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UPPER CHESAPEAKE
HEALTH
SELF-LEARNING PROGRAM
ANNUAL SAFETY
EDUCATION PROGRAM
December 2011
Fire, Safety, Infection Control, TB, Legal
Compliance, HIPAA, Communication
Assistance, Risk Management,
Occupational Health & Team Member
Injury Reporting, Patient Safety, and
other important information including
the Management of Unsafe Behavior
Supplement for those requiring this
update/review.
1


UCH is accredited by The Joint Commission
The Joint Commission standards deal with quality of
care issues and the safety of the environment in which
the care is provided.

When an individual has concerns about patient care and
safety in the hospital, that the hospital has not addressed,
he or she is encouraged to contact the hospital’s
management.
 If the concerns cannot be resolved through the hospital,
the individual is encouraged to contact The Joint
Commission

You may address your concerns to:
Division of Accreditation Operations
Office of Quality Monitoring
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181

You may also send the concerns by




Fax: 630.792.5636
Telephone: 1.800.994.6610
Email: [email protected]
Medical staff and team members reporting safety or quality of
care concerns to The Joint Commission are immune from any
disciplinary or punitive action taken by UCH.
2
PURPOSE:
To provide a review of pertinent Fire, Safety, and Infection
Control policies, patient safety, and other information. The
supplement provides an annual review for those trained in
Management of Unsafe Behavior.
To fulfill regulatory and The Joint Commission requirements
for annual fire, safety, electrical safety and infection control
review, including AIDS, Hepatitis and TB.
OBJECTIVES:
After Reviewing this Self-Learning Program or after attending
an appointment with the Education & Resource Development
Department, the participant will be able to:
Define the priority actions to take in fire and exposure to
hazardous substance and chemical emergencies.
State the purpose of MSDSs in their work area.
State the number one method used to prevent the spread of
infection.
Verbalize role in providing a safe environment for patients,
visitors, team members, and self.
Discuss the prevention and spread of AIDS, Hepatitis B & C, and
TB.
Discuss your role in communication assistance and legal
compliance.
For management of unsafe behavior, discuss the alternatives to
restraints.
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Contributors
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Lynne Adams, Director, UCMC QHIM – Privacy Officer
Amy Myers, Safety Manager
Todd Dousa, Safety Coordinator
Debbie Bittle, Director of Risk Management
Ron Green, Director, Clinical Engineering
Colleen Clay, Director, Healthcare Epidemiology &
Infection Control
Barbara Finch, Director, Service Excellence and
Resource Development
Thomas French, Director, Security Services
Jane Gordon, Director, HMH QHIM – Privacy Officer
Diane Campbell, Education Specialist
Lisa Karmel, Director, Guest Services
Karen Linderborn, Education Specialist, Course
Coordinator
Mark Moody, Director, Occupational Health
Carolyn Phillips, Accreditation Coordinator
Cindy Triplett, Education Specialist
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CONTENT:
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
Emergency Information
Fire Plan Review
Hazard Communication
Infection Control Overview
Occupational Health – Injury Reporting
Abuse Reporting
Legal Compliance & Communication
Assistance
HIPAA Privacy & Security
Body Mechanics
Supplement: Management of Unsafe
Behavior Update/Review
REFERENCES: Available on UCH Intranet: Reference Library/ Policy
Libraries
Revised 6.01, 12.01, 12.02, 12/03,
11/04, 11/05, 11/06, 10.07, 10/08 ,
12/09, 12/10
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DIRECTIONS:
1.
2.
3.
4.
5.
Review the 2011 SLP packet of information.
a.
If you prefer to review the information with a member
of the Education & Resource Development
Department team, please call for an appointment.
(UCMC - 2900 or HMH - 5344)
Complete the Post-Test on-line or as a hard copy. You
may use the SLP or any of the references as resources. If
you need assistance, contact the Education & Resource
Development Department.
The ON-LINE post test is automatically graded and sent to
the ERDD. If you did a hard copy of the post test you
MUST RETURN the Post-Test answer sheet to the
Education & Resource Development Department office at
UCMC or HMH immediately.
If you don't pass with an 80% your incorrect responses to
the questions will be reviewed with you in writing/e-mail
or in person by a member of the Education & Resource
Development Department.
Upon successful completion of the Post-Test you will
receive 2 contact hours of education credit AND fulfill
your requirement for ANNUAL MANDATORY
EDUCATION.
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I. EMERGENCY INFORMATION
Dial 3333
Code Phone
THE NUMBER TO CALL on any
Hospital Telephone to initiate
EMERGENCY PROTOCOLS
GIVE the operator your name & location
and tell the nature of the emergency
you are reporting!
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KNOW the CODES to ACTIVATE
EMERGENCY RESPONSES:
CODE RED: Fire, Smoke, or Excessive Heat Get fellow Team Members to help, pull the fire alarm AND dial 3333.
“RACE” and “PASS” help you remember what to do.
CODE BLUE A: Cardiopulmonary Arrest, Adult
CODE BLUE C: Cardiopulmonary Arrest, Child 8 years old or younger
CODE PINK: Attempted or Actual Infant/Child Abduction
CODE GREEN: Disruptive or Combative Person
Requires response by team members and security to protect the person
from harming self or others
CODE GREEN SHELTER-IN-PLACE:
Armed. Threatening person inside building
Called if someone threatens another person with a deadly weapon or
shots are fired inside the building
CODE PURPLE: Security Response Urgent
A security matter that requires only Security Officers to response. The
matter is urgent, but not critical in nature
CODE YELLOW: Disaster Event
Report to your department and follow the UCH and Department
Emergency Operations Plan
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How do I access
the Emergency
Plans?
The Emergency Operations Plan is located in UCH Intranet
– from the UCH Intranet site home page, go to
“Resources” at the top of the page and select
Emergency Management (Code Yellow), 2010
Emergency Operations Plan.” This plan covers many
internal and external events.
Some emergency situations are covered by separate plans.
These include: Bomb Threat, Fire (Code Red),
Evacuation, Hazardous Materials Spill & Infant/Child
Abduction (Code Pink). These are found on the Intranet
in the Reference Library under Policies & Procedures in
the Environment of Care Manual.
Know your role in a Disaster! REPORT to your department
and follow the UCH and department Emergency
Operations Plan.
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What is Emergency
Management?
POLICIES & PROCEDURES are
designed to do four things:
1) MITIGATION – actions to reduce the chance of or
lessen the impact from a disaster event.
2) PREPAREDNESS – equipment, policies & training
to enable quick and effective response
3) RESPONSE – implementing plan in reaction to an
unplanned event or drill in a coordinated, successful
manner.
4) RECOVERY – getting back to normal business after
a major disaster event.
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Types of Emergencies /
Disasters
1)EXTERNAL - The facility is not
damaged, but it requires the hospital to
prepare for potential impacts, including loss
of power, reduction of external services or
the potential to receive any casualties.
Examples are hurricanes, floods, tornadoes,
radiation releases, civil disturbance,
building collapse or transportation
disasters.
2) INTERNAL - The facility has a failure of
a critical system that could potentially affect
patient care or normal operations.
Examples are fire, water shortages, power
loses, explosions, or acts of violence.
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What is our PLAN?
Written policies and
procedures assist us in
responding to an emergency.
Drills are held at least twice a year
to practice a quick and appropriate
response.
The GOALS:
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Prepare through training drills and
awareness of the plan. KNOW
your role as part of both the
hospital plan and your
departmental plan.
Manage resources and make
decisions based on the needs of
the community and our patients,
working closely with local
emergency agencies.
Give the best care to the greatest
number of patients with a
coordinated effort by all.
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The BOMB THREAT PLAN advises
team members in the steps to take in
the event of a bomb threat. As a
review, these are the steps you would
take if you receive a BOMB Threat
over the telephone:
1. Try to keep the caller on the phone as
long as possible, and
2. Ask questions to gather information,
such as where exactly is the bomb
located (questions to ask can be found
in the yellow Environment of Care
Quick Reference Chart).
3. Write down as much information as
you can remember about the caller as
well as specific information regarding
the bomb.
4. Dial, or have a co-worker dial, 3333
immediately to report the situation.
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Code Green Shelter
in Place
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Designates a Hostile Person and/or
Possible Weapon
In the event of any dangerous
criminal activity within our facilities,
there may be an immediate need to
communicate hospital-wide that
everyone should seek shelter and
avoid public areas.
Situations may include a hostile
person, use of a deadly weapon, a
shooting, a serious assault, an
escaped forensic patient and/or a
hostage situation.
Team Members should find the
closest lockable room and
barricade inside far from the door.
Cell phones should be set to
vibrate or silent.
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Code Green Shelter
in Place
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Take immediate action:
 Inform people in your immediate surroundings
to follow you to a secure area, such as an
office or the closest area that can be locked.
 Team members that are not responsible for
direct patient care should try to exit the
building if not in the affected area. Clear clear
public waiting rooms and hallways if in the
immediate area.
 DO NOT attempt to shut patient room doors
as in a Code Red; protect YOURSELF.
 The cafeterias will be secured.
 The gift shop and conference rooms in use
should be secured by those inside these
areas.
When hospital security has been advised by law
enforcement and administration, an ALL CLEAR
announcement will be made using overhead
paging and text pagers. Once the incident is over,
return to your workplace and report to your
manager.
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Code PINK
Code PINK is an actual or
attempted infant or child
abduction.
All UCH team members will need to
be watchful for ANYONE
attempting to leave the unit/facility
with an infant or child in any
fashion.
ALL TEAM MEMBERS are to
respond immediately to the
nearest exit or hallway. BE
ALERT for any suspicious
person(s) carrying any package
– not just an infant or child!
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Code PINK
To help all team members be more
alert to the “size” of the child
involved in the situation, the
following is included when a CODE
PINK is called . . .

If the child is less than one, state to the
operator when calling the CODE PINK to
announce “Code Pink - Infant”.

If the child is over the age of one, state to
the operator when calling the CODE
PINK to announce “Code Pink – Age
____ (state approximate age of child)”.
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CODE PINK . . . Team
Members should pay
attention to anyone:

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Physically carrying an infant instead of
using a bassinet.
Attempting to leave the facility with an
infant on foot, rather than by wheelchair.
Carrying large packages (i.e. gym bag),
particularly if they are "cradling" or
"talking" to it.
Notify Security Services
IMMEDIATELY, if you observe any
such behavior. If the person is
attempting to leave the building, try
to prevent them from leaving.
Security Services phone numbers:
HMH – 5314 UCMC - 2444
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If a CODE PINK is in
effect:
Explain to all visitors who are
unable to exit the facility that
a security incident has taken
place. Reassure them they
will be allowed to leave as
soon as possible and thank
them for their cooperation.
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Rapid Response Team
(RRT)
The RRT is a team of clinicians assist with
assessment and treatment of a patient that has
had an acute change in his/her condition. The
RRT can be called ANYTIME. An ICU Nurse, a
Respiratory Therapist, and the Intensivist/PA/NP,
if needed, after the ICU Nurse asses the patient,
will respond. The Primary Nurse is always a part
of the team. The Stroke Facilitator will also be
contacted if a stroke is suspected.
Purpose: The RRT is a patient safety strategy that
can “rescue” patients when their conditions
decline. It can reduce the number of code blues
and the inpatient mortality rate.
To ACTIVATE the RRT dial ext 3333 and
request the Operator page the RRT.
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Rapid Response Team
(RRT)
The RRT will respond to a Rapid Response Team CALL in
any location with the hospitals, and at UCMC on the
ground floor of the ACC.
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
The RRT will assume responsibility for the treatment of
the patient if he/she is an inpatient.
The ED will also respond to RRT calls in ancillary
departments as well as the UCMC ground floor – the ED
will assume responsibility for treatment of the patient is
not an inpatient.
Patients and family members can call the RRT directly
by dialing ext. 3339 from any hospital phone and
asking the Operator to call the RRT to the patient’s
room. Encourage patients and family members to call
whenever the patient is in an emergency medical
situation and is unable to get the attention of the nurse;
if there is a sudden worsening in the patient’s condition
and the healthcare team is not present; or if there is a
breakdown in communication over what needs to be
done to treat them.
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Rapid Response Team
(RRT)
There are additional Rapid Response Team:
 A Pediatric Rapid Response Team (PRRT) can be
called when there is a need to assess a pediatric patient
in any area of the hospital. A PRRT if for children and
adolescents up to the age of 18. A PALS nurse and a
Respiratory Therapist with ACLS responds. At UCMC a
pediatric hospitalist, a pediatric nurse and the 1 West
charge nurse respond.

The STEMI RRT includes the Primary Nurse, ICU
Nurse, RT, EKG Tech, IV Team Nurse, and the
Intensivist as first responders. The ICU nurse is to take
the STEMI medication box to the bedside.

The OB STAT Team can be called to respond to OB
emergencies . The team is consists of designated
Family BirthPlace team members as well as pediatric
hospitalist, anesthesiologist, respiratory therapist and
other clinical team members as needed.
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RESPONDING to Emergencies for all
other areas on Campus
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For All Other Areas on Campus: Upper Chesapeake Health
will provide immediate medical support and evaluation to those
individuals requiring medical attention while on Upper
Chesapeake facility grounds. The on-campus emergency
response is intended to determine the need for medical
treatment and provide for safe transport to an appropriate
treatment area in a safe and timely manner.
Notification: This notification can come from hospital personnel,
visitors, physicians, law enforcement agencies and guests
passing through the campus.
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Once a team member is notified of an emergent situation, they will contact the
Switchboard by dialing extension 3333.
The Switchboard will call a Rapid Response to the location of the emergent
event.
The Switchboard will then contact the Emergency Department and the Security
Department (each will immediately respond to investigate the situation). The
Switchboard will notify the Administrative Coordinator if on duty.
The Emergency Department and Security Department team members will
respond to the area according to policy.
On campus emergency policy and procedure is being moved to the Rapid
Response Policy and will soon be updated on the UCH Intranet Reference
Library
If a UCH team member is either on or off duty, and encounters an emergency
situation on the hospital premises, UCH requires the individual to assist in the
emergency until relieved by the RRT or EMS.
FYI – AEDs (Automatic External
Defibrillators) are now located in the ACC
and the Physician Pavilions
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II. FIRE PLAN REVIEW
CODE RED
Every TEAM MEMBER MUST know
and understand WHAT to do
when a Code Red is called!
Every TEAM MEMBER MUST know
and understand WHAT to do if
they discover a Fire or Smoke!
Every TEAM MEMBER MUST know
and understand WHAT to do if
they smell or see smoke, or feel
excessive heat in an area that
should not be HOT!
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There are 4 steps that are
CRITICAL and can be
remembered by the word
R
A
C
E
Rescue anyone in immediate danger
Alarm: Sound the ALARM – Get fellow Team
Members to help!
Pull the Fire Alarm and Dial 3333
Tell the operator the exact location of the fire.
Get fellow Team members involved to help respond.
(Note: Pull stations are at doors to stairs or outside,
and nursing stations)
Contain the fire: - Close Doors & Windows
Extinguish the Fire if it is no larger than a waste
basket AND you can do so without endangering
yourself, OR
Evacuate if there is an overhead announcement to do
so from your area or a supervisor tells you to.
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NEVER DELAY IN REPORTING A FIRE
Never delay in reporting SMOKE
SEE FIRE --- INITIATE Code Red
SEE SMOKE --- INITIATE Code Red
SMELL SMOKE?
 Attempt to locate the origin of the smell.
 If you investigate and think the smoke is from
a fire activate the pull alarm and CALL 3333.
 NOTIFY your supervisor or Facilities Services
if you can’t locate the smell or don’t think it is
related to a fire.
By knowing what to do and responding
effectively, you enhance our Fire Protection
Plan and provide a safe environment for
our patients and fellow team members
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EXTINGUISHING A FIRE
REMEMBER – DO NOT fight the fire if it is larger than the
size of waste basket OR if there is excessive heat or smoke.
KNOW the Class of Fire you haveClass A – Common combustibles (paper, wood, cloth–things
that leave an ash)
Class B – Flammable liquids or gases
Class C – Electrical (energized electrical equipment)
TYPES of Extinguishers available-
Class
ABC
Class B & C
ONLY
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Another 4-Step Word for
Using an Extinguisher
•Pull the pin
(before you approach the fire)
•Aim the nozzle
(at the base of fire)
•Squeeze the handle
(start about 6-10’ from the fire)
•Sweep side to side
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What to do if an Inpatient Unit Patient
Room Smoke Detector Alarms
UCMC ONLY
All UCMC Inpatient Room smoke detectors are
connected to the Nurse Call system. If activated the
following will occur:
• Individual smoke detector will alarm inside patient
room.
• A “critical alarm” will ring through the nurse call system
to all nursing CISCO phones and to the console at the
nurses’ station on the unit with the fire/smoke.
• The Switchboard Operator will receive notification of
the specific room number with fire/smoke.
If an inpatient unit smoke detector alarms inside a
patient’s room, go to the patient room where the alarm is
sounding. Follow RACE acronym.
Rescue anyone in immediate danger
Alarm – Activate manual pull station, Call 3333,
Notify Team Members in area of fire. (even if you do
not see or smell smoke)
Contain – Close and latch all doors.
Extinguish – Extinguish small trash can size fires.
Evacuate – If there is an overhead announcement to
do so from your area or a supervisor informs you to.
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ALSO
REMEMBER:
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Fire Exits & Smoke Doors must NEVER be
blocked and must remain closed during a
fire/smoke event
Keep stairs and corridors clear at all times –
NEVER store objects in halls, even if objects
are on wheels.
Reassure patients and visitors that Code Red is
in effect and we are taking appropriate action.

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You may need to explain what a Code Red is:
“We are taking precautions as there may be a fire
or smoke in the hospital – we will keep you
informed”
Team Members assigned to non-patient care
areas should remain in their department, if not
the fire zone.
Team Members assigned to patient care areas
should return to their unit. Be prepared to
evacuate patients and visitors to another smoke
compartment on the same floor if the fire is
nearby.
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AND:
 If in the Code Red location, take charge
of the area and provide leadership to
Team Members.
 Designated Team Members from
Facilities & Security will report to the
Code Red scene. Have a Team
Member wait in the main corridor to
direct respondents to the Code
location. Get Facilities to help cut
power to electrical equipment that is on
fire, if needed.
 Oxygen, gas or other devices that could
aid in the spread of fire should be shut
off (see Patient Care Area slide for
more on oxygen shut-off).
 Keep telephone lines open during any
emergency by not using them unless
absolutely necessary. Avoid calling the
switchboard if you can get information
any other way – they are VERY busy
during a code.
REMAIN CALM
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SPECIAL ISSUES –
PATIENT CARE AREAS
Nursing Team Members
 Report to your nursing unit
promptly
 Account for all patients
 CLOSE doors to patient rooms
 Inform patients and visitors that
the Fire Plan is in effect and to
stay in their room until they
receive further instructions
 Be reassuring and calm
 Clear hallways of all items
 Be ready to implement
evacuation procedures
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SPECIAL ISSUE –
CLOSING OXYGEN VALVES
Respiratory Care Team
Members

Report to scene to assist with
O2 valve shut-off
Nursing Team Members

Charge Nurse or Clinical Nurse
Manager takes charge of O2
issues, if Respiratory TM does
not arrive
Oxygen shut-off priorities
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Identify any patients with a critical need for O2
Assess the proximity of fire and risk to piped O2
Balance the two risks - do any patients need tank
O2 prior to shutting valve AND is there time to do
so without severe fire risk?
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Remember:
Treat every Code Red as an emergency,
even if you think it is a drill. Drills save
lives as they help us rehearse
emergency procedures.
All departments must clear hallways
and close all doors during fire drills,
even if the event is not in your
department or work area.
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SPECIAL FIRE SAFETY TOPIC:
INTERIM LIFE SAFETY
MEASURES (ILSM)
The Joint Commission tells us
that when we have known
disruptions to usual fire safety
features, we must implement
ILSMs
Construction activities that
interfere with Life Safety, such
as those that block hallways,
change exit routes or interfere
with fire safety systems, are
considered such “disruptions.”
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Examples of ILSM Actions
Disruption: Exit paths are temporarily changed
ILSM: Know changes to escape routes (signage
posted), make sure they stay clear
Disruption: Fire detection, suppression or alarm
systems are shut down for needed
work
ILSM: Rounds are made every two hours to look
for possible fire safety issues (usually
Security), control the storage of combustibles
(good housekeeping), ensure emergency exits
are unobstructed
Disruption: The end of a hall is blocked, making a
temporary dead-end.
ILSM: Pay attention to signage informing
occupants of the temporary condition and help
remind patients and visitors in that area of that
condition.
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OTHER ILSM ISSUES
Whatever the disruption may be, it is
important that all Team Members
understand the impairment and ILSMs.
Please pay close attention to signage,
emails from your supervisor and any
other ILSM communications.
There are a variety of other actions taken
by Contractors, Facilities and Safety to
ensure the safety of our patients, team
members & visitors during life safety
disruptions that will not directly
involve you. If you have ANY
questions, please contact your Safety
Officer @ ext. 3120 or pager 410 – 588 0643.
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The safety and well-being of our
patients, families, visitors and
team members are of paramount
importance.
Help to eliminate
fire hazards by
keeping your
work area clean
and free from
non-essential
combustible
materials.
Memorize the
BASIC Fire Plan
- “RACE”
KNOW YOUR
RESPONSIBILITIES
Report fire
hazards
Report all
fires or
suspected
fires.
KNOW where fire
fighting equipment
is and know how
to use a fire
extinguisher –
“PASS”.
KNOW the location
of all fire exits and
how to get to them in
the event of
evacuation.
CLOSE
DOORS
Keep
hallways,
stairs and
exits clear at
all times.
A word about Electrical Safety . . .
ELECTRICAL SAFETY IS
EVERYONE’S
RESPONSIBILITY!
ALL electrical equipment brought into our hospitals
MUST be checked by Bio-Med (if clinical equipment)
or Facilities (if not clinical) BEFORE use. A sticker
will be applied when this check is done, which will give
a date for a recheck, if needed. If you find any
electrical equipment without a sticker or with an
outdated sticker, inform your supervisor.
REPORT any damaged or malfunctioning equipment:
~ DO NOT USE the equipment.
~ REMOVE it from use.
- Put the ORANGE UCH “DEFECTIVE
EQUIPMENT” tag on the equipment so that it is
not used. Write down what is wrong, your
department, your name and the date.
- Take it to Facilities or Bio-Med or call and
arrange for pick-up to make sure it will be
fixed.
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III. Hazard Communication
What is Hazard
Communication?
It is information and education to
INCREASE your awareness about
chemical hazards in your workplace!
It’s your “RIGHT TO
KNOW”
“Right to Know” LAW: The “Access to
Information About Hazardous and Toxic
Substances Act” gives team members a way to
learn about chemical hazards in the workplace
and how to work safely with these materials.
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PRODUCT HAZARDS: Spills,
Exposure and Poisonings
Be aware that many products can
contain hazardous ingredients.


Educate yourself on every product you use.
Read labels.
Know where to get more information about
hazards of a product.


Know how to get an MSDS.


(ANSWER – Material Safety Data Sheet / MSDS)
(ANSWER – It is on the yellow & black MSDS sticker on
the phones. Some departments maintain hard copies in
notebooks. Copies are maintained at both hospitals in
Risk Management in case phones/faxes are not working)
MSDSs contain information on:






Chemical Identification & Hazardous Ingredients
Physical Data
Fire, Health & Reactivity Hazards
Spill Procedures
Personal Protective Equipment
Medical treatment for exposure
READ
ME!
41
CONTROL / MINIMIZE
YOUR EXPOSURE

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






Know your product.
Ask your supervisor if you don’t know.
Keep your work area clean.
Practice safe work habits.
Use Personal Protective Equipment, if
needed.
Don’t eat, drink, or apply cosmetics
around hazardous products.
YOU need to know what to do for a spill
of any chemical used in your department.
Each department with hazardous
materials is responsible to keep spill kits
readily accessible and fully stocked.
Contact your Safety Manager at ext. 3120
if you need further information.
42
IV. Infection Control Overview
SAFETY also includes providing an
environment that minimizes the risk
of infection for patients, visitors, team
members and the community.
Simon says
“INFECTION
PREVENTION
&
CONTROL
IS
EVERYONE’S
RESPONSIBILITY!”
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Important information before you start
this Infection Control and Bloodborne
Pathogen section

If at any time during the review
of the Infection
Control/Bloodborne Pathogen
training you have any
questions, please contact a
member of the Healthcare
Epidemiology and Infection
Control Department. One of
them is available 24 hours a
day, seven days a week.
 Call
3106, 3104 or 5047
 off-hours page 410.588.0407
Let’s review some very
important points...
44
HAND HYGIENE: The MOST
important measure to prevent
the spread of infection!
Perform hand hygiene by using the waterless hand sanitizer .
 when entering and exiting a patient care environment (cleanse
in/cleanse out)
 before and after contact with a patient or anything a patient has
touched.
 before donning gloves when preparing to perform patient care
 before eating, drinking, smoking, applying makeup, or handling
contact lenses.
 before performing invasive procedures.
 before medication preparation.
 after removing gloves
Perform hand hygiene by using soap and running water if (scrub for
15-20 seconds):
 Your hands are visibly soiled
 You finished caring for a patient with Clostridium difficile
 Your hands feel gritty after many consecutive uses of waterless hand
sanitizer
Other aspects of hand hygiene include:
 Keep fingernails neat and clean and do not allow the length to exceed
¼ inch beyond the fingertip
 Artificial nail enhancements are not permitted for any team member
who provides direct hands-on patient care
 Use the hospital approved lotion to help moisturize the skin
45
Keep yourself safe from germs follow OSHA’s law!
OSHA states that
• eating,
• drinking,
• applying cosmetics or lip balm,
• handling contact lenses
are prohibited in work areas where
there is a likelihood of exposure to
blood or other potentially infectious
materials.
Be sure that you are following this in
clinical areas, patient care areas,
desks/counters and medication
carts/areas - - IT’S THE LAW and it is meant to
protect you from infection!
46
STANDARD PRECAUTIONS
Use STANDARD
PRECAUTIONS in
the Care of All Patients
•Prevent spread of bloodborne
pathogens through the use of safe work
practices used in all patient care
activities.
•Wearing Personal Protective Equipment
(PPE) appropriate to the task you are
performing.
47
USE Personal Protective
Equipment (PPE)






PPE is available in all areas of the
hospital.
PPE includes gloves, face protection,
gowns, etc.
Wear appropriate PPE if you WILL or
MAY come in contact with blood or
potentially infectious materials.
FOLLOW established job procedures if
you work in a job where contact with blood
or potentially contaminated body fluids or
contaminated material is possible.
Do not take shortcuts, DO NOT put
yourself or our customers at risk.
For a detailed description of PPE and its
use, please contact the Healthcare
Epidemiology & Infection Control
Department, the Safety Manager or the
Risk Management Department.
48
ALERT FOR CLINICAL AREAS
UCH Isolation Policies


There are 3 categories of isolation used at UCH
All patients on isolation are to be placed in a
private room


If a private room is not available, select an
appropriate roommate. Refer to the Infection
Control Policies and Procedures on the
Intranet and review the Isolation Precautions
Policy for guidance on roommate selection.
When initiating isolation be sure to complete the
following:
1.
2.
3.
4.
5.
6.
7.
Place an isolation sign on the patient room
door
Place an isolation supply box on the patient’s
room door
Place an isolation sticker on the spine of the
patient’s chart
Enter into Meditech the category of isolation
being used for the patient
Provide appropriate patient/family education
and document
Follow policy for proper use of personal
protective equipment
Dedicate equipment used for isolation patient
if possible; if unable, disinfect equipment
before use on another patient
49
ALERT FOR CLINICAL AREAS
UCH Isolation Policies
Let’s REVIEW the three (3) categories of
isolation
1.
Airborne Precautions

Prevent the spread of infections that are transmitted
by small particle droplets that remain suspended in
the air

The patient is placed in a negative pressure room
and keep door closed.

Notify Facilities when a patient is placed on
Airborne Precautions so they can monitor the
ventilation in the room.

Team members wear a PAPR for patient care

If patient must leave room, patient is to wear a
surgical mask while out of room
50
ALERT FOR CLINICAL AREAS
Isolation categories continued . . .
2.
Contact Precautions

Prevent the spread of infections that are transmitted
from skin-to-skin contact or contact with a
contaminated object, i.e., MRSA, VRE other MDRO
(Multi-Drug Resistant Organisms)

used for known or suspected C. difficile. Be sure to
check “must wash with soap and water” on isolation
sign for C-diff.

Team members & visitors must wear gown & gloves
if they touch anything in the patient room
3. Droplet Precautions

Prevent the spread of infections that are transmitted
by large-particle droplets that can be created by
certain medical procedures or by coughing, talking or
sneezing, i.e., influenza.

Team members must wear a surgical mask when
providing patient care

Patient must wear a surgical mask when out of the
room
REMEMBER: For all categories of isolation, read and follow
the instructions on the isolation sign posted on the patient
room door.
51
PREVENT NEEDLE
STICKS/SHARPS
INJURIES

Dispose of needles and sharps in puncture
resistant containers immediately after use.

Use needle safety devices properly; engage
safety devices immediately after use of
sharp

NEVER re-cap a used needle by hand.

NEVER leave needles or sharps exposed or
unsecured.

NEVER practice hand to hand transfer of
any sharps; place sharps on a neutral field
to avoid this type of transfer.
 This applies primarily in areas such as
the OR and ED.
52
MORE INFECTION CONTROL INFORMATION:
 KNOW the location and review the
Bloodborne Pathogens
Exposure Control Plan:

It contains information specific to your job.
 The plan is located in the Infection Control Manual on the
intranet
 Review the task list that applies to your area.
 The plan is reviewed and revised annually.
 You are responsible for knowing about any changes that
occur.
 HANDLE contaminated or potentially
contaminated waste according to procedure
ensuring that it is identified properly, i.e. RED
BAG, Bio-Hazard Label, etc.
53
More Infection Prevention tips
Prevention of Central line associated
bloodstream infections
• Use CVC insertion checklist with each line
insertion
• Provide patient/family education about CVC
infection prevention and document this education
• Avoid use of femoral site if possible
• Be sure dressing is dry and secure
• Scrub the hub each time accessing line
• Assess need for line daily & document; remove
when line is no longer needed
54
More Infection Prevention tips
Prevention of Surgical Site Infections
Before & During Surgery
• patient pre-op bath with antiseptic
solution
• antibiotics within 1 hour of
incision
• follow procedure for surgical hand
scrub
• wear proper surgical attire
• do not remove hair from operative
site unless necessary
• if hair is removed, do in preop area using electric
clippers
• use chlorhexidine to prep surgical
site
• allow prep to dry prior to
incision
• do not routinely flash sterilize
instruments
• minimize traffic in & out of
the OR
After Surgery
• disinfect hands before caring for
wound
• make sure dressing is dry &
intact
• follow procedure for dressing
changes
• d/c prophylaxis within 24
hours of surgery end time
55
IMPORTANT INFORMATION FOR
REVIEW BY ALL TEAM MEMBERS
Review of AIDS, HIV, Hepatitis B, Hepatitis C, and TB
AIDS and HIV Fact Sheet
• AIDS is caused by a virus called HIV (Human
Immunodeficiency).
•“AIDS” stands for Acquired Immunodeficiency
Syndrome.
• HIV infects certain cells of the immune system called Thelper cells.
• HIV can kill these cells, and then a person can develop
other serious diseases.
• HIV is in blood and other body fluids
• The virus is in the blood, semen, vaginal secretions,
cerebrospinal fluid, synovial fluid, pericardial fluid,
peritoneal fluid, amniotic fluid, saliva in dental
procedures, and any body fluid that is visibly
contaminated with blood.
•The virus can be there even if the person has no
symptoms of AIDS or HIV infection. People who are
infected with HIV will carry the disease for the rest of
their lives.
56
People at highest risk of HIV
infection are:

Drug users who share needles

People who have received blood transfusions
infected with HIV, including people who
have hemophilia.

Anyone who has sex with a man or woman
who has HIV or AIDS, or who is at high risk
for HIV or AIDS.

Babies born to mothers who have HIV.
HIV is spread by exposure to blood and body
fluids.
HIV can be spread during sex, by sharing dirty needles to
inject drugs, from mother to baby (before or during birth,
or by breast milk), by getting stuck by a dirty needle, or by
getting blood or other infected body fluids onto a mucous
membrane (mouth or eyes) or onto broken skin. The virus
is not spread by casual contact such as living in the same
household or working with a person who carries HIV,
shaking hands, hugging, or sharing food or drink.
57
Incubation Period and Period of
Communicability:
Although the time from infection to the development of
detectable antibodies is generally 1-3 months, the time
from HIV infection to diagnosis of AIDS has an
observed range of less than 1 year to 10 years after
infection. The period of communicability is unknown
but is presumed to begin early after onset of HIV
infection and extend throughout life.

Early Symptoms to
look for:

Late Symptoms to look for:

white patches in the
mouth (thrush)

fever

weight loss


swollen lymph
glands in the
neck, under
arms and in the
groin area
certain cancers
(Kaposi’s sarcoma,
certain lymphomas)

opportunistic infections
(Pneumocystis
pneumonia, certain
types of meningitis
toxoplasmosis, certain
blood infections, TB,
etc.
58
Hepatitis B Fact Sheet
Hepatitis B is an infection of the liver caused by a virus.
The virus is in blood and other body fluids.
The virus can be found in the blood, semen, vaginal
secretions, cerebrospinal fluid, synovial fluid, pleural
fluid, pericardial fluid, peritoneal fluid, amniotic fluid,
saliva in dental procedures, and any body fluid that is
visibly contaminated with blood. Once infected the virus
can be found in the blood for several weeks before
symptoms start until several months later. Five to ten
percent of adults and up to 90% of babies who catch
Hepatitis B will go on to carry the virus in their blood and
other body fluids for the rest of their lives -- and can
continue to pass the virus on to others.
Hepatitis B virus is spread by exposure to blood and
body fluids.
The virus can be spread by sex, by sharing dirty needles
used to inject drugs, by getting stuck with a dirty needle,
or by getting blood or other infected body fluids onto a
mucous membrane (mouth or eyes) or onto broken skin.
The virus also can be passed from mother to baby, usually
at the time of birth. The virus is not spread by casual
contact such as shaking hands or hugging.
59
People at higher risk of Hepatitis B infection
are:
- Drug users who share needles.
- Anyone who has sex with a man or woman who has
Hepatitis B or is a Hepatitis B carrier.
- Anyone who has multiple sex partners.
- Babies born to mothers who have the virus.
- People who are on kidney dialysis or are
hemophiliacs.
- People born in Asia, the Caribbean, South America,
Africa, the Pacific Islands, and American Indians and
Native Alaskans (the risk extends to their children).
- Health care workers, dental care workers, emergency
workers, laboratory workers, and others who have
contact with blood and body fluids.
- People who live with a person who is a Hepatitis B
carrier.
60
Incubation Period and Period of
Communicability
The time from infection to the development of the
appearance of the Hepatitis B antigen is 45 to 180 days.
It can be as short as 2 weeks and rarely as long as 9
months. All persons who are HBsAG positive are
potentially infectious. About half of people who catch
Hepatitis B never feel sick.
Symptoms to look for:
- tiredness
- loss of appetite
- fever
- vomiting
- yellow eyes and skin (jaundice)
- dark urine, stool light in color
61
Hepatitis C Fact Sheet
Hepatitis C is an infection of the liver caused by a
virus. The virus is in blood and other body fluids.
The virus is found in the blood, semen, vaginal
secretions, cerebrospinal fluid, synovial fluid, pleural
fluid, pericardial fluid, peritoneal fluid, amniotic fluid,
saliva in dental procedures, and any body fluid that is
visibly contaminated with blood. It was formerly know
as non A, non B Hepatitis.
People at higher risk of Hepatitis C infection are:
- Drug users who share needles
- People who are on kidney dialysis
- Health care workers, dental care workers,
emergency workers, laboratory workers, and others
who have contact with blood.
62
Hepatitis C virus is spread by
exposure to blood and body fluids.
The Hepatitis C Virus is spread by exposure
to blood and possibly other body fluids. The
virus can be spread by sharing dirty needles
used to inject drugs, by receiving blood
transfusions contaminated with Hepatitis C
or by getting stuck with a dirty needle.
Incubation Period and Period of
Communicability:
The time from infection to development of the
appearance of infection is usually 6 to 7 weeks
but can range from 2 weeks to 6 months. The
period of communicability is from 1 to 2 or
more weeks before the onset of the first
symptoms. Infectiousness may persist
indefinitely in most persons.
63
Hepatitis C - Symptoms to look for:
- Loss of appetite
- Vague abdominal discomfort
- Nausea and vomiting
- Sometimes yellow skin and eyes (jaundice)
REMEMBER:




The Hepatitis B vaccine is offered to
team members who are at risk for
occupational exposure to blood or other
potentially infectious materials.
It is free of charge and is administered
in 3 injections.
The vaccine is not made from blood
products; you cannot get AIDS or
Hepatitis from the vaccine.
Contact Occupational Health for more
information about the vaccine.
64
In the event that you receive a needle stick, are
cut by contaminated glass, or are exposed to
blood or a potentially infectious body fluid,
report it immediately to the Occupational
Health Nurse and your Supervisor.
A “Report of Occupational Injury or Illness”
MUST be filed and designated procedures
must be followed as defined in the Exposure
Control Plan.
When you are exposed, it is called an
Occupational Exposure to Blood or
Body Fluids.
65


An occupational
exposure is any
skin, eye, mucous
membrane, or
parental contact
with blood or
another potentially
infectious
materials.
The source patient
is the individual
with whom the
team member has
had an
occupational
exposure.

Most exposures do
NOT result in HIV
infection. The risk
of becoming
infected with HIV
after a needlestick
or cut from a HIV
positive source is
about 1 in 300.
66

An occupational exposure is considered a
medical emergency. You must contact
OCCUPATIONAL HEALTH immediately so
that evaluations of your exposure can be
done and medical treatment (if applicable)
can be provided.



If it is after 4pm Monday – Friday or on a
weekend, contact the Administrative
Coordinator
Wash the exposed area with soap and
water and let it bleed freely. If you are
splashed in the eyes, mouth or nose,
rinse the area thoroughly with water.
Complete a Report of Occupational Illness
or Injury according to the instructions
later in this packet.
67

The Occupational Health Nurse or
Administrative Coordinator will provide first aid
and determine if an occupational exposure has
occurred.

If an exposure occurred, a Rapid HIV test will
be done on your blood sample. The source
patient will be asked to consent to the same
blood test. If the source patient is unable to
give consent and no next of kin is available to
consent, or the patient refuses to give consent,
their previously drawn blood in the lab will be
tested. The source patient must be told if this is
done.

Follow-up HIV testing is recommended for a
positive rapid HIV test. The testing is done at 6
weeks, 3 months and 6 months after the
exposure. This will be done in Occupational
Health at no cost to you.
68


If the rapid HIV test
is positive, you will
be given medication.
This medication is
called post exposure
prophylaxis (PEP).
Studies have shown
that if PEP is taken
within the first two
hours of an
exposure it may
reduce your risk of
becoming infected
with HIV.


If you take this medicine,
you will be referred to an
infectious disease
specialist within five
days of your exposure.
Testing, medication and
physician appointments
are provided to you at no
cost.
69





ALWAYS wear gloves when
handling blood or body fluids.
Empty needle boxes when
they are two thirds full; Don’t let
them become full.
Do Not recap needles or place
used needles on beds, overbed
stands or in the mattress of a
patient’s bed.
Use needle safety devices
appropriately.
Take your time and always be
aware of what you are doing!
We care about you and your
Safety.
70
TUBERCULOSIS (TB)
REGULATION: Every hospital is required by OSHA to have a copy
of the federal standard 29 CFR 1910.1035. A copy is located in the
Safety Office. The hospitals must also have a TB Exposure Control
Plan and a Respiratory Protection Program. Please review these
procedures to follow to protect yourself from exposure to TB.
TB is caused by bacteria named Mycobacterium
tuberculosis. This bacteria is so small that it can float
on particles of dust in the air. Someone who has
untreated TB disease can spread this bacteria when
he/she coughs, sneezes, or talks. This provides a way
for the organism to become airborne. Someone may
then inhale the organisms into his/her lungs.
Infection depends upon the number of TB bacteria in the
air. Once the bacteria get into the lungs, it may spread
throughout the body. When you have a healthy immune
system, your body limits the spread and inactivates the
organism. This occurs 4-12 weeks after exposure. The
only sign you may have is a positive skin test (PPD). A
positive PPD test alone does not mean you have TB
disease or are contagious.
71
When the body’s immune system is too
weak to control the organism, TB becomes
active. This is sometimes referred to as
either latent TB or TB disease. About 10%
of the population with TB infection (+PPD)
go on to develop disease.
TB usually occurs in those who have HIV
infection, the elderly, and those who are
receiving chemotherapy. It usually occurs
within 6-12 months after infection. At this
point, the person is infectious and the TB
organism is in the sputum.
Normally, when a person is diagnosed with TB, he/she is
admitted to the hospital, placed in isolation, and treated
with certain medications. This person could be
hospitalized 3 days to 2 weeks. Six months of therapy is
required to eradicate the disease. 50% of people with TB
fail to complete therapy which may lead to reactivation
of disease and even drug resistance (MDRTB). This
means that the organism was partially destroyed and
developed resistance to the drugs that were used
previously. The disease can no longer be treated with the
normal drugs.
72
WHAT CAN WE DO TO PROTECT
OURSELVES FROM EXPOSURE?
It is important to identify the disease early - Be
alert for the following symptoms:
- Productive cough for greater than 3 weeks
- Weakness/lethargy
- Coughing up blood
- Night sweats
- Weight loss
- Loss of appetite
- Fever
• Diagnostic test for TB should be done -- Skin test
(PPD), and if positive, followed by a chest x-ray. If the
chest x-ray is positive, a sputum test is done for TB.
• If TB is suspected or known, isolate the patient.
Airborne isolation is used.
• Notify Facilities Management when placing a patient
on airborne isolation so they can check the negative air
pressure of the room.
73
WHAT CAN WE DO TO
PROTECT OURSELVES
FROM EXPOSURE to TB?

Anyone who enters the room must wear
special RESPIRATORY PROTECTION,
either a PAPR or N95 respirator.


Only certain team members who have been fit
tested in the last 12 months are allowed to use
the N95 respirator. All other team members
must use the PAPR.
The PAPR is a Powered Air-Purifying
Personal Respirator; a battery powered
device that provides positive – pressure
filtered air through a protective hood.
74
For those team members who are trained in the
use of the PAPR, please review the following
information . . . All other team members, please
proceed to SLIDE 77.
Use of the PAPR: When a patient is placed on Airborne
Precautions, all health care workers entering the room
must wear a PAPR. The team member must have prior
training on the use of the PAPR. PAPRs are obtained from
Equipment Distribution.
Perform the following outside of the isolation room:
1. Visually inspect the PAPR unit and the breathing tube for any
damage.
2. If any damage is noted do not use the item - return it to
Equipment Distribution and obtain another unit.
3. Visually inspect hood for any damage. If damaged, dispose it
and obtain a new one.
4. Turn on the PAPR unit to assure that an adequate air flow is
generated at the end of the breathing tube.
THE PROTECTION AFFORDED BY THE SYSTEM
CAN BE NEGATED BY USING A SYSTEM WHICH
HAS VISIBLE DAMAGE.
75
5. Connect the breathing tube to the hood. Be sure it is
seated properly.
6. Turn the PAPR unit on, place the unit around your
waist and fasten the waist belt at a position that is
comfortable, with the motor at the small of your back.
BE SURE PAPR UNIT IS TURNED ON
PRIOR TO ENTERING THE ROOM
7. Place the hood over your head.
8. Check the fit of the hood by doing the following:
a. Check that there is good seal to the face.
b. Air should escape through the holes at the base of
the mask and by the ears only.
c. Check that the air flows to the front of the hood.
IF THE HOOD IS NOT WORN
PROPERLY YOU WILL NOT BE
PROTECTED!
DO NOT TURN THE UNIT OFF WHILE
IN THE PATIENT’S ROOM
76
9. The PAPR system should be removed in the following
manner:
a. Remove the hood.
b. Disconnect the breathing tube from the hood.
c. Remove the PAPR filter unit from your waist.
d. Turn off the PAPR filter unit.
10. Inspect the entire unit for any evidence of
contamination or damage. Remove light
contamination by wiping the area with a disinfectant.
11. Decontaminate the hood by wiping it with an
antimicrobial wipe that MUST NOT contain alcohol.
DO NOT USE ALCOHOL WIPES. A grossly
contaminated hood is to be discarded. At the end of
the shift, place the hood in the soiled utility room for
cleaning (ensure that your name is written on the
hood).
12. Store the unit in the anteroom on the cart or shelf.
Note: When isolation is discontinued, place the PAPR
units, breathing tubes and hoods in the soiled utility
room. return the unit, breathing tube, hoods and cart to
the dirty utility room.
NOTE: Each unit will be replaced every 3 days with a
fully charged unit by Equipment Distribution.
77
THERE ARE SEVERAL UCH
Team Member HEALTH ISSUES
that you need to remember:
1. Team Members are to have a PPD done upon employment,
but only those “at risk” team members (those with
patient contact) are required to have annual PPD’s.
2. If you are exposed to someone with TB who was not
properly isolated, the Occupational Health nurse will
contact you. You may get tested depending on when
your last PPD was done. You would be tested again in
10 - 12 weeks. This is to see if you were infected.
3. If you should develop any of the symptoms listed above,
contact Occupational Health.
If you have any questions about TB and/or need
any additional information on the content of
this section of the packet, contact the
Healthcare Epidemiology and Infection Control
office at extension 5047 or 3106.
78
V. Occupational Health - Injury Reporting
Report of Occupational Illness or Injury
If YOU Experience an On-The-Job INJURY or ILLNESS,
Please follow these steps IMMEDIATELY:
If you have an On-The-Job injury or illness:
 Report to Occupational Health, your supervisor, or the
Administrative Coordinator IMMEDIATELY.
 They will assess your injury and may refer you for further
treatment.
 Complete Section I of the “Report of Occupational Illness or
Injury” prior to the end of the shift during which the illness/injury
occurred. If you are unable to complete the form, your supervisor or
his/her designee will assist you in completing the form.
 Have your Supervisor or the Administrative Coordinator review
and sign the form.
 Forward the yellow copy of the completed form to the
Occupational Health office prior to your departure from UCH for the
day.
 Send any doctor's notes you may receive to the Occupational
Health Nurse Office.
 Send any and all medical bills/receipts that you receive to the
Occupational Health office.
If you have any questions about reporting a team member incident or about
workers’ compensation, please call the Director of Occupational Health at
443.643.4805 or on pager 410.588.0372.
79
Special Tip
for ALL
On-The-Job Injuries
and Illnesses
The review of your injury to
determine if you are eligible for
workers’ compensation cannot begin
until Occupational Health is notified
or receives your Report of
Occupational Illness or Injury, so
please complete and forward the form
immediately.
80
The FORM you will fill out is available in
your work area. It is divided into three
sections.
UPPER CHESAPEAKE HEALTH
REPORT OF OCCUPATIONAL ILLNESS OR INJURY
Section I
Team member fills out the
detailed information as requested
on the form
Section II
Occupational Health
Nurse or Triage Nurse
completes this section
covering the outcome of
the occurrence and
follow-up
Section III
Supervisor Follow-up
FORM # 24901
81
What if you may return to
work, but have restrictions?


Contact Occupational Health
at ext. 4805 or by pager
410.588.0372 IMMEDIATELY.
Upper Chesapeake has a
Transitional Duty Program
that allows team members
who were injured on the job
to return to work, providing
UCH can accommodate the
restrictions.
82
REMINDER

ALL injuries must be reported to the
Risk Management Office and to the
Occupational Health Nurse. This
includes:
 Team
Members
 Physicians
 Agency Staff, and
 Contract Staff

Always complete a “Report of
Occupational Illness/Injury” form –
It’s to protect your health! For
questions, please call:
 Occupational
Health Nurse at UCMC –
ext. 3422
 Occupational Health Nurse at HMH –
ext. 5532
83
Patient Safety is our Top Priority
and YOU are the Key
Every Team Member plays an
important role ensuring a safe
environment

You are the Experts in your field!
 You can identify Policies, Procedures &
Practices that can create safe conditions for
our patient’s well being.
It is Everyone’s Responsibility to

Identify potential hazards
 Report unusual or unsafe situations or
unexpected outcomes
 Manage situations where an adverse event
occurs
 Prevent it from reoccurring
84
Patient and Visitor Safety
What and How to Report Events
What is a Reportable “Event”
Adverse Event/Incident/Error/Near Miss –Any
happening that is not consistent with the routine care
of our patients or the routine operation of the facility.
It can also be the existence of circumstances that
can cause harm if left unchanged.
Examples: Patient or visitor falls; medication or
treatment errors even if it did not impact or reach the
patient…(but it might next time if left unreported and
unchanged)
The Goal of Reporting
With reported events, we focus on identifying and
improving the processes that are found to have
contributed to the event. We recognize that people
can and will make mistakes, so we must redesign
the process or avoid human errors and mistakes.
85
…More on Patient Safety
Reporting of conditions that can, or have
caused harm to our patients and visitors is
everyone’s responsibility!
Non Punitive Reporting Policy
UCH recognizes that if we are to succeed in creating a
safe environment for our patients and visitors, we must
create an environment in which it is safe for caregivers
to report and learn from Events and Near Misses.
UCH promotes openness and requires that errors be
reported, while ensuring that reporting errors be
handled without the threat of punitive action.
Remember to:
 Complete an incident report in ETS (Event Tracking
System) in Meditech before the end of your shift.
 Take immediate steps to prevent the event from
happening again, then begin a thorough investigation
to uncover the root causes and then correct the process.
 If the event is serious, or can lead to serious injury or
death, follow the “Sentinel Event” Policy in the Policy
Library and contact/page the Risk Manager
immediately at exts: HMH:5671 or UCMC:3102.
86
Safety & Security
Remember that Safety is our First
Priority as defined in our 4 Service
Excellence Standards





Always wear your ID Badge.
Ask for an escort by Security to your
car if you are fearful of walking to your
vehicle, especially after dark.
Keep the doors of your car locked with
windows up.
Keep the valuables in your car out of
sight.
Keep yourself and other team
members safe by being aware of your
surroundings at all times - If you see
something or someone suspicious,
notify Security Services.
87
VI. Abuse Reporting
Recognizing Victims of
Abuse
The Abuse Reporting Policy is to
protect children or vulnerable
adults from abuse and to provide
guidance to healthcare
practitioners when fulfilling their
moral and legal duty of reporting
suspected and actual abuse.
 Adult victims of domestic
violence are identified and team
members intervene in their care
in a manner that protects their
safety and privacy.
88
Remember...



If you suspect that a child or adult is
the victim of abuse you will need to
report this to the appropriate agencies
in accordance with Maryland statue.
If you work in a nonclinical department
and overhear or suspect abuse
please report this to the team member
in charge of the patient's care, such
as the RN.
Please review the on-line policies and
procedures for indicators for reporting
suspected abuse and domestic
violence.
89
VII. Legal Compliance and Communication Assistance
Legal Compliance is one
way we:


Act with integrity and
earn the trust of those in
our community
Act responsibily as team
members and follow all
legal requirements when
treating and caring for
patients.
90
The Key Elements of the
UCH Compliance Plan
1.
2.
3.
Education to assure that team members
are aware of laws and regulations
related to the work we do and how those
laws apply to patient care. Examples
are EMTALA, Medicare Secondary
Payer Requirements, and HIPAA.
Regular Monitoring to assure that we
are in compliance with regulations.
Monitoring includes Organ Donation,
Advance Beneficiary Notices, transfers
to other hospitals, charging & billing
practices, and access to protected health
information (PHI) of others.
Reporting of concerns and/or
questionable activities, without fear of
retaliation.
91
What Should I Report to
Compliance
ADD in all of Debbie’s slides
92
False Claims and Whistleblower
Protection Policy
Did You Know . . .




UCH has a policy that requires to require all team members to report all
known or suspected violations of the Federal False Claims Act (FFCA).
A person violates the FFCA by knowingly submitting or causing another
to submit false claims for payment of government funds from
government grant
What is the Federal False Claims Act?
 The FFCA sates in part, that it is a violation of Federal law for any
person to knowingly present, or cause to be presented, to the
Federal Government a false or fraudulent claim for payment or
approval or who knowingly makes or causes to be made a false
record in order to get a false claim paid by the Federal
Government.
Whistleblower Protection
 It is also the policy of UCH that persons reporting such suspected
violations (sometimes referred to as “whistleblowers”) will not be
retaliated against for making reports in good faith.
The False Claims and Whistleblower Protection Policy is located on the
UCH Intranet in the Reference Library. The policy is in the Hospital and
Administrative Policies.
93
Communication Assistance

Laws require health care
providers to make
communication services
available to people with
communication barriers at no
cost to the individual.
 Barriers
may include deaf or
persons with a hearing loss, and
non-English speaking patients,
parents, guardians, companions,
and members of the public.
94
Important Information for
Team Members that
Interact with
Patients and Families





It is important to determine communication barriers
promptly at first contact with the patient (i.e.,
registration, triage, admission, scheduling phone call).
When communication barriers exist, TMs must promptly
obtain and use assistive devices/ services. Contact
Guest Services or Administrative Coordinator (AC) to
obtain.
TMs should not be used as interpreters unless it is a
patient safety issue and only until contact is made with
an interpreter either by speaker phone or an in-person
interpreter arrives.
Even if the person is able to use pen and paper, has a
family member or companion interpreting for them, or
“understands some English” NEVER ASSUME this is
an acceptable method for them to communicate.
Always offer the individual interpretation services and
express that it is at no cost to them.
95
Items available to help the
deaf or persons with a
hearing loss

Sign Language Interpretation Computer
(aka WOW to be obtained from Guest Services or AC).

In-person interpreter

Speech amplifier (pocket talkers available on
(If above WOW not
effective. Must obtain authorization by Guest Services
or AC who will obtain interpreter).
Nursing Units).


Maryland Relay - dial 711
Teletypewriter (TTY) (obtain from Guest
Services or AC).

Television Closed Captioning
(press CC on
call bell to activate).

In-room patient telephones have ring and
volume controls.
96
Items Available to Help
Non-English Speaking
(or Limited English Proficient)

Interpreter by speaker phone
(contact Guest Services or AC to obtain speaker
phone which can be left in patient’s room for future
use, or use TM wireless phone using speaker feature
in urgent situations).

In-person interpreter (Guest Services
or AC must obtain and authorize first, after
determining speaker phone to be ineffective).

Word/Picture sheets (sometimes
referred to as Communication Boards).
97
VIII. HIPAA Privacy & Security
Review of HIPAA Privacy

HIPAA, the Health Insurance
Portability and Accountability Act of
1996, became effective April 2003.
 Security
standards became effective
April 2005


The law ensures that a patient has
the right to have his/her health
information kept private and
secure/confidential.
HIPAA protects the security and
privacy of all medical records and
other health information that is used
or shared in any form - Paper,
electronic, or verbal.
98
HIPAA Privacy LAW
HIPAA is Federal Law and
compliance is mandatory.
 Patient information must be
protected through
conscious effort at all times
no matter where you are!
 The ONLY exception is
when information is shared
in order to provide care,
treatment and payment for
services

99
Protected Health Information

The health information that is
covered under HIPAA is called
Protected Health Information or
PHI.
 PHI
is any information, whether
spoken, electronic or written, that
relates to the past, present, or future
physical or mental health or condition
of an individual, as well as the provision
or payment related to that health care.
 PHI is health information created or
received by a covered entity,
regardless of form, that could be used
directly or indirectly to identify the
individual.

Covered entities include hospitals, care
providers, third party payers, such as
insurance companies, and anyone who
processes health information.
100
Maintaining Privacy of PHI

Where is PHI found?
 Paper
Records of health
information:
Medical Records/Patient charts
 Faxed copies of medical
information.

 Computer
(electronic)
information of files:
Information read off of a
computer screen
 Information transmitted over the
Internet
 Laptops and hand held devices
such as PDAs.

 Video
or audio tape
 Photographs
101
Protecting Patient
Information




UCH polices protect PHI
Information that relates to a
patient’s health cannot be used
unless authorized by either the
patient or someone acting on the
patient's behalf, or unless
permitted by regulation.
Access to information is limited to
only those individuals who need
the information for a legitimate
purpose.
HIPAA ensures that an individual's
health information may only be
used for health purposes.
102
Safeguards

Safeguards protect the privacy
and confidentiality of our
patients

Ensure that information is kept out of
public view/access
 Maintain the confidentiality of your
computer access codes - log off
computers when you are no longer able to
secure the computer information and
NEVER share passwords.
 Routine audits of electronic medical
record access are done to ensure that
patient privacy is protected.
 Team members that do not maintain
patient confidentiality and/or do not
adhere to UCH HIPAA policies and
procedures are subject to the disciplinary
process and possible termination.
103
HIPAA Privacy

Patient Choice
 At
the time of admission, patients are
provided with information about HIPAA
-the Notice of Privacy Practices
 Patients may chose to be
CONFIDENTIAL - these patients will
not be listed in the Hospital Patient
Directory and we MUST keep their
presence in the hospital
CONFIDENTIAL.
 Patients electing to be confidential will
have a “c” on their admission record
indicating their status.
 All patients admitted to UCH are not
confidential until they indicate their
wishes to be confidential
104
HIPAA Privacy Officer


HIPAA requires that each covered
entity have a Privacy Officer.
The Privacy Officers at UCH are:
 UCMC
and ACC: Lynne Adams,
Director of QHIM/UCMC
 HMH: Jane Gordon, Director of
QHIM/HMH

To contact the PRIVACY
OFFICER, send an email to the
“Privacy Officer/HIPAA”.
 This
is no anonymous
 You will receive a reply to your
question or issue.
105
Electronic Security
Under HIPAA



Security of electronic systems is
essential to the continued
normal business operations of
UCH and is mandated by HIPAA
The Electronic Security Policy
resides in the Administrative
Policy Manual
Security standards, password
systems, remote access to the
UCH network are all covered in
the policy
106
Security
Awareness &
Training

Security Reminders
 We
must ALL be diligent and
aware of possible vulnerabilities of
electronic transactions,
maintenance of virus updates,
awareness and implementation of
new policies, etc.

Protection from Malicious
Software
 Team
members are responsible for
reporting and handling the receipt
of an unusual or suspect file
through email; including steps to
clean/quarantine it.
107
Security of
Workstations

Workstation Use
 Computer
systems in public
access areas must use
privacy screens and have
limited password protected
access to network resources
when not in use
108
Access Control:
PASSWORDS


Each user is assigned a unique identifier
Password standards are defined in the
“HIPAA Security Policy”

All sign-ons require dual authentication = user name
& password
 Signing of electronic documents requires a third level
authentication = use of PIN
 Passwords consist of a minimum of 8 characters &
requires a mix of alpha and numeric characters


“Strong” passwords mixing letters and numbers are preferred
Avoid whole words, common names or well known information

All password access will be subject to auditing and
revocation at the request of any UCH Director.
 Passwords will be reissued every 90 days
 Users requiring a password reissue MUST have a
confidentiality agreement on file and provide two
methods of identification (birthdate and last four digits
of the SS#) in the event that a password is lost and
must be revalidated
109
Access Control

Automatic Logoff

In order to protect EPHI, UCH requires
sign off by the user immediately upon
completion of computer usage.
 Workstations automatically log-off the
user after specified periods of inactivity, or
require log-in of the same user from a
screen-saver.

Remote Access

Remote access is provided for UCH team
members and affiliates at the request of a
Director.
 All remote connections are under the
purview of the NSE and requires director
level approval prior to utilization
 All remote connections will be subject to
monitoring and routinely audited.
110
Transmission Security
Encryption
 UCH
has implemented
encryption/decryption technology in
order to protect their EPHI during
transmission.
 Encryption of electronic
transmission of PHI is in place for
all communications on an open
network (i.e. the internet).
 Encryption and email:


A major risk organizations is the use of
email by providers with patients, health
plans and other providers.
Security of the UCH email system is
extremely important and every team
member’s responsibility.
111
UCH Policy: Information
Security

Printing

EPHI should not be printed,
photographed, videotaped,
copied or reproduced in any
way without a defined
requirement and any copying
should be limited to the
minimum necessary to achieve
the requirement at hand
 NEVER leave EPHI hardcopies
unattended in an unsecured
area

Discard hardcopies in secure
recycling bin
112
UCH Policy: Information Security
Photographs and/or videos may
be taken by a physician or at
their direction under any of
the following conditions:




With the consent of the patient or the
patient's personal representative; or
For internal educational purposes only,
to include confidential peer review; or
For patient care, such as wound
documentation and monitoring.
Photographs and/or videos will not be
re-disclosed or transmitted in any format
outside of UCH without the patient's or
the patient's personal representative's
documented consent.
113
UCH Policy: Information Security
E-Mail

The e-mailing of sensitive electronic
data and EPHI should be avoided
whenever possible.
 EPHI should only be communicated
via e-mail under the direction of a
Department Manager.
 EPHI sent via e-mail must be sent
via a password protected document
attachment. The password for the
document must be communicated
via a separate medium with the
receiving party.
114
UCH Policy: Information Security
Remote Workers



Users accessing the UCH system
remotely are responsible for ensuring
that remote devices are not at risk to
spread viruses or malicious software
or capture or track information
exchanged during the session of
remote connectivity.
Team members and affiliates working
with EPHI remotely will be subject to
auditing, remote observation of
sessions and session termination as
required to protect UCH EPHI.
All EPHI accessed from a remote
location must remain within the UCH
network and not be downloaded or
printed at the remote site unless
clearly required to provide patient care
or enable financial processes related
to providing patient care.
115
Portable Electronic
Storage Devices (PESD)


Definition – any device
capable of storing
electronic data and is
easily or regularly
transported outside of the
primary facilities.
Devices (include but are
not limited to) – laptops,
tablets, floppy disks, USB
drives, CD-ROMs, DVDROMs, PDAs, memory
cards or external drives
(thumb drives)
116
Use of Portable Electronic
Storage Devices (PESD)


Efforts should be made to avoid the transport
of electronic data whenever possible.
All devices and data being removed from
UCH premises must be done so with the
knowledge and permission of a department
Director or other senior leader.





All portable devices should have password protection
enabled if available.
All sensitive and EPHI files transported must be password
protected.
When possible, all sensitive and EPHI files transported
must be encrypted.
Electronic data should never be copied to
and left on a personal device such as a
home PC or other remote system where it
may be recovered later.
Any loss of device or data belonging to UCH,
its customers, patients or associates should
be reported immediately via the ETS system
for review by the appropriate bodies.
117
UCH Security Officer

As with HIPAA Privacy, there is
assigned security
responsibility.
 AT
UCH the VP of IT is
responsible for overall Electronic
Security
 UCH has identified a designated
Network Security Engineer
(NSE) reporting to the IT VP

The UCH NSE is Rick Buchman
118
IX. Body Mechanics
USING PROPER BODY
MECHANICS AND MOVING
TECHNIQUES CAN KEEP
YOUR BACK HEALTHY AND
HELP PREVENT INJURIES.
PRACTICE HEALTHY BODY MECHANICS:

Use good posture when you stand, sit and walk.

SITTING - Keep your feet rested on the floor with hips
and knees bent at a 90 degree angle

REACHING - Keep feet “shoulder width apart”, get close
to the item you are reaching for, and DON’T TWIST at
the waist to reach the object - MOVE your entire body
through the reach.

LIFTING –Size up the load before lifting. Keep your
back straight and lift by bending and straightening at
your knees and hips; keep load close to your body. Get
help or use a cart or lift when lifting an object, if
possible. Before lifting a patient, identify the need for a
Hover Matt. Get help to avoid patient and self injury.

AVOID INJURY - Whenever possible, use assistive
equipment, lifts, slide-boards, HoverMatts, a buddy, etc.
to reduce the risk of injury and provide comfort to the
patient.
119
General Advice:






Use good posture and ergonomic
resources to prevent injury and strain
on the body.
If standing or sitting for prolonged
periods of time change position and/or
shift weight every 10-15 minutes.
It is better to push something then pull
it.
Stress and poor diet can contribute to
back problems; Eat healthy and
participate in an exercise program.
Keep your work environment safe and
free of hazards that may lead to injury.
Help each other for patient safety and
to protect yourself from injury.
REMEMBER:
Use your HEAD, not your back!
120
X. Supplement: Aggressive Patient Management
For Team Members trained in
Aggressive Patient Management/
Management of Unsafe Behavior
This is your annual review/update!
All Nursing, Admitting,
Security Officers and Facilities
Team Members MUST complete
this section
SKIP this section if you have not had
this training
- Go To SLIDE 133 121
Main Goals when Dealing with
Aggressive Persons:

Prevent/Decrease the chance for
agitation/aggression. Recognize anxiety! It is
well documented that aggression arises from a
frustration of desires/needs. Be aware of early signs
of anxiety and aggression . Be prepared to interact
quickly to defuse the situation. Be supportive and
show concern. Address frustrations.

Defuse the situation. Maintain safety for all
parties involved; the acting out person, team
members, patients, and visitors. Be aware of the
need to adhere to patient’s rights. Use direct
approach and set limits.

Respond to violence. Approach the person calmly
using a supportive stance, confidence, and a low key
attitude. A combative person should be contained
using non-violent crisis interventions and a team
effort. Knowledge by team member of basic self
defense is documented to reduce the number of
assaults and severity of injury.

Reduce tension. After the incident use therapeutic
rapport to debrief the incident. Discuss what
happened, how it was handled, what went well and
what could be improved.
122
Underlying Factors of
Patient Behaviors
The potential for aggressive behavior
is higher in patients with
underlying issues which include:
1. Hospitalization. Being in the hospital may
increase feelings of fear, anxiety,
vulnerability, and perceived (actual) loss of
control/power.
2. Anger about being in the hospital (i.e.:
their body isn't functioning the way it is
supposed to).
3. Non-compliance with medication.
4. History of violence.
5. History of drug/alcohol abuse.
6. Dementia or delirium as a result of a
disease process such as, head injury,
fever, hypoglycemia, or other electrolyte
imbalance.
Investigate to determine if addressing the
underlying issue may correct the
tendency toward aggressive behavior.
123
VERBAL INTERVENTION TIPS AND
TECHNIQUES:
DO:
1. Listen sincerely.
2. Remain calm.
3. Be aware of your body language and nonverbal messages.
4. Give directives, enforce limits, keep language
simple.
5. Isolate the situation as much as possible, avoid
audiences.
6. Be consistent.
DON’T:
1. Overreact.
2. Get into a power struggle.
3. Make false promises.
4. Be threatening.
5. Use jargon; it tends to confuse and frustrate.
124
Remember restraints are used only as a
last resort to control a situation.
They should be used only after alternative
interventions such as verbal de-escalation,
providing companionship or supervision,
changing or eliminating bothersome
treatments, modifying the environment,
reality orientation and psychosocial
interventions, or diversionary techniques
have been attempted (and documented) and
deemed inappropriate for the situation. If the
situation is so out of control that there is no
choice but to immediately restrain the person,
the situation and why alternatives were not
appropriate must be documented in detail.
The KEY is SAFETY and
DOCUMENTATION!
125
Types of Restraint:

Restraint/Seclusion for Violent or
Self-Destructive Behavior: These are
to be used as an emergency measure to
protect the patient against harm to self
or others. Seclusion occurs when the
patient is prevented from leaving a
designated area or room.

Restraint for Non-Violent or Non-SelfDestructive Behavior: These are to be
used to protect medical devices, such as
dressings, IV, tubes, or to support
healing (pre/post-op restrictions, medical
condition). They are only to be used
when other less restrictive interventions
were attempted/documented and did not
work to prevent the interference.
126
Alternatives to Restraints for
Violent or Self-Destructive
Behavior

Calm
Environment

Time out
 Quiet area
 Dim lights
 Contact with
team member
127
Alternatives to Restraints
for Non-Violent or NonSelf-Destructive Behavior

Music
 Running water
(fountain)
 TV/reading
material
 Family members
 Activity Apron
 Bed, chair or body
alarms
128
Prisoner Patients





Law enforcement officer is
responsible for maintaining
control of the patient.
They should not interfere with
medical treatment of patient.
Handcuffs ARE NOT a hospital
restraint or seclusion.
Handcuffs are managed by the
law enforcement officer.
Law enforcement personnel
receive training regarding
hospital expectations.
129
Your Role with Prisoner
Patients
Responsible for checking
for skin breakdown
around handcuffs
 Responsible for checking
for proper body alignment
while the patient is in
handcuffs

130
-
:
REVIEW:
Use of Restraints




Restraint/Seclusion for Violent or
Self-Destructive Behavior is used as
a last resort to prevent harm to self
or others.
Restraint for Non-Violent or NonSelf-Destructive Behavior is used as
a last resort to promote medical
healing. Examples would be
preventing access to an IV line,
dressing, etc.
PRN orders ARE NOT ACCEPTED
and are not to be transcribed.
Restraint orders must be renewed at
least every calendar day or as noted
in the Restraint & Seclusion policy.
131
Clinical Interventions for
someone in Restraint/Seclusion



Patient needs to be in 
full view at all times
(Violent/SelfDestructive Behavior
ONLY)
Documentation of
observation of patients
q15 minutes
(Violent/SelfDestructive Behavior
ONLY)
Circulation & alignment 
checks of restrained
extremities – adjust
restraints and massage
extremities as needed
Care requirements as
defined in policy with
documentation of all
actions and care

Range of Motion
 Offer toileting
 Offer fluid &
nourishment
 Bathing & oral hygiene
offered/provided
Ongoing assessment of
need for restraint/
seclusion to continue –
Discontinue
restraint/seclusion as
soon as behavior no
longer poses a safety
concern
132
Dealing with an
aggressive person is
a TEAM EFFORT
Call a CODE GREEN by dialing
3333.
Tell the operator your name and
location.
Reference: Code Green Shelter in Place –
Hostile person/possible weapon
133
Joint Commission
Highlights
When using non-volient crisis
intervention a TM observer
must always watch the
patient’s airway.
 Never restrain a child or adult
patient in a prone position.
 Offer first aid to anyone who
has sustain an injury during a
non-volient crisis intervention.

134
Be sure to answer the questions
on the
Post-Test for this supplemental
section. If you have any
questions,
contact the Education and
Resource
Development Department.
135
YOU HAVE COMPLETED
THIS MANDATORY
EDUCATION PROGRAM
NOW…
Assess your knowledge by taking the on line Post
Test for your job group in eLearning by January 31,
2011!
NOTE: SECURITY OFFICERS, ADMITTING and
FACILITIES TEAM MEMBERS should click here to
take the post test or take the “Annual Mandatory
Post Test with APM (UCH-00842)” under the Nurse
tab of eLearning.
Thank you!
136