Download Clermont Hospital Physician Orientation Manual

Clermont Hospital
Medical and Allied Health Staff
Orientation and
Reference Manual
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Table of Contents
TOPIC
PAGE
Welcome to Mercy Health – Clermont Hospital………………………………………..
Medical Staff Overview…………………………………………………………………
Bylaws, R&R……………………………………………………………………………
Physician Response Time……………………………………………………………….
Patient Experience……………………………………………………………………….
Medical Records – Completion Tips……………………………………………………
Disruptive Behavior……………………………………………………………………..
Impairment……………………………………………………………………………....
Incident Reporting/SafeCARE…………………………………………………………..
Quality Initiatives………………………………………………………………………..
MEWS, Rapid Response, Code Blue, Clinical Administrator…………………………..
CarePATH (EPIC)………………………………………………………………………
Dictation Instructions……………………………………………………………………
Translators, Interpreters…………………………………………………………………
Patient Complaints………………………………………………………………………
Employee Health………………………………………………………………………...
Pharmacy, Anticoagulation Clinic………………………………………………………
Infection Control………………………………………………………………………...
Laboratory……………………………………………………………………………….
Pain Management………………………………………………………………………..
Spiritual Care, Advance Directives, Ethics……………………………………………...
Behavioral Health Institute……………………………………………………………...
Physical Environment, Emergency Management, Emergency Codes…………………..
Reporting to Joint Commission………………………………………………………….
Contact Information – Nursing Units……………………………………………………
Contact Information – Management Team……………………………………………...
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Medical Staff Reference
Welcome to the Mercy Health – Clermont Hospital Medical Staff!
Clermont Hospital was established in 1973 and since that time, has served as Clermont County’s
leading healthcare provider, offering advanced, convenient medical care. Clermont Hospital
features one of the region's newest and largest intensive care units, one of the region's first
dedicated wound care centers, 24/7 emergency care and inpatient/outpatient surgery. The
Eastgate Medical Center also provides eastside residents a convenient option for top-notch
surgery and other healthcare services. Formerly known as the Surgery Center of Cincinnati,
Mercy Health – Eastgate Medical Center provides outpatient surgery and a wide range of
specialists that treat health conditions including orthopaedics, pain management, podiatry,
gastrointestinal and urology. Eastgate Medical Center will soon have physician offices, physical
therapy care, occupational health and urgent care.
Mt. Orab Medical Center features 24-hour emergency medical care, comprehensive imaging and
diagnostic services and Laboratory Services. Imaging and diagnostic services at Mt. Orab
Medical Center include: CT Scanning, general X-ray, Electrocardiogram (EKG) and lab services.
Mercy Hospital Clermont opened in 1973 and is licensed for 157 beds. You are joining a staff of
over 470 Physicians and Allied Health Professionals and a hospital with 810 employees. Mercy
Clermont is a 6-Time Reuters Top 100 hospital. The main hospital number is (513) 732-8200.
Below is a list of specialized offerings provided by Mercy Health – Clermont Hospital to help
you be well.
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24-Hour Emergency Care
Adult Behavioral Health Services
Outpatient Diabetes Services and Education
Cancer Care/Oncology
Cardiology
Critical Care
Lung/Pulmonary Services
Lung Specialists
Medical Imaging Centers
Orthopaedic Care/Joint Replacement
Palliative Care
Primary and Specialty Care
Sports Medicine
Rehabilitation and Therapy (Outpatient)
Women's Center
Wound Care Center
Mercy Hospital Clermont
Acute Admissions
Behavior Med Admissions
Inpatient Surgeries
Outpatient Surgeries
ER Visits – Clermont
ER Visits – Mt. Orab
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2013
20,145
5,833
1,107
3,188
36,536
17,940
OUR MISSION | What we do
Mercy extends the healing ministry of Jesus by improving the health of our communities with
emphasis on the people who are poor and under-served.
OUR VALUES | The principles that guide our behavior
Excellence, Compassion, Human Dignity, Sacredness of Life, Justice, and Service
STANDARDS OF BEHAVIOR | How we, as employees, behave to deliver on the Mission,
Values and Promise
Compassion: We seek to understand, listen and explain.
Advocate: We are the voice for the vulnerable.
Respect: We demonstrate the highest regard for and welcome all people.
Excellence: We commit to the highest standard of quality care, joyful service, and teamwork.
OUR PROMISE | How we want patients, residents, guests, and community to feel each and
every time they have an experience with us.
We promise to make each and every patient’s life better – mind, body and spirit.
We enjoy being of service to our patients, residents, guests, community, and one another.
We make healthcare easy so our patients can enjoy their lives.
THE MEDICAL STAFF
2014 – 2015 Medical Staff Officers
Chief of Staff: Dr. Param Hariharan
Chief Elect: Larry Graham, M.D.
Immediate Past Chief of Staff: Joe Renusch, M.D.
MEC Members at Large: Ajeet Dube, M.D. and Stephen Meyers, M.D.
Chair, Department of Emergency Medicine: Joe Renusch, M.D.
Chair, Department of Medicine: Samir Ataya, M.D.
Chair, Department of Psychiatry: Larry Graham, M.D.
Chair, Department of Surgery: Brian Shiff, M.D.
2014 – 2015 Committee Chairs
Acute Care – Samir Ataya, M.D.
Advisory (Peer Review) – Briana McFawn, M.D.
Cancer – Foroogh Jazy, M.D.
Cardiology Division – Stephen Meyers, M.D.
Credentials – Param Hariharan, M.D.
Ethics Committee – Tim McKinley, M.D.
Medical Executive – Param Hariharan, M.D.
Pharmacy & Therapeutics/Infection Control – David Beck, M.D.
Quality Council – Larry Graham, M.D.
General Medical Staff Meetings on the 2nd Tuesday in April and October at 6 p.m. Department
and Sections meet at the direction of the Department/Section Chair.
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Medical Staff Social Events
Annual Seafood Fest held in April or May of each year.
Annual Anderson-Clermont Medical Staff Golf Outing held in September of each year.
Annual Anderson-Clermont Medical Staff Holiday Party held on the 1st first Friday in December.
Manager, Medical Staff Services
Mindy Hays, CPMSM
(513) 732-8327
[email protected]
Mindy Hays is the Manager of Medical Staff Services at Mercy Clermont. Please direct any
questions you may have related to credentialing, privileging, Medical Staff Committees,
Medical Staff Governance, Bylaws, Rules and Regulations, Call Schedules, Medical Staff Social
Events, etc. to this office. An updated event and meeting calendar and any announcements are
located in the physician lounge. A monthly Medical Staff meeting calendar and Newsletter are
also distributed via email so it is important to ensure that your current email address is on file in
the Medical Staff Office.
Physician Parking Available
Convenient physician-only parking is available. As you enter the main Hospital drive, turn left
and follow the roadway to the north side of the hospital - the parking spaces will be just to the
left of the Physician Pavilion entrance. Enter door # 21 to the Physician Lounge.
Medical Staff Members Photo Identification Badge
Obtain a photo identification badge from the Medical Staff Office during business hours. This
must be worn at all times in the hospital. The badge contains a magnetic strip that allows
entrance to the physician lounge and the external door after hours. You will also be issued an
Imprivata badge for medication ordering in EPIC.
Medical Staff Bylaws and Rules & Regulations
Current documents can be found on the Clermont intranet site and at http://www.emercy.com/for-healthcare-professionals-resources.aspx.
Expectations of Medical Staff Membership
1. Compliance with Medical Staff Bylaws, Rules & Regulations
• Maintain current evidence of licensure, DEA, and professional liability insurance
• Complete medical records documentation in accordance with Bylaws/R&R
• Participate in the Emergency Department call schedule, as required
• Ensure timely remittance of annual Medical Staff dues
2. Participate in Medical Staff committees
3. Adherence to National Patient Safety Goals, including Core Measures
4. Compliance with approved patient care protocols and evidence-based medicine
Physician Response Time
In accordance with the Medical Staff Rules & Regulations, when called by the Emergency
Department, Physicians must respond by phone within 15 minutes of the initial call. If there is
no reply within 15 minutes, a second call will be placed. If there is no response within 30
minutes of the second attempt, the Department Chairperson will be contacted to handle the
emergency and to address the non-responsive behavior with the on-call Physician. If the
Department Chairperson is not available, the Chief of Staff or Designee will be contacted.
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The above timeframes shall be followed for all calls, regardless of department or unit from which
the call originated, unless otherwise specified.
Patient Experience
Mercy Health Clermont Hospital is committed to exceeding our patients’ expectations with
regards to their experience while they are in our facility. Management and staff goals include
specific patient experience targets. The Medical Staff, in particular, has also made this a priority.
Patients are surveyed on the following areas utilizing a Press Ganey survey tool.
During this hospital stay how often did doctors treat you with:
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Courtesy and respect?
Listen carefully to you?
Explain things in a way you could understand?
Below are key things to remember in every patient interaction:
What makes a good communication?
• Informative in a way the patient can understand
• Empathetic
• Respectful
• Calming
• Setting expectations
• Good listener
What makes a good listener?
• Sits down
• Keeps hand off of door knob
• Puts phone on vibrate and does not answer it when with a patient
• Makes good eye contact/good tone of voice
• Has good body language
• Empathetic
• Doesn’t judge
• Doesn’t interrupt
• Asks open ended questions
• Re-states for clarity
• Undivided attention
Medical Record Completion – Tips
Please refer to the Medical Staff Rules & Regulations for a complete listing of requirements.
History & Physical
On chart & updated within 24 hours of admission and prior to surgery; Not older than 30 days
from admission or outpatient surgery; If performed outside the hospital, must be updated and
include language indicating the “patient was examined”; Must be signed, dated & timed
(impacts paper documents); Elements include:
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History of present illness/reason for procedure
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Summary of relevant past medical and surgical history, including current
medications; allergies; previous procedures; other previous significant medical
history;
Physical examination of vital signs; airway and lungs; heart; and examination of
involved area
Diagnosis/assessment and treatment plan
Informed Consent
• Must be signed, dated, & timed prior to procedure being performed
Timeout
• Must be performed immediately before the procedure with full team participation; Must
agree to “correct patient”, “correct procedure”, and “correct site marked”
Post Procedure Progress Note
Completed immediately after operation, other high risk procedures and before the patient is
transferred to the next unit or area of care; Includes:
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Surgeon or proceduralist and assistants
Procedure(s) performed
Description of findings
Estimated blood loss
Specimens removed
Post procedure diagnosis
Full Operative Report
Prepared upon completion of the operative or other high risk procedure and includes items noted
above plus any complications and the management of those events
Pre-Operative documentation for post-operative assessment/orders
Cannot be completed before the operation or procedure; If documentation is started prior to the
procedure and pended, the esignature must be refreshed to pull in the correct date and time post
procedure
Pre-Anesthesia Evaluation
Must be performed immediately prior to anesthesia or moderate sedation and documented
Beware: evaluation times that coincide with the first medication administration are not
considered to be pre-anesthesia evaluations
Discharge Summary - Must include:
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Reason for hospitalization
Final diagnoses
Significant findings
Procedures performed & treatment rendered
Condition at discharge
Specific instructions provided to the patient or family
Disruptive & Inappropriate Behavior
The Medical Staff recognizes that disruptive/inappropriate behavior has the potential to
adversely affect patient care. A Member who engages in conduct disruptive to the operations of
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the hospital is subject to counseling and action under the Rules & Regulations and the
Practitioner Effectiveness Committee Policy (PEC). The PEC serves as a guideline to assist the
Medical Staff in addressing Practitioners who exhibit disruptive, inappropriate or unprofessional
behavior that, whether by pattern of behavior or individual incident, has the potential for causing
imminent harm to individuals. Please refer to the Medical Staff Rules & Regulations for details.
Impairment
“Impairment” as used in this rule shall mean a condition which is, or may adversely affect
patient care at the Hospital, including, but not limited to, physical or mental conditions;
psychiatric disorders; emotional disorders; behavioral disorders; deterioration through the aging
process or loss of motor or perceptive skill; or habitual or excessive use or abuse of drugs,
including alcohol or impairment from the habitual or overuse of drugs or alcohol.
Please refer to the Medical Staff Rules & Regulations for specifics on managing physician health
and impairment, including self-referral and the Medical Staff process for assessment and
treatment of Member health issues.
Incident Reporting For Physicians Available Through SafeCare
SafeCARE is an electronic safety event reporting system available on all hospital computers.
Use the system to enter actual safety events, near misses, and professional conduct concerns. To
enter a report, select “SafeCARE” from the “Quick Links” drop-down menu on the MHP
Intranet. Enter the issue, complete all mandatory fields, and include a brief narrative. Either the
applicable department manager or risk management will address the issue and follow up with
you. Remember to specify the patient name and medical record number, location or department,
and your contact information. (Reports can also be entered anonymously.)
Michelle Williamson, Director of Risk Management
Anderson Office: 513-624-4059
Clermont Office: 513-735-1538
Core Quality Initiatives
Below is what is included in the 2014 Quality Harm Composite, which is the primary focus of
our Quality work in 2014 in addition to the continued focus on reducing all cause, inpatient
readmissions within 30 days of hospital discharge.
Harm Composite Score - Coded Harm (Acute Inpatient)
OB-GYN Related Measures
QH-09: Uterine Rupture (per 1000 Patients)
QH-13: Maternal Blood Transfusion (per 1000 Patients)
QH-14: 3rd or 4th Degree Perineal Laceration (per 1000 Patients)
QH-31: Birth Trauma (per 1000 Patients)
Surgery Related Measures
QH-17: Postop Physiologic & Metabolic Derangement (per 1000 Patients)
QH-18: Postoperative Wound Dehiscence (per 1000 Patients)
QH-19: Postoperative Respiratory Failure (per 1000 Patients)
QH-20: Wrong Site Surgery (per 1000 Patients)
QH-24: DVT / PE after certain Orthopedic Surgeries (per 1000 Patients)
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Hospital Wide Harm
QH-25: Air Embolism (per 1000 Patients)
QH-26: ABO Blood Incompatibility (per 1000 Patients)
QH-27: Hospital Acquired Injury (per 1000 Patients)
QH-28: Hospital Acquired Pressure Ulcers - Stage 3/4 (per 1000 Patients)
QH-29: Retention of a Foreign Object (per 1000 Patients)
QH-30: Poor Glycemic Control (per 1000 Patients)
Healthcare Associated Infections
QH-04: HAI Clostridium Difficile (per 10,000 Patient Days)
QH-05: HAI Staphylococcus Aureus Septicemia (per 1000 Patient Days)
QH-06: HAI Central Line Associated Blood Stream Infections (per 1000 Patient Days)
QH-07: HAI Catheter Assoc Urinary Tract Infections (per 1000 Patient Days)
QH-08: Ventilator Associated Pneumonia (per 1000 Patient Days)
QH-21: Mediastinitis after Coronary Artery Bypass Graft (per 1000 Patients)
QH-22: Infections after certain Orthopedic Procedures (per 1000 Patients)
QH-23: Infections after Bariatric Surgical Procedures (per 1000 Patients)
Modified Early Warning System (MEWS) -- Early Detection of Patient Deterioration
A nurse may call and mention the MEWS score, which is a scoring system that identifies high
risk patients. The score is calculated based on heart rate, blood pressure, respiratory rate,
temperature, and neurologic status. The score is calculated in Epic to enable nurses to identify
patients who are deteriorating and who need urgent intervention and may call for a Rapid
Response Team. The Clinical Administrator evaluates all elevated MEWS > 4 or if scores a 3
three times in a row.
Rapid Response Team
The Operator overhead pages “Rapid Response Team” and location three times. Respondents
include the Clinical Administrator who leads, the Clinical Coordinator, and Respiratory therapist.
Others like radiology or EKG tech may be called as needed. This is intended for “pre-codes” or
significant change in status requiring an immediate evaluation. Staff, patients, family members
or visitors can activate the Rapid Response Team by calling the emergency number at x88456.
Code Blue
Codes should be called to the emergency # at 88456. The operator overhead pages "Code Blue"
and location three times. The Clinical Administrator assumes the leadership role and follows
ACLS protocol until a physician is present. Primary responders to code blue in addition to the
clinical are the Hospitalist or Specialist in house during the day and the Emergency Department
doctor at night and off hours, ED Charge RN, Respiratory Therapist, and EKG tech. Secondary
responders to code blue are radiology, pharmacy and phlebotomist from laboratory. Code blue
occurring in the Emergency Department are handled by ED staff; MD, RN, and Respiratory
Therapist and pharmacy. The Clinical Administrator audits all codes and the Acute Care
Committee routinely reviews code blues.
The Clinical Administrator (CA)
Shifts: 6a-6p and 6p-6a. They cover the hospital 24/7.
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Location: their office is located on the second floor, East end, Room 201.
Contact Information: Phone: 735-7683.
Primary responsibilities: The CA is primarily responsible for throughput. They work closely
with the physicians to make appropriate bed placement for each patient. They do all patient bed
placement using EPIC and Awarix tracking board, working with the transfer center and shift
leads closely on each unit. When unable to be done by Transfer Center, they quick register direct
admit patients in EPIC so physicians can perform order entry. They manage all staffing and
adjust staffing levels every 4 hours based on the hospital needs. They are the primary nursing
responder to all in-house codes, Rapid Responses and Code Blue’s. They are all critical care
trained and can manage patients anywhere in the hospital if needed. They are responsible for
updating GCHC with bed availability, and during disaster situations. They are responsible for
initiating the chain of command when there is an issue that needs administrative assistance. They
are trained in hazmat, evacuation and disaster management and lead the Emergency Operations
until a higher administrator arrives. Night shift CA’s do an in-house restraint log and all are
responsible for locating any equipment or supplies that might be needed through the house
during ancillary departments off hours. They start IV’s at all hours and several are ultrasound
guided IV therapy trained. They complete a CA report twice a day that is sent to administration
electronically. They also follow-up on all elevated MEWS, Troponins, and Lactic acid scores inhouse.
CarePATH (Epic) Electronic Medical Records and Physician Order Entry
The hospital provides a fully electronic environment for physicians including the Epic electronic
medical records, physician-order entry, digital radiology and remote access. All physicians are
required to attend EPIC physician training prior to caring for patients. You will receive your
log-in at that time. There is a monthly Epic class schedule. Register at [email protected]. Epic may be used for all documentation and is fast and easy with customization;
dictation is still permitted.
The Physician CarePATH Support line is available 24/7 at the Doc Help Line: 981-5050
Epic Access From Home or Office
The website for OUTSIDE the hospital is https://chpEconnect.health-partners.org Best to use
Windows Explorer or Firefox. Only works with Firefox on the Mac (not Safari). Does NOT
work on an iPad.
You will need to download Citrix the first time you use this site. Click Accept. This may take
some time. Enter your Epic Username and password to enter the Citrix site. Very important –
Scroll down to MSWO in the third box. Citrix will load. This takes a minute. Be patient. You
will need to download Citrix the first time you do, call 981-5050 for guidance and help.
Click on the Epic Hyperspace PRD South Central icon. At the Epic Hyperspace log-in screen
put in your username and password, just like in the hospital.
Three Methods for Order Authentication
The Ohio Board of Pharmacy requires a secondary authentication for any medication orders.
That’s why we must use the RF-ID “tap” to sign orders or the challenge questions or RSA token
outside the hospital. Away from the hospital, the RSA token is used as secondary authentication
when ordering any medication. This must be activated and a PIN number specified before use.
Call 981-5050 to set up an RSA token. Otherwise, challenge questions work in all three cases.
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Epic Challenge Questions
To meet Board of Pharmacy requirements, set a total of 15 “challenge questions” under the EPIC
tab and remember that no two answers can be the same, answers must be at least three
characters, and case sensitive. The Ohio Board of Pharmacy requires a pool of 15 questions.
You answer two questions with each order.
Dictation Instructions
If in-house, dial 76370; outside dial 981-6370.
Enter last 5-digits of Medical License number, followed by # sign.
To create a dictation, press 1.
Enter 2-digit worktype, then # key.
01 H&P
02 H&P Pre-op
03 Consult
04 Operative Note
05 Discharge Summary
07 Emergency Department admission (or 01 for H&P)
08 Emergency Department note
14 Letter or memo
Enter patient location: 2 = Clermont
Enter 10-digit account number, then # key.
A job number will be provided at this point; write it down and enter into an Epic note.
Ready to dictate. Press 2 to begin recording. Press 8 to end the report and start another OR hang
up to disconnect.
Begin dictation with:
• Patient name
• Patient account number
• Date (admission, discharge, surgery, etc.)
Any problems with dictation or transcription, call regional transcription at 981-6495 or after
hours call the IT Service Desk at 800-498-1408. You may pick up a dictation pocket card from
transcription services or from the Medical Staff Office.
Translators Available, call the Operator
In accordance with CLAS Standards and Title VI, patients who are identified as Limited English
Proficient (LEP) will be provided access to qualified interpreters to aid in facilitating
communication related to patient needs at all times. LEP patients are those do not speak English
as their primary language and who have a limited ability to read, write, speak or understand
English. To obtain a dual headset phone call the operator at “O”. This stays with the patient
until discharge.
Bilingual employees cannot be used as staff interpreters unless they have undergone the process
to become a qualified interpreter. Services of a qualified foreign language interpreter must be
offered, at no additional cost, to all patients and/or relatives identified as Limited English
Proficient. To preserve patient confidentiality, family and friends should not be asked to interpret
for a patient unless there is an emergency situation (until an interpreter can be arranged and
arrives), or the patient expressly requests to use that person. Document this in the medical
record.
Over the phone Interpreters, dial “O” for the operator
Pacific Interpreters is the preferred vendor. Language Line and Vocalink are used as a back up
service for rare languages.
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Sign Language Interpreters
MHF contracts with Affordable Language Services – who
specialize in medical translation. They are used by Cincinnati Children's Medical Center. They
are certified and trained on medical terminology with and required continuing education.
When Patients Complain -- We Want to Know
If you have a patient with a complaint or issue with care during their hospital stay notify the
charge nurse, clinical administrator or department manager so that the issue can be handled
immediately. If you have a patient with a complaint (grievance) regarding an ED visit, outpatient
visit or procedure, or about their hospital stay after they are discharged, please refer them to our
Patient Representative – Annette Ellerhorst – at 735-7792. We want to know when patients have
a bad experience, we want to improve.
Department of Pharmacy
The Pharmacy is open 24/7. The Pharmacy phone number is (513) 732-8291.
Bill Carroll, Director
Connie Holmes, Clinical
Donna Branham, Lead
Anticoagulation Clinic
We also offer an on-site pharmacist-managed anti-coagulation clinic available by physician
referral. In order to refer a patient to the clinic, the physician must complete the required
information and sign both the referral form and the collaborative care agreement. The form can
then be scanned to the pharmacy or faxed to the clinic (513) 732-8766 (fax), or a call can be
placed to the Clinic Line at (513) 732-8719. If an inpatient is referred to the clinic, the physician
should check the correct box indicating whether or not he/she wants anticoagulation therapy
management by the clinic personnel to begin immediately or upon discharge from the hospital.
Every attempt will be made to visit inpatients to establish a clinic appointment; otherwise
patients will be contacted at home by telephone.
Location: 3020 Hospital Drive, Suite 100, Batavia, Ohio 45103
Employee Health
Annette Ellerhorst is our Employee Health Nurse. Currently the EH office is open 3 days per
week. The office is located on the first floor of the Hospital, inside Purchasing (by the back
loading dock). The office number is 735-7779.
Records of vaccinations and TB skin testing
Please send an updated copy of your current vaccinations and most recent TB skin test to the
Employee Health Department. Employee Health is located inside Purchasing inside the hospital
by the loading dock.
Tuberculin skin test) – TB Skin Testing is available on site in Employee Health Office.
Annual TB Testing begins in March with deadline for completion of May 1st for any Mercy
employed physicians. Clermont is considered “low risk” for TB transmission
Respirator Fit Testing – Annual fit testing for N-95 respirators is done by Employee Health in
June, July and August Fit testing is recommended for any physician that has contact with patients
in airborne precautions. If you are not fit tested, for your safety you should wear a PAPR when
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entering a patient’s room in airborne precautions. Contact Employee Health or Infection Control
for any questions.
Hepatitis B Vaccine – Is offered to all medical staff free of charge through the Employee Health
Department (Ext. 87779).
Combined tetanus, diphtheria and pertussis (Tdap) vaccine – Is recommended for all
healthcare workers. Tdap is available free of charge through the Employee Health Department
to employed physicians.(Ext. 87779).
Influenza vaccines - Flu vaccines are available through Employee Health free of charge for any
provider with privileges. Flu vaccines are mandatory for all Mercy employed physicians. For
NHSN reporting requirements we do ask that non-employed physicians provide us with
information
Bloodborne Pathogen Exposure
If you are exposed, use the digital pager 1-855-343-5076 and enter your 10-digit call back
number when prompted. The BBP hotline is staffed 24/7 by an Employee Health nurse who
will order labs on both the source patient and the physician involved free of charge (Note-if labs
are ordered by the physician involved through CarePath(Epic) on the source- charges will be
incurred by the patient) Labs include Rapid HIV, Hep C and Hep B antigen on source and HIV,
Hep C and Hep B antibody on physician involved. This hotline is also used for any other
communicable disease exposure that can be treated with prophylaxis, for example meningitis.
Needle/sharps disposal
Physicians/LIPs are required to properly dispose of their own used needles and sharps during
procedures. Safety sharps are to be used in place of non-safe sharps whenever available and
feasible.
Infection Control
Mary Barnett is our Infection Preventionist. Her phone number is 732-8498.
Hand Hygiene
All staff, including physicians, is expected to perform hand hygiene with soap & water or the
alcohol hand hygiene product before and after touching patients, before touching clean
equipment and after touching soiled equipment. We instruct our patients to observe their
healthcare providers performing hand hygiene – they are watching what we do.
Isolation
Patients in isolation have yellow carts outside their door and signs on the door way. All staff,
including physicians, is expected to follow the directions on the card for the personal protective
equipment (PPE) that should be worn. Discard PPE and wash your hands upon leaving the
room. PPE should not be worn out into the hallway. Again, our patients are watching if we are
consistent.
Categories of isolation are:
• Droplet - Some examples are Invasive Haemophilus influenzae type b disease, Neisseria
meningitidis, diphtheria, pertussis, and influenza.
A surgical mask must be worn before entering these patients’ rooms.
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• Airborne – Some examples are for Measles, Varicella (including disseminated zoster) &
Tuberculosis
These patients need to be placed in a negative pressure (airborne isolation) room as soon as possible. An
N-95 particulate mask or a Power Air Purifying Respirator (PAPR) must be worn before entering these
patients’ rooms. Fit-testing for N-95 masks and/or instructions on PAPR use is available through the
Employee Health Department (Ext. 87779).
o Contact – Wxamples are any known/suspected infection/colonization with an MDRO,
persons with uncontained drainage or a condition that promotes heavy environmental
contamination.
The minimum PPE is gloves to enter the room. Wear a gown if you are against the bed or
environmental objects in the room.
o Contact Alert (for C diff) - This is for suspect/known C diff patients.
Gloves and gowns should be worn into the room.
PPE should be discarded inside the patient room followed by hand hygiene. No PPE should be worn
outside the patients’ room.
There is an INFECTION field in the top EPIC header that may be populated with an MDRO. The history
should show the date and source of the MDRO.
Keep yours items clean
All staff is encouraged to use the hydrogen peroxide wipes to frequently clean off personal
stethoscopes and personal items such as keyboards and phones. For items used in a Contact Plus
isolation room (used for C Diff) use the Clorox wipes.
Device-Related Infections
Device related infections are a big focus of our program. Please assess the need for urinary
catheters and central lines on a daily basis and discontinue if no longer necessary. If the device
is still needed, please document the reason why.
Prevention of central line associated blood stream infections (CLABSIs)
•
We follow the Institute for Healthcare Improvement’s (IHI’s) Central Line Bundle:
1. Hand hygiene prior to insertion or manipulation of catheter
2. Maximal barrier precautions in preparation for line insertion. Person inserting the
line and those assisting are to wear a cap, mask, sterile gown and gloves. Cover
the patient from head to toe with a sterile drape.
3. Chlorhexidine skin antisepsis (with Chloraprep) prior to insertion and during
dressing changes.
4. Optimal catheter site selection, with Subclavian vein as the preferred site for nontunneled catheters in adults. We discourage use of the femoral vein unless
absolutely necessary.
5. Daily review of central line necessity with prompt removal of unnecessary lines.
•
Some other initiates which we follow at MCH to prevent CLABSIs include:
Page 14 of 23
•
•
•
Use of Biopatch: Chlorhexidine gluconate (CHG) – impregnated dressing on
insertion site
Use of SwabCap on central and PICC lines: alcohol impregnated cap to ensure
proper disinfection of ports prior to accessing
“Scrub the Hub” for 10 – 15 seconds with alcohol prep pad prior to access of IV
ports
Antibiograms
Hospital-specific antibiograms are available on the MHPnet. Click on “Clinical Resources” on
the left hand side. The antibiogram is the top tile on the right.
Mercy Health Clermont Clinical Laboratory
Manager: Chad Balwanz (732-8236) [email protected]
Laboratory Main Phone: 732-8233 available 24/7 for questions
Hematology and Coagulation: 732-8607
Chemistry: 732-8608
Blood Bank: 732-8606
Microbiology: Mercy Core Lab at 215-0020
Pathology/Histology: 732-8237
Pathologist on site 8 am – 4 pm, Mon-Fri
After hours, call the main number at 732-8233 to contact the on-call pathologist.
Medical Director: Dr. John Svirbely, office: 732-8309
Pager: 819-0059 Email: [email protected]
Turn-around Times
• Stats: 45 minutes
• Routine samples which have been ordered for first morning draw are collected starting at
5:00 a.m. and should be completed by 7:00 a.m. All other routines will be completed
within regular business hours.
• Arterial Blood Gases: 15 minutes
• Type & Screen: 1 hour (15 minutes for O-neg emergency need, 2 units always available)
• Histology samples: 24-48 hours
Referral Tests
• Many less commonly ordered tests are sent to one of the referral laboratories utilized by
MHP.
• Most are sent to ARUP, located in Utah. Specimens are sent daily and most results are
back within 48 hours.
• If you need information on a particular test please visit the ARUP website at
www.aruplab.com or call the main lab number (732-8233) for assistance.
• Infrequently ordered tests which need a "stat" turn-around time will be sent to a local
laboratory that performs those tests: (i.e. stat coag factors go to University Hospital
Laboratory).
Add-on Tests
Please call the lab before adding on a test to a sample previously sent to the lab to ensure the
amount of sample and age are within limits for the new test being added. Then in EPIC go to:
1. Order Entry for the patient.
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2. In the "New Order" box type the test to be added-on and hit ENTER.
3. Click on the desired test to highlight and then click "ACCEPT".
4. The test will display in a blue box - click on the "priority (ie routine) listed in the blue box.
5. At "Priority" box click on the magnifying glass, choose add-on, and ACCEPT.
6. Choose "ACCEPT" again to place the order.
Blood Bank Available Products:
• Packed Red Blood Cells
• Fresh Frozen Plasma
• Apheresis Platelets (considered a therapeutic dose that is equivalent to 6-8 random donor
platelets)
• Cryoprecipitate
Ordering Blood Products: EPIC ordering for blood products is a multi-step process.
• Order a "Type and Screen" if one has not been ordered within the last 3 days. Type and
Screen tests on in-patients expire after 3 days and need to be re-ordered as necessary.
• Order "PREPARE.” This is what was traditionally known and ordered as a cross-match.
This section gives options for number of units, special instructions (i.e. irradiated).
• Order "TRANSFUSE". This section gives options for duration, special needs (i.e. blood
warmer), and pre-medication notes.
• The PREPARE and TRANSFUSE are set up together as a single order screen, but these
components can be ordered separately by unselecting one part or the other.
• Order blood products in EPIC under "GEN BLOOD".
Pain Management
Review of Pain Assessment and Management in EPIC
Review nurse’s documentation of patient’s pain assessment/management on Doc Flowsheet in
EPIC. This information is pulled into a report in Patient Summary called Pain Monitoring.
Managing Pain
Upon Admission or After Procedure: MDs/PAs/NPs need to REORDER:
- long acting opioid pain meds for chronic pain (e.g., Oxycontin, Oramorph, Methadone, etc.);
and
- adjunct pain meds (e.g., Cymbalta, Pregabalin, Gabapentin, etc.).
Patient Controlled Analgesia (PCA) & Chronic Pain Med Administration:
Patients appropriate for patient controlled analgesia (PCA) must be mentally alert and have the
cognitive, emotional and physical abilities to understand the operation of the PCA and be able to
safely manage his/her own pain.
Upon ordering PCA, following parameters must be specified:
o Loading bolus: Initial analgesia dose
o PCA dose (“bolus” dose): The patient controlled dose delivered on patient demand
o Continuous (“basal” rate): Low-dose, continuous infusion rate; only for opioid tolerant
patients
o One-hour limit: The maximum amount of analgesia the patient can receive in one hour
o Lockout interval: The time period during which patient cannot activate the pump – i.e., a 10min lockout interval would prevent the patient from receiving a bolus more frequently than every
10 minutes.
- Other systemic narcotics should be limited while on PCA.
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- In order for the patient to receive their chronic pain narcotic with the PCA, the MD, who has
ordered the PCA, needs to approve (in verbal or written format) the chronic pain med to be
given. When the Attending MD or the Resident MD is placing the order for the chronic pain
narcotic, he/she needs to add in the Administration Instructions: “OK to give chronic pain opioid
med with PCA per Dr. _____________.”
* Equianalgesic doses are drug and route conversions approximately equal to a single morphine 10mg IV or 30mg PO dose. This table is a guideline only. The
equianalgesic dose is not the usual starting dose. Dosing must be individualized and titrated according to the patient’s age, condition, response, and clinical
situation.
* To account for incomplete cross-tolerance when converting to a new opioid, start with 50-75% of the equianalgesic dose and the new opioid and titrate to
effectiveness.
* Duration: the shorter time generally refers to parenteral administration of opioids; the longer time generally refers to oral administration of immediate-release
opioids.
* NR = not recommended at that dose
Spiritual Care Services
Mercy Hospital Clermont provides chaplaincy services 24/7 and may be contacted by calling the
operator. The Chaplains are certified through professional chaplaincy associations and represent
multi-faith backgrounds and approaches. Chaplains are available to all of our patients and their
families who need spiritual and/or emotional support; chaplains are members of the interdisciplinary team; chaplains assess for spiritual needs without disrespecting anyone’s beliefs,
values or faith background; chaplains support a holistic approach to patient care recognizing that
attention to spiritual and emotional needs are important elements in healing; chaplains provide
assistance with advance directives and end-of-life discussions with the patient and family
members. Chaplains are also available to all hospital staff for spiritual and emotional support.
Advance Directive Information and the Chaplaincy Role
Chaplains receive referrals for advance directive information. Health Care power of Attorney
(HCPOA) and Living Will (LW) information is offered to all patients admitted to our facility.
Page 17 of 23
The HCPOA lets the patient name who they would want to make their health care decisions if
they are unable to do so. The LW directs the physician on a patient’s wishes for end-of-life care.
The HCPOA goes into effect if the patient is temporarily or permanently unable to speak for
him/herself. The LW is activated only after two physicians determine and document the patient
has a terminal condition (defined in the document) or is permanently unconscious with little hope
of regaining consciousness. The LW is not a DNR order. A DNR order must be written by a
physician. While chaplains are available to discuss end-of life issues related to a patient’s
journey with illness, meaning and hope, they do not discuss DNR orders. Code status
discussions are done by clinical staff as they require the patient to understand how their medical
condition affects their goals. If a patient expresses specific end-of-life wishes to the chaplain,
he/she will document them in the medical record. The LW takes precedence over the HCPOA.
Mercy belongs to the US Living Will Registry and offers registration free to any patient and their
families. This is a national database that stores the ADs electronically so that caregivers have
access to them wherever the patient is. Chaplains help patients complete this process.
Ethics
Ethical concerns are handled with a multidisciplinary approach. Patients (or their decision
makers) are given all the information and support they need to make decisions. The patient’s
physician should be advised of patient concerns. The Ethics Committee is a consultative resource
for patients, families, physicians and staff. Chaplains are also available to support patients and
their medical team in difficult discussions. Spiritual Care is represented on the hospital ethics
committee.
How do I request an ethics consult?
•
•
•
CALL THE HOSPITAL OPERATOR, providing your name, location, and contact
information.
Note: Please tell the operator you are calling from Mercy Health Clermont so the correct
consultants respond.
Appropriately document the consultation request in the electronic medical record.
Example: “Called the operator for an ethics consultation at 1:32 p.m. – Signed Steven J.
Squires”
OB ethics questions, which may happen infrequently at Mercy Health Clermont, follow a
different process, going to the Mission leader and the regional or system director of ethics.
What should I expect in the consultation process?
•
•
•
The chaplain-on-call will call you back to get more information about your concern.
If your concerns are unresolved after this conversation, the chaplain will call the ethics
consultant on call. He or she will gather information, determine next steps and establish
expectations.
Ethics will review the consult process and incorporate your feedback after the consult.
The following are realistic and unrealistic expectations of and reasons for requesting
ethics…
Page 18 of 23
Credentialed Medical Staff Required to Follow Ethical and Religious Directives (ERD)
Catholic health care is premised on the human dignity of all persons and the sacredness of human
life. Our Bylaws require that all Medical Staff abide by the Ethical and Religious Directives
(ERDs) for Catholic Health Care Services. Compliance with these ERDs is a condition for
medical staff privileges.
When you accept hospital privileges, you are agreeing to practice in a manner consistent with the
ERD when rounding and performing procedures at any Mercy facility. “Consistent” neither
implies nor suggests that the physician personally espouses the Directives or adheres to the
Catholic faith. “Consistent” does imply that the physician will participate in the healing mission
of the hospital and will not provide a limited set of prohibited services – direct abortion, direct
sterilization, active euthanasia or some means of contraception.
A full copy of the ERDs is available at http://www.usccb.org/bishops/directives.shtml.
Behavioral Health Institute
The President and CEO of Catholic Health Partners (CHP), Michael D. Connelly, with the
support of the Board of Directors, made a bold commitment to address the needs of the mentally
ill, an underserved population. Donna Markham, OP, PhD was invited to join CHP with the
mandate to effect the transformation of the delivery of behavioral health services to serve the
health of the population encompassed by the regions of CHP. This includes initiating evidencebased treatment procedures in acute care, partial hospitalization and intensive outpatient services.
It also involved embedding behavioral health clinicians in primary care physician practices.
Rather than treating mentally ill persons as pariahs who are kept out of sight and out of
proximity to our healthcare facilities, CHP committed to a comprehensive plan that involves
capital improvements, staff training and development, the initiation of treatment outcome
measures and the expansion of services designed to assist patients in their process of healing. It
is expected that this process of transformation will take at least three years to fully implement.
This year’s focus is on the acute care treatment program and involves staffing realignment and
training in best practices.
Capacity in the Behavioral Health Unit after July 2104 will be 24 inpatient and we anticipate a
capacity for 30 outpatients by January 2015.
Page 19 of 23
Behavioral Health Adult Admission Criteria
1. The patient will have a primary diagnosis recognized by the current edition of the
Diagnostic and Statistical Manual (DSM) and:
2. The patient will have at least one of the following criteria:
a. Demonstrates a danger to self, others or property.
b. Manifests major impairment in activities of daily living and in occupational
functioning as outlined in the current edition of the DSM.
c. Demonstrates continued decline in functioning manifested by impairment in
ability to provider for his/her basic physical needs.
d. Condition prevents him/her from benefiting from less intensive levels of care
requiring 24-hour nursing/medical assessment, intervention and monitoring.
e. The patient has not responded to treatment at a lesser level of care and is
exhibiting an acute exacerbation of severe symptoms and/or significant decrease
of functioning.
f. The patient exhibits acute psychotic thought processes with acute, marked social
and/or occupational dysfunction of such severity that his/her health and safety are
at imminent risk.
3. The patient is able to participate in and benefit from therapeutic processes and milieu.
4. There is reasonable expectation that there can be improvement, control or stabilization of
the presenting symptoms.
5. There is a degree of medical stability that does not require ongoing, significant active or
invasive medical treatment for management.
6. The person is over the age of 18.
Behavioral Health Adult Exclusion Criteria
Patients admitted to the Behavioral Health Unit will not be admitted if the following are present:
1. The person has significant physical illness, injury or condition that requires active or
invasive medical treatment.
2. The patient is under a criminal court order for treatment and does not meet medical
necessity.
3. The patient is in need of a forensic treatment setting.
4. Cases in which the patient has a recent history of sexual crimes or is a registered sex
offender will be reviewed with the Psychiatry Medical Director.
5. The patient is actually in need of a long-term treatment setting and does not meet medical
necessity.
6. The patient’s sole diagnosis (or diagnoses) is/are: substance abuse, substance
dependence, dementia, development delay, malingering and/or antisocial personality
disorder.
7. The patient is presented for admission as an alternative to incarceration, placement in a
residential home or intermediate care facility and whose behavior could be better treated
in another setting until placement can be arranged.
8. Presentation of inpatient care is due to an absence of resources (i.e., being homeless,
evicted or unable to return to place of residence).
Physical Environment
Environment of Care/Safety Information
Dial #88456 to report all emergencies.
Page 20 of 23
Fire Safety Plan
Remember R A C E when responding to a fire.
R = Rescue patients and visitors
A = Sound the Alarm pull the fire alarm and dialing #88456
C = Confine or contain the fire
E = Extinguish the fire
Remember PASS when using Fire Extinguishers.
P = Pull the pin
A = Aim at base of fire
S = Squeeze the lever below the handle
S = Sweep from side to side
Hazardous Materials Management
Various hazardous materials are used throughout the hospital. These could pose a threat if a spill
or release should occur. MSDS (Material Safety Data Sheets) are found on the intranet. The
MSDS gives detailed information on a specific chemical product, including the chemical
ingredients, potential hazards, and safety precautions. Call Safety/Security at #83911 to report a
spill. Do NOT attempt to clean up a spill unless you or the personnel involved are properly
trained to do so.
Emergency (Disaster) Management
This Emergency Preparedness Plan is designed to manage the hospital’s resources, such as,
space, supplies, communications, and personnel, during such emergencies. Emergency
Operations Center (Incident Command) is located across from the Emergency Department
conference room. Physicians should report to the Emergency Operations Center (Incident
Command), for assignment. The Medical House Physician will take charge of the assignment of
physicians until relieved by the Medical Staff Operations Chief on-call.
Reporting to Joint Commission
Any individual who provides care, treatment or services at Mercy Health Clermont Hospital who
has concerns about the safety or quality of care provided may file a report with The Joint
Commission by calling 1-800-994-6610. No disciplinary or punitive action will occur because
of reporting of safety or quality of care concerns.
Page 21 of 23
MERCY HOSPITAL CLERMONT NURSING UNITS
Unit
Beds
2W
Nursing Admin.
Clinical Administrator
59
PCU
ICU
Behavioral Health
Institute
32
16
24
Unit
Phone
732-8623
735-7683
Mgr
Phone
732-8759
732-8759
Manager
Description
Lena DePuccio
Lena DePuccio
732-8300
732-8643
Kim Gamble
Medical/Surgical
Clinical Administrators, Iflex,
Safety Companions
Progressive Care Unit - Telemetry
735-1555
732-8629
732-8643
732-8558
Kim Gamble
Ann Hoffman- Ruffner
Intensive Care Unit
Acute Inpatient Psychiatric, Partial
Hospitalization and Intensive
Outpatient Services
732-8349
404-7748
Angie Gilkerson
Emergency
Department
(14 until summer
2014 due to
remodel)
20 PHP/IOP
(12 until approx.
January 2015)
ED – Clermont
*unit is
undergoing
remodel
25
(with 5 treatment
areas)
ED – Mt. Orab
8
981-4745
404-7748
Angie Gilkerson
PACU
6
732-8255
732-8369
Del Schneider
Emergency
Department
Recovery Room
OR
SDS
5
16
732-8255
732-8255
732-8369
732-8369
Del Schneider
Del Schneider
Operating Room
Same Day Surgery
MANAGEMENT TEAM CONTACT LIST
Name
Title & Department
E-mail
Office Phone
Lambert, Robert MD
Associate Medical Director
[email protected]
735-7799
Gilkerson, Angie
Clinical Dir., Emergency
[email protected]
732-8349
Lacortiglia, Jennifer
Clinical IS Specialist
[email protected]
732-8276
Voorhees, Chip
Dir. Food & Nutrition
[email protected]
732-8299
Leinberger, Roger
Dir. Imaging Services
[email protected]
735-1510
Grove, Marty
Dir. Nursing Clinical Services/Ed.
[email protected]
732-8785
Carroll, Bill
Dir. of Pharmacy
[email protected]
732-8670 / 624-3268
Richardson, Lisa
Dir. of Quality & Case Management
[email protected]
735-7599 / 624-4536
Schneider, Del
Dir. of Surgery
[email protected]
Taylor, Tracy
Dir. Volunteers Services
[email protected]
732-8582 / 732-8218
Cantrell, Ray
Bickett-Young,
Mandi
Eastgate Administrator
Eastgate Surgery Center
Office Coordinator
[email protected]
947-1130
[email protected]
947-1130 / Fax 947-8541
Ellerhorst, Annette
Employee Health/Patient Rep.
[email protected]
735-7779 / 735-7792
Kappel, Sherry Helen
Executive Admin. Assist.
[email protected]
732-8278
Barnett, Mary
Infection Control Specialist
[email protected]
732-8498
Page 22 of 23
732-8369 or 81513
Name
Title & Department
E-mail
Office Phone
Balwanz, Chad
Lab Operations Mgr.
[email protected]
732-8236
Gamble, Kimberly
Manager ICU
[email protected]
735-8643
Barton, Kathy
Med. Records Sprv. (MHA/MHC)
[email protected]
Gaskin, Richard
[email protected]
853-7311
Whitt, Michele
Mgr. Clinical Engineering
Mgr. Environmental
Services/CS/LS
[email protected]
732-8574
Hays, Mindy
Mgr. Medical Staff Services
[email protected]
732-8327
Carmean, Lauren
Mgr. of Admitting
[email protected]
735-7747
Bauer, Bonna
Mgr. Plant Operations & Security
[email protected]
732-8570
Flannery, Michele
Mgr. Rehab Services
[email protected]
732-8209
Vickers, Debbie
Mgr. Specialized Services
[email protected]
732-8547
Tritch, Pam
[email protected]
DePuccio, Lena
Mrg. Case Management
Nurse Mgr. – Nursing
Administration
624-4903
Off 732-2733/
Clinical 732-8213
Graham, Jeff
Pres. Mercy East & Market Leader
[email protected]
624-4054
Schultz, Julie
Heintzelman, Gayle
Program Dir., Wound Care Center
Site Administrator/CNO
[email protected]
[email protected]
735-8922
732-8590
Smith, Krista
Hoffman-Ruffner,
Ann
Supervisor - Respiratory
[email protected]
732-8761
[email protected]
UBE/OT Behavioral Health
[email protected]
VP, Accreditation/Operational
Snyder, Rita
Safety
[email protected]
Clinical Administrator x87683
Security Cell: 507-3234; Pager 540-1156; Cisco phone #83911
Maintenance: Office x88571; Cisco Phone Off Shifts: #82799
Medical Staff Reference Updated:
October 25, 2011; March 5, 2014
Page 23 of 23
624-1274 A/735-1739 C
732-8558
981-6823
Fax 981-6176