Download Orientation for the Nursing Student

Self Orientation requires a review of the same information that all new Tenet employees review.
You are responsible for reading all information contained on the CD (or in the binder).
Please follow these instructions:
 Read through all sections on the CD (or in the orientation binder) and complete the quiz
enclosed in the “Forms” folder. After completion, return to the Human Resource Department
with all other forms.
 All employees will read and sign the “Confidentiality Statement” and “Statement of
Responsibility” forms, Return with the completed quiz to the Human Resource Department.
 ID badges will be made in the HR department at the completion of the orientation.
HIPPA Training
• Click on the link below to complete the training.
At the end of the video, complete the post test,
print and turn in with other tests.
• Tenethealth.com at:
http://www.tenethealth.com/about/pages/Informati
onPrivacySecurityandHIPAATraining.aspx
CULTURAL APPRECIATION
Cultural Competency in Healthcare
Settings
Topics to Be Covered
• What is Diversity?
• Our Business Case for
Diversity
• Values and Beliefs
• Diversity Initiatives
• Celebrate Diversity
What is Diversity?
• The differences that make each of
us unique.
• In the past, our country was the
great melting pot; we were
expected to blend together.
• Today, we’re a mosaic- accepting
each others differences
• Culture- the values, beliefs and
practices shared by a group.
Our Business Case for
Diversity
• Awareness of cultural factors can
improve patient and family
education – one area of focus for
the Joint Commission survey.
• Meet our community needs. Our
community is diverse.
• Make sure patients get the best
possible care. Take their cultural
views on health into account; they
will respond better to care.
What does population change
mean for us?
• Make up of patients
change.
• Make up of workforce
change.
• Services rendered to
patients change.
Values and Beliefs
Treat each patient as an
individual:
• Avoid stereotyping.
• Consider other factors that may
affect care such as age.
• Learn about each patient’s unique
views on health care.
• Know your own cultural beliefs
and practices.
• Know how to show politeness, how
often to seek medical care and
appropriate ways to treat children
or older people.
Values and Beliefs
Be aware of cultural factors:
• Country of origin. How long a person
has lived here may affect his or her
views toward health
• Preferred language
• Communication Style. A person’s
culture may affect how he or she
expresses pain.
• Religion
• Food preferences
• Family relationships
Values and Beliefs
Take time to learn about each patient:
• Ask questions to avoid cultural
stereotypes. Differences exist among
members of the same group.
• Learn the patient’s views about health.
• Show respect. Ask how a patient would like
to be addressed.
• Consider privacy needs.
• Use interpreters effectively
Diversity Initiatives
• Interpreters Available
- AT&T Language line available 24/7
contact unit supervisor or overhouse
supervisor for assistance
• Chaplin Available 24/7
• Patient Rights and other medical
information both in English and Spanish.
• Community outreach for everyone, but
have targeted initiatives based on the
needs in our community.
• Community Advisory Boards
Diversity Initiatives
Spalding Regional Medical
Center’s Diversity Standard
We recognize and respect the cultural,
physical and social differences among
our employees, patients and visitors.
We realize that each of us comes from
a different background and brings a
range of talents and opinions that
enrich our environment. We mirror
the community we serve and strive to
appreciate our differences.
Diversity Initiatives
Spalding Regional Medical Center’s
Diversity Guidelines:
• Take the time to better understand coworkers and customers.
• Discourage jokes and negative comments
about race, religion, color, national origin,
disability, gender and age.
• Do not discriminate against patients,
customers or other employees on the basis
of race, religion, color, national origin,
disability, gender or age.
Celebrate Diversity!
• Take pride in your own
uniqueness.
• Welcome others as
individuals with special
qualities.
• Enjoy your similarities and
your differences.
Communication and
Team Dynamics
Three components of a team are:
•Team Mission Statement: a simple statement of purpose
known by every member of the team which provides a
“reason for being”
•Team Vision Statement: expresses the destination of the
team in a way that builds commitment to it
•Team Success Criteria: specific and measurable criteria
that lets you know when you have achieved what you set out
to do
Team Member Selection
A successful team requires individuals to combine
different abilities into a cohesive unit which is able to
achieve tasks beyond the capabilities of its members.
The Innovator – produces new ideas and strategies
The Coordinator – directs the group, maintains control
and direction of the discussion
The Investigator – is knowledgeable of available
resources, researches ideas and determines what can be
done
The Evaluator – weighs the facts, considers the pros and
cons of each option
The Shaper – highly motivated and are excellent at
sparking life into a team
The Worker – good communicator who helps reduce
tension in the group by promoting better co-operation
among team members.
The Finisher – an organizer who ties up loose ends
during the final stages of implementation
The Implementer – concerned with detail, capable of
directing others, can be depended on to carries out the
final details
Characteristics of Good Team Building
-
High level of interdependence among team members
-
Team leader has good people skills and is committed to a team approach
-
Each team member is willing to contribute
-
Team develops a relaxed climate for communication
-
Team members develop a mutual trust
-
Team members are prepared to take risks
-
Team is clear about goals and established targets
-
Team member roles are defined
-
Team members know how to examine team and individual errors without
personal attacks
-
Team has the capacity to create new ideas
-
Each team member knows he/she can influence the team agenda
Resolving Conflict
Conflict is inevitable, natural, and even healthy. What is
unhealthy is unresolved conflict that is allowed to affect an
otherwise productive team. When conflict arises explore
each team member’s position thoroughly. Consider your
own as well as your team member’s position keeping in
mind that the conflict may be about personalities and needs
rather than the subject matter. Approach possible solutions
together through collaboration.
Build for your team a feeling of oneness, of dependence
upon one another and of strength to be derived by unity.
Vince Lomabardi
Infection Control
Clinical Orientation
Spalding Regional Medical Center
Isolation Practices…
You are expected to set the
example for others (non-licensed,
families, guests)
STANDARD Precautions
 CONTACT Precautions
 DROPLET Precautions
 AIRBORNE Precautions

CONTACT precautions:





Put gown and gloves on BEFORE entering room
Remove gown and gloves JUST BEFORE
leaving room and discard INSIDE room
Perform hand hygiene when leaving room
Disposable stethoscopes, thermometers, BP
cuffs ONLY!!
DO NOT use your own stethoscope
DROPLET precautions:




Droplets are large (>5 micrometers) and heavy;
they settle on horizontal surfaces usually within
a few feet of the point of aerosolization
(coughing, sneezing, talking, singing)
SURGICAL mask needs to be worn when
entering the room (NOT N-95)
Obtain a new mask each time you enter the
room
DO NOT wear mask outside of the room
AIRBORNE Precautions
How Swine Flu is contracted
AIRBORNE precautions:








Requires use of N-95 respirator
Must be fitted for this respirator by Employee Health Nurse
Provides protection from tiny particles (<5micrometers) that
stay suspended in air and travel on air currents for long
distances
YOU MUST DO A FIT CHECK EVERY TIME YOU DON THIS
RESPIRATOR (and before you enter the room)
Door to room must remain CLOSED! (No exceptions)
Room must be under negative pressure
You must notify Engineering to check negative pressure
BEFORE patient is admitted into room; they will check it
every day thereafter
You may use the respirator multiple times during a shift,
unless it becomes soiled with blood or body fluid, if it
becomes moist, or you can no longer achieve an occlusive
seal when you fit-check it
SCIP=Surgical Care Improvement Project
“CATS”
CATS, continued

CLIPPERS
-never RAZORS

ANTIBIOTICS
-give the correct antibiotic for the type of surgery
-administer the first dose within 60 minutes of the
incision time
-stop the antibiotic within 24 hours of the close time of
surgery

TEMPERATURE
-maintain the patient’s core temperature at or above
96.8 degrees

SUGAR
-maintain normoglycemia of cardiac surgery
patients
Surgery and Foley Catheters…


Foleys MUST be removed within 48 hours of a
surgical procedure unless the MD gives the
specific written rationale why it must be kept.
Exceptions:
-OBGYN
-urologic, perineal
-intermittent catheterization prior to surgery
or who had Foley prior to admission
-ICU patient on diuretics
NPSG’s………….2010







Lucky “7” ---- Infection Prevention
Reduce the risk of Healthcare Associated Infections
07.01.01—Hand Hygiene
07.03.01—Prevent MDRO infections
07.04.01—Prevent ClaBSIs
07.05.01Prevent SSIs
Manage as sentinel events all cases of unanticipated
death or major permanent loss of function related to a
healthcare associated infection
Central Line BUNDLE
Meticulous Hand Hygiene
 Maximal Barrier Precautions
 Chlorhexidine Skin Antisepsis
 Optimal Site Selection
 Daily Review of Line Necessity

Ventilator Associated
Pneumonia Bundle
Maintain HOB @ 30-45 ° at all times
 Daily Sedative Interruption
 PUD Prophylaxis
 VTE Prophylaxis

Foley catheter best practices







Hand Hygiene
Maintain sterile system—no breaks
Maintain surgical asepsis on insertion
Maintain bag below level of bladder
No kinking or looping of tubing
Maintain use of Stat-Lok Device to prevent
tension, traction
Remove Foley as soon as possible!
STAFF EDUCATION:
Your Role in Preventing the Spread of
Multiple-Drug Resistant Organisms (MDROs)
Cheryl Kirchner, RN, BSN, MS
National Director, Clinical Quality Improvement
July 2009
Tenet’s goal is to stop the spread of
infections in our hospitals.
Everyone is needed to help.
Healthcare-associated infections (HAIs)
• Infections that patients acquire during the course of
receiving treatment for other conditions within a
healthcare setting.
• Variety of causes, including (but not limited to):
– the use of medical devices, such as catheters and ventilators
– complications following a surgical procedure
– transmission between patients and healthcare workers
– antibiotic overuse
• Risk for all hospitalized patients.
Source: CDC website http://www.cdc.gov/ncidod/dhqp/healthDis.html
Healthcare-associated infections are one of the top ten
leading causes of death in the United States.
In American hospitals alone, healthcare-associated
infections account for an estimated…
• 1.7 million infections each year
– Most (1.3 million) were outside of intensive care units
– 9.3 infections per 1,000 patient-days
– 4.5 infections per 100 admissions
• 99,000 associated deaths each year
– 32% of all HAI are urinary tract infections.
– 22% are surgical site infections.
– 15% are pneumonia (lung infections).
– 14% are bloodstream infections.
Source: Klevens, Edwards, Richards, et al. Pub Health Rep 2007; 122:160-6
What is an MDRO?
Multiple Drug-Resistant Organisms (MDROs)
are bacteria and other germs that have
developed resistance to antibiotic medications
such as penicillin and amoxicillin.
Examples of MDROs
• MRSA (Methicillin-resistant Staphylococcus aureus)
– Two types: Hospital-acquired and Community-acquired
– Most infections caused by staph are skin infections, but
staph also can cause more serious infections such as
blood and joint infections, and pneumonia. Skin infection
may appear as a spider bite that will not heal.
• VRE (Vancomycin-resistant Enterococci)
– Infection can lead to diseases of the urinary tract, bloodstream, heart valves
(endocarditis) and brain (meningitis), as well as to serious infections in open
wounds.
• Drug-resistant TB (Tuberculosis)
– TB can cause infection in the lungs or other parts of the body.
• C. diff Clostridium difficile is a toxin-producing bacteria.
– C. diff can result in diarrhea that turns into colitis.
Sources for pictures: mrsasymptomsinfo.com; mrsadiagnosis.com/mrsa-basics/
Examples of MDROs
• Drug resistant Staphylococcus aureus "Staph" Infections
– MRSA (Methicillin-resistant Staphylococcus aureus)
• HA-MRSA (Healthcare-Associated MRSA)
• CA-MRSA (Community-Associated MRSA)
– VISA/VRSA (Vancomycin-Intermediate/Resistant Staphylococcus aureus)
Source: CDC; JAMA. 2006;295:269-270 ; IHI.ORG
Examples of MDROs
Other drug-resistant organisms
– VRE (Vancomycin-resistant Enterococci)
– ESBL Gram negative bacteria that produce extended spectrum
beta lactamase enzymes, which result in resistance to most
antibiotics.
• K. pneumoniae (Klebsiella pneumoniae)
• Acinetobacter
• S. pneumoniae (Streptococcus pneumoniae)
– Drug-resistant TB (Tuberculosis)
– C. diff Clostridium difficile is a toxin-producing bacteria.
– K oxytoca (Klebsiella oxytoca)
– E coli
Impact of MDROs in the Health Care System
• Infections caused by MDROs are associated with
worsened clinical outcomes, including an increased risk of
death
• MDRO infections also are associated with significantly
increased costs to hospitals, mostly attributable to
increased lengths of stay.
• Media, legislative and regulatory pressures are compelling
hospitals to more effectively control MDROs
Legislative Pressure:
Many states have laws regarding reporting
of hospital acquired infections.
Check this hyperlink to see if your state does:
http://www.apic.org/scriptcontent/custom/dyncontent/le
gislation/index.cfm?section=government_advocacy
Regulatory Pressure:
No additional payment for selected hospital acquired
conditions that are not present on admission.
Centers for Medicare & Medicaid
Hospital Inpatient Prospective Payment Systems
Final Rule effective on October 1, 2008
Selected hospital acquired
conditions include:
 Catheter-Associated Urinary Tract
Infection (UTI)
 Vascular Catheter-Associated
Infection
 Surgical Site Infection
Mediastinitis After Coronary Artery
Bypass Graft (CABG)
Regulatory Pressure:
National Patient Safety Goals (NPSG)
2009
Goal 7 – Reduce the risk of health care-associated infections.
A. Meet Hand Hygiene Guidelines (NPSG.07.01.01)
B. Report Sentinel Events Resulting from Infection (NPSG.07.02.01)
C. Prevent Multi-Drug Resistant Organism Infections (NPSG.07.03.01)
D. Prevent Central-Line Associated Blood Stream Infections (NPSG.07.04.01)
E. Prevent Surgical Site Infections (NPSG.07.05.01)
MDROs are a Growing Problem
•
MDRO infections among hospital patients have
continued to rise, despite widespread efforts to control
their spread.
–
•
MDROs are being seen even among patients in the community.
Two main factors drive the spread of MDROs
1. Overuse and misuse of antibiotic medications.
2. Cross-transmission between patients in healthcare settings.
Persons at Risk for an MDRO Infection
• Persons with low immune systems, severe illness or disability,
chronic illnesses that are difficult to treat and get worse over time
(for example, kidney failure or cystic fibrosis)
• Persons being treated for burns or persons with open wounds or
surgical wounds (especially in the belly or pelvic area)
• Persons with invasive medical equipment (for example,
tracheotomy tubes or implanted catheters)
• Persons with long or repeated hospital stays, especially if they are
often treated with antibiotics
• Persons who do not finish all of the antibiotics prescribed by their
doctors
MDRO Colonization and Spread
• Colonized patients carry MDROs with no signs of infection.
– Colonization generally comes about through spread of MDROs from
patient to patient and is often a precursor to later infection.
• Both colonized and infected patients can be the source of
spreading MDROs to others through
– The animate environment (e.g., hands)
– The inanimate environment (e.g., equipment)
– A combination of the animate and inanimate environment
Tenet’s Two-Fold Approach to
stop the spread of infections in our hospitals.
• First, we must continue to improve the culture for
hand hygiene, making the message simple and
direct.
• Second, we must intervene to prevent the spread
of infection when people are admitted to a
hospital or visiting patients in the hospital.
MDRO Cycle of Transmission
• Intervention must occur to break the cycle of transmission
from organism to host (patient), host (patient) to
environment, environment to healthcare worker and
healthcare worker transmitting the organism.
• Source control at the patient level and point of care control
at the healthcare worker level are essential to success.
• Ensuring and maintaining clean hands and environment
are the basic building blocks of this program.
MDRO Cycle of Transmission
ORGANISM
HOST
HEALTHCARE WORKER
ENVIRONMENT
MDRO Cycle of Transmission
ORGANISM
Who can spread the
organism?
HEALTHCARE WORKER
All persons who touch
the patient.
HOST
Patient
ENVIRONMENT
All persons who touch
the patient’s
surroundings.
Source control at the patient level and point of care control at
the healthcare worker level break the cycle of transmission.
ORGANISM
HOST
Source Control
Antibiotic Stewardship
Community Outreach
Source Control
Clean Hands
Active surveillance
Targeted decolonization
Antibiotic Stewardship
HEALTHCARE WORKER
ENVIRONMENT
Point of Care Control
Clean Hands
Isolation Precautions
Prevention Bundles
Point of Care Control
Clean Environment:
Decontamination of
environment and
equipment
Breaking the cycle of transmission
involves EVERYONE on the TEAM!
The Program Plan to Break the Cycle of
Transmission is a Team Effort.
PROGRAM PLAN
TASKS
• Identify patients at risk for MDRO
 Nursing
• Staff Education regarding MDRO prevention
 Hospital Educators
• Patient / Family Education regarding MDROs
 Case Managers
(Reminder: “If it is not documented, it is not done.”)
• MDRO Surveillance
INDIVIDUALS WHO ARE
INVOLVED
 Infection Preventionists
• Decontamination of environment and equipment
 Plant Operations
• Targeted decolonization
 Environmental Services
• Antibiotic Stewardship
 Laboratory / Microbiologists
• Isolation Precautions
 Pharmacist
• Prevention Bundles
 Dietary Services
• Implement a laboratory alert system for patients
who have an MDRO
 Materials Management
• Measure and monitor MDRO prevention
processes
 Information Technology
• Communicate results with key stakeholders
 Administration, Physicians
 Quality Management
The Program Plan to Break the Cycle of
Transmission is a Team Effort.
PROGRAM PLAN
TASKS
• Identify patients at risk for MDRO
 Nursing
• Staff Education regarding MDRO prevention
 Hospital Educators
• Patient / Family Education regarding MDROs
 Case Managers
(Reminder: “If it is not documented, it is not done.”)
• MDRO Surveillance
INDIVIDUALS WHO ARE
INVOLVED
 Infection Preventionists
• Decontamination of environment and equipment
 Plant Operations
• Targeted decolonization
 Environmental Services
• Antibiotic Stewardship
 Laboratory / Microbiologists
• Isolation Precautions
 Pharmacist
• Prevention Bundles
 Dietary Services
• Implement a laboratory alert system for patients
who have an MDRO
 Materials Management
• Measure and monitor MDRO prevention
processes
 Information Technology
• Communicate results with key stakeholders
 Administration, Physicians
 Quality Management
COMMUNICATION
Has this
patient been
screened for
MRSA?
How many
patients have
an MDRO?
Is this patient
infected with
an MDRO?
Does this room
need special
cleaning?
Do I need to
wear protective
clothing?
Were the
antibiotics
discontinued?
Patient / family
MDRO education
completed?
Did the patient
wash his / her
hands?
COMMUNICATION
Verbal  Speak up!
• Confirm with co-workers (that means
everybody, including physicians) that hands
are clean, environment is clean, prevention
measures have been followed, etc.
• Ask patients if their hands are clean.
Written  Pay attention!
Electronic
• Automatic alerts on the
computer, laboratory
result reports, etc.
• Reports for directors
and administrative staff
that help with staffing,
cleaning plan, etc.
• Isolation Signs
• Physician Orders
• Notes on patient charts
• MDRO Flag on the Patient Face Sheet
• Reports that are posted to track compliance with prevention measures
Center for Disease Control and Prevention (CDC)
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Targeted plan for physicians
1. Prevention Infection
Step 1. Vaccinate
Step 2. Get the catheters out
2. Diagnose and treat infection effectively
Step 3. Target the pathogen
Step 4. Access the experts
3. Use antimicrobials wisely
Step 5. Practice antimicrobial control
Step 6. Use local data
Step 7. Treat infection, not contamination
Step 8. Treat infection, not colonization
Step 9. Know when to say “no” to “vanco”
Step 10. Stop antimicrobial treatment
4. Prevent transmission
Step 11. Isolate the pathogen
Step 12. Break the chain of contagion
Source: http://www.cdc.gov/drugresistance/healthcare/default.htm
Individual Actions to
Prevent the Spread of MDROs
Everyone, Every time
• Clean Hands
• Clean Environment
When Indicated
• Isolation precautions
• Active surveillance for MDROs
• Targeted decolonization of patients
• Prevention Bundles
• Antibiotic Stewardship
Clean Hands
These images illustrate the critical importance of hand hygiene in caring for
patients, including those not known to carry antibiotic-resistant pathogens.
An imprint of a health care
worker's ungloved hand after the
worker had performed an abdominal
examination of a patient.
After the worker's hand had been
cleaned with alcohol foam, another hand
imprint was obtained, and the resulting
culture was negative for the MDRO.
Source: Donskey and Eckstein NEJM 360 (3): e3, Figure 1 January 15, 2009
http://content.nejm.org/cgi/content/full/360/3/e3/F1
Clean Hands
Your 5 Moments for Hand Hygiene
More information: http://www.who.int/gpsc/5may/background/5moments/en/index.html
Clean Hands
Soap and Water
Alcohol-based Handrub
If hands are visibly dirty, wash
with soap and water.
If hands are not visibly dirty, use
an alcohol-based hand rub.
1. Wet hands and apply soap.
2. Rub hands together for 15 to 20
seconds and make a lather.
3. Rinse hands well.
4. Dry hands using a paper towel or air
dryer. If possible, use your paper
towel to turn off the faucet.
1. Apply product to the palm of one hand.
2. Rub hands together for 15 to 20
seconds.
3. Rub the product over all surfaces of
hands and fingers until hands are dry.
Total Process time:
40-60 seconds
Total Process time:
20–30 seconds
Alcohol-based hand rub is:
• more effective
• faster
• better tolerated
Always use SOAP AND WATER to clean hands when caring for
C. difficile patients or patients having diarrhea.
What is Clostridium difficile?
• Clostridium difficile (C. difficile) is a bacterium that is
related to the bacterium that cause tetanus and botulism.
• The C. difficile bacterium has two forms, an active,
infectious form that cannot survive in the environment for
prolonged periods, and a non active, "noninfectious" form,
called a spore, that can survive in the environment for
prolonged periods.
• Although spores cannot cause infection directly, when they
are ingested they transform into the active, infectious form.
Source: www.medicinenet.com/clostridium_difficile_colitis/article.htm
Clean Hands at the POINT OF CARE
Point of care – refers to the place where
three elements occur together:
(1) the patient,
(2) the health-care worker and
(3) care or treatment involving patient
contact (within the patient zone)
• This requires that a hand hygiene
product (e.g. alcohol-based handrub, if
available) be easily accessible and as
close as possible (e.g. within arm’s
reach), where patient care or
treatment is taking place.
• Point of care products should be
accessible without having to leave the
patient zone.
Patient Zone
Clean Hands?
It is an expectation of
Tenet and part of being a
true patient advocate
Kindly remind ANYONE who
does not clean their hands
properly to do so.
to question
physicians,
coworkers,
other staff
and visitors
if they have clean hands.
Clean Environment
• Environmental hygiene is aimed at eliminating the
reservoir of MDROs on hospital surfaces and
equipment.
– MDROs can persist in the environment despite routine
cleaning practices
– Some MDROs can remain for weeks without proper
surface disinfection.
– Patients admitted to rooms previously occupied by a
patient with an MDRO are at higher risk for developing
infection with that MDRO.
Clean Environment
ROOM LOOKS CLEAN BUT
… the X represents MDRO
culture positive sites
Source: The Risk of Hand and Glove Contamination after Contact with a VRE
(+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
Clean Environment
• Nearly ¾ of surfaces in patients rooms are
contaminated with an MDRO.
– Examples of high-touch surfaces include door
knobs, bed rails, telephones, light switches,
bedside tables and curtains.
Once caregivers touch these surfaces, their
hands or gloves are contaminated.
Source: Infection Control and Hospital Epidemiology (v. 9, 1997) 622-627.
The Environmental Services (EVS) Team is
CRITICAL!
Everyone can pitch in…
It is recommended that all patient equipment be disinfected
with antibacterial wipes before and after patient use.
• Physical Therapists should disinfect patient equipment, such
as walkers, crutches and common areas that patients come
into contact with, including stairs and handrails.
• Transportation Services should disinfect wheelchairs,
stretchers, etc.
• Nurses/Aides/Techs should disinfect patient equipment,
such as blood pressure cuffs, commodes, etc.
• Physicians and Nurses should disinfect non-invasive
instruments such as stethoscopes, hemostats, etc.
Clean Environment
• All objects that come in contact with patients should be considered
as potentially contaminated.
• Cleaning and disinfecting high touch surfaces is essential to the
health of hosptial patients, visitors and healthcare workers.
Appropriate disinfectant
+ Adequate contact time
+ Friction
= Good Cleaning
• Be sure to READ THE INSTRUCTIONS on cleaners and
FOLLOW THE MANUFACTURER’S GUIDELINES for product
use and maximum disinfecting.
Isolation Precautions
Isolation Precautions
• Be aware of possible effects of isolation on patients:
– Patient perceptions of depression and anxiety;
– More preventable adverse events (e.g., pressure ulcers);
– Patient dissatisfaction with treatment.
• Recommended actions when patients are
placed on Contact Precautions:
– Make a point to enter the room to assess
the patient for
• increased anxiety and/or depression
• preventable adverse events related to
immobility
– Be sure to document assessments
Source: CDC/HICPAC MDRO Guidelines, p. 26;
http://www.cdc.gov/ncidod/dhqp/pdf/ar/MDROGuideline2006.pdf
Isolation Precautions
Gloves and other personal protective equipment
(PPE) should not be worn in public areas.
Gloved hand
touching elevator button
Gloved hand
touching wheelchair
Gloved hand
touching cell phone
Gloved hand
touching computer
Personal Protective Equipment (PPE) also
NOT A FASHION STATEMENT.
Isolation Precautions
Transportation of Patient In Isolation
Contact - Enteric
Contact
Airborne
Droplet
• Cover patient with • Cover patient with • Put mask on
sheet / blanket
sheet / blanket
patient
• Put mask on
patient
• Notify receiving
personnel
• Notify receiving
personnel
• Notify receiving
personnel
• Notify receiving
personnel
• No gowns or
gloves with
transport.
• No gowns or
gloves with
transport.
• Limit transport
• Limit transport
1. Remove and dispose of contaminated
PPE and perform hand hygiene prior to
transporting patient.
2. Wear clean PPE to handle the patient
at the transport destination.
Sources: http://www.cdc.gov/ncidod/dhqp/gl_isolation_contact.html
http://www.osha.gov/SLTC/etools/hospital/hazards/ppe/ppe.html
Take clean PPE to the
transport destination.
Other Possible Infection Control Steps
• Grouping of patients
• Grouping of staff
• Use of designated
beds or units for
patients with MDROs
• Unit closure (rare)
Other Possible Infection Control Steps
• Check patients who are most likely to have harmful bacteria on
their skin to determine appropriate precautions and/or
treatments.
• Specially treated cleansing cloths, which target harmful staph
bacteria, can be used by patients before surgery to reduce the
risk of infection.
• Ensure specific prevention measures are in place for patients
who have medical devices, such as intravenous tubes, breathing
tubes or urinary catheters.
• Antibiotic stewardship involves avoiding overuse and ensuring
the best choices are made when selecting and giving antibiotics
to patients.
Active surveillance for MDROs
• Active surveillance for MDROs is designed to identify
patients who are colonized but not overtly infected with
MDROs
– Swab samples from the nose, rectum, or other body sites can be
examined in the lab to detect specific MDROs.
– By identifying these individuals, measures can be taken to prevent
the spread to other patients.
– Active surveillance has been shown to reduce the frequency of
MDRO infection in specific populations in a wide variety of settings.
MDRO Surveillance
• Supportive reasons for susceptibility (or sensitivity) testing
– Susceptibility testing is often used to determine the likelihood that a
particular drug treatment regimen will be effective in eliminating or
inhibiting the growth of the infection.
– Enables a “sentinel event” approach to new MDROs
– Facilitates molecular typing of MDRO isolates
• Reporting Options
– Enhanced susceptibility reports
• Pathogen-specific
• Facility- or unit-specific
• Provider-specific (for feedback)
– Incidence Monitoring - Selected Pathogens
• By unit; by provider (per 1000 patient days)
• Requires teamwork (Laboratory, Information Technology and Infection
Prevention and Control)
MDRO Surveillance Questions
• Still unanswered:
– Proper timing of Active Surveillance Cultures
– Site(s) and protocol(s) for obtaining cultures
– Coordination with contact precautions
• Healthcare worker (HCW) surveillance cultures?
– Usually not needed unless HCWs are epidemiologically
linked to MDRO transmission.
Targeted Decolonization of Patients
• Decolonization of patients aims to eradicate MDROs
from colonized patients in an effort to prevent
subsequent infection or spread.
Specially treated cleansing cloths,
which target harmful staph bacteria,
can be used by patients before
surgery to reduce the risk of infection.
Decolonization of Patients
Topical antibiotics may be applied; However, current guidelines, citing
concern for the development of resistance to the drugs used for
decolonization, advise against widespread use of this practice.
Considerations for those who choose to proceed:
• Decolonization of MDRO is most successfully achieved with MRSA.
– Less likely to succeed with VRE
– Rarely reported for Multiple drug-resistant gram negative bacilli (MDR-GNB)
• Limiting factors:
– Availability of surveillance cultures
– Need for follow-up cultures
– Occurrence of
• Last decolonization
• MRSA strain was resistant to mupirocin, or
• Emergence of resistance during decolonization
• HCW decolonization not usually needed
Prevention Bundles
See .edu courses for review of strategies to prevent:
• Central Venous Catheter Blood Stream Infections (CVCBSI)
• Ventilator Associated Pneumonia (VAP)
• Catheter Associated Urinary Tract Infections (CAUTI)
• Surgical Site Infections (SSI)
Overview of Antibiotic Stewardship
In the hospital setting, it is estimated that as much as
50% of antibiotic use is unnecessary.
Antibiotic misuse fosters the development and spread of antibiotic resistance.
• Antibiotic stewardship involves limiting inappropriate antibiotic
use while optimizing the selection, dose, duration and route of
therapy with the most appropriate drug for the patient.
• Stewardship programs have been associated with improved
antibiotic use and reduced costs.
Judicious Use of Antibiotics
• Attention to antibiotic ordering patterns
– (IT, pharmacy and medical staff support)
– Expert/peer review
• Use antibiograms to help educate
medical staff regarding appropriate
antibiotic selection
• Limit formulary choices
– Prior approval programs
• Automatic stop orders
– Physician reminder systems
– (lab and pharmacy support)
• Review drug firms’ sales efforts on
antibiotic prescribing patterns
Summary
• Clean hands and a clean environment are the two most
important methods of controlling the spread of bacteria
and other germs that cause HAIs.
• We’re asking everyone, including our patients and visitors,
to clean their hands before and after touching another
person or the patients’ environment.
• Kindly remind ANYONE who does not clean their hands or
environment properly to do so.
The safety of our patients and caregivers
is of utmost priority.
• While not every action noted in this presentation
may pertain to your specific duties, all employees
can help prevent the spread of MDROs by
focusing on two basic elements of cleanliness:
clean hands and a clean environment.
The Basics of
Patient Safety
People Are Set-Up to
Make Mistakes
Incompetent people are, at most, 1% of the
problem. The other 99% are good people
trying to do a good job who make very
simple mistakes and it's the processes that
set them up to make these mistakes.
Dr. Lucian Leape, Harvard School of Public Health
How Can Safety be Improved?
Human errors occur because of:
 Inattention
 Memory lapse
 Failure to communicate
 Poorly designed equipment
 Exhaustion
 Ignorance
 Noisy working conditions
 A number of other personal and
environmental factors
Where to Start

Consider safety improvement
recommendations made by
external groups

Implement Patient Safety
Goals
Patient Safety Standards
Improve accuracy of patient identification
1.


Use two identifiers NPSG.01.01.01
Eliminate transfusion errors related to pt misidentification NPSG.01.03.01
Improve effectiveness of communication among
caregivers
2.




Read back and verify NPSG.02.01.01
Standardization of abbreviations NPSG.02.02.01
Measure turn around of critical test results NSPG.02.03.01
Standardized approach to hands-off communication, including opportunity to
ask & respond to questions NSPG.02.05.01
Improve Safety of Using Medications
3.



Look alike- sound alike drugs NSPG.03.03.01
Label medications and containers on and off the sterile field NSPG.03.04.01
Reduce patient harm associated with use of anticoagulant therapy
NSPG.03.05.01
Patient Safety Standards
7.
Reduce the risk of health care associated infections





8.
Hand hygiene NPSG.07.01.01
Infection related sentinel events NSPG.07.02.01
Prevent infections due to multiple drug-resistant organisms NSPG.07.03.01
Prevent line-associated bloodstream infections NSPG.07.04.01
Prevent surgical site infections NSPG.07.05.01
Medication Reconciliation Across the Continuum




9.
On Admission NSPG.08.01.01
At Transfer NSPG.08.02.01
At Discharge NSPG.08.03.01
Modified med rec process where meds used minimally/prescribed
for short duration NSPG.08.04.01
Reduce the Risk of Harm Resulting from Falls NSPG.09.02.01

Implement Fall Reduction Program
Evaluate Effectiveness
Patient Safety Standards
13.
Encourage Patients Involvement in their Own Care

Encourage patients and families to report concerns about safety
NSPG.13.01.01
15. Identify Safety Risks

Identify patients at risk for suicide NSPG.15.01.01
16. Improve recognition and response to changes in patients
condition

Code Prevention Team NSPG.16.01.01
Patient Safety Standards
UNIVERSAL PROTOCOLPrevent errors in surgery
1. Conduct pre-procedure verification
process UP.01.01.001
2. Mark the procedure site UP.01.02.01
3. Procedure time Out UP.01.03.01
Patient Rights
HIPAA
 Advanced Directives
 Bioethics

Everyone Has a Role in
Patient Safety



Employees and Physicians
Management
Administrative and
Medical Staff Leaders
Steps to Improve Safety
Basic Tenets of Human Error
 Everyone commits errors.
 Human error is generally the result of
circumstances that are beyond the
conscious control of those committing the
errors.
 Systems or processes that depend on
perfect human performance are fatally
flawed.
A Strategic Objective
We must redesign our processes so
that simple mistakes don’t end up
harming patients
 Eliminate opportunities for errors
 Build better safeguards to catch and
correct errors before they reach the
patient
What hospital staff need to
know about the impaired
and/or disruptive practitioner
The Impaired Practitioner
Definition – one whose behavior or
performance has been affected
by alcohol, chemicals, and/or mental
or physical illness that interferes with
his or her ability to function
competently.
Signs of Substance Abuse
 Difficulty meeting schedules or deadlines
 Odor of alcohol
 Slurred speech
 Poor hygiene
 Poor coordination
 Isolation from others
 Frequent or unexpected absences
 Family problems
 Doesn’t answer pages
 Denial
 Financial problems
 Inappropriate anger
 Dramatic mood swings
What should you do if you suspect
practitioner impairment?
1. Report incidents to your supervisor – report up
hospital chain of command
2. File an incident/occurrence report
3. Report issue to Vice President Medical Affairs,
CMO or Chief of Staff
4. Call the Ethics H
Reporting may save a life!
What should you not do?

Discuss suspicions with other staff or practitioners
(always maintain confidentiality)

Attempt an intervention with the practitioner yourself

Allow patient safety to be jeopardized at any time –
Call your supervisor immediately!

Tolerate physical abuse or threats – Call security!
Behaviors of a Disruptive
Physician or Practitioner
 Employs threatening or abusive language
 Makes degrading or demeaning remarks
 Uses profanity or other offensive language
 Uses threatening or intimidating physical behaviors

Makes public derogatory remarks about the quality of
care provided by others
Behaviors – continued
 Writes inappropriate entries in medical record
concerning quality of care
 Imposes strange requirements on staff having
nothing to do with good patient care
 Creates a hostile environment
 Has little or no insight into the
effects of his or her behavior
What are your options if you encounter a
disruptive practitioner?
 Report all instances to your supervisor
 File an incident/occurrence report
 File a report through your peer review process
 Call your CNO or Chief of the Medical Staff or other
medical staff leader
 Early intervention is the key,
so don’t let this slide!!
What should you not do?
 Argue with the physician or practitioner
 Tolerate physical abuse or threats of violence – call
security
 Allow patient safety to be jeopardized
 Take it personally
 Ignore it and not report
Occurrence
Reporting System
Occurrence Reports are an essential part
of the visitor and patient safety programs
They are used to:
1. Investigate and reduce risks to patients
2. Document the facts surrounding an
occurrence
3. Identify trends within departments or across
the hospital that can be addressed by
improving processes.
When & What You Should Report
When?
The occurrence reporting policy and
procedure requires that you submit an
occurrence report before the end of
your shift.
What is reportable?
1. An occurrence that is not consistent with the
routine operation of the hospital or the routine
care of the patient or patients.
2. Actual injury or the POTENTIAL for injury, illness,
or property damage is enough for an occurrence
report to be completed.
Fact vs. Opinion
Occurrence reports should not be used
to blame an individual or department.
When completing a report, you should
keep your comments to the
facts of the event and avoid
opinions, speculation, and blame.
Fact vs. Opinion
Which scenarios are fact or opinion?
1. Patients states they had a wallet in a drawer.
The previous nurse must have taken it.
2. Patient states they had a wallet in their drawer
and that it is missing
3. Cardiac consultation ordered 12/5/04. Nurse A
and B failed to note order and call consult.
Consult called 12/8/04 after identifying
omission.
4. Cardiac consultation ordered 12/5/04. Chart did
not indicate consult completed. Consult called
on 12/8/04.
Performance
Improvement
Performance Improvement at Spalding Regional Medical Center addresses
all services, sites and units of the medical center. Performance Improvement
focuses constantly on improving services provided by leaders and
departments, and care received by all patients, especially those with high risk
and problem prone diagnoses. Data obtained from the community is also
used to identify opportunities for improvement. Improving health outcomes for
our community is the centerpiece of our performance improvement plan.
 Spalding looks at population based risks factors, individual risks factors,
community demographics, major health problems, availability of health
services, environmental factors and relationship of these factors to produce
the community health status and uses the PDCA model to implement those
initiatives. (See PDCA Model).
Spalding Regional Medical Center uses a systematic organization-wide
approach to monitor quality that is used to plan, design, measure, assess and
continually improve organizational performance across the institution.
An example of this approach is the Commitment to Quality (C2Q) teams that
focuses on major PI initiatives. Some of the C2Q teams are Nursing/Clinical
Quality, ER, Radiology, OR, and IHI 100K lives, LOS, Medication
Administration and Safety. Examples of initiatives are the safety measures
and the publicly reported quality indicators. Each department has the safety
measures posted. Attached is a list of the quality indicators. (See Quality
indicators monitored and reported at Spalding)
Performance Improvement Methodology
We use the concept of total quality management in a Plan Do Check Act (PDCA) model to organize our improvement initiatives.
Begin
Identify the outputs
provided by the
hospital/department
Does the analysis
support the
hypothesis?
No
State team's ideas
about what is going
wrong within the
process
(Develop Hypothesis)
Yes
Identify the output to
be improved
Create a team
Develop a description
of the process which
creates the output
(flowcharting)
Identify customers of
the output
Gather the customer's
requirements
State team's ideas about what
is going wrong within the
process (Develop hypothesis)
Do you have
enough data?
No
Collect Data
Yes
Brainstorm possible
solutions (fishbone)
Select "best" solution & document
new process (Matrix)/(Flowchart)
Develop implementation
plan (action plan)
Collect data
(use original data collection plan)
Analyze data
Develop a plan for collecting
information (data) about how
the process is currently being
performed (collection plan for
basline data
Is there
quantifiable
improvement?
No
P – Plan – Yellow
Collect Data
Yes
D – Do – Blue
Monitor new process
C – Check – Green
Analyze the Data
Begin
Again!
A – Act - Red
QUALITY MEASURES
MONITORED AND REPORTED
SPALDING REGIONAL
MEDICAL CENTER
The following information is to be completed on every patient admitted with
a core measures diagnosis and is listed on time out sheets
Advance
Directives
SRMC complies with the Patient Self Determination Act
and requires all patients (over the age of 18) to have
documentation of Advanced Directives. The Advance
Directive informs the hospital of the patient’s healthcare
decisions.
Advance Directives may include the following:
•Living Will
•Healthcare Surrogate Designation
•Refusal of Treatment
•Durable Power of Attorney for Healthcare
•Organ Donation
• During the admitting process or pre-admission
process the patient should receive information
regarding communicating health care choices
and Advance Directives. This information is
included in the Patient Information Packet.
• If the patient has an Advanced Directive, a copy
is placed in the Medical Record. If a patient
wishes to execute an Advanced Directive, the
patient is provided with a copy of the Advance
Directive form (from Admissions dept. or the
Case Management/Social Services dept.) and the
steps outlined in the policy are followed.
Bioethics
SRMC encourages ethically informed, responsible and
compassionate decision making and practice throughout
the range of our hospital’s activities. An Ethics committee
provides a forum for case by case debate of ethical issues
when there is conflict among healthcare professionals
stemming from controversial patient care decisions.
Complaints
and
Grievances
• Every patient has the right to file a general complaint or
concern about his/her care and treatment and not be
penalized in any way for doing so. Any healthcare team
member receiving a complaint from a patient along with
the person in charge will, as soon as possible, attempt
to correct the problem. The concern will be referred to
the Department Manager or Shift Supervisor. All
significant complaints and grievances will be referred to
Risk Management and/or Customer Service.
Communication
• SRMC utilizes AT&T Language Line Services as a
mechanism to meet the special needs required by our
customers who do not speak English. AT&T Language
Identification cards are available in Administration,
Nursing Office and Nursing Departments to assist in the
determination of the language being spoken. The
complete procedure is documented in the policy and
procedure.
Safety Presentation
Code Red → Fire

The operator will announce Code Red and then a location. Each
department has different functions during a Code Red. Please ask
your supervisor what your function is.

Please familiarize yourself with the proper fire control procedures
and escape routes. Make sure you know where your fire
extinguisher is located and the location of the fire alarm pull stations

Your first order is to remove any patients from the fire area

Second, notify by pulling a fire alarm station

Third, try to contain the fire by shutting doors

Fourth, if possible try to extinguish the fire. If not, evacuate.

After the fire has been cleared by the proper channels, the operator
will announce, “Code Red, All Clear”
Code Red continued
At the hospital we use the acronym RACE and PASS
R rescue A alarm C contain E extinguish or evacuate
P pull pin A aim
S squeeze
S spray
When using a fire extinguisher:
Pull the pin, Depress the handle, and Use sweeping motion at
the base of the fire. Do Not Use the fire hose cabinets
A = Common Combustibles
C = Electrical Equipment
B = Flammable Liquids
Code Zero
&
Code Secure
 Code Zero means evacuation:
Horizontal, Vertical, or Total
 Code Secure means Facility Lockdown:
NO One enters or leaves the hospital for
any reason
Code Blue
Code Pink
Dr. 200
Code Blue
 Code Blue is a Cardiac Arrest/Cardiopulmonary Arrest
 This is when a person becomes unresponsive and
pulseless
Code Pink
 Patient, Infant to 14 years of age, found unresponsive
or needing resuscitation efforts
Dr. 200
 Dr. 200 is a Code Blue on an infant in Labor and
Delivery or the Nursery
Code Weather Alert
 Pending Status indicates the probability of a severe weather
condition that might interfere with hospital operations.
 Active Status indicates that a severe weather condition
already exists and additional activities should be
undertaken.
– Departments are to remain operational. Staffing levels
will be maintained to provide established standards of
care.
– It may become necessary to remove certain patients from
areas in front of windows. Windows should remain
closed unless otherwise instructed.
– Assure patients they are safe and the hospital is taking
the proper steps to insure their safety.
Code D
Code D is an emergency or disaster that seriously
overtaxes or threatens to overtax the routine
capabilities of the hospital
All nurses and other personnel without specific
assignments in the plan will report their availability
to their supervisors and remain in their areas until
further instructions
Disaster functions are pre-assigned and designated
by position rather than by name
“Code D” Instructions for
General Staff
Follow the 5 R’s
REMAIN in the Hospital - Do Not Leave
RETURN To Your Assigned Work Area
REPORT To Your Immediate Supervisor
REASSESS Your Assigned Patients or Job Duties and
Report Status to Your Supervisor
RESPOND to All Instructions
“Code D” Instructions for
Supervisor/Manager
RETURN To Your Assigned Work Area
REASSESS the Condition of Your Unit
(Physical area, Staff, & Patient Responsibilities)
1. Delegate Disaster Call List to assess availability.
Do Not Ask Staff to come in.
Labor Pool Leader will decide this.
2. Complete Disaster Unit Report
REPORT To Your Immediate Supervisor
(Supervisors Report to Dept. Director/OHS
at night)
RESPOND to All Instructions
Code Adam
Code Adam is an infant
or child abduction
Levels Are:
1. Infant – 1 Year
2. 1 – 4 Years of age
3. 5 – 12 Years of age
4. 12 Years and older
Code Beta/Code Alpha
These behavioral codes are called as an emergency
summons utilized in the event of an acute acting out
or violent episode with any person within the
facility. A Behavioral Code is determined as a
person having the potential to cause injury to self
and/or others.
Code Beta
A Code Beta may be called in any situation which cannot be
resolved by the staff present, and when verbal interventions
have not been successful.
Calling a Code Beta does not mean that the individual will be
physically restrained.
Code Alpha
 If the subject is in possession of a weapon (i.e. knife, gun or
club), Code Alpha will be the emergency summons.
 The response to this code will be to notify the PBX operator
at the emergency number (extension #1234) and call
Security at extension #2419. The PBX operator will notify
the Griffin Police Department immediately.
 Staff should not approach the subject, but secure the area
and wait for the local police to arrive
Code Lift
If a patient, visitor, or employee has fallen and the
first responder needs additional help in lifting the person,
the emergency number will be called (1-2-3-4) and a Code
Lift plus location will be called overhead.
Once a Code Lift is called, all available transporters,
engineering personnel and Over House supervisor should
respond to the call.
Before the person is lifted, an RN should triage the
person and determine what is needed in the lift. If help is
needed in lifting a patient from a bed to a chair or a chair to
the bed, a portable lift is located on the first floor.
MET Team
Medical Emergency Team
The MET team may be consulted to assist in the assessment and
the emergency management of patients that the staff member
has general concerns about or who develop an acute change in
their condition. The patient or family member may request a
MET team consult as well.
Any member of the patient care team who has a concern or
needs assistance in the assignment or evaluation of a patient
may activate a consult with the MET team by dialing the
emergency number (1-2-3-4) and advising the operator MET
Team needed and patient’s room number. A MET team plus
location will be called overhead.
The MET team members are ICU RN and/or Over House
Supervisor and Respiratory Therapist.
MSDS – Material
Data Sheets
 There is a MSDS on every chemical used in the
hospital.
 This includes cleaners, whiteout, glue, sprays, etc.
 These sheets are located in the Emergency Room and
the Engineering Department for your review if needed.
 Chemical Spill kit is located in the Plant Operations
Office on the 2nd floor
Abuse
See attached policy
End of Life
Issues
End of life is a condition that is caused by injury,
disease or illness which has resulted in severe and
permanent deterioration, indicated by the incapacity
and complete physical dependency and for which, to a
reasonable degree of medical certainty, treatment of the
irreversible condition would be medically ineffective.
Focus on end of life issues is not about cure, but about
care. Individuals have the right to self-determination
and decision-making regarding end of life issues
through Advance Directives. Cultural and religious
beliefs should be respected, therefore the health care
provider should examine their own attitudes and
spiritual beliefs regarding end of life issues in the
context of providing patient care.
Elizabeth Kubler-Ross
described the process of dying
and five stages in preparation
for death:
•
•
•
•
•
•
denial
isolation
anger
bargaining
depression
acceptance
Grief is an expected response
to loss. Four stages of grief
have been described:




shock and numbness
searching and yearning
disorientation and disorganization
resolution and reorganization
Palliative care is a shift from cure to
comfort caring for the whole patient,
not just the illness. Palliative care is
about feeling comfortable in body,
mind and spirit. Meeting these needs
may involve comforting the patient’s
family as well.
Each person approaches death in
their own way, bringing to this last
experience their own uniqueness.
• Death comes in its own time; its own
way.
Death is as unique as the individual
who is experiencing it .
Organ
Donation
Organ Donation
Clinicians should be aware of the legislative
factors involved in organ donation. The
uniform Anatomical Gift Act was enacted in
1970 by all 50 states. The act legally
provides anyone above the age of 18 with the
right to indicate willingness to become a
donor at the time of death. The act also
authorizes the next of kin to donate and
protects the health care professional from
liability related to participating in the donation
process.
These laws constitute the framework
for “required request” in addition to
approximately 454 state laws that
require families be given the option to
donate or to decline to donate.
Ninety-five percent of all donor
situations occur in the critical care
units.
Identifying Potential Organ
Donors:
All donors of vascular organs are patients who
have been declared brain dead utilizing
criteria that have been established within a
particular locale or institution (Simmons et al.,
1984). The nurse must be familiar with the
policy and procedure specific to his or her
institution. There have been many criteria
used to diagnose brain death. Flye (1989)
has reviewed many of the criteria used and
has found three principles common to all:
There have been many criteria used to
diagnose brain death. Flye (1989) has
reviewed many of the criteria used and
has found three principles common to
all:
1. Coma of established cause: no toxins,
physiologic abnormalities corrected
2. Cerebral unresponsiveness,
Absent brainstem reflexes: pupils,
oculovestibular responses, respiration
Clinicians, as well as all others involved in the
consent process, should understand the decision
to donate an organ is highly personal and
emotional one. It is made under stressful
conditions, thus the discussion should take place
in non-threatening, private environment. The
topic should not be discussed at the patient’s
bedside, in the waiting area, or in open public
places. The actual request for a donation will be
made by staff from Lifelink of Georgia and have
the ability to address questions that the family
may have regarding timing, cost, and distribution
of the organs, the surgical procedure and the
effects on funeral plans.
The manner in which a family is approached can
make the difference in a positive or negative
outcome. Families who receive accurate, truthful
information, who have questions answered, and
who believe they have been dealt with honestly
are more likely to respond positively to a request
for organ and tissue donation. The nurse is
probably one of the most important people
involved in this process. Nurses are more likely
to identify the potential donor, call the referral to
the OPO and be involved with approaching the
family because of their existing relationship with
the family.
The donor families often find emotional
benefit from their decision to donate.
Research shows that beyond their altruistic
satisfactions, they may often find solace
and comfort in knowing their loved ones
live on through others. Many nurses also
receive benefit from the knowledge that
their participation
Medication
Administration
Pharmacy Hours
24 hours; 7 days per week (work
assignment below is MondayFriday scenario)
• In-house Pharmacist – ext 3743
• 1st and 2nd Floor Pharmacist 3771
• 3rd and ICU Pharmacist – 3790
• Clinical Pharmacist - 1400
• Before 9A or after 4P or on the
weekends call ext 6910
Medication
Administration/Rights
1. Medications are safely and accurately administered
•
MARs are printed around 4am daily
•
Any changes to orders must be handwritten on the MAR
•
You may request a new printed MAR on new admissions,
level of care transfers, and post-operatively
•
Every time a medication is administered it must be
documented on the MAR. If it is not charted on the MAR and
that chart is audited then those charges are lost.
•
If the administration of any medication is ever in question
then the patient’s chart should be reviewed before
administering. Do not rely on the cardex alone.
•
For all meds the administration times must be accurately
charted. (i.e.: if Vancomycin is to be given at 09:00, but is
actually given at 09:30 then you must circle the printed time,
write the actual time the med was given, and initial.)
Medication Errors and Adverse
Drug Reaction Reporting
Reporting is NON-PUNITIVE!!
– The hospital responds to ALL actual or
potential adverse drug events and
medication errors.
•
You can access the eSRM system on
e-tenet.com to report ADRs and
medication errors. Every single event,
even if you feel it is minor, should be
reported.
Medication Access/Delivery
Process
Each unit has a Pyxis Machine where stock
medications are stored.
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You must fill out the appropriate paperwork to be granted
access to these machines. There is a pyxis packet that you
can keep as a reference. This packet will also be what you
use to complete your Pyxis competency & thus be granted
access to the Pyxis machine.
All medications require an order to be sent to the
Pharmacy and entered into the system prior to access to
the medication. Some medications (as defined by JHACO)
can be over-ridden. These medications are limited and for
use in emergent and/or urgent situations in which the
patient’s status would be changed if there was a delay in
treatment.
As each medication in each Pyxis machine falls below its
PAR level the Pharmacy is notified and the medication is
refilled on the next hourly round.
Medication Access/Delivery
Process con’t.
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•
•
For non-formulary items they will often be placed in a bin
in the tower of the Pyxis labeled “Meds Ordered Not
Loaded.” When accessing these items, you must choose
that icon on the Patient’s profile in order to access that
medication. If that icon is not present on the patient’s
profile then it can be over-ridden.
All specially made IV’s such as Zantac drips, antibiotics,
Potassium IV fluids, etc are placed on the appropriate
hook that correlates to that patient’s specific room
number. Some medications will also be stored in the
refrigerator. You can access the refrigerated items
through the patient’s profile or through the override
function.
Other medications, such as certain antibiotics, are loaded
in the pyxis machine and shall be removed and activated
by nursing for immediate patient use.
IV Preparation by Nursing
1.
2.
3.
Only medications that are being made for immediate patient
use and considered emergent can be mixed on the floor.
Aseptic technique must be used to prepare all medications.
Label all IV solutions
Controlled Substances
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•
•
•
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All controlled substance are secured either in the Pyxis
machines or in some areas of the
hospital in locked cabinets.
A narcotic inventory is to be done on each Pyxis machine
once per week on Mondays. You can suspend a narcotic
inventory count in the event that another nurse needs
immediate access to the Pyxis.
A nurse can waste a partial dose of a narcotic if another
nurse witnesses the waste.
The wasted dose should be disposed of properly. You can
also return the waste to the pyxis return bin to have the
Pharmacy waste.
A nurse can NOT waste a whole dose of a narcotic. This
will result in an incident report.
Pain
Management
Margo McCaffery (1979) states that pain is
whatever the patient says it is, existing
whenever the patient says it does. Pain
has physical, emotional, and spiritual
components.
Pain Management is a team effort that allows
the patient to be as comfortable and free of
pain as possible. The team consists of the
patient, family, physician, nurse, physical
therapist, pharmacist, clergy, and social worker.
Pain management means the nurse should be able to:
• 1. Assess each patient’s pain
• 2. Use pain relief methods effectively
• 3. Educate patients and family
4. Reduce barriers to effective pain management
Pain Assessment measures the amount of
pain the person is experiencing and the effect it
is having on the person as a whole. The initial
screening questions regarding pain need to
determine if the patient is in pain now or has
been in the last few weeks or months. If the
patient answers affirmatively, examine the pain
site and then further questions must be
addressed.
Pain Assessment con’t.
1.
2.
3.
4.
5.
6.
7.
Location – Ask the patient to point to the site(s) of pain on
their body or on a body diagram.
Intensity – Ask the patient to rate his pain on 0-10 scale. (see
attached scale and faces)
Quality - A description of the pain in the patients own words
should be elicited
Onset/Duration – Elicit information about patterns of pain
(continuous or intermittent) and variation.
Aggravating/Reliving Factors – Ask what makes the pain better
and worse.
Effects of Pain – Effects on daily life functions such as
sleeping, eating, dressing, working, emotions, etc.
Examine pain site – Observe for swelling, redness, tenderness,
guarding, splinting, etc.
For Non-Verbal patients: FLACC assessment scale is used to score pain rating on a 0-10 scale
Category
Score
0
Score
1
Score
2
FACE
No particular
Expression or
smile
Occasional grimace, or frown,
withdrawn,
disinterested
Frequent to constant
quivering chin, clenched
jaw
LEGS
Normal position
or
Relaxed
Uneasy, restless, tense
Kicking, or legs drawn up
ACTIVITY
Lying quietly,
Normal position,
Moves easily
Squirming, shifting back and
forth, tense
Arched, rigid or jerking
CRY
No cry (awake
or asleep)
Moans, whimpers; occasional
complaint
Crying steadily, screams or
sobs, frequent complaints
CONSOLABIL
ITY
Content, relaxed
Reassured by occasional
touching, hugging or being
talked to, distractible
Difficult to console or
comfort
Each of the five categories is scored
which results in a total score
between 0-10.
After scoring, continue to complete Pain
Management Assessment for all items
that are applicable.
Finally, discuss the present pain management
regimen and effectiveness, pain intensity, as
well as the individuals pain goals related to
function and quality of life.
After the initial assessment, the patient must
be reassessed regularly to ensure the pain is
relieved. The clinician should evaluate the
patient’s pain every time they assess the
individual. Any patient with unrelieved pain
must be evaluated every two hours or more
often if indicated. The plan of care should be
adjusted accordingly. Each subsequent
assessment should evaluate the effectiveness
of the treatment and if the pain has/has not
been relieved. The clinician should determine
the source of unrelieved pain.
Goals of Pain Management:
1. At time of initial patient evaluation inform patients
that pain relief is an important part of their care.
2. Initial and follow-up assessments will use the
patient’s self report of pain as their primary
indication of pain.
3. The assessment will focus on the location, quality,
and intensity of pain.
4. Health care professionals in conjunction with the
patient will establish and implement a plan to
achieve pain relief.
5. Review and modify the plan of care for patients at
regular intervals to achieve the best possible pain
relief.
Restraints
Spalding Regional Medical Center’s philosophy concerning
restraints is that use of a restraint device is the done as a last
resort and only after the all reasonable alternatives have been
tried and have failed. Alternatives to restraints should always be
attempted prior to use. There should always be a physician
order that states: reason for restraint, time limitation, and type of
restraint. These orders must always be signed and dated
appropriately. The patient should be assessed, reassessed, and
restraints reordered according to policy and procedure and also
depending on the type of restraint. Restrained patients need to
have their restraints taken off and skin checked. Also check that
food and fluids are offered and allow bathroom use every two
hours. This must be documented as per the SRMC policy and
procedure. The nurse should be knowledgeable regarding the
policy and procedure for Restraints for SRMC.
Restraints
Physician Notification:
Non-Violent/Non-Self-Destructive Restraint Use
Immediately
Violent/Self-Destructive Restraint Use
Immediately
Restraints
Physician Face-to-Face Assessment:
Non-Violent/Non-Self-Destructive Restraint Use
24 hours initially
Violent/Self-Destructive Restraint Use
1 hour initially
Restraints
Physician Face-to-Face Re-assessment:
Non-Violent/Non-Self-Destructive Restraint Use
Each Calendar Day
Violent/Self-Destructive Restraint Use
Pts 18 and older- Q 8 hours
Pts 9 – 17 – Q 4 hours
Pts less than 9 – Q 4 hours
Restraints
Maximum time for Monitoring:
Non-Violent/Non-Self-Destructive Restraint Use
Q 2 hours
Violent/Self-Destructive Restraint Use
Q 15 minutes with continuous observation
Blood
Administration
See attached policy
Discharge
Planning
Discharge Planning /
Social Services
• Nursing Service must assess all patients for
psychosocial needs at the time of admission and
document their findings on the Nursing Admission
Assessment. Every patient admitted to Spalding
Regional Medical Center must receive an assessment
of their discharge planning needs and if needs are
identified, the patient/family must be referred to
Social Services for a follow-up assessment.
The following admissions should be
automatically referred to Social Services:
a. CVA’s
b. Hip Fractures
c. Individuals who are more than 75 years of age and
living alone
d. Overdose/suicide patients
e. Patients from an extended care facility
f. Patients for nursing home placement
g. Women’s Services at risk situations
h. Identified needs per nursing assessment sheet
• 2.
Social Services / Unit Based Care Coordinator must
screen all admissions within one business day. If a
emergency need arises when Social Services and Care
Coordination are not on site, the Nursing Staff should
notify the Overhouse Supervisor. The Overhouse
Supervisor contacts Clinical Care Coordinator/Director as
needed.
• 3.
If home health or post discharge planning needs are
identified, the patient must be given their choice of the
post discharge caregiver/vendor. If the patient does not
have a choice, the Patient Choice Form and a list of
vendors to select from must be given to the patient/family
to choose a vendor. (Completed by Nursing Staff only if
Care Coordination staff not on site). Most often
discharges are planned ahead and arrangements have
been made with forms completed and on chart at the time
of discharge.
4. Once the patient selects a vendor, notify
the vendor of the service to make
arrangements for delivery of the equipment
to the hospital or home depending on the
need. (Exp. Walker or Bedside comode) The
vendor’s phone number is listed on the
patient choice –vendor selection form.
Contact Care Coordination if there are
questions concerning post discharge setup or
if other than simple DME—exp: IV Antibiotics.