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Fresno Medical Center
Nursing Student Orientation
Education Services
Kim Clifforth RN BSN MSN CNS Interim Education Manager
Joe Ruiz Education Training Coordinator 559-448-5550
Service Credo
”Our cause is health. Our passion is service. W e're here to make lives better."
Welcome to nursing at Kaiser Permanente. W e are excited to have you here as a
student and be part of the great nursing care that we provide for our members. This
document will provide you with a brief summary of our organization, the major programs
in place to ensure safe, quality care, and your responsibilities as a student. W e ask that
you read this prior to your hospital orientation session.
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Founded in 1945, Kaiser Permanente is the nation’s largest nonprofit health plan
serving 8.6 million members.
KP serves members in California, Colorado, Georgia, Hawaii, Maryland, Ohio,
Oregon, Virginia, Washington, and the District of Columbia.
Medical centers: 35
Medical offices: 454
Fresno Medical Center
o Medical Offices opened in 1985
o Kaiser Foundation Hospital opened in 1995
o Employees in Fresno: over 2100
o Physicians employed by Kaiser Fresno Hospital: 254
o RN’s and LVN’s employed at the Fresno Medical Center: over 650 in staff and
management positions
o Hospital capacity - 169 licensed beds; Medical/Surgical 48, Critical Care 12,
Telemetry 71, Special Care Nursery 12, Perinatal 26.
Fresno Medical Center Leadership
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Jeffery A. Collins
Varouj Altebarmakian, MD
Jose DeAnda
Beth Carlson,RN
Sr. Vice President and Area Manager
Physician-in-Chief
Medical Group Administrator
Chief Nursing Officer
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Patient Care Services
Fresno Medical Center
Exceptional Care
Every Patient
Every Time
Nursing practice in the Fresno
Medical Center is guided by the
Science of Human Caring. Every
patient can expect to receive care
in accordance with the Caritas
principles
Fresno Vision
We aspire to create a compassionate, healing environment, centered around caring for
the individual patient and family, congruent with their needs for comfort, safety, dignity
and respect, reflective of the patient’s and family’s culture and values.
Mission
To provide a unique, individualized care experience through building authentic
relationships, providing competent, compassionate care with thoughtful consideration of
ethics of face.
Philosophy
Through implementation of the Human Caring Theory (Jean W atson), every caregiver
establishes a personal relationship with their patient, creating a nurturing and healing
environment. This promotes and restores the patient to an individual optimal level of
physical, mental, spiritual and emotional well being
Responsibility
Each Registered Nurse and caregiver is accountable to create a caring and healing
environment for each individual patient without exception.
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Patient Safety
Nurse Knowledge Exchange - NKE
BEFORE SHIFT
•
Previous Shift Preparation
DURING CHANGE
Use Nursing Handoff Navigator on KP HealthConnect
(electronic medical record)
•
Bedside Rounds
•
Patient Care Board
•
Patient Teach Back
DURING SHIFT
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Updating the Care Board and prepared/printed report tool
National Patient Safety Goals
Patient Identification
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Use two patient identifiers when:
o Administering medications
o Collecting blood samples and specimens for clinical
testing
o Prior to receiving radiological procedures
o Providing treatments or procedures
Eliminate Transfusion Errors
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Before initiating a blood or blood component transfusion,
the patient is objectively matched to the blood or blood
component during a two-person bedside or chair-side
verification process
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Improve Effective Communication Among Care Givers
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Improve the timeliness of reporting critical test values
Anticoagulation Management Program
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Use approved protocols and policies
Provide patient education
Hand Hygiene
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Use World Health Organization (WHO) or Centers for
Disease Control and Prevention (CDC) hand hygiene
guidelines
Infection Prevention
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Use protocols / guidelines related to Multiple Drug Resistant Organisms (MCRO)
Use protocols / guidelines related to Blood Stream Infections (BSI)
Use protocols / guidelines to prevent Surgical Site Infections (SSI)
Medication Reconciliation
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Obtain a complete list of patient’s medications upon admission
including over-the-counter and herbs
Medications are reconciled upon admission
Medication list is given to patient / next provider at the time of
discharge
Universal Protocol – applies to surgery and invasive procedures
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Pre-procedure verification
o Right patient and correct side / site identified
o Relevant documentation (H&P, consent) present
o Correct diagnostic tests / images present
o Correct implants / blood products / special equipment present
 Site marked by surgeon or procedurist
 Time out / procedural briefing completed
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•
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Review MAR
Verify correct time
Enter medication room
Put on Non-Interruption Wear
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Check allergies
Pull medication(s)
Verify right patient
Verify right meds
Verify right dose
Verify right route
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Go to Patient’s Room
Gel or wash hands
Turn down TV / radio
Turn on lights
Verify correct patient using two identifiers
• Explain the med and its purpose
(verifies right med 2nd time)
• Ask patient if they have any questions
• Re-verify dose
• Re-verify route
• Re-verify time
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Administer medication
Document on MAR
Gel or wash hands
Remove Sash
Exit patient room
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Abbreviations that are not allowed in documentation of patient care
CODES
EMERGENCY RESPONSE
Code Blue
Cardiac emergency
Code C
Emergent Cesarean section
Code Dry
Loss of domestic water
Code Grey
Emergent security needs for a physically or verbally abusive,
threatening, or hostile individual.
Code Infant Blue
Medical emergency infant/pediatric
Code Orange
Hazardous material spill/release exposure
Code Pink
Code Red
Code Silver
Unauthorized removal of an infant or pediatric patient from a
unit or the facility.
Activate Fire Response Plan, Implement Rescue-AlarmContain-Evacuate (RACE)
Person with a weapon and/or hostage situation
Code Update
Internal or external activation of the Hospital Incident
Command System (HICS)
Recalling of all departments to provide an emergency
information update
Code White
Health Connect full system outage
Code Yellow
Bomb threat
Help Stat
Immediate assistance needed
Code Triage - Internal/External
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o World Health Organization (WHO) - 5 Moments for
Hand Hygiene
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Use when patient has or suspected of having Clostridium
difficile infection (C.diff)
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REMEMBER TO REMOVE YOUR MASK PRIOR TO LEAVING THE ROOM!
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STUDENTS WILL NOT BE “FIT TESTED” SO THEY WILL NOT BE ABLE TO ENTER
AIRBORNE PRECAUTION ROOMS!
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HEROES Program
Hospital & Emergency Department Reliability & Operational Excellence for Safety
1. Prevention of and harm from falls
2. Prevention of Hospital Acquired Pressure Ulcers (HAPUs)
3. Improve and/or sustain performance of rapid response teams thereby reducing the
number of Code Blues outside of the ICU
4. Prevention of Hospital Acquired C diff
Fall Prevention – the TEAM concept
•
To identify patients at risk for falling (Schmid scale) or at highest risk for a serious
injury from falling (Schmid Plus scale), two assessment scales are used
• The TEAM bundle is used to help remember the key steps of
• Toileting / activity
• Environment
• Assessment
• Medication Multidisciplinary Review
(Assessment screen for KP HealthConnect)
•
The following two tables provide the nursing interventions for patients at risk for
falling or at highest risk for serious injury for a serious injury from falling.
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Schmid Scale Interventions
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Schmid Plus Scale Interventions
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Hospital Acquired Pressure Ulcers (HAPU) Prevention
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To identify patients at risk for a pressure ulcer the Braden score is used to assess
risk
• The SKIN bundle is used to help remember the key nursing interventions (see
screen shot from KP HealthConnect)
Rapid Response Team (RRT) Called
Dial RUNN or 7866
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The goal is to reduce the number of Code Blue calls outside of the critical care unit
The team consists of a critical care RN and a respiratory therapist
The team can be called for any single or combination of criteria regardless of code
status. The criteria, but not limited to, are a follows:
Acute HR change to <40 or >130
Acute SBP change to <90mmHg or >200mmHg
Acute RR change to <8 or >28
Acute SaO2 change to <90% withO2
Acute change in consciousness / level of response
Acute change in urine output <50ml in 4 hours
Persistent or changing pattern of chest pain
Seizure, new onset
Severe/uncontrolled pain
Other: ___________________________________
Condition H initiated by patient/family member
Prevention of Hospital Acquired C diff
See information on page 10
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Core Measures
Clinical Guideline Reminders
ACUTE
ACUTE MYOCARDIAL
MYOCARDIAL INFARCTION
INFARCTION
Aspirin within 24 hours before or after arrival
Aspirin prescribed at discharge
LVSF assessed either prior to arrival (there is no
time limitation), during hospitalization, or is
planned for after discharge
ACEI or ARB for LVSD (EF<40% or
described as moderate/severe )
Adult smoking cessation/advice counseling for
patients who smoked any time in the year prior to
hospital arrival
Beta-blocker prescribed at discharge
Fibrinolytic within 30 minutes of arrival
or clearly document reason for lytic delay
Statins prescribed at discharge
Document
Document any
any contraindications
contraindications
to
to beta-blockers,
beta-blockers, aspirin,
aspirin, or
or ACEI/ARB
ACEI/ARB or
or Statins
Statins
COMMUNITY-ACQUIRED PNEUMONIA
COMMUNITY
COMMUNITY-ACQUIRED
PNEUMONIA
CONGESTIVE
CONGESTIVE HEART
HEART FAILURE
FAILURE
LVSF assessed either prior to arrival (there is no
time limitation), during hospitalization, or is
planned for after discharge
ACEI or ARB for LVSD (EF<40% or
described as moderate/severe )
Adult smoking cessation advice/counseling for
patients who smoked any time in the year prior to
hospital arrival
Discharge instructions: (all need to be
documented and meds must match MD D/C
summary)
•Diet
•Follow-up
•Symptoms worsening
•Activity
•Medications
•Weight Monitoring
Document
Document any
any contraindications
contraindications to
to ACEI,
ACEI, ARB
ARB or
or both
both
Document
Document LVF
LVF assessment,
assessment,
i.i. e.
e. moderate,
moderate, severe
severe or
or EF<40%
EF<40%
Document
Document discharge
discharge medications
medications in
in chart
chart
Sign
Sign eRX
eRX medication
medication sheet
sheet
SURGICAL
SURGICAL CARE
CARE IMPROVEMENT
IMPROVEMENT PROJECT
PROJECT
Chest X-ray indicates pneumonia 24 hours prior to
or any time during hospitalization
 Prophylactic antibiotics administered within one hour
before surgical incision
Initial antibiotics received within 6 hours
 Prophylactic antibiotics consistent with current
recommendations
Initial antibiotics selected for CAP in
immunocompetent patients follows the guidelines
 Prophylactic antibiotics discontinued within 24 hours of
surgery end time
Blood cultures (performed prior to antibiotics)
within 24 hours before or < 6 hours after hospital
arrival.
 Appropriate removal of hair pre-op (i.e. clippers)
Foley Catheter Removed POD 1 or POD 2
Pneumococcal vaccination (patients 65 yrs or older
or immunocompromised
Influenza vaccination (October – March)
Adult smoking cessation advice/counseling for
patients who smoked any time in the year prior to
hospital arrival
Drug-Resistant Pneumococcus: document risk
factors and use appropriate antibiotic
 Colorectal surgeries: Normothermia within 15 minutes
after leaving the OR (96.8 - 100.4)
 Appropriate Venous Thromboembolism Prophylaxis is
received. Document reason for not administering VTE
prophylaxis.
 Beta Blocker therapy received during perioperative
period.(24 hrs prior to surgery incision through DC from
PACU) Document date and time BB received.
Document
Document reason
reason to
to continue
continue antibiotics
antibiotics
beyond
beyond 24
24 hours
hours (i.e.
(i.e. infection
infection or
or rule
rule out
out infection)
infection)
Quality Department 07/2010
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Workplace Safety
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A wide variety of equipment is available to transfer and lift patients for the
safety of both staff and patients
Review the equipment with your instructor prior to use
The table on the following page provides guidance on how to select the
proper equipment for moving / transferring the patient.
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Handle with CARE
Keeping our patients Safe
Keeping our staff Safe
C
A
R
E
Cooperative?
Able to Assist?
Resources
Equipment
o Patient’s level of
cooperation and
comprehension
Boosting
Up in Bed
Repositioning
Side to Side
Yes
No - Communicate
to team; Stay arms
length away;
Address patient in
side facing position
Yes
o
Patient’s level of
assistance
o Weight bearing
capacity
o Upper extremity
strength
o Weight/Height
o Patient conditions
Fully: Caregiver
assistance not needed
o Number of staff
o During any patient handling task, if
caregiver is required to lift > 35#, lift
equipment must be used
Partially
 Less than 200#,
use 2-3 persons
 Greater than or
equal to 200#, use
min of 3 persons
 Greater than 300#,
use Hovermatt &
appropriate
number of
caregivers
 Min of 2 persons
 Bed flat or Trendelenburg, if able and
NO aspiration risk
 Side rails down for boosting
 Bed height to waist of shortest
caregiver performing move
 FReD**- EZ Slider, Slipp sheet
 Ask patient to flex knees and push on
count of 3
 Over bed Trapeze
Go to next step >>>
Fully
Partially
Assisting
Out of Bed
No
Go to next step >>>
Yes
Full weight bearing &
upper extremity
strength? Yes
No
 1 person
Go to next step >>>
 Min of 2 persons
Go to next step >>>
 Min of 2 persons
(Standing, Bed
to Chair/Toilet)
Bed to Bed
 Less than 200#,
use 2-3 persons
 Greater than or
equal to 200#, use
min of 3 persons
 Min of 2 persons
No - Use proper
mechanical lift
equipment
Transfer all
patients with FReD
 Min of 2 persons
 Mechanical lift with supine sling Golvo, Viking, Arjo
 FReD**- EZ Slider
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Bed flat or Trendelenburg if able
Encourage patient to use side rails
Wedge for positioning
Bed flat or Trendelenburg if able
Bed height to waist of shortest
caregiver performing move
 FReD** - EZ Slider, Slipp Sheet
 Mechanical lift with supine sling –
Golvo, Viking, Arjo, as appropriate
 Non-skid footwear on patient
 Gait Belt
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Gait Belt
Sit to Stand (Sabina, Steady)
Walker
Mechanical lift with full body sling –
Golvo, Viking, Arjo
 Hover Mat or AirPal
 EZ Slider, Slipp Sheet, or Slide Board
** FReD - Friction Reduction Device (eg: EZ Slider, Slipp Sheet, Slide Board, Hover Mat, AirPal, Glide)
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PATIENT CARE SERVICE BASIS THEIR CARE ON THE SCIENCE OF CARING.
The Philosophy & Science of Caring, Jean Watson,
rev edition 2008
10 Caritas Processes
EMBRACE altruistic values and practice loving kindness
with self and others
INSPIRE faith and hope and honor others
TRUST self and others by nurturing individual beliefs,
personal growth and practices
NURTURE helping, trusting, caring relationships
FORGIVE and accept positive and negative feelings –
authentically listen to another’s story
DEEPEN scientific problem-solving methods for caring
decision making
BALANCE teaching and learning to address the individual
needs, readiness and learning styles
CO-CREATE a healing environment for the physical and
spiritual self with respects human dignity
MINISTER to basic physical, emotional and spiritual
human needs
OPEN to mystery and allow miracles to enter
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Injury
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If you are injured while at Kaiser Permanente, i.e., fall, needle stick, you must
report the injury immediately and before you leave the hospital.
Notify your instructor and the nurse manager. The nurse manager will direct you
to the appropriate department for assessment. Treatment or referral will be as
indicated in the contract between the school and Kaiser Permanente
The instructor will notify Education Services before leaving the hospital
Incidents
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If any unusual incident occurs during your care of the patient immediately notify
your instructor and the nurse responsible for the patient.
You may also need to assist the nurse in completing a Responsible Reporting
Form.
Student Responsibilities
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When on Kaiser Permanente premises wear the Kaiser Permanente photo
identification badge and the school uniform or a lab coat with school emblem.
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Use employee parking lot Code 666666#
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Documentation – per Health Connect protocol.
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Report all care observations to the RN responsible for the care of your patient and
to your instructor
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See limitations below.
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Remember that any observation or care provided at Kaiser Permanente is
confidential. Details of confidentiality and privacy are in supplemental documents.
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At the end of the clinical rotation complete an evaluation of your experiences as a
student at Kaiser Permanente. We want to know if there are any ways in which
we can improve student experiences.
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