Report must be completed
and submitted within
24hours of the occurrence
to the department
manager.

Report only the facts on the
report.; documentation
should be nonjudgmental.

No copies are to be made
of this form; original report
form comes to Quality
Management.

Do not refer to the
Occurrence report in the
patient’s Medical record.

Contact Quality
Management at ext.215
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Test
1.
What is the name of MCH continual process improvement cycle?
Fishbone Diagram
2. Flow Chart
3. PDSA
1.
2.
Complain and Grievance reporting process is a confidential
process?
True
2. False
1.
3.
When completing Occurrence report ______?
Report only the facts.
2. Complete report within 24 hours.
3. Do not make copies for Medical Records.
4. All of the above.
1.
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2016 National Patient Safety Goals
MANAGED BY:
TABITHA KENT BA OM (R)(RT)(MR)
DIRECTOR, QUALITY MANAGEMENT
EXTENSION 215
Background

The National Patient Safety Goals (NPSGs) were established in 2002 to help
accredited organizations address specific areas of concern in regards to
patient safety.

The first set of NPSGs was effective January 1, 2003.

The Patient Safety Advisory Group advises The Joint Commission on the
development and updating of NPSGs.
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Patient Safety Advisory Group

Panel of widely recognized patient safety experts.

Nurses, physicians, pharmacists, risk managers, clinical engineers, and other
professionals.

Hands-on experience in addressing patient safety issues in a wide variety
of health care settings.

Advises The Joint Commission how to address emerging patient safety
issues.

NPSGs, Sentinel Event Alerts, standards and survey processes, performance
measures, educational materials, Center for Transforming Healthcare projects.
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2016 NPSGs

No new goals for 2016.

Clinical Alarms NPSG:


Phase 2 is now effective. Hospitals are expected to establish and implement
policies and procedures for managing clinical alarms and to educate
individuals about alarm systems.
The listed goals are for goals that would pertain to the Critical Access
Hospital setting.
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Patient Identification

Goal 1:

Improve the accuracy of patient identification.

NPSG.01.01.01: use at least two patient identifiers when providing care,
treatment, and services.

NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification.
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Improve Communication

Goal 2:

Improve the effectiveness of communication among caregivers.

NPSG.02.03.01: report critical results of tests and diagnostic procedures on a
timely basis.
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Medication Safety

Goal 3:

Improve the safety of using medications.

NPSG.03.04.01: Label all medications, medication containers, and other
solutions on an doff the sterile filed in perioperative and other procedural
settings.

NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use
of anticoagulant therapy.

NPSG.03.06.01: Maintain and communicate accurate patient medication
information.
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Clinical Alarm Safety

Goal 6:

Reduce the harm associated with clinical alarm systems.

NPSG.06.01.01: Improve the safety of clinical alarm systems.
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Health Care-Associated Infections

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Goal 7

Reduce the risk of health care-associated infections.

NPSG.07.01.01: Comply with either the current Centers for Disease Control and Prevention
(CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand
hygiene guidelines.

NPSG.07.03.01: Implement evidence-based practices to prevent health care-associated
infections due to multidrug resistant organisms in acute care hospitals.

NPSG.07.04.01: Implement evidence-based practices to prevent central line-associated
bloodstream infections.

NPSG.07.05.01: Implement evidence-based practices for preventing surgical site infections.

NPSG.07.06.01: Implement evidence-based practices to prevent indwelling catheterassociated urinary tract infections (CAUTI).
Universal Protocols

Universal protocols for preventing wrong site, wrong procedure, wrong
person surgery.

UP.01.01.01: Conduct a preprocedure verification process.

UP.01.02.01: Mark the procedure site.

UP.01.03.01: A time-out is performed before the procedure.
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For more information…

The national patient safety goals for each program and more information
are available on The Joint Commission website at:
www.jointcommission.org
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Test
1.
2.
3.
Use at least ___ patient identifiers when providing care, treatment, and services?
1.
1
2.
2
3.
3
4.
0
In order to reduce the risk of health care associated infections the ___ or ___ hand hygiene guidelines should be followed.
1.
American Hany Hygiene Association.
2.
CDC
3.
WHO
4.
A&B
5.
B &C
In stage 2 clinical alarms NPS, hospitals are expected to establish and implement policies and procedures for managing
clinical alarms and to educate individuals about alarm systems.
1.
True
2.
False
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EMTALA
MANAGED BY:
TABITHA KENT, ARRT, MRI
DIRECTOR, QUALITY MANAGEMENT
EXTENSION 215
Overview

EMTALA is the emergency medical treatment and labor act. It was
created in an effort to prevent the dumping of patients who are unable
to pay for services. It was also created to provide care to any individual,
regardless of creed, citizenship or race.
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Consequences of Non-Compliance

CMS can terminate the hospital from participation in the
Medicare/Medicaid program, and losing Medicare
reimbursement may cause the hospital to close its doors.

The hospital and the physician may be subject to civil money
penalties of 25,000 for hospitals with less than 100 beds. The OIG
may also exclude the physician from participation in Medicare,
Medicaid, and other state programs. Other licensed professionals
can have disciplinary action taken by their licensing or certifying
board, such as the State Board of Nursing.
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Consequences of Non-Compliance

A violation of EMTALA can also result in the loss of a hospital’s
accreditation with The Joint Commission.

The Civil Rights Division of the DHHS can investigate in a criminal or civil
discrimination case.

If a hospital suspends a physician’s privileges over an EMTALA violation, it is
reported to the National Practitioner Data Bank or NPDB. Failure to
discipline offending physicians is a violation of the law.
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Consequences of Non-Compliance

Physician violations may result in an investigation or sanction against
the hospital by the state Peer Review Organization or PRO (now called
the Quality Improvement Organization or QIO), state licensure board,
local Medicare intermediary, or state health program.

Patients can sue the provider and facility in a civil lawsuit for punitive
damages or in a malpractice suit if they are harmed.

Any hospital that incurs financial loss as a direct result of another
Medicare-participating hospital’s violation of EMTALA can sue that
hospital in federal court to recover its monetary losses.
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Definition of an
Emergency Department

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Under EMTALA, a person who “comes to the ED” is someone who presents to
the hospital’s ED or elsewhere on the hospital property and requests
examination or treatment. Hospital property includes the entire hospital
campus and includes the parking lot, sidewalks and driveway. However, the
new rules clarify that this does NOT include structures that are not part of the
hospital, such as physician offices, skilled nursing facilities, or other “non-hospital
entities” that participate separately in Medicare; or restaurants, shops or other
non-medical facilities - even if they are owned and operated by the hospital
and are adjacent to the main hospital building or on the main campus.
Understanding the Medical Screening
Exam (MSE)

Under normal circumstances, once a patient arrives at the ED,
EMTALA requires that the facility provide a Medical Screening Exam to
anyone who:

Requests an exam or treatment for a medical condition, has such a request made
on his or her behalf, or based on the individual’s appearance it is apparent that they
need an examination or treatment. This request for treatment can come from
anyone, including the patient, a family member, a police officer, a bystander, or a
minor.
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Medical Screening Exam (MSE)

A MSE is a physical or mental health evaluation used to determine if the
patient has an emergency medical condition. Under EMTALA, an
emergency medical condition is an acute condition with symptoms of
such severity that a lack of immediate medical attention could either:

Place the health of the individual in serious jeopardy (or in the case of a
pregnant woman, the mother and/or fetus).

Cause serious impairment to bodily functions.

Result in serious dysfunction of any organ.
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MSE

The hospital must provide the medical screening exam and
necessary treatment within its capabilities. This includes the
services of all departments, personnel and equipment.
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MSE

A medical screening exam must never be delayed to ask for a
patient’s payment method or insurance status.

EMTALA states that the medical screening exam must be conducted
by a qualified medical person, based on the patient’s condition,
complaint, and history.

The patient must be afforded the same level of screening as any other
patient who presents with a potential emergency medical condition.

The MSE must be appropriate.

MSEs must follow the facility’s own policies and procedures.

The MSE must be within the capability of the ED.
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MSE
Triage is not
considered a
medical screening
exam!!
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MSE

If the medical screening exam determines that there is NOT an
emergency medical condition, then EMTALA does not apply and the
facility is not obligated to provide further care or treatment.

If the medical screening exam determines that there IS an emergency
medical condition, and the patient is admitted for inpatient services in
good faith, EMTALA no longer applies.
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Pregnant Women and an
Emergency Medical Condition:

EMTALA states that pregnant women who present to the ED with
contractions and are in true labor are considered to have an
emergency medical condition IF:

There is not enough time to safely transfer the patient to another
hospital before delivery, or

The transfer may pose a threat to the health and safety of the
woman or unborn child.

Labor is defined as the process of childbirth beginning with the latent
phase of labor or early phase of labor, and continuing through the
delivery of the placenta.
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Understanding the
Transfer Process

Transfer: The movement (including discharge) of a patient outside of a
hospital’s facilities; or outside the direction of any person that is employed
by, affiliated with, or associated with the hospital – either directly or
indirectly. An appropriate transfer is the movement of a patient to another
facility that has the space, qualified personnel and resources to care for
the patient or unborn child.
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Understanding the
Transfer Process

There must be proper documentation in the medical record of whether or
not the patient has been stabilized prior to discharge, admission, or
transfer.

A transfer certificate must be filled out completely and signed by a
qualified medical person.

The patient must be transferred by a qualified medical team and with the
proper equipment.

All pertinent medical records must be sent with the patient.
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EMTALA Test
The consequence for violating EMTALA include:
1.
1.
Terminating the hospital from Medicare/Medicaid programs.
2.
Losing Joint Commission accreditation.
3.
Civil lawsuits
4.
All of the above
A person who “comes to the ED” is someone who presents at
one of the following in an attempt to secure emergency care,
except:
2.
1.
A car in the ED entrance.
2.
The main entrance of the hospital.
3.
Physician offices adjacent to the hospital.
4.
The sidewalk of the hospital.
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EMTALA Test
1.
2.
3.
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The following is true about MSE:
1.
An MSE can be delayed to ask for patient’s insurance status, if the condition doesn’t look serious.
2.
An EMTALA approved MSE is not subject to a hospital’s policies and procedures.
3.
A qualified medical person must conduct the MSE.
4.
An MSE is conducted to determine whether the patient has an admittable illness or condition.
If the MSE determines that there is not an emergency medical condition, then the facility is not
obligated to provide care or treatment?
1.
True.
2.
False.
A patient can be transferred to another facility if:
1.
The hospital does not have the capability to care for the patient.
2.
The benefits of treatment outweigh the risks of transfer.
3.
The physician signs a transfer certificate.
4.
All of the above.
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Bloodborne Pathogens Training
MANAGED BY:
CHELSEY CARGLE, RRT
DIRECTOR, RESPIRATORY SERVICES
EXTENSION 240
OSHA’S Bloodborne Pathogens (BBP)
Standard

Occupational Exposure to Bloodborne Pathogens (29 CFR 1910.1030).

Originally published December 1991; revised in April 2012.

Covers all occupational exposure to blood and other potentially
infections material (OPIM).

Healthcare workers (HCWs) are entitled to a copy of the standard.
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Major Provisions of the BBP Standard

Defines terms such as exposure incident and engineering controls.

Requires an exposure control plan.

Discusses methods of compliance.

Hepatitis B Virus (HBV) vaccination and post exposure follow-up.

Labeling and training.

Record keeping.
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Important Definitions

Other Potentially Infectious Material (OPIM)-includes:

Semen

Vaginal secretions

Cerebrospinal fluid

Body fluids (synovial, pleural, pericardial, peritoneal, and amniotic)

Saliva and any body fluid visibly contaminated with blood

Unfixed tissue or slides

Cell, tissue, or organ cultures

Blood or organs from experimental animals
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Other Important Definitions

Occupational Exposure- reasonably anticipated skin, eye, mucous
membrane, or parenteral contact with blood or OPIM as a result of
performing your job.

Parenteral- piercing mucous membranes or the skin barrier through such
events as needle sticks, human bites, cuts, and abrasions.

Universal (standard) Precautions- an approach to infection control that
considers ALL blood and OPIM to be infections for HIV, HBV, and other
bloodborne pathogens.
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Bloodborne Pathogen (BBP)

A disease-causing microorganism found in human blood, blood products,
and other boy fluids.

Examples:

Human immunodeficiency virus (HIV), the virus that causes AIDS

Hepatitis B virus (HBV)

Hepatitis C virus (HCV)

Other pathogens, such as those causing malaria or syphilis
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Usual Exposure Routes of HCWs

Sharps injuries:

Examples: needle sticks, scissor or scalpel cuts and nicks

Splashes or splatters of blood or OPIM into eyes, mouth, or nose.

Open skin contact with a source of blood or OPIM:

Examples: Cut, abrasion
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Bloodborne Illnesses

HBV and HCV

Acquired immune deficiency syndrome (AIDS)

Others (depending on patient population)
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BBP Transmission


Occupational

Sharps injuries.

Mucous membrane or open-skin contact with blood or OPIM.
Non-occupational

Sexual contact with infected person.

Sharing needles or syringes.

Infected mother to infant.

Blood transfusion (rarely in the United States since screening introduced).
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Hepatitis Facts


Hepatitis is caused by a virus that affects the liver, causing inflammation and damage.

There are at least 6 strains ( A, B, C, D, E, and G).

All except A and E are bloodborne.

B and C are of most concern from an occupational exposure standpoint.
All strains cause similar symptoms:

Anorexia

Weakness

Nausea/vomiting

Headache

Chills/Fever

Jaundice
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HBV Infection

6%-30% of the estimated 800,000 to 1,000,000 sharps injuries per year will
cause an HBV infection.

50% of HBV infected individuals are unaware.

Individuals can be infected with more than one viral strain at a time.
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HBV Prevention

Hepatitis B vaccination is 95% effective in preventing HBV infections.

The vaccine is safe and provided free to exposed employees.

Employees can be vaccinated upon hire or at a later time.

The vaccine is a series of 3 shots over a six-month period of time.
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HCV Infection

Approximately 1-2% of hospital workers have evidence of HCV-infection
(CDC 1998).

Seroconversion after percutaneous exposure to HCV-positive source
averages 1.8%.

75%-85% of infected individuals develop chronic HCV infection if
untreated.

Often causes no symptoms initially.

No vaccine, but treatment is available .
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HIV Infection

HIV infection causes AIDS, a life-threatening illness that suppresses the
immune system, placing individuals at risk for other diseases, such as
tuberculosis and cancer.

Early symptoms of AIDS include flulike symptoms:

Fever

Diarrhea

Headache

Joint or muscle pain

Rash

Nausea
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HIV Infection

As of June 2001, CDC documented 57 cases of seroconversion following
documented occupational exposures.

Of the 57 documented cases, 48 were associated with percutaneous
injury.

CDC is aware of an additional 140 other cases with presumed
occupational exposure.

Most documented cases involved nurses and lab technicians.
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How HIV is NOT Transmitted

Contact with doorknobs, toilet seats, etc.

Casual contact.
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HIV Transmission

Average risk after percutaneous injury is 0.3% (1 in 300). Hollow-bore
needles and high viral titer affect risk.

Average risk after mucous membrane exposure is 0.1% .

Non-intact skin exposure risk is <0.1%.

There is not a vaccine available for HIV.
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Exposure Control Plan (ECP)

Required for all employers who have employees with potential
occupational exposure.

Describes specific measures used to control BBP exposures.

Must be review and, if necessary, updated annually.

ECP is maintained by: The Safety Officer and Infection Control
Department.

Employees are entitled to a copy of the plan.

Copies of the ECP are available in The Safety Manual and the Monroe County
Hospital website.
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Purpose of the ECP

The ECP provides facility specific policies and procedures to:

Help prevent accidental exposures

Provide means to report exposure incidents

Perform post-exposure follow-up and appropriate treatment

Identify labels and signs indicating infectious materials
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HCW Jobs with BBP Exposure Potential

Clinical personnel:

Physicians/ NP/ PA

Nurses

CNA’s

Respiratory therapist

Laboratory technicians; etc.

Housekeeping and maintenance

Laundry

First aid providers

Others: ER Registration Staff
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Examples of Procedures with Exposure
Potential

Performing vascular access procedures.

Handling or removing contaminated waste.

Handling contaminated equipment or laundry.

Analyzing blood or OPIM specimens.

Cleaning blood or body fluids in common areas.

Rendering first aid.
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How to Minimize Exposure

Follow Universal (standard) precautions.

Use engineering and work-practice controls.

Use appropriate personal protective equipment (PPE).
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What are Universal (standard)
Precautions?

Universal (standard) precautions- is the practice of considering ALL body
fluids potentially infectious materials.

All HCWs must use universal (standard) precautions whenever there is a
chance of exposure to blood or OPIM, according to OSHA.

Hand washing is key!

Employees must wash hands with soap and water or flush mucous membranes
with water immediately following contact with blood or OPIM.
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What are Engineering Controls?

OSHA defines an engineering control as a control that isolates or removes
the hazard from the workplace.

Examples:

Sharps containers

Biological hoods

Sharps with engineered sharps injury protections

Needleless systems
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Facility-Specific Engineering Controls

Sharps containers for disposal of used needles, lancets, scalpels, etc.

Sharps with engineered sharps injury protections.


Example: needle stick prevention devices
Limitations: they reduce but do not eliminate the potential for sharps
injury.
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Sharps with Engineered Sharps Injury
Protections

Also known as Needle stick Prevention Devices (NPDs).

Types:




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Needleless systems a device that does not use needles for:

Collection of body fluids or withdrawal of body fluids after initial venous or arterial access is established.

The administration of medications or fluids.

Other procedures that involve potential for occupational exposure to BBP due to percutaneous injuries from
contaminated sharps.
Shielded needles a device with the safety mechanism attached:

Syringes with a sliding sheath that shields the attached needle after use.

Needles that retract into a syringe after use.

Shielded or retracting catheters.
Plastic capillary tubes
Needless IV tubing
Needle stick Prevention Devices
Selection and Evaluation

NPD evaluation process:

Non-managerial worker participation

NPD evaluation criteria.

Appoint a Sharps Review Committee periodically to review new devices.
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Work-Practice Controls

Measures that reduce the likelihood of exposure by altering the way you perform a task or job.

Examples:

Minimizing splashing, spraying, splattering, and generation of droplets.

Sharps handling and disposal in sharps containers.


Contaminated needles and other contaminated sharps should NOT be bent, recapped, or removed.

Sharps containers must be:

Puncture resistant

Leak-proof on sides and bottom

Labeled biohazard
Specimens of blood or OPIM must be placed in a container which prevents leakage during collection,
handling, processing, storage, transport, or shipping.

The container should be labeled and closed prior to transport.

If the specimen could puncture the primary container, the primary container should be placed within a secondary
container that is puncture resistant.
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Prohibited Work Practices

No eating, drinking, smoking, applying cosmetics or lip balm, and
handling contact lenses in an area with blood or OPIM.

No food in areas where blood or OPIM may be present.

No recapping of needles.

No mouth pipetting/suctioning of blood or OPIM.
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Work-Place Limitations

Work practices must be used correctly and consistently by all employees
to be effective in reducing the likelihood of BBP and sharps exposures.
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What is Personal Protective Equipment
(PPE)?

Personal Protective Equipment- is specialized clothing or equipment worn
by an employee for protection against a hazard.

Examples:


Gloves

Disposable gowns

Lab coats

Face shields or masks

Eye protection (goggles)

Additional items can be ordered as needed
Contact your department manager
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Facility-Specific PPE Practices

PPE is provided free to employees for use while working.

PPE is chosen to fit the task and the worker(s) who will be using it.

PPE supplies are generally kept in each department.


Gloves are available in every patient room.
If you need additional PPE supplies, contact the Director of Purchasing at
Ext. 130.
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When do I use PPE?

PPE should be worn anytime when contact with OPIM, including
contaminated equipment is anticipated.

When in doubt, USE PPE!
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Gloves

There are a variety to choose from, including latex-free gloves.

Gloves should be worn when contact with blood, OPIM, mucous membranes,
and non-intact skin is anticipated; when performing vascular access
procedures and when handling or touching contaminated items or surfaces.

Gloves should be replaced as soon as practical when contaminated or as
soon as possible when they are peeling, torn, punctures, or when their ability
to function as a barrier is compromised.

Before using gloves, check for small holes or puncture marks. These are big
enough to allow a virus to pass through!

Double gloving is a practice that reduces, but does not eliminate the
occurrence of needle stick injuries.
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Goggles and Face Shields

Goggles and Face Shields protect the surrounding skin and mucous
membranes of the eyes, nose, and mouth from exposure.

Should be worn whenever splashes, spray, spatter, or droplets of blood or
OPIM may be generated and eyes, nose, or mouth contamination can be
anticipated.
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Gowns

When required, put them on BEFORE starting to work.

Do not remove the gown while wearing “dirty” gloves or if hands are dirty

Choose an appropriately sized gown to maximize comfort and protection.
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Sequence for donning and removing
PPE
Sequence for donning PPE
Sequence for removing PPE
1.
Gown
1.
Gloves
2.
Mask or respirator
2.
Face shield or goggles
3.
Goggles or face shield
3.
Gown
4.
Gloves
4.
Mask or respirator
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How to don a gown:




Select appropriate type and size
Opening is in the back
Secure at neck and waist
If gown is too small, use two gowns


Gown #1 ties in front
Gown #2 ties in back
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How to don a mask:
Surgical mask
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N-95 mask

Place over nose, mouth and chin.

Select a fit tested respirator.

Fit flexible nose piece over nose
bridge.

Place over nose, mouth and chin.

Fit flexible nose piece over nose bridge.

Secure on head with ties or elastic.

Secure on head with elastic.

Adjust to fit.

Adjust to fit.

Perform a fit check:

Inhale – respirator should collapse.

Exhale – check for leakage around face.
How to don goggles and face shield:

Position goggles over eyes and secure to the head using the ear pieces or
headband.

Position face shield over face and secure on brow with headband.

Adjust to fit comfortably.
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How to don gloves:

Don gloves last.

Select correct type and size.

Insert hands into gloves.

Extend gloves over isolation gown cuffs.
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How to remove gloves:


How to Remove Gloves (1):

Grasp outside edge near wrist.

Peel away from hand, turning glove inside-out.

Hold in opposite gloved hand.
How to Remove Gloves (2):

Slide ungloved finger under the wrist of the remaining glove.

Peel off from inside, creating a bag for both gloves.

Discard.
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How to remove goggles and face
shield:

Grasp ear or head pieces with ungloved hands.

Lift away from face.

Place in designated receptacle for reprocessing or disposal.
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How to remove a gown:

Unfasten ties.

Peel gown away from neck and shoulder.

Turn contaminated outside toward the inside.

Fold or roll into a bundle.

Discard.
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How to remove a mask:
Surgical Mask

Untie the bottom, then top, tie.

Remove from face.

Discard.
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N 95 Mask

Lift the bottom elastic over your head
first.

Then lift off the top elastic.

Discard.
Removing PPE

Remove contaminated PPE immediately after use.

If any area on your body has blood or OPIM on it after removing PPE,
wash with soap and water.

Generally speaking, gloves should always be considered contaminated.

ALWAYS wash hands after removing gloves and other PPE.

All PPE should be disposed of into the red trashcan with step pedal.
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Limitations of PPE

Does not eliminated the exposure source.

Must be worn correctly and at all times in work tasks where exposures may
be encountered.

Must be the right type and fit.

Must be changed whenever soiled.

May be uncomfortable to the user.

May affect task performance.

May impede communications.
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Biohazardous Waste

Biohazardous waste is material contaminated with blood or OPIM.

Biohazard waste is disposed of in labeled biohazard waste bags/
containers.

Examples:

Sharps go into sharps disposal containers.

PPE, paper towels, and other contaminated waste that will NOT puncture a
bag goes into a biohazard waste bag.
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Biohazard Waste Bag/Container

Labels on the biohazard bags and containers must have at least 1 of the
following:

Fluorescent orange or orange-red with lettering and symbols in contrasting
color.

Has the word “BIOHAZARD” printed on it

Has the “BIOHAZARD” symbol on it
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Biohazard Waste Containers at This
Facility

The following biohazard containers are located in each clinical
department.

Large closed containers labeled biohazard.

Small closed containers labeled biohazard.

Biohazard bags.

Sharps containers-also located in every patient room.
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Blood or OPIM Decontamination and
Cleanup Procedures

All equipment and environmental and working surfaces should be
cleaned and decontaminated after contact with blood or OPIM
according to established procedures which are outlined in your
department.

Use an approved disinfectant according to manufacturers’ guidelines or
a fresh 1:100 chlorine bleach solution.


Bleach solution must be prepared daily and discarded after 24 hours.

Bleach solution is used to clean surfaces and medical equipment.
Contact Environmental Services at Ext. 144
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Environmental Survival

The Hepatitis C virus can survive outside the body at room temperature,
on environmental surfaces, for up to 3 weeks.

Hepatitis B virus can survive outside the body at least 7 days. During that
time, the virus can still cause infection if it enters the body of a person who
is not infected.

HIV does not survive long outside the human body (such as on surfaces),
and it cannot reproduce outside a human host.
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Laundry

Wet contaminated laundry must be placed in bags or containers which prevent
soak-through and/or leakage of fluids to the exterior.

Employees who have contact with contaminated laundry must wear appropriate
PPE.

Contaminated laundry must:

Be handled as little as possible with minimum agitation.

Be bagged or containerized at the location where it was used and cannot be
sorted or rinsed in the location of use.

Be placed and transported in bags or containers color coded or labeled
biohazard.
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Prevention of Bloodborne Pathogen
Infection

Hepatitis B Vaccine.

Incident Reporting.

Post-exposure follow-up.
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Hepatitis B Vaccine

Is offered at no cost to all employees who have occupational exposure,
and post-exposure evaluation and follow-up to all employees who have
had an exposure incident.

Should be given before assignment to tasks involving occupational
exposure to HBV.

Administered according to the latest CDC guidelines.

If employee refuses the vaccine, a signed waiver is required for vaccine
refusal.

The hepatitis B vaccine is administered in the Emergency Room.
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Exposure Incident:

An exposure incident has occurred if:

Blood or OPIM (not your own) has come into direct contact with your eyes,
mouth, mucous membranes, or open wounds.

You have punctured your skin with a contaminated sharp object.
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What to Do After an Exposure Incident

WASH the affected area(s) with plenty of soap and water immediately
following exposure.

REPORT the exposure immediately to your supervisor. If supervisor is not
available, notify the charge nurse. Prompt evaluation is important.

Your supervisor or charge nurse will provide you with the necessary paperwork
and will help document the exposure.
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After an Exposure Incident

The injured employee must be escorted to the Admissions in the
Emergency Room to complete the accident/incident report form and lab
request form.

The lab request form must be signed by the ER physician.

The employee will be examined by the ER physician and the physician will
complete orders for drug and alcohol screens.

Any test results, medical recommendations, or other information will be
shared with you.

The incident will be recorded on the Sharps Injury Log.
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Sharps Injury Log Information


Includes details of all exposure incidents:

Type and brand of device involved.

Where incident occurred.

Description of how incident occurred.
Maintains employee confidentiality (personal identification is not
recorded).
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Post-Exposure Follow-Up

Medical evaluation.

Post exposure prophylaxis (PEP), if clinically indicated.

Physician’s written opinion.

Counseling and evaluation of reported illnesses.
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Post-exposure Evaluation
Requirements

Follow the latest CDC requirements for post-exposure evaluation and
prophylaxis.

Document the route of exposure and the circumstances under which the
exposure incident occurred.

Identify and document the source .

Test the source blood after consent is obtained to determine HBV and HIV
infectivity.

Make test results available to the exposed HCW.

Upon consent, test HCW blood.
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Evaluation Requirements

If the employee consents to baseline blood collection, but does not give
consent at that time for HIV testing, the sample will be preserved for at
least 90 days. If, within 90 days of the exposure incident, the employee
elects to have the baseline sample tested, such testing may be
performed.

Advise HCW to seek medical attention.

Provide counseling.

Evaluate test results to offer treatment if needed.
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Types of Prophylaxis

HBV:



Vaccine, Hepatitis B immunoglobulin
HIV:

Zidovudine

Lamivudine (3TC)

Expanded regimen: Indinavir (IDV) or similar acting agents when increased risk
HCV:

None
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Physician’s Written Opinion

The employer obtains and provides the employee with a copy of the
evaluating physician’s opinion within 15 days of the completion of the
evaluation.

Contains:

Limited medical information.

Documentation that the employee was informed of the results of the
evaluation and any medical conditions resulting from exposure to blood or
OPIM which require further evaluation or treatment.

All other findings or diagnoses will remain confidential and will not be included
in the written report.
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Record Keeping


What records are kept?

Medical and training records.

OSHA Illness and Injury.

Sharps Injury Log.
How long are they kept?

Medical records are kept for the duration of employment plus 30 years.

Training records are kept for 3 years from the date on which the training
occurred.

Medical records kept confidential.

Access to records: employee, OSHA.
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Remember:

Avoid all contact with blood or OPIM.

Hand hygiene is key to preventing infection.

Use PPE as required.

Get vaccinated against HBV: HBV vaccine is free and eliminates a
potential risk.

Report any exposure incident that occurs as soon as possible.
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Tuberculosis (TB)

Room 274 is our negative pressure isolation room used for patients with TB.

Prior to entering the room, don the appropriate PPE including N-95 mask.
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Tuberculosis (TB)

Our hospital currently does not receive many TB patients.

Signs/symptoms to be aware of:


Coughing up blood

Chest pain, or pain with breathing or coughing

Unintentional weight loss

Fatigue, Fever

Night sweats/Chills
Always give patients who are coughing a tissue to cover their mouth or you
may request the patient to wear a surgical mask until they are evaluated by a
physician.
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Test
1.
2.
The best way to prevent the spread of infection is by:
a.
Washing your hands.
b.
Staying away from people.
c.
Keeping your eyes closed.
d.
Not talking.
The location of our TB (negative pressure) room is:
a.
In the ER.
b.
Room 274.
c.
In the hallway.
d.
In the maintenance department.
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Test
3.
Our exposure control plan:
a.
Tells you what to do if you fall
b.
Details on your paycheck
c.
Tells you what to do if you have a needle stick or splashed by blood or OPIM
d.
Is not important
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Resources
•
World Health Organization www.who.int/csr/.../whoemcesr982sec5-6.pdf
•
CDC
•
OSHA
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Health Care Associated Infection and Hand
Hygiene Improvement
MANAGED BY:
CHELSEY CARGLE, RRT
DIRECTOR, RESPIRATORY SERVICES
EXTENSION 240
Health Care-Associated Infection
(HCAI)

Also referred to as "nosocomial" or "hospital" infection.

HCAI is an infection occurring in a patient during the process of care in a
hospital or other health care facility which was not present or incubating at the
time of admission. This includes infections acquired in the health-care facility
but appearing after discharge, and also occupational infections among HCW
of the facility.
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HCAI: The Worldwide Burden

Estimates are hampered by limited availability or reliable data.

The burden of disease both inside and outside health-care facilities is
unknown in many countries.

No health-care facility, no country, no health-care system in the world
can claim to have solved the problem.
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Estimated Rates of HCAI Worldwide

At any time, it can be estimated that hundreds of millions of patients suffer
from HCAI every year worldwide.

Of every 100 hospitalized patients at any given time, 7 in developed and
10 in developing countries will acquire at least one health careassociated infection.

In intensive care units (ICU), HCAI affects approximately 30% of patients.
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The Impact of HCAI

HCAI can cause:

prolong hospital stays

create long-term disability

increase resistance to antimicrobials

represent a massive additional financial burden for health systems,

generate high costs for patients and their family

unnecessary deaths
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Prevention of HCAI

Validated and standardized prevention strategies have been shown to
reduce HCAI.

Many infection prevention and control measures, such as appropriate
hand hygiene and the correct application of basic precautions during
invasive procedures, are simple and low-cost, but require staff
accountability and behavioral change.
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Hand Transmission

Hands are the most common vehicle to transmit health care-associated
pathogens.

Transmission of health care-associated pathogens from one patient to
another via health-care workers’ hands requires 5 sequential steps.
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Why should you clean your hands?

Any HCW, caregiver, or person involved in patient care needs to be
concerned about hand hygiene.

Therefore, hand hygiene concerns you!

You must perform hand hygiene to:

Protect the patient against harmful germs carried on your hands or present on
his/her own skin.

Protect yourself and the health-care environment from harmful germs.
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How To Clean Your Hands

Hand rubbing with an alcohol-based handrub is the preferred routine
method of hand hygiene if hands are not visibly soiled.

Handwashing with soap and water is essential when hands are visibly dirty
or soiled following visible exposure to body fluids.

If exposed to spore forming organisms such as Clostridium difficile (C. diff)
clean hands with soap and water.
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Hand Hygiene and Glove Use

The use of gloves does not replace the
need to clean your hands!

You should remove gloves to perform hand
hygiene, when an indication occurs while
wearing gloves.

You should wear gloves only when
indicated, otherwise they become a major
risk for germ transmission. (see pyramid in
the hand hygiene why, how and when
brochure and in the glove use information
leaflet).
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Compliance With Hand Hygiene

Compliance with hand hygiene differs across facilities and countries, but is
globally <40%.

Main reasons for non-compliance reported by HCW:

Too busy

Skin irritation

Glove use

Don’t think about it
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Time constraint is a major obstacle for
hand hygiene:

Adequate handwashing with soap and water requires 40-60 seconds.

Average time usually adopted by HCW: <10 seconds.

Alcohol-based handrubbing: 20-30 seconds.
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Health Care-Associated Infection and
Hand Hygiene Improvement Test
1.
2.
3.
Adequate handwashing with soap and water requires:
a.
5 minutes
b.
20-30 seconds
c.
40-60 seconds
Hands are the most common vehicle to transmit health care-associated pathogens?
a.
True
b.
False
Why is it important to wash your hands?
a.
Protect the patient against harmful germs carried on your hands or present on his/her own skin.
b.
An infection can cause a prolonged stay in the hospital or even death.
c.
All of the above.
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Resource(s)
•
World Health Organization
http://www.who.int/gpsc/country_work/burden_hcai/en/
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Safety Management Program
MANAGED BY:
JOHN STOREY
FACILITIES MANAGEMENT
EXTENSION 156
Safety Management Program


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Safety Committee:

Meets monthly.

Conducts 2 safety surveys per year.

Report any unsafe condition you become aware of immediately .
Incidents/Accidents

Report incidents/accidents immediately to your supervisor or the Charge Nurse.

Complete the Incident/Accident report.

Report to emergency room for exam.

Report to Lab for drug screen/alcohol test.

Return Incident/Accident Form to HR.
Safety Management Program

Accident Review Committee:

Will convene as soon as possible after an incident/accident is reported.

Accident will be reviewed, employee/supervisor interviewed, and steps
initiated to help prevent accident from occurring again.
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Safety

Safety Drills are conducted quarterly and can occur at any time. You
may be asked to be an evaluator and to write down what you observed
during the drill.

If you have any safety concerns related to patients or employees please
call John Storey at ext 156.
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Safety Data Sheets (SDS)

A sheet designed to provide workers with proper procedures for handling
or working with a particular substance.

Every chemical you work with has a MSDS and is located in your
department.

The ER has the Master SDS with all chemicals located in the hospital.
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