Download Aspirus Medical Staff

Welcome to Aspirus Wausau Hospital
Aspirus Wausau Hospital is a regional health resource for north central Wisconsin and the Upper
Peninsula of Michigan. Aspirus Wausau Hospital is a Magnet facility licensed for 321 (with 263
available) beds and staffed by 350 physicians in 35 specialties. Best known for its world-class
cardiovascular program, Aspirus Wausau Hospital also provides leading edge cancer, trauma, women’s
health, and spine and neurological care.
Aspirus Wausau Hospital Mission & Vision
Mission Statement
Aspirus is an integrated, community-governed healthcare system, which leads by
advancing initiatives dedicated to improving the health of all we serve. We work
collaboratively with others who share our passion for excellence and compassion
for people.
Vision Statement
Aspirus is the region’s health care system of choice. We deliver value,
innovation, excellence and compassion.
Passion for Excellence. Compassion for People
Aspirus Wausau Hospital Values
Value Statements
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Compassion – We care for our patients above all. We exist to serve those who
choose us. We strive to exceed expectations by showing utmost concern for
their physical, emotional, and spiritual needs.
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Excellence – We create, innovate, and embrace change. We provide superior
quality, showing measurable results. We always aim to improve. We provide a
safe environment for all.
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Integrity – We honor our commitments. We treat everyone with dignity and
respect, being consistent with the trust given to us. We are accountable for our
actions.
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Collaboration – We work well together across the Aspirus system. We partner in
service with people and organizations that share our vision. We value our
workforce. We are active in the community.
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Fiscal Accountability – We prepare for the future of health care wisely. We
effectively and efficiently manage resources, providing excellent and affordable
services that ensure a strong future.
Orientation Guide
This comprehensive orientation includes some key information for your review prior
to practicing at Aspirus Wausau Hospital.
Contents
• Introduction of Hospital Leaders/Services
• Medical Staff Information/Policies
• Communication Methods
• Hospital Department Specific Information
• HIM/CPOM
• CME
• Onsite Orientation – Provider Support Services Contact Information
Aspirus Wausau Hospital Services
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Aspirus Health Foundation
Bariatrics
Behavioral Health Services
Birthing Center/Newborn ICU
Cancer Center
Cardiology
Cardiopulmonary/Vascular Lab
Diabetes Education Center
Digestive Care/GI
Genetic Counseling
Heart & Vascular Institute
Home Health
Home Medical Equipment
Hospice/Palliative Care
Imaging (Radiology)
Joint Replacement Center
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Kidney Care/Outpatient Dialysis
Nephrology
Pharmacy Services
Pulmonary Medicine
Reference Laboratory
Regional Sleep Disorders Center
Rehabilitation, Outpatient Services
Respiratory Services
Senior Health
Spine & Neurosciences
Surgical Services
Trauma Center
Women's Health
Wound & Hyperbaric Center
Medical Staff Structure
Board of Directors
(Joint Commission Required)
Bylaws/Credentials
Committee
Dr. Rengel is President of the Medical Staff
Dr. Hackworth is Vice President of the Medical Staff
and chair of Bylaws/Credentials Comm
Dr. Riveron is Medical Staff Secretary/Treasurer and
chair of Quality Review Comm
Medical Executive Committee
President, President Elect,
Secretary/Treasurer
Quality Review
Committee
DIVISIONS of the Medical Staff
Hospital Based
Chief and Vice Chief
Surgeons & Interventionists
Chief and Vice Chief
Medicine
Chief and Vice Chief
Community Medicine
Chief and Vice Chief
Specialty Representatives are
appointed from the following:
Anesthesia
Emergency
Hospitalists
Pathology
Neonatology
Radiology
Specialty Representatives are
appointed from the following:
Cardiology
Gastroenterology
General Surgery
Neurosurgery
OB/GYN
Oral/Maxillofacial Surgery
Ophthalmology
Orthopedics
Otolaryngology
Pain Medicine
Plastic Surgery
Thoracic Surgery
Urology
Specialty Representatives are
appointed from the following:
Cardiology
Family Medicine
Infectious Disease
Internal Medicine
Medical Oncology
Nephrology
Neurology
Pediatrics
Physical Medicine Rehab
Psychiatry
Pulmonary/Critical Care
Radiation Oncology
Specialty Representatives are
appointed from the following:
Allergy
Dentistry
Dermatology
Endocrinology
Family Medicine
Internal Medicine
Ophthalmology
Podiatry
Psychology
Rheumatology
Organized Medical Staff
The Medical Staff Bylaws Outlines the following:
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Purposes and Responsibilities
Medical Staff Membership
Categories of the Medical Staff
Allied Health Practitioners
Procedures for Appointment and
Reappointment
Determination of Clinical Privileges
Corrective Action
Interviews, Hearing & Appellate
Review
Fair Hearing Plan
Officers
Refer to OnBase Policy #10379
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Committees
Divisions of the Medical Staff &
Specialty Representation
Medical Staff Meetings
Privilege and
Immunity/Confidentiality
Rules, Regulations, Policies & Forms
Conflict Resolution
Dues and Assessments
Histories and Physicals
Bylaws Amendments/Revisions &
Adoption
Medical Staff Officers/Meetings
Officers
President, President-Elect and Secretary/Treasurer are elected biannually via
annual meeting or electronic voting in addition to Division Chiefs and Vice Chiefs.
Specialty representatives are appointed every two years as well. Two years terms
beginning in July.
Meetings
On going Medical Staff committees and specialty meetings are held on a regular
basis. Please contact Provider Support Services at [email protected] for
information regarding dates and times.
Provider Support Services
(aka Medical Staff Services Office)
Providers Support Services provides professional support to Aspirus Wausau
Hospital Medical Staff and acts as a liaison between Administration and the
Medical Staff.
Please let us know if you need anything! Our group email is [email protected].
To contact us individually:
Linda Hackbarth
Director of Provider Support Services
Ph. (715) 847-2268
email [email protected]
Staci Rothamer
Provider Support Assistant
Ph. (715) 847-2276
email [email protected]
Chrystal Rohde
Provider Support Specialist
Ph. (715) 843-1104
email [email protected]
Medical Staff Communication
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Dr Know – weekly electronic newsletter
– Provide PSS a current and working email address (this address is kept
confidential)
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Provider Website
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Communication boards in physician lounge
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Mailings
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Meetings (MEC, QRC, Specialty, Committee)
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Email
Medical Staff - Hospitalists
These physicians provide care for patients during their
hospitalized stay and transfer care back to the patients’ primary
care physicians upon patient discharge. This hospital based care
is available 24 hours a day, seven days a week.
Practice Manager 715. 847.2989
Student Rotations/ Shadowing
• Please contact Physician Recruitment at 715 8472996 or if interested in student rotations.
• Students are not allowed to be in the hospital
without completing an approval process.
Refer to Onbase Policy #7028
Credentialing & Privileging
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Initial Appointment
– Appointment is based on provider’s specialty, and limited to two years from
appointment date.
– The appointment will include approved privileges.
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Reappointment
– Occurs every two years
– Paperwork sent to provider’s primary practice address. Return the
reappointment application by the due date to avoid possibility of privileges
expiring.
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Clinical Privileges granted by the Board
– Privileges are granted at Initial appointment and Reappointment after the
Board of Directors has reviewed and approved your request. Please review
your approved privileges and contact Provider Support Services if you desire
to add or delete privileges. Any changes need to be approved by the Board.
New procedures/services requires additional information such as the
development of privilege criteria. Privileges for all AWH providers are
available on the intranet at I Privileges – Search.
Please refer to Onbase Policy #10379 section 6.2
Practitioner Background Checks
It is the policy of Aspirus Wausau Hospital to comply with Wisconsin law pertaining to background checks. The
checks are intended to identify Practitioners who have been charged with or convicted of a serious crime,
abused or neglected a patient or child or misappropriated patient property. Background checks are conducted
for newly appointed Practitioners and every four years thereafter.
Every Practitioner shall notify the President of the Medical Staff or Chief Executive Officer of Aspirus Wausau
Hospital or their designees as soon as possible, but no later than the Practitioner’s next workday, when he or
she has:
– Been convicted of any serious crime, act or offense.
– Been investigated by any governmental agency for any act, offense, or omission, including an investigation
related to abuse or neglect of, or threat of abuse or neglect to a child.
– A pending charge against him or her for a serious crime, act or offense.
– A finding by a government agency or similar authority that he or she has abused or neglected a patient or
misappropriated the property of a patient.
– A determination by a governmental agency or similar authority that he or she has abused or neglected a
child.
– A license, authorization or certificate that is not current or that is limited so as to restrict him or her from
providing adequate patient care.
We appreciate your understanding and cooperation with this State requirement.
Medical Staff & Hospital Policies
Access to all Policies and Procedures can be
found on the AWH intranet. Click on the Policy &
Procedures Link.
• Aspirus Wausau Hospital Policy & Procedures
For questions on accessing policies please dial 0 and ask for the house supervisor.
Medical Staff Policies
Peer Review Policy
Aspirus Wausau Hospital and its Medical Staff are responsible for the quality of care provided to the patient
population seen throughout the institution. Therefore it is the policy of Aspirus Wausau Hospital to support
the Medical Staff peer review process. The peer review process is a non-biased, professional activity
performed by the Medical Staff (with the assistance and involvement of hospital professional support
personnel) to measure, assess, and where necessary, improve performance of both an individual and/or
system processes. The results of peer review are communicated on an ongoing basis and are used as one
factor in the bi-annual Medical Staff reappointment process.
Ongoing Professional Practice Evaluation (“OPPE”)
OPPE includes the routine monitoring of clinical cases, performance and outcomes data, or occurrences,
to identify opportunities for improvement whether via process improvement or individual and group
performance. OPPE is carried out by specialty peer review committees or select multi-specialty Medical
Staff committee (MMC)
Focused Professional Practice Evaluation (“FPPE”)
FPPE consists of formal evaluation of the details of the performance of a particular member of the
Medical Staff or AHP under certain circumstances such as: When a member or AHP with clinical privileges
is new or when an existing member or AHP has been granted a new privilege; or When questions arise
about whether a practitioner can continue to provide safe, high-quality care.
Refer to On Base Policy #7311
Medical Staff Policies (cont’d)
MEDICAL STAFF CODE OF PROFESSIONAL BEHAVIOR
To create and maintain a culture of safety and quality, it
is the policy of the organized Medical Staff of Aspirus
Wausau Hospital (AWH) that all practitioners who are
members of or affiliated with the Medical Staff conduct
themselves in a professional, cooperative and
appropriate manner while providing services as a
practitioner at AWH. The Medical Staff Bylaws, of which
this Code of Professional Behavior is attendant, shall be
the exclusive means for review and disciplining Medical
Staff members for inappropriate or disruptive behavior.
Inappropriate and disruptive behavior interferes with the
provision of quality patient care and the orderly
administration of the hospital or its Medical Staff. Safety
and quality thrive in a positive environment that
supports teamwork and respect for others.
Refer to OnBase Policy #12885
MEDICAL STAFF SUPPORT COMMITTEE POLICY
PRACTITIONER HEALTH ISSUES
The Medical Staff Support Committee (MSSC) is a
peer review committee providing a forum for
assistance, advocacy, monitoring, education,
consultation, intervention, and recommendations
of policies related to Medical Staff and Allied Health
impairment and disruptive behavior. The Medical
Staff Support Committee exists to ensure processes
exist to identify and manage matters of individual
health for ACI and AWH Medical Staff members and
Allied Health Practitioners that is separate from
actions taken for disciplinary purposes. MSSC’s goal
is to improve the quality of care and promote the
competence of the Medical Staff and Allied Health.
Refer to OnBase Policy #6219
Medical Staff Policies - ALLIED HEALTH PRACTITIONERS
An Allied Health Practitioner (AHP) is an individual other than a physician, oral and
maxillofacial surgeon, dentist or podiatrist who is qualified by academic and/or clinical training
and by prior and continuing experience and current competence in a discipline which the Board
of Directors has determined to allow to practice in the Hospital and who either are to provide
guidelines specific to Allied Health Practitioners associated with AWH Medical Staff. The three
types of Allied Health Practitioners are:
Licensed Independent Practitioners (LIP) –Psychologists and Certified Nurse Midwives. LIPs are
granted clinical privileges but are not members of the Medical Staff.
Advanced Dependent Practitioners (ADP) –. Currently approved disciplines include: Physician
Assistants, Nurse Practitioners, and Certified Nurse Anesthetists. ADPs are granted clinical
privileges but are not members of the Medical Staff.
Dependent Allied Health Practitioner (Dependent AHP) – Provide care to patients in the
hospital under the supervision of a member of the Medical Staff. Currently approved disciplines
include: Surgical Assistants, Dental Assistants, Audiologists. Orthopedic Clinical Nurses, GI
Procedure Assistants, and Physician Employed Research Personnel.
Medical Staff Policies - ALLIED HEALTH PRACTITIONERS (cont’d)
AHPs meet as a group on a quarterly basis and have elected three (3 ) officer
positions (President, President Elect & Secretary) to help lead and focus the
committees goals.
If you would like to contact one of the officers, please contact Provider Support
Services [email protected].
AHPs are credentialed and authorized to practice at AWH through the Medical Staff
and Board of Directors.
Refer to OnBase Policy #4910
Medical Staff Policies – RESTRAINT ORDERS
• After all other options have been exhausted (i.e. Patient Sitters, family
members), the use of restraint must be ordered by a Medical Staff member,
licensed resident, advanced practice nurse, physician assistant or independent
practitioner.
• Restraints must be ordered prior to application except in emergency
situations, when the order can be obtained either during the application of
restraint or immediately (within a few minutes) after the restraint has been
applied.
• The order must also be time-limited up to a maximum of 24 hours as an order
of shorter duration may be more appropriate for some. If the order is
renewed for another 24 hour period, ordered or appropriate designee must
conduct a face-to-face evaluation before writing the new order.
• Restraints must be discontinued at the earliest possible time, regardless of the
length of time identified in the order.
Refer to Onbase policy #6146
Medical Staff Policies - Preoperative Anesthesia Assessment Of Patients
Guidelines for oral intake before elective procedures requiring anesthesia (general,
regional, Monitored Anesthesia Care (MAC))
• Blood work recommendations for patients
• Cardiac Clearance guidelines
• Chest x-ray guidelines
• EKG guidelines
Before patients are brought into the OR for elective surgery or anesthesia, a complete
history and physical examination (H&P) and pertinent physical findings must be
recorded on the medical record. If an H&P has been obtained within 30 days prior to
admission, updates to the patients condition since the assessments must be recorded
at the time of admission. A licensed independent practitioner who has privileges to
perform an H&P can do this update.
Refer to Onbase policy #3138
Rapid Response Team (RRT)
To prevent further deterioration, the RRT may be called to the bedside of any hospitalized
patient, 18 years of age and older, experiencing a change in condition such as:
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Systolic blood pressure less than 85
mm/Hg or greater than 200 mmHg
Heart rate less than 40 or greater than
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SpO2 less than or equal to 90% with
increasing 02 requirements
Respiratory rate less than 8 or greater
than 30
Respiratory distress/compromised airway
Chest pain: new onset
Altered level of consciousness
Acute change in mental status, agitation,
or restlessness
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Sudden loss of ability to speak
New, repeated, or prolonged seizures
Unexplained lethargy/difficulty waking
Uncontrollable bleeding
Loss of peripheral pulse or change in color
of extremity
Failure to respond to treatment for
change of condition
Uncontrollable pain
Acute change in urine output less than 50
ml in 4 hours
RN or family member concern for patient
condition
Rapid Response Team (cont’d)
RRT CONSISTS OF: An Advanced Cardiac Life Support (ACLS) educated Medical/Surgical ICU RN,
Cardiac Telemetry RN and Respiratory Therapist (RT). An Aspirus Hospitalist may be paged if
additional assistance is identified.
RESPONSIBILITIES OF Rapid Response Team:
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Perform assessment.
Begin resuscitation to avoid further decline in condition.
Quickly obtain data for physician
Communicate clearly about patient condition with attending physician and/or
hospitalist.
Mentor non-critical care staff.
Utilize appropriate equipment as needed
The RRT is available in the hospital 24/7
To active RRT please dial 44.
Refer to OnBase Policy #7222
Emergency Call Coverage
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Active Members of the Medical Staff of Aspirus Wausau Hospital shall be responsible for providing on
call coverage for attached and unattached patients presenting in the Emergency Department of Aspirus
Wausau Hospital in accord with this policy.
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The call schedule for a particular specialty shall include those physicians who are members of the
Medical Staff and who are qualified to practice the core privileges within that specialty.
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Emergency Department unattached patient call coverage shall be provided equally by all members of
the Aspirus Wausau Hospital Medical Staff within a given specialty.
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A physician on call should be available via telephone, pager or other mobile communication unit. A
physician on call must be able to respond in person to the Emergency Department within thirty (30)
minutes from initial contact if requested by the Emergency Department physician.
Refer to OnBase policy #6740
CORPORATE COMPLIANCE
Strong ethics policy & corporate culture that fosters ethical behavior
Refer to OnBase Policy #2348 –Corporate Ethics-Conflict of Interest
Policies & procedures to support a program
Refer to OnBase Policy #7410 – Corporate Compliance Plan
Monitoring & auditing systems
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Documentation
Charging
Coding
Billing
Reimbursement
Accurate and clear orders
Complete and legible notes
Medical necessity for services
Authentication of entries (sign & date)
It is your Duty to report issues and your obligation to cooperate in compliance activities and
investigations.
Corporate Compliance Team
Chief Compliance Officer - Cari Logemann 715-847-2166 or 800-450-2339
Physician Representative - Dr. Rick Reding
Compliance Auditor/Privacy Officer - Sandy Lakey, 715-847-2181
[email protected]
CORPORATE COMPLIANCE (cont’d)
HIPAA Privacy Program - It’s everyone’s Responsibility
It’s about Patients Rights
Right to Privacy Notice
Right to Access
Right to Amend
Right to Disclosure
Right to Restrict
Right to File a Complaint
Your Responsibilities
Respect the patient’s right to privacy
Only access information needed to do your job
Keep Information Confidential
Curb human nature – curiosity – sharing experiences
Disclosure of Personal Health Information violates the law
Know Aspirus’ privacy policies
Report Violations to the Compliance Hotline
Compliance Hotline
715. 847.2166 or
800.450.2339
Refer to Onbase Policy #5133
Dr. Joseph F. Smith Medical Library
Jan Kraus, MLS
Dr. Joseph F. Smith (1869 – 1952)
Photo: St Mary’s Hospital – Wausau – Medical Staff 1938
Resources
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UpToDate CME
DynaMed
Micromedex & Clinical Pharmacology
MD Consult
Prescriber’s Letter & Medical Letter
OVID, online books, journals, etc.
Teaching
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Site visits to partner hospitals
One-to-one or formal classes
Evidence-based medicine
Heath Literacy
Vol. Community Faculty UW Madison
Technology
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“Virtual Library” since 2001
Library, Health Literacy & Provider websites
iPads, Podcasts, PowerPoint's, etc.
8 computer workstations
eDocDelivery
Research & Publishing
Library staff will do research for you:
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Clinical questions, direct patient care
Non-direct patient care, grants, white papers …
Patients, family members
Publishing
Library’s collections
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Medical
Nursing/Allied Health
Management/Leadership
Patient/Community
Reference
• Please call the Library for passwords and access
instructions to UpToDate CME, etc.
Online Access
Library Staff Contact Information
Aspirus Intranet
– Select Resources/References
– Medical Library
In Epic
– Click on the red EPIC button in the
upper left corner
– Select Library Resources
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Website: www.aspiruslibrary.org
Email: [email protected]
Phone: 715.847.2184
Fax: 715.847.2183
Medical Staff Resources - Bioethics Committee
Whenever a clinical situation arises that presents a bioethical dilemma for a patient, his/her
significant other(s) or any member of the health care team involved in the case the Bioethics
Committee is available to address the issue. The Bioethics Committee does not mandate changes
in care, but recommends options in regard to addressing the situation and implementing the most
ethically acceptable decision.
It is the responsibility of the physician and the nursing staff to advise the patient and his/her
significant other(s) of their rights to access the Committee.
The Bioethics Program may be accessed through the Bioethics Committee Chair or Provider
Support Services at 847-2276 or 843-1104. After hours please dial 0 and ask for the House
Supervisor.
Refer to OnBase Policy #2498
Medical Staff Resource – Physician Connect
Physician Connect line is 877.697.4324 or 715.847.2737.
Aspirus Physician Connect Operator determines if the caller is looking for Advice for Treatment or Transfer of a
Patient. They document the patient demographics and page the requested Aspirus provider using the On-Call
Schedule. The operator call back number is followed by *888 indicating the page is for a consult or potential
transfer and a physician is holding to talk to them.
The Aspirus Provider, or their assistant, is expected to respond to the page within five minutes. If a response is
not received within five minutes, the operator will either initiate a second page or contact an appropriate
member of the Medical Staff.
When the Aspirus Provider answers the page, the Physician Connect Operator conferences the call for the two
providers. The Physician Connect Operator also remains conferenced in on the call to facilitate any other
necessary connections and/or to contact MedEvac for transport.
After the conversation is completed, the Aspirus Physician Connect Operator calls MedEvac for transport if
required, connects the Aspirus Provider to Hospital Supervisor if appropriate, and documents the disposition of
the call.
Medical Staff Resources - Laboratory Services Provided
Hours: 0630-1730 M-F, 0630-1200 Saturday and Sunday
Location: West Lobby entrance behind Starbucks and next to Patient Registration.
Appointments are preferred, but not necessary.
Chemistry
• Blood Gas Analysis
• Cardiac Marker Analysis – Example: CKMB, CPK,
Troponin T, NT-ProBNP
• Routine Chemical Analysis – Examples: Electrolytes,
Total Protein, Glycosylated A1C, medical ETOH
• Therapeutic Drug Monitoring – Examples:
TheopyLline, Vancomycin, Valproic Acid
• Thyroid Testing – Examples: TSH, FT4, T3
• Tumor Marker Analysis – Examples: CA 1-25, CA 199, CEA, PSA, AFP(Tumor Marker)
• Body Fluid Chemical Analysis – Examples: Total
Protein, Glucose, Albumin
• Other Immunochemistry testing – Examples:
Follicle Stimulating Hormone, Estradiol,
Progesterone, Luteinizing Hormone, Quantitative
Human Chorionic Gonadotropin (HCG)
Coagulation:
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Routine Coagulation testing (PT, PTT,
Fibrinogen)
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Coagulation Factor Analysis
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Coagulation Abnormality Studies
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For Outpatient services (blood draws, urine and
semen analysis collection*)
Medical Staff Resources - Laboratory Services Provided (cont’d)
Hematology:
• Routine Hematology Testing
• Body Fluid Analysis – cell counts, and
differential
• Special Stains for Hematologic Samples
Microbiology:
• Routine Culture and Sensitivity Testing
• Organism Identification
• Parisitology
Immunology:
• Antibody Analysis
• HIV testing
Molecular Testing:
• Factor V Leiden Mutation,
• Prothrombin Nucleotide 20210 G/A Gene
Mutation (Factor II)
• Clostridium difficile,
• Chlamydia
• Gonorrhea
Transfusion Services:
• Blood and Blood Product Compatibility
Testing
Urinalysis:
• Routine Urinalysis Testing
• Semen Analysis –fertility and Post
Vasectomy
• Stool for Reducing and Non-Reducing
Substances
Flow Cytometry:
• Immnuophenotyping of Blood, Bone
Marrow and Tissue
• Helper/Suppressor Analysis
Medical Staff Resources - Laboratory Services Provided (cont’d)
LAB RESULTS/REPORTS
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Computer – Lab results are available in Epic as soon as
tests are completed. If patient had work done as an
outpatient (ER, pre-op, etc.) this is also available in Epic.
The results of tests referred to Aspirus Reference
Laboratory by Aspirus entities also appear in the Epic
medical record.
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Paper Reports – only upon request.
LAB SPECIMEN COLLECTION
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Collection time – routine AM collection is from 04000500 for critical care units and 0400-0600 for all other
care units. Lab does routine collection rounds every
hour. Tests ordered as routine will be collected during
the next hourly rounds. Use of routine priority when
ordering tests facilitates combining draws so patient
doesn’t get multiple venipunctures.
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Nursing staff collects specimens from patient lines and
ports, Respiratory Therapy does arterial sample
collection on critical care patients, and lab collects all
other blood samples.
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Whenever possible lab will use specimens already in lab
rather than having patient receive another venipuncture
when test is ordered with Routine or STAT priority.
Improperly identified or labeled specimens will be
recollected unless specimen is irretrievable.
LAB RESULT AVAILABILITY
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Test Completion Time – Goal is to have general chemistry,
hematology, and coagulation testing complete by 0700 M-F.
QUESTIONABLE RESULTS/REPEAT TEST REQUESTS
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Lab staff will validate questionable results before they are
reported
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Lab will repeat tests at no charge to confirm results when
requested by physician
REFERENCE LAB
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Associated Regional University Pathologists (ARUP) is the
primary reference lab used by Aspirus. ARUP is one of the
largest reference labs in the US and is widely used by
hospitals because of their excellent reputation for quality and
value. Samples we send to them go by air to their main lab.
Results electronically download into our computer system
and are reported as tests are completed.
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For a complete test listing please see our online Reference
Manual – available on the Aspirus Intranet – Resources and
References page. You may also access the manual from the
Aspirus Public website located under Reference Laboratory
on the Our Services Page – www.aspirus.org/ourServices.
Medical Staff Resources Blood Supply & Ordering Information
The Aspirus Wausau Hospital Transfusion Service (x72127) receives blood components through the Blood Center of
Northcentral Wisconsin (BCNW), 211 South Forest Street, Wausau.
The following components are available in our hospital:
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Prestorage leukocyte-reduced red blood cells (300 cc)
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Fresh frozen plasma (~200 cc)
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Random donor platelet packs (50 cc)
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Pooled Cryoprecipitated AHF (120 cc)
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Platelet Pheresis (~260 cc)
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Other products including - albumin, immune globulin, Rh Immune Globulin (300mg/dose) are available
through Pharmacy.
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Packed red blood cells (Prestorage leukocyte-reduced red blood cells are transfused for all red blood cell
transfusions.
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Irradiated products (red blood cells and platelets) are prepared on site for individuals at risk for
transfusion-associated graft-vs-host disease.
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CMV seronegative cellular components are available through the BCNW.
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Autologous and Directed-donor units may be drawn at BCNW. A physician order is required for donation.
Autologous units should be made 3-5 days before needed to assure completion of all processing tests. A
surcharge for autologous and directed units is billed to the patient. Blood donated by blood relatives to be
used as a directed donation requires irradiation before transfusion.
Medical Staff Resources - Pathology
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Associates in Pathology, S.C. offers
comprehensive, CAP certified Histology and
Cytology laboratories processing
approximately 18,000 surgical cases and
20,000 cytology cases, annually. Personalized,
local pathology consultation including frozen
section interpretation is provided
24/7. Routine results are usually available
within 24 hours after receipt of the specimen.
Main office:
(ph) 715-847-0075 or
1-888-228-3375
(fax) 715-847-0065
Hospital Office:
(ph) 715-847-2130
(fax) 715-847-2133
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Normal hours of operation are 7:30am –
5:00pm, Monday – Friday
(excluding major holidays)
Histology Lab:
(ph) 715-847-2000 x53126
(fax) 715-847-2133
Secretary 715-847-2130
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On-call pathologist available 24/7
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During normal operating hours, call 847-2130
Cytology:
(ph) 715-847-2000 x50075
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Outside normal operating hours, call Aspirus
Wausau Hospital operator (847-2000) and
request to page the Pathologist on call
•
To see a listing of AIP Pathologists, click here.
Billing Inquiries:
715-847-0075 or view our FAQ’s on the web
www.aipathology.com
General inquiries: [email protected]
Safety – Aspirus Wausau Hospital Codes
Safety – Aspirus Wausau Hospital Codes (cont’d)
Safety – Aspirus Wausau Hospital Codes (cont’d)
Medical Staff Resources - Medical Imaging
The Medical Imaging department consists of seven
subspecialties of diagnostic radiology:
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Diagnostic X-ray 24hr/7 days
Computerized Tomography CT 24 hrs/7days
Ultrasound (US) 24hrs/7days
Intervention/Angio IR
Magnetic Resonance MR
Nuclear Medicine
Women’s Imaging Center
Ph. 715.847.2283 or x72283
Medical Staff Resources - Nutrition Services
•
All patients are screened by nursing for nutrition risk on admission
•
Patients with positive nutrition screens, specific lab levels or diagnosis, and physician
consults will have in depth nutrition assessments
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Patient education is provided by physician consult
•
All patients on tube feeding and parenteral nutrition will be assessed
•
Patients will receive meals by Room Service while at AWH – they can order between 6:30am
and 6:30pm daily
•
Nutrition Supplements are provided by physician order or as ordered by Clinical Nutrition
Staff
•
Orders for Diet as Tolerated are not accepted. Instead please write for an end diet: i.e.
Advance diet as tolerated to General or to Consistent Carbohydrate
•
The Clinical Nutrition Staff is on site 7 days a week, 8:00am to 4:30pm. Dial 0 and have the
nutritional staff paged
Medical Staff Resources - Pharmacy
Following services are Monday – Friday by Clinical Pharmacists
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•
•
•
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Parenternal Nutrition consults
Hyperemesis Gravidarum Consults
Follow up initial pharmacokinetic consults
Consults that require lengthy research
Pain Management
Following Services are 24/7 basis:
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•
•
•
•
•
•
•
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Drug information
Pharmacokinectic Dosing
Renal Dosing Adjustment
Therapeutic Interchange
BBMC Anticoagulation clinic Referrals
Patient Teaching
Medication Reconciliation
Pharmacy Number
Hyperglyceia Management Policy – Pharmacy to dose
Pharmacy Phone number is 847-2871. Office Fax 847-0005
Medical Staff Resources – Surgical Services
SCHEDULING GUIDELINES
Standing specialty and scheduling release times assigned to all allocated blocks are as follows :
Cardiac Surgery
0 days
Dental
10 days
Dermatology
10 days
ENT
5 days
Eye
5 days
General Surgery
2 days
GI Procedures
5 days
GU Surgery
3 days
GYN Surgery
2 days
Neurosurgery
2 days
Orthopedic Surgery
2 days
Plastic Surgery
2 days
PV/Vascular Surgery
2 days
For the complete policy and bump schedule please refer to Onbase policy #10138
Medical Staff Resources – Interpreter Services
DO YOU NEED AN INTERPRETER?
DO NOT USE FAMILY MEMBERS OR FRIENDS!
Accurate Translations provides interpreter services to
Aspirus, Inc., for the Deaf & Hard of Hearing, Spanish,
Arabic and several other languages 24/7 via video on-demand.
For Aspirus Wausau Hospital campus locations, iPads will be housed in the Aspirus Security
Department and available for checkout when a patient need arises. For offsite Clinic locations,
please contact Human Resources for available options.
Hmong and Laotian - Video on-demand translation will initially be available Monday-Friday,
9:00am-5:00pm only. For Hmong and Laotian translation needed outside of these hours, use of
the telephone translation option is preferred. However, onsite interpreter services are also
available. As interpreter services needs warrant for Hmong and Laotian languages, availability via
video on-demand may be extended.
Remember to have all patients who require an interpreter sign a Patient Determination Form,
whether they elect to utilize an interpreter, or decline the service .
Quality – Patient Safety
When you have concerns about patient safety or quality of care you
should….
Use your chain of command:
•
•
•
First, always notify and discuss your concern with the Department Director and/or House
Supervisor
You can also report your concerns to your Administrator and or the President of the Medical Staff.
It is the policy of AWH that no employee or physician will be disciplined for reporting in good faith
any concern about patient safety or quality of care.
Quality – Patient Safety Event and Unanticipated Outcomes
Organization-wide paperless electronic reporting via Aspirus Intranet of:
• Any unusual event that is inconsistent with the normal routine operation of the health care entity, or any
unexpected outcome that has caused some harm, or has the potential to cause some injury to a person.
•
These capture potential as well as actual:
–
Patient safety events,
–
Medication Events/ ADRs
–
Equipment/product failures
–
Patient Complaints
Once reported, incident will be
investigated, disclosed, and documented
which is a Joint Commission requirement.
•
Refer to OnBase Policy #3289
Just Culture
What is a Just Culture ?
• A Just Culture manages risk by promoting an open and fair environment in which we learn
from our (and others’!) mistakes and are accountable for our behavioral choices.
• We recognize that none of us is perfect and no systems are perfect, but we can work together
to design safer systems and make better choices.
A Just Culture is NOT:
•
•
•
•
•
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Blame Free
Guilt Free
Without consequences
Black and white
Easier
Faster
The Three Behaviors
Human Error
At-Risk Behavior
Reckless Behavior
Product of Our Current System
Design and Behavioral Choices
A Choice: Risk Believed Insignificant
or Justified
Conscious Disregard of Substantial
and
Unjustifiable Risk
Manage through:
Manage through:
Manage through changes in:
•
•
•
•
•
•
Choices
Processes
Procedures
Training
Design
Environment
Console
•
•
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Removing incentives for at-risk
behaviors
Creating incentives for health
behaviors
Increasing situational
awareness
Coach
•
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Remedial action
Punitive action
Investigation is Key………..
Punish
What happened? What normally happens? What does procedure require?
Why did it happen? How was the organization managing risk?
Just Culture Continued…
The Basics
•
•
•
•
•
The Goals
• All are accountable & feel safe to
To err is human
“raise their hand’ and report
errors/near-misses.
To drift is human
• We do not base our responses on
Risk is everywhere
the severity of an outcome.
We must manage in support of
• We see increased peer-to-peer
our values
coaching that curbs at-risk
We are all accountable
behaviors, therefore improving
safety & bettering outcomes.
Quality – Discharge Planning
Quality – Discharge Planning
INFECTION CONTROL -TB CONTROL PROGRAM
•
Medical Staff are required to have a PPD skin test at the time of appointment to the Medical
Staff and annually thereafter.
•
Provider Support Services will send notification of annual PPD skin testing.
•
Providers may have the skin test performed through Aspirus Wausau Hospital Reference Lab
or at a healthcare facility of their choice.
•
Providers with a history of a positive PPD skin test should have that result on file in the
Provider Support Services and will exempt from further skin test requirements. A signs and
symptoms questionnaire is completed annually.
•
RESPIRATORY PROTECTION PROGRAM – RESPIRATOR FIT TESTING
Any provider who sees patients who requires respiratory-AFB isolation because of suspected
or confirmed active pulmonary tuberculosis must be fitted for a N95 respirator before
entering the room.
•
Contact Employee Health at 715-847-2785 to schedule the medical evaluation fit testing .
Infection Control - Hand Hygiene
When to wash with soap and water:
•
Wash with soap and water when hands are visibly
dirty or soiled with blood or body fluids
•
Wash hands with soap and water before eating
and after using the restroom
•
If hands are not visibly soiled use an alcohol
based hand disinfectants decontaminate hands:
When to Decontaminate Hands with Alcohol Hand
Rubs:
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Before having direct contact with patients
•
Before inserting Foley catheters, IV catheters or
other invasive devices
•
After contact with a patient’s intact skin (taking
pulse, blood pressure,)
•
After contact with body fluids, excretions,
mucous membranes, non-intact skin and wound
dressings if hands are not visibly soiled
•
If moving from a contaminated body site to a
clean one during patient care
When to Decontaminate Hands with Alcohol Hand Rubs (cont’d):
•
After contact with objects (including equipment) in the immediate vicinity of the
patient
•
After removing gloves (gloves do not provide complete protection against
acquisition of microorganisms - bacteria from patients are recovered from up to
30% of healthcare workers hands after they remove intact glove
Technique for Use of Alcohol Based Hand Antiseptics
•
Apply enough to cover the entire surface of hands and fingers
•
Rub the antiseptic on to your hands until it is dry – if your hands feel dry after
rubbing for only 10 – 15 seconds, you didn’t use enough
•
Do not wipe excess antiseptic off your hands
•
Wash your hands with soap and water when they are visibly dirty or contaminated
with blood, body fluids
•
Do not use if exposure to C. difficile spores is anticipated – use soap and water
THE "BOTTOM LINE" - REQUIRED OF ALL CLINICAL STAFF
GOOD HAND HYGIENE: HAND DISINFECTION WITH AN ALCOHOL HAND RUB
(OR HANDWASHING WITH SOAP AND WATER IF HANDS ARE DIRTY) MUST BE
DONE PRIOR TO ENTERING AND UPON LEAVING
ANY PATIENT'S ROOM
Infection Control - OSHA’S Blood Borne Pathogens Standard
Methods of Compliance
Significant exposure
Standard Precautions
One of the following occurs:
•
Barrier precautions used to prevent contact with all
patients blood, body fluids, mucous membranes,
excretions, secretions, non-intact skin
•
Needle stick injury or cut with a sharp object contaminated
with blood, bloody body fluids or potentially infectious
•
Personal protective equipment (gowns gloves masks,
face shields, goggles) available in patient care areas
•
Use safety needles/sharps available in all patient care
areas
•
Splash into mucous membranes (eyes, mouth)
•
Do not eat, drink, apply cosmetics or lip balm, or
handle contact lenses in areas where there is a
reasonable likelihood of exposure to blood or other
potentially infectious materials Follow indications for
hand hygiene
•
Blood, bloody body fluid or potentially infectious material
•
Dispose of medical waste in red bags
•
Dispose of used needles in sharps containers
Specimens of blood or other potentially infectious
materials are placed in a container that prevents
leakage
•
All contaminated surfaces/equipment will be
decontaminated with a hospital approved disinfectant
material
on non-intact skin
These should be reported immediately to Employee
Health at ext. 72785 during regular business hours or
to the Hospital Supervisor after hours for follow up.
Refer to OnBase policy #129
Pain Management
• AWH utilizes a verbal pain scale from 0 to 10 where 0 represents “no pain” and 10
represents “worse pain”.
• Pain is assessed and documented on patient admission, every 4 hours, with
change of caregiver and with each new report of pain.
Clinical Documentation
Abbreviations for Medical Staff
• All abbreviations, acronyms, symbols and dose designations in the reference
Stedman’s Abbreviations, Acronyms & Symbols are approved for use with the
exception of dangerous abbreviations (see next slide)
• Approved abbreviations apply to both electronic and handwritten documentation.
• All final diagnoses, complications, operative procedures, medications and consents
shall be recorded without the use of symbols or abbreviations.
• Dangerous abbreviations with list on “ Do not abbreviate patient safety” card are
not be used in both electronic and/or handwritten documentation.
References: Abbreviations Approved for Charting Policy # 7464
Dangerous Abbreviations for Clinical Documentation Policy #7465
Do not abbreviate Patient Safety card #PHARM-052
Clinical Documentation Program
Aspirus Wausau Hospital has had a Clinical Documentation Improvement
Program since 2010.
The Clinical Documentation Specialist (CDS) communicates with providers
regarding missing, unclear, or conflicting medical record documentation in an
effort to clarify and obtain the documentation that will support the
appropriate severity of illness, expected risk of mortality and complexity of
care.
Documentation Query Process
• The CDS reviews most inpatient charts
• When clarification in the documentation is needed, the CDS
will place a Documentation Query in the patient’s chart.
• You are asked to provide the requested clarification within
the progress note and DC summary.
Medical Staff Clinical Documentation (cont’d)
Banned Abbreviation
Potential Problem
Preferred Term
U (for unit)
Mistaken as zero, four or cc
Write “unit”
IU (for international unit)
Mistaken as IV (intravenous) or
10 (ten)
Write “international unit”
QD (for daily)
QOD (for every other day)
Mistaken for each other, use of a
period after Q can be mistaken
for an “I” and the O can be
mistaken for “I” so understood
as QID instead of QD or QOD
Write “daily” or “every other day”
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
Decimal point is missed creating
a 10-fold overdose
Never write a zero by itself after a
decimal point (X mg) and always
use a zero before a decimal point
(0.X mg)
MS, MSO4, MgSO4
Confused for one another can
mean morphine sulfate or
magnesium sulfate
Write “morphine” or “magnesium
sulfate”
Medical Record Completion
•
Attending practitioner responsible for completeness of the medical record.
•
H & Ps required to be placed in the chart within 24 hours of admission
Note* H&P Updates require the following documentation:
– That the H&P was reviewed
– That the patient was examined
– Note any relevant changes or no changes
•
Operative Report must be dictated within 24 hours of procedure.
•
Inpatient telephone & verbal orders must be signed, dated & timed within 48 hours (Note: Another
Medical Staff member may sign, date & time these).
•
Medical Records/Reports must be complete within 30 days. A cautionary notification will be sent from
HIM within 20 days; A phone call and notice of possible suspension will occur on the 30th day;
Suspension will occur if the practitioner does not complete his/her deficient chart within 35 days.
Dictation Process
• Please click on the following attachment for step by step instructions on using the dictation
equipment at Aspirus.
MedQuist Manual
CPOM/EPIC
•You will need to schedule your CPOM/EPIC training. This is typically done by
the clinic or practice manager when scheduling your orientation.
•You will receive user names and passwords to access the electronic medical
record once membership and privileges are approved by the Board. If you
need to have your passwords reset, please contact IT at 715.847.2300.
•Privileges may not be exercised until CPOM/EPIC training has been
successfully completed.
•Please contact Leslie Sedivy our EPIC trainer if you prefer to do some on-line
training prior to your orientation. [email protected]
On-site AWH Orientation
• Orientation Scheduled on Mondays from 11am – 12pm in Provider
Support Services.
• Expectation is that providers complete the online orientation prior to the
on site orientation.
• Issuing of ID badge, Parking Stickers, and Hand Scan will be done during
On-site orientation.
• CPOM training will be scheduled Monday afternoon and Tuesday
morning. Please remember to access the on-line learning modules at
(link)? Double check on this info
Thank You
We look forward to collaborating with you to realize
our mission of making a difference in peoples lives
through passion for excellence and compassion for
people.