Procedure - Phlebotomy - Therapeutic POLICY: DEFINITION ...

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Current Status: Pending PolicyStat ID: 5761068

Original: 6/1/2001Last Approved: N/ALast Revised: 11/12/2019Next Review: 2 years after approvalOwner: Cynthia Murray: Manager,

Surgical Services & SterileProcessing

Policy Area: Nursing

Procedure - Phlebotomy - TherapeuticPOLICY:

DEFINITION/PURPOSE:

SUPPLIES:

Therapeutic phlebotomy may only be performed by nursing staff that have completed the competency for thisskill, or by physician familiar with the procedure. The ordering physician is responsible for the care providedduring procedure. For emergent symptom management, if ordering physician is not present a Code Blueshould be called at which time an Emergency Department physician will respond.

Therapeutic phlebotomy is defined as the removal of blood and the substances contained within it from thecirculatory system via venipuncture or IV access to reduce a fraction of the patient's whole blood volume. Itrequires a physician order to be performed. The usual conditions where therapeutic phlebotomy would beperformed are: clinical situations where there is excessive iron or red blood cells, such as polycythemia vera orhemochromatosis. Once blood has been removed, it must be labeled and disposed in hazardous wastecontainer.

While it is a routine procedure, care must be taken not to bleed more than 10% of a patient's blood volume atany one time except in unusual circumstances.

1 18g IV Catheter1 extension loop with adapter1 3-way stopcock for intermittent infusion if required1 blood collection bag (from Materials Management)1 IV start kit1 BP Cuff1 tape1 Blood scale (from Blood Bank)1 Chlorhexidine prep (Chlora-prep)1 2x2 gauze pad

Non-sterile gloves

Face shield or mask and googles

Procedure - Phlebotomy - Therapeutic. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5761068/. Copyright © 2019 St. Louise Regional Hospital

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PROCEDURE:Preparation for the Phlebotomy1. Verify physician’s order to include:

◦ Documented reason (rationale) for therapeutic phlebotomy

◦ Amount of blood to be removed in ml

◦ Pre-procedure lab work with treatment parameters

◦ Replacement of fluids if ordered (type, volume and rate of replacement)

2. Order pre-procedure lab work to ensure that patient is not already at the target goal. Review lab work. Ifpatient has lab work done within 48 hours of procedure, this may be used as baseline.

3. Hold therapeutic phlebotomy procedure for hematocrit less than 45 and/or ferritin less than 50. Notify theprovider of the above lab value(s) and that procedure is being held.

4. From Blood Bank, obtain the following items:

1. Blood collection bag with transfer tubing

2. The blood scale (must be returned to Blood bank as soon as procedure is completed) Verify bloodscale is calibrated using standardized container of known mass before every procedure to ensurethat correct volume of blood is drawn.

3. Label the collection bag "NOT FOR TRANSFUSION"

5. Verify patient is well hydrated. Offer patient juice and /or water.

6. Assemble equipment and explain procedure to patient.

7. Verify and witness patient’s informed consent for therapeutic phlebotomy and place in the medical record.

8. Identify the patient with two patient identifiers.

9. Take baseline temperature and vital signs for comparison post-phlebotomy.

◦ If SBP is less than 90mm Hg and/or HR greater than 130/min, contact MD prior to proceeding.

◦ If temperature is greater than 99.6F, notify physician prior to proceeding.

10. Call a Time Out Period to confirm the correct patient, the correct procedure, and the correct amount ofblood to be removed. This must be done with another nurse.

The Therapeutic Phlebotomy

1. During the procedure, the patient should never be left unattended due to the danger of exsanguination.

2. Perform hand hygiene and don PPE.

3. Scrub a 2 inch site with Chlorhexidine cleanser.

4. Apply the BP cuff to upper arm and inflate to 90mm Hg (40-50mm Hg may be adequate).

5. Give the patient a rolled up washcloth to squeeze intermittently during blood removal.

6. Perform Venipuncture per hospital policy, use large vein, Anticubital vein is recommended. Attachextension loop with adapter and secure in place.


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7. Insert the needle of blood bag into the adapter of extension tubing.

8. Place the blood drainage bag on a scale on the floor to weigh blood removed (1ml =1.06 grams).

9. Loosen the BP cuff to 60 mm Hg once blood flow is adequate.

10. Unclamp saline lock if needed and let gravity pool the blood to the drainage bag.

11. During Blood withdrawal monitor vital signs every 5 minutes. Observe venipuncture site for any signs ofhematoma. Observe for any signs or symptoms of dizziness, headache or other complaints.

◦ Connect 2 way stop cock to the extension loop.

◦ Connect a syringe to the 2nd port.

◦ draw 40 ml blood at a time, closing flow to the drainage bag during blood withdrawal.

◦ Repeat manual drawing as tolerated or amount to discarded is reached.

12. When desired volume is achieved, clamp the line and deflate the BP cuff. Document volume removed inmedical record.

13. Replace Fluids as ordered by physician post phlebotomy, document replacement fluid lot number inmedical record.

Post-Procedure1. Obtain post-procedure vital signs and notify physician of the presence of new hypotension or tachycardia.

2. Have patient remain in a semi-sitting position for thirty minutes. Encourage PO fluids. If stable assistpatient to standing position, if no positive symptoms, discontinue IV and apply pressure to the site untilbleeding has stopped. Apply gauze with tape.

3. Document the following:

1. Patient tolerance of procedure.

2. Total amount of blood withdrawn in ml as measured via scale.

3. Any unusual events.

4. Start and end time of therapeutic phlebotomy.

5. amount of fluid volume replaced and lot number of IV solution used.

6. Vital signs performed

7. Post-procedure note.

4. Discharge outpatients to home as ordered if VS remain stable and patient tolerates ambulating in room. Ifinpatient, report to primary care nurse details of procedure and assessment of patient.

5. Double bag the blood container in a red bag and label with patient name and medical record number anda sign that states, “Not for Transfusion”. Send the bag to the lab for disposal.

All revision dates: 11/12/2019, 7/13/2017, 9/1/2007

Attachments:


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Approval Signatures

Step Description Approver Date

Health and HospitalCommittee (HHC)

Kristy Takeda: Health Care Program Analyst pending

Medical LeadershipCommittee (MLC)

Brittney Slibsager: Medical Staff Services Manager [KT] 11/20/2019

Director of Nursing,Critical Care, & NursingAdministration

Gloria Dela Merced: Hospital Executive [MD] 11/19/2019

Medical Director, ClinicalLaboratory

Ada Chan, M.D.: Medical Director Clinical Laboratory 11/13/2019

Clinical Lab Manager Denise Chorley: Clinical Lab Manager 11/13/2019

Owner Cynthia Murray: Manager, Surgical Services & Sterile Processing 11/13/2019

Medical ExecutiveCommittee (MEC)

Brittney Weltz: Medical Staff Services Manager [KT] 3/4/2019

VP / CNE Lori Katterhagen: VP Patient Care & Clinical Services / CNE 1/8/2019


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Original: 10/1/2007Last Approved: N/ALast Revised: 10/23/2019Next Review: 3 years after approvalOwner: Pam Holmquist: Infection

Prevention and CaseManagement Director

Policy Area: Infection Prevention & Control

Health Screening - Students and ContractWorkers

PURPOSE:

POLICY:STUDENTS IN NURSING CLINICAL ASSIGNMENTS:1. It is the responsibility of the student's school to assure required screening has been completed and

documented prior to assignment at St. Louise Regional Hospital.

2. It is the responsibility of the student's clinical instructor to maintain records and all records will bemaintained in St. Louise Regional Hospital Employee Health Services Department. Records will beprovided to Employee Health as soon as available and must be reviewed and cleared by both EmployeeHealth and Nursing Education prior to starting. Employee Health will send clearance to NursingEducation who will send the final clearance to the school after compliance/credentialing documents arealso complete.

3. Employee Health will do N95 Mask Fit testing and CAPR training prior to assignment at St. LouiseRegional Hospital at no cost for those who enter rooms of airborne isolationpatients.

OTHER STUDENTS:1. It is the responsibility of the student's school to assure required screening has been completed and

documented prior to assignment at St. Louise Regional Hospital.

2. Students records will be reviewed in Employee Health prior to starting work. All TB screenings,immunizations, titers, and chest x-rays are the responsibility of the individual.

3. Employee Health will do N95 Mask Fit testing and CAPR training prior to assignment at St. LouiseRegional Hospital at no cost for those who enter rooms of airborne isolation patients as needed.

To comply with Title 22 Hospital Licensing Act, 70723 (q-d), and Centers for Medicare and MedicaidServices,(CMS),Conditions of Participation for Infection Control 482.42 and pertinent OSHA Standards,students and contract workers assigned to St. Louise Regional Hospital will complete health screeningrequirements. Students and contract workers will provide a completed "Health Screening Form for Studentsand Contract Worker" prior to assignment to Employee Health Services.

Health Screening - Students and Contract Workers. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/4822948/. Copyright © 2019 St. Louise Regional Hospital

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4. Once health screening requirements are met, Health Screening Records will be maintained in St. LouiseRegional Hospital Employee Health. Employee Health will send a clearance to Nursing Education onceall EHS requirements are met.

CLINICAL CONTRACT WORKERS (intermittent):1. It is the responsibility of the individual worker's employer to assure required screening has been

completed and documented prior to clinical assignment at St. Louise Regional Hospital.

2. It is the responsibility of the Department Manager/Director to which the contract worker is assigned toforward such record to Employee Health Services for review.

3. All TB screenings, immunizations, titers, and chest x-rays are the responsibility of the individual.

4. Employee Health will do N95 Mask Fit testing and CAPR training prior to assignment at St. LouiseRegional Hospital.

5. Once health screening requirements are met, Health Screening Records will be maintained in St. LouiseRegional Hospital Employee Health Department.

CONTRACT WORKERS:1. It is the responsibility of the hiring Department Manager/Director to notify Employee Health Services and

Human Resources of assignment prior to clinical assignment at St. Louise Regional Hospital.

2. Individuals medical records will be reviewed in Employee Health Services prior to starting assignment. Alltiters, immunizations, TB screenings and chest x-rays will be the responsibility of the individual or theiremployer unless otherwise stated in individual contracts. Employee Health will send clearance to HumanResources who will send final clearance of all compliance/credentialing/medical requirements uponcompletion to the appropriate company.

3. Employee Health will do N95 Mask Fit testing and CAPR training prior to assignment at St. LouiseRegional Hospital at no cost as needed.

4. Responsible Department Manager/Director will be notified in writing by Human Resources of theindividual's clearance to start work.

5. The individual's Health Screening Records will be maintained in Employee Health Services.

NURSING CONTRACT AND REGISTRY WORKERS1. It is the responsibility of Nursing Administration/Staffing Office to notify Employee Health and Human

Resources of assignment to St. Louise Regional Hospital. It is the responsibility of Employee Health toassure required screening has been completed prior to clinical assignment at St. Louise RegionalHospital.

2. All titers, immunizations, TSTs and chest x-rays will be the responsibility of the individual or theiremployer.

3. N95 Mask Fit testing will be the responsibility of the individual's employer or may be completed at SLRHEmployee Health upon arrival.

4. The individual's Health Screening Records will be maintained in the Employee Health Services Office.


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PROCEDURE:A. POST OFFER/PRE PLACEMENT

The post offer/pre-placement screening will consist of items listed on attached EHS ScreeningRequirements for Students and Contractors:

1. RUBELLA

a. Documentation of immunity by one dose of Rubella Vaccine/MMR OR

b. Positive Rubella titer indicating immunity.

2. RUBEOLA

a. Documentation of immunity by two doses of Rubeola/MMR Vaccine

b. Positive Rubeola titer indicating immunity.

3. CHICKEN POX

a. Documentation of prior history of disease by physician statement OR

b. Positive Varicella titer OR.

c. Documentation of 2 doses of Varivax immunization.

4. MUMPS

a. Positive Mumps titer OR

b. Two doses of Mumps/MMR vaccine

5. HEPATITIS B (for clinical staff)

a. Documentation of Hepatitis B Vaccination Series AND

b. Documentation of positive HBsAb 1-2 months after series completion* AND/OR

c. Copy of signed Hepatitis B Declination Form

d. Students are required to have documentation of three dose series; in case of exposure aHBsAB will be performed by Employee Health Services.

6. TUBERCULOSIS

a. Documentation of TST (two-step) the most recent within three months prior to clinicalassignment and the prior TST done within prior year OR

b. Documentation of IGRA TB blood testing within 3 months of placement OR

c. Documentation of positive TST/positive IGRA and negative Chest x-ray within three monthsprior to agency hire or start of school program and current symptom review and no symptoms ofTB.

d. If an individual is a converter at anytime during placement, documentation of medical evaluationfor prophylaxis is required.

7. TETANUS, DIPHTHERIA AND PERTUSSIS (Tdap)

a. Between the ages of 19-64 who have direct patient contact and not received Tdap in the past,should receive a dose of Tdap without regard to the interval since the previous dose of Td.Pregnant HCP need to get repeat doses during each pregnancy. Tdap will replace Td on anevery 10 year basis OR a declination should be signed.


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8. INFLUENZA (Applicable from October 1 – March 31 Annually)

a. Documentation of current annual Influenza vaccine OR

b. Documentation of current annual Influenza decline form and wearing of a mask whenever in apatient care area during the above time frame.

B. ANNUAL

1. TUBERCULOSIS SCREENING

a. Documented positive TST/IGRA individual: Review Pulmonary TB symptoms and Chest x-ray ifnecessary

b. Documented non-reactive TST/IGRA individual: Tuberculin Skin Test/IGRA annually

c. Employee Health will do N95 Mask Fit testing annually every 12 months, at no cost, for thosewho enter rooms of airborne isolation patients.

2. Tuberculin Skin Tests/IGRA, Rubella, Rubeola, Varicella, Mumps and Hepatitis B titers may beobtained through Employee Health and the cost of the test may be charged to employer of contractworker.

REFERENCE:1. CDC: Advisory Committee on Immunization Practices and Immunization Action Coalition ; February 2016

2. CDPH Immunization and Immunity Testing Recommendations for California Healthcare Personnel andHealth Science Students; August 2015

3. CMS 2007 Conditions of Participation for Infection Control 482.42

4. Title 22 Hospital Licensing Act, 70723 (q-d)

5. CDC : Guideline update January 2003

6. OSHA Standard 29CFR 1910.134 Bloodborne Pathogens

7. California Code of Regulations - Title 8, Section 5199. Aerosol Transmissible Diseases


Attachments:Approval Signatures







Brittney Weltz: Medical Staff Services Manager 1/30/2019

Pharmacy &Surveillance (P&S)Committee



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Human ResourcesDirector

Jillian Madison: Director, Human Resources 6/1/2018

Employee HealthNurse

Liesel Short: Employee Health Nurse 5/31/2018

Owner Pam Holmquist: Infection Prevention and Case Management Director 5/21/2018


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Original: 10/1/1999Last Approved: N/ALast Revised: 10/23/2019Next Review: 3 years after approvalOwner: Angela Vasquez: Food &

Nutritional Services DirectorPolicy Area: Food and Nutritional Services

Infection ControlPURPOSE:

POLICY:A. Standard/Universal Precautions will be followed. All body substances are assumed infectious and shall be

treated as such by all personnel at all times, for all patients, regardless of patient's diagnosis.

B. All employees will follow the guidelines for Infection Control as stated in the Hospital Infection ControlManual.

C. RESPONSIBILITIESDepartment Director

1. Monitor and assure Infection Control Standard/Universal Precautions practice of staff.

a. Evaluate cleanliness and food-handling practices.

b. Provide safe food service for patients and employees.

c. Ensure proper maintenance and operation of equipment.

d. Keep adequate records regarding temperature of refrigerators and freezers within thedepartment.

e. Provide and document personnel education regarding personal hygiene, food preparation,handling and storage, and sanitation at the time of hire, annually, and as necessary. Identifyactual and potential infection control problems and inform the Infection Control Practitioner.

f. Submit all new or revised policies and procedures that may relate to infection control to thePharmacy and Surveillance Committee for review prior to adoption

g. Report ill employees with communicable infections or questionable work status to EmployeeHealth or Infection Control.

h. Participate as requested in epidemiologic investigations.

i. Maintain ice machines in a clean and sanitary manner.

j. Evaluate employee performance including items related to infection control/sanitation/safety oneach employee job description.

k. Provide for the accessibility of aprons, hairnets, gloves, hand soap, and hand sanitizer to

To provide guidelines for prevention of infection in the Food and Nutrition Services Department.

Infection Control. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/4665832/. Copyright ©2019 St. Louise Regional Hospital

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prevent employee exposure to communicable diseasesEmployees

a. Comply with Infection Surveillance, Prevention and Control policies and procedures and with Healthand Sanitation/Food Handling practices established by state and local law.

b. Report any infectious exposure occurring at work to the immediate supervisor.

c. Routinely report any observation of unsanitary conditions.

d. Participate in Infection Surveillance, Prevention and Control educational activities.

e. Follow all procedures and guidelines as outlined in Food and Nutrition Service Procedure Manual,

f. Food handlers with diarrhea are not to remain at work. They are not to return to work until 24 hoursafter diarrhea has stopped or they have received clearance from a physician or from EmployeeHealth.

Infection Control Coordinator

a. Collaborate with Nutrition and Food Services on education programs relevant to InfectionSurveillance, Prevention and Control.

b. Provide consultation and direction on issues relevant to Infection Surveillance, Prevention andControl.

c. Inform Nutrition and Food Services of infectious exposure that may have occurred and provideappropriate referral for follow up.

d. Enlist the services of Nutrition and Food Services when conducting epidemiologic investigations, asindicated.

D. Personal Attire

1. All employees must report for work in a clean uniform.

2. All personnel shall wear hair nets or caps.

3. Employees shall wear no jewelry except: plain wedding bands, and studded earrings.

4. Beard covers are worn, if facial hair is evident.

5. Aprons are promptly changed when they become soiled. Aprons are not worn into rest rooms oroutside of the department.

6. Aprons are changed and hands washed when employees move from soiled to clean area.

7. Employees shall prevent miscellaneous items from falling into food by not carrying items in shirtpockets, behind the ears, stuck in the hair, etc.

8. Personnel will comply with OSHA Bloodborne Pathogen Exposure Control Plan. Personal protectiveequipment (gloves, gowns, and eyewear) is to be used if exposure to body, body fluids, excretionsand secretions is likely

E. Hand Hygiene

1. Employees shall comply with the SLRH Hand Hygiene Policy.

2. Employees shall thoroughly and frequently perform handwashing using soap and running water orhand sanitizer:

a. Before beginning work;

b. Between handling of dirty dishes or equipment and handling clean food or utensils;


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c. After each toilet use;

d. After all work breaks;

e. After removing gloves;

f. Between handling uncooked and cooked foods;

g. After each instance: coughing, sneezing, smoking, touching face and/or hair;

h. After visiting patient rooms, prior to returning to food production areas; and

i. After each touching of inanimate objects that may be a source of contamination if the nextcontact with the hand(s) is food or food contact surfaces

F. Visitors in Food and Nutrition Services Department

1. Only food service employees are allowed in the food preparation and service areas.

2. Other personnel may be given clearance to work in these areas if required to do so in theperformance of their duties and must wear hair covering

G. Supplies, Materials and Equipment

1. Food is to be stored in a manner to prevent spoilage or contamination. Items used in foodpreparation are to be carefully inspected before use for signs of spoilage or contamination.

2. All equipment is disassembled, cleaned and sanitized after use.

3. De-glazed, cracked or chipped china and glassware is to be discarded.

4. Dishwashing and utensil washing will conform to the standards set forth by state and countyregulations.

5. Disposable containers and utensils are not be used more than once.

6. Cutting boards are to be used only for designated food groups, i.e., cutting boards used to preparemeats are not to be used for preparation of fresh vegetables.

7. Trays returning from patient use or the cafeteria will be handled as potentially contaminated.

H. Housekeeping Measures

1. Work counters are cleaned after each use.

2. Floors are swept and mopped at least once per day.

3. Tray carts are wiped after each meal with a sanitizing solution.

4. Tables are wiped after all meals and more frequently during peak periods with a detergent solution.

5. Environmental Services is responsible for sweeping and mopping the cafeteria dining room.

6. Refrigeration units are cleaned routinely.

I. General Patient Food Tray Delivery

1. Food Service personnel shall request nursing personnel to clear tray tables of personal items,hygiene linens, dressings or other items prior to delivering meal trays/nourishment to patients.

2. Food service provided to patients in the Emergency Room area shall be provided in accordance withStandard/Universal Precautions. Meals/nourishments for Emergency patients shall be delivered andretrieved by nursing personnel.

3. Food service personnel involved in the rinsing and washing of patient dishes and trays shall wash


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hands before beginning in such duties and upon completion thereof and before proceeding toanother area and/or task.

4. Gloves shall be worn during all tasks involved in rinsing and washing of all patient dishes and trays.

5. In the event Food service personnel discover trays and/or dishes which are visibly soiled with feces,urine, emesis, blood, dressings, or sharps, or contaminated therewith, or discover any item notgenerally considered to be a food service item, such contamination/item should be reportedimmediately to the appropriate supervising personnel and said tray and/or dish so contaminatedshould be set aside in such area as designated. Contaminated item will be removed by nursingpersonnel. The Infection Control Practitioner is notified.

6. Protective equipment (gloves, goggles, gowns and aprons) shall not be standard procedure for FoodService personnel delivering and retrieving meal and nourishment trays and dishes but shall beavailable and utilized where appropriate and/or where designated by Standard/Universal Precautionsprocedures for the nursing floor and/or area involved and/or at the discretion of the supervisingpersonnel in charge.

7. Lowerators and dish storage cabinets are cleaned according to the Cleaning Schedule.

8. For patient food service, individually prepackaged servings of milk, margarine, cream, sugar, andcondiments are used. For the cafeteria, salads and desserts are chilled and displayed behind a"sneeze guard".

9. Employees wear protective gloves while handling clean silverware for patients.

10. All foods being displayed, held, or transported are protected from contamination in cleanrefrigerators, heat maintenance equipment, ice tables, or carts, and appropriately covered.

11. Hot foods are held in heated wells at trayline.

12. Food items served chilled are held in refrigerated areas until service times.

13. Food items that have been in the patients' rooms are discarded.

14. During service and handling, employees refrain from touching the food contact surfaces of dishesand serving utensils.

15. Warewashing procedures ensure sanitized service ware and prevent recontamination.

16. Disposable containers and utensils are discarded after the initial use.

17. Food for a patient prepared outside the hospital may occur under the following conditions:

a. The physician writes an order for "food from home".

b. The food should not be contraindicated on the patients' diet.

c. The food should be eaten immediately or if is to be eaten at a later time, nursing will cover, labeland date the food/beverage and store it in the patient refrigerator.

d. It is nursing responsibility to document in the medical record that the patient ingested foodprepared outside of the hospital.

e. Generally, inpatients are not allowed use of the cafeteria service area.

J. Patient Food Services for Patients in Isolation

1. All trays for patients that are isolated are served on regular dishes.

2. Nursing personnel are responsible for delivery and pick up of trays to patients in rooms with a "stop"


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sign alert posted.

3. Suspected Food-Borne Outbreak

a. Infection Control Practitioner is notified.

b. Any leftover food from meals should be sent to laboratory for culture.

K. Cafeteria Foods

1. Hot foods are held in heated wells during service in the cafeteria. A heated warming cabinet mayalso be used for holding hot foods

2. Food items served chilled are displayed on chilled counters in the cafeteria, ice tables or held inrefrigerated areas until service.

L. Waste Control

1. All appropriate food items are discarded into waste receptacles nearest the work areas.

2. All other garbage is put into leak-proof, non-absorbent garbage cans with liners and removed aftereach meal and as necessary

3. Garbage cans are emptied into the outside compactor as needed.

4. Garbage cans are steam cleaned; lids are washed in the dishmachine weekly and as needed.

5. Garbage cans have tight-fitting lids

M. Pest Control

1. At no time are solid poisons or strips or related contaminants left exposed in production/service/storage areas.

2. Regular extermination is performed by a contracted exterminator.

a. Routine spraying is done in such areas as baseboards, backs of large equipment, cabinets, andlower-level storage areas with an approved insecticide; traps are put out for rodents. Thecompany is responsible for laying all baits and applying all sprays.

b. Any evidence of pests found by employees is reported to the Director.

c. The Director inspects all areas where food is stored, prepared and served.

d. The company services the area on a scheduled basis and as needed.

N. Controls on the System

1. Environmental culturing will be done under the direction of the Infection Control department asneeded.

2. Temperatures are monitored in the dishwashing areas to assure maintenance of wash and rinsewater temperatures.

3. Temperatures are monitored in the refrigerated units and food service area to assure food ismaintained at the appropriate temperature.

O. Food and Nutrition Associate Education

1. All new employees are instructed in proper handwashing technique.

2. Annual mandatory education should include at least the following:

a. Health and cleanliness;


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b. Correct hand washing procedures;

c. Sources of foodborne illnesses;

d. Routes of transmission of infection;

e. Cleaning of equipment and physical plant;

f. Techniques to minimize sanitation hazards during handling, storage, preparation and serving offood;

g. Care and storage of supplies;

h. Proper disposal of wastes

All revision dates: 10/23/2019, 4/1/2015, 6/1/2012, 8/1/2009, 8/1/2007







Medical ExecutiveCommittee


Pharmacy &SurveillanceCommittee


Chief ExecutiveOfficer (CEO)

John Hennelly: Chief Administrative Officer 4/3/2018

Infection Preventionand CaseManagement Director

Pam Holmquist: Infection Prevention and Case Management Director 3/5/2018

Owner Angela Vasquez: Food & Nutritional Services Director 3/5/2018


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Original: 10/1/2003Last Approved: N/ALast Revised: 10/23/2019Next Review: 1 year after approvalOwner: Anthony Le: Pharmacist

ManagerPolicy Area: Organization-Wide

Allergy ScreeningPOLICY:

PURPOSE:

PROCEDURE:1. Upon admission or at the initiation of care in the emergency room, St. Louise Regional Hospital personnel

will determine if the patient is allergic to a medication, food, contrast media or other item, e.g. latex. Theadmission clerk or nursing personnel will enter this information or the notation of No Known Allergies,"NKA", into the demographic database section of the hospital's clinical computer system.

2. Prior to administering any medication, food, etc, nursing personnel will confirm the allergy data and ifnecessary modify the demographic database section of the hospital's clinical computer system.

3. When the patient demographic information is sent to pharmacy, the pharmacist will annotate themedication or contrast data into the demographic database section of the hospital's clinical computersystem. If this information is unavailable the pharmacy will not process pharmacy orders until the allergystatus of the patient has been documented.

4. When the pharmacist notes the patient is allergic to a component in the medication orders, the pharmacistwill contact the floor nurse or the physician to determine if the order is correct or should be changed. If thephysician still wants to prescribe the medication, the pharmacist or nurse will annotate such fact in theappropriate section of the hospital's clinical computer system. If the physician changes the order, thepharmacist/nurse will complete a verbal order. Calls made by the pharmacist to the physician will bedocumented in the hospital's clinical computer system.

All revision dates: 10/23/2019, 8/1/2007

Attachments:

It is the policy of St. Louise Regional Hospital to determine if a patient is allergic to any medication and ensurethat the patient is not exposed to that allergen. Allergy information will be entered into the hospital's clinicalcomputer system.

To insure that a patient will not experience an adverse event associated with a known allergen.

Allergy Screening. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5607690/. Copyright© 2019 St. Louise Regional Hospital

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Approval Signatures


Health andHospitalCommittee (HHC)


MedicalLeadershipCommittee (MLC)




Pharmacy &SurveillanceCommittee (P&S)


Director ofNursing, CriticalCare & NursingAdministration

Gloria Dela Merced: Dir. of Nursing, Critical Care & Nursing Admin. [KT] 9/12/2019

Owner Anthony Le: Pharmacist Manager [KT] 9/12/2019

Allergy Screening. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5607690/. Copyright© 2019 St. Louise Regional Hospital

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Emergency Department - Discharge PrescriptionsPOLICY:

PROCEDURE:1. The physician shall write a medication order, in the Medical Record for the medication to be dispensed.

Notation of direct dispensing to the patient by the Emergency Department physician shall be noted in thepatient's medical chart.

2. The order shall include the name of the medication, strength, quantity, and instructions. Quantity shall belimited to 2 or 3 doses.

3. The physician must, prior to dispensing, offer to give a written prescription to the patient so that thepatient may have the option to have it filled at any pharmacy. The patient shall be instructed to have theprescription filled by a near-by outside pharmacy.

4. The Nurse, acting as an agent of and under the direct supervision of the prescribing physician, mayacquire the medication from the automatic dispensing machine (i.e. Pyxis) per hospital procedures and insufficient quantity as per the physician order.

5. The Nurse, acting as an agent of and under the direct supervision of the prescribing physician, shall labelall medications dispensed to the patient according to state and federal laws and regulations and ensureall of the requirements of good pharmaceutical practice are met. The dispensing information is recordedand provided to the pharmacy when the pharmacy reopens. Dispensing information will be forwarded tothe appropriate regulatory agencies by the pharmacy director as required by law.

6. The physician must include the following information on the "Prescription Label" as stipulated inCalifornia State Pharmacy Law.

◦ Name of Patient

◦ Prescription (RX) number

To provide a means of supplying patients with a limited supply of medications restricted to only those hourswhen prescription services from community pharmacies in the immediate area are unavailable or the failure toprovide the medication will cause an unnecessary health risk for the patient. The law provides for dispensing ofmedications by physicians to patients provided the information required for a prescription dispensed by apharmacy is included on the prescription label and the same information is included in the patient record. Thenurse or physician may use this properly labeled medication to give an initial dose of medication in theEmergency Department until the prescription may be filled by an outpatient pharmacy.

Emergency Department - Discharge Prescriptions. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5608306/. Copyright © 2019 St. Louise Regional Hospital

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◦ Date of issue

◦ Name of Prescriber

◦ Drug Name

◦ Drug Strength

◦ Direction for the use of the drug

◦ Quantity

◦ Expiration date (included on unit dose packaging).

◦ Auxiliary Cautionary labels

◦ Name and address of the hospital

7. The physician must check the final product and initial the label prior to dispensing to the patient.

8. The physician or nurse, after verification by physician, may dispense the discharge medications to thepatient.

9. Verbal and when possible written discharge medication counseling must be performed prior discharge bythe nurse or physician.

10. Record Keeping: The medication dispensing record shall be maintained and documented in the medicalrecord and the activities report maintained by the Pyxis Medstation automated drug dispensing system.These records shall be maintained and readily retrievable as per applicable laws and regulations.

REFERENCE:












Director of Gloria Dela Merced: Dir. of Nursing, Critical Care & Nursing Admin. [KT] 9/23/2019

California State Board of Pharmacy Regulation Section 4076Health and Safety Code 11190 and Business and Professionals Code Section 4170


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Nursing, CriticalCare & NursingAdministration



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ManagerPolicy Area: Pharmacy

IV to Oral Conversion for MedicationsINTRODUCTION AND BACKGROUNDPOLICY:

• Minimization of risk associated with parenteral therapy• Potential reduction in length of stay• Reduction in direct drug cost• Reduction in drug administration cost• Reduction in drug preparation cost• Ensured response to pharmacist recommendation• Greater involvement in patient care and documentation of pharmaceutical care services

1. H2 Receptor Antagonists

2. Quinolones

◦ Levofloxacin

◦ Ciprofloxacin

3. Fluconazole

4. Metronidazole

5. Pantoprazole

6. Linezolid (Zyvox)

7. Azithromycin

8. Doxycycline

The Pharmacy Departments will develop and implement an IV to PO (or NG) conversion policy that authorizespharmacists to automatically switch therapy based on approved criteria for oral medication administration. Thispolicy would apply to a select list of agents. Benefits of such a system are:

The pharmacist will review the therapy of all inpatients receiving the following parenteral agents and write achart order converting the parenteral agent to the oral equivalent when the patient meets all inclusioncriteria for oral medication administration.

These medications are 100% bioavailability equivalent from IV to PO.

IV to Oral Conversion for Medications. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5611135/. Copyright © 2019 St. Louise Regional Hospital

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POSITION STATEMENTPROCEDURE:1. Within 24 hours of the initiation of the identified parenteral agents, the pharmacist will review the patient's

chart to assess the feasibility of oral medication administration.

2. Table 1: Criteria for oral medication administration:

◦ Oral intake advised by physician:

▪ No NPO order in chart

▪ No preoperative of postoperative fast ordered

▪ Oral dietary intake (or tube feed tolerance)

▪ Other medications administered orally

▪ No risk of aspiration (i.e., decreased level of consciousness, seizures, HOB flat, etc.)

▪ No gastrointestinal obstruction

◦ Reliable oral medication tolerance:

▪ No nausea, vomiting or diarrhea

▪ No order for continuous gastric suctioning

▪ No malabsorption syndrome

▪ No gastric or esophageal motility disorder

▪ No short bowel syndrome

◦ Medication is not ordered for urgent/emergent situation requiring rapid onset of drug action.

◦ Patient is not refusing oral medications

◦ Patient is not being treated for a CNS/meningeal infection(IV antimicrobials should be maintained for these infections)

3. When the patient is receiving the parenteral form of a medication listed in Table 2, the pharmacist willreview the chart and Write a chart order for the equivalent oral doses of the identified agent(s) tocommence 24 hours after the order is written.

Example: "Change IV Pepcid to PEPCID 20mg PO BID per Protocol."

4. The pharmacist will leave a Pharmacy Communication note in the Physician Progress Note section of thechart alerting the physician to the order. The physician may countersign the order or change the orderback to IV dosing. If parenteral therapy is preferred the physician will note the reason for continuing the IVmedication on the Pharmacy Communication note. The pharmacist will document the reason for IVtherapy in the hospital's clinical computer system.

Table 2: Targeted IV Medications - for 24 hour conversionMedication Class Medication - IV Oral Dosing Conversion IV to PO

H2 Antagonists

Famotidine 40mg/24hr 20mg q12hrs 1:1


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Medication Class Medication - IV Oral Dosing Conversion IV to PO20mg/24hr 20mg qday 1:1

Antimicrobials

Levofloxacin 500mg q24hr 500mg q24hr *per Rx

250mg q24hr 250mg q24hr *per Rx

Ciprofloxacin 400mg q12hrs 500-750mg q12hrs *per Rx

200mg q12hrs 250-500mg q12hrs *per Rx

Metronidazole 500mg q8hrs 500mg q8hrs 1:1

500mg q12hrs 500mg q12hrs 1:1

Fluconazole 400mg q24hr 400mg q24hr 1:1

200mg q24hr 200mg q24hr 1:1

100mg q24hr 100mg q24hr 1:1

Linezolid 600mg q12hr 600mg q12hr 1:1

Azithromycin 500mg q24hr 500mg q24hr 1:1

250mg q24hr 250mg q24hr 1:1

Doxycycline 100mg q12hr 100mg q12hr 1:1

Proton Pump inhibitors

Pantoprazole All IV doses Pantoprazole 40mg daily*Recommended IV to PO Dose conversion per pharmacists' clinical and pharmacokinetic assessment.

5. The pharmacist may also contact the physician directly, if convenient, to receive authorization toimplement the IV to PO conversion immediately on all parenteral agents identified in this policy. If averbal order is obtained, the pharmacist will write a chart order to switch the parenteral agent to the oralform with no delay.

6. The pharmacist will readdress the potential for IV to PO conversion every 48 hours while the patientremains on parenteral therapy.

7. The pharmacist will document interventions according to current procedures.


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Attachments: Pharmacy Communication Note Intravenous toOral Medication Conversion


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Approval Signatures










VP / CNE Lori Katterhagen: VP Patient Care & Clinical Services / CNE [KT] 1/4/2019

AntimicrobialStewardship ClinicalPharmacist

Olga DeTorres: Antimicrobial Stewardship Clinical Pharmacist [KT] 1/4/2019

Owner Norman Fox: Pharmacy Director [KT] 1/4/2019


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Tetanus ProphylaxisPURPOSE:

DEFINITIONS:

POLICY:

A. Clean Wounds

1. Uncertain or less than 3 doses previously received.

2. More than 10 years since last dose/booster.

B. All Other Wounds

1. Uncertain or less than 3 doses.

2. More than 5 years since last booster.

C. tDAP vaccine is indicated in patients 10 through 64 years old. tDAP may be used for tetanus prophylaxisin wound management. Determine whether the patient has completed primary immunization. Patientswith primary immunization and who sustain wounds that are minor and uncontaminated, should receive abooster dose of tetanus toxoid (tD) if they had not received tetanus toxoid containing preparation withinthe past 10 year. For tetanus prone wounds, a booster is appropriate if the patient has not received atetanus toxoid containing preparation within the last 5 years. tDAP vaccine can be used as a one-timealternative to Tetanus and Diphtheria Toxoids Absorbed.

D. Tetanus Immune Globulin

1. If uncertain or less than 3 doses and determined necessary by the physician.

PROCEDURE:A. Considerations

To provide guidelines for Tetanus immunization and booster as recommended by the Center for DiseaseControl.

Serious or Tetanus Prone Wound: Contaminated with dirt, feces, soil, saliva, puncture wounds, avulsions,missile wounds, crush injuries, burns, or frost bite.

Tetanus immunizations should be considered under the following circumstances:

Tetanus Prophylaxis. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/4553463/. Copyright© 2019 St. Louise Regional Hospital

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1. Has the patient completed the primary Tetanus series?

2. Has the patient received a booster during the last 10 years for clean wounds and 5 years for seriousor Tetanus prone wounds?

3. Contraindications to Pertussis prophylaxis, include any of the following responses related to previousPertussis immunization:

a. Encephalopathy (within 7 days)

b. Convulsion (within 3 days)

c. Persistent screaming or crying (3 hours or more within 48 hours)

d. Collapse or shock

e. Temperature above 104.9° (unexplained by another cause)

f. Allergic reaction

4. Local reaction to Tetanus immunization does not preclude its use

5. Use adult tDAP or Td for patients greater than 10 years old. DTaP, for patients less than 10 yearsold.

B. Equipment

1. tDAP (first time dose),Td (Tetanus) Booster 0.5ml (10 year or greater) DTaP, pediatric less 10 yearsold.

2. Hypertet 250 units (as ordered by physician)

3. 3ml syringe

4. 25 gauge needle

5. Alcohol swab

6. Small Bandage

C. Procedure Steps

1. Document Tetanus immunization history.

2. Determine the need for Tetanus prophylaxis.

3. Obtain physician order.

4. Provide educational literature (see attached) to patient/legal representative.

5. Answer questions as required.

6. Obtain written consent for immunization.

7. IM injection of vaccine.

8. Observe for potential adverse response.

9. Explain signs and symptoms of normal response versus adverse reaction to immunization.

D. Documentation

1. Date of last immunization/status of series

2. Vaccine information materials provided

3. Vaccine type, dose, site


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4. Manufacturer, lot number, expiration date

5. Response to immunization

6. Discharge/follow-up instructions

7. Name/title of person administering vaccine








Medical Executive Committee(MEC)


Pharmacy & Therapeutics(P&T) Committee


Medicine Department Brittney Weltz: Medical Staff Services Manager 7/30/2018

Surgery Department Brittney Weltz: Medical Staff Services Manager 7/30/2018

Maternal Child HealthDepartment (MCH)


Emergency Department Brittney Weltz: Medical Staff Services Manager [KT] 6/13/2018


Owner Norman Fox: Pharmacy Director 5/15/2018


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Original: 10/1/1999Last Approved: N/ALast Revised: 10/23/2019Next Review: 3 years after approvalOwner: Laura Guido: Director of Ancillary

ServicesPolicy Area: Organization-Wide

Respiratory Therapy Role in NeonatalResuscitation

PURPOSE:

POLICY:A. The Neonatal Resuscitation Provider (NRP) Certified Registered Nurse and physician will initiate steps to

resuscitate an infant who is unable to maintain adequate ventilation or circulation.

B. Resuscitation will follow American Academy of Pediatrics Neonatal Resuscitation Provider (AAP-NRP)Guidelines. A physician will perform intubation and/or view cords as needed and order the administrationof medications.

C. The NRP Certified Respiratory Therapist will be asked to attend high-risk deliveries and provideassistance as needed. Their responsibility includes assisting with the physician in intubations, intubatewith endotracheal tube (ET) or Laryngeal Mask Airway (LMA), stabilization of the ET tube, setting upnecessary equipment for the care of the sick infant, and perform cord and blood gas analysis upon orderof a physician.

PROCEDURE:A. Prepare Equipment:

1. Radiant Warmer

a. Turn on and adjust heat.

2. Turn oxygen ON to deliver 100% set flow to 5- 10 l/min

a. Adjust Anesthesia bag or Self-inflating bag with oxygen reservoir to deliver pressure of 30- 40cm when squeezed and 5cm when not squeezed.

b. Select appropriate size mask. If meconium is present have meconium adapter readily available.

3. Turn suction ON.

a. Check vacuum pressure not >100mmHg.

b. Pinch tubing to make sure suction working properly.

To provide guidelines to establish an airway, institute breathing, maintain cardiac support, while minimizingheat loss.

Respiratory Therapy Role in Neonatal Resuscitation. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/4070680/. Copyright © 2019 St. Louise Regional Hospital

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4. Prepare Endotracheal tube.

a. Select appropriate size. Shorten tube to 13cm if time permits. Re-apply ET adapter.

b. Insert stylet into ET tube to just above the end of the tube.

c. Place ET tube with adapter back into sterile packaging and place in convenient location.

5. Laryngoscope.

a. Select appropriate size blade (No. 0 or No. 1).

b. Check laryngoscope for brightness of bulb.

6. Steps in Resuscitation—Follow NRP recommended procedures:

a. Place baby under radiant warmer and remove wet towel.

b. Maintenance of infant's temperature during resuscitation is imperative to prevent furthercompromise.

c. Dry infant (for meconium stained infants do not dry until airway is determined to be clear orunable to completely clear airway and infant severely depressed).

d. Establish an airway.

▪ Position infant with neck slightly extended.

▪ Suction the mouth then the nose with bulb syringe or suction catheter.

e. Evaluate Respirations.

▪ If breathing, evaluate heart rate.

▪ If apneic or gasping or persistently cyanotic:

▪ Tactile stimulation (DO NOT waste time doing this) begin positive pressure ventilation with100% oxygen usually at a rate of 40-60 breaths per minute.

▪ Assess ventilation by chest excursion and breath sounds.

▪ If inadequate ventilation, evaluate infant's neck position, seal of mask on infant's face, andsecretions.

f. Infant requires intubation if unable to effectively bag and mask ventilate or bag and maskventilation is likely to be prolonged.Pressures:

▪ 15-20 – infant with normal lungs

▪ 30-40 – initial breath following delivery

▪ 20-40 – infants with pulmonary disease.

B. Intubation

1. To minimize hypoxia during intubations:

a. Ventilate infant with bag and mask with 100% oxygen, limit intubations attempt to 20 seconds,and provide free-flow oxygen during intubation attempt.

b. If unable to intubate after 20 seconds, ventilate infant with bag and mask with 100 oxygen.

2. Ventilate infant with the least amount of pressure necessary. Infant should appear to be taking ashallow or "easy" breath.


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3. Use Miller Size 0 laryngoscope blade for premature and Miller Size 0 or 1 for term infant.

a. Make sure stylet DOES NOT extend past end of ET tube.

b. Vigorous suctioning may stimulate vagal nerve, causing bradycardia.

4. After ET tube placement is confirmed by x-ray, trim ET tube so that no more than 4cm extendsbeyond infant's lip.

5. An oral gastric (OG) catheter should be inserted to prevent abdominal distension after 2 minutes ofassisted ventilation.

Endotracheal IntubationApprox.Weight

Approx.Gestation

ETSize

Approx. Distance ofInsertion

Size SuctionCatheter

<1000 gms <28 wks 2.5 6-7 cm 5

1000-2000gms

28-34 wks 3.0 7-8 cm 6.5

2000-3000gms

34-38 wks 3.5 8-9 cm 8 Fr.

>3000 gms >38 wks 3.5,4.0

9-10 cm 8 Fr.

6. Artificial ventilation can be stopped once infant has established spontaneous respirations and heartrate above 100.

C. Laryngeal Mask Airway (LMA) Insertion

1. Deflate the cuff and the lightly lubricate the mask. Use size 1 LMA

2. Perform slight head tilt, open the patient's mouth and insert the tip of the mask along the hard palatewith the open side facing but not touching the tongue.

3. Insert the mask further, using the index finger to provide support for the tube.

4. Eventually, resistance will be felt at the point where the tip of the mask lies at the upper esophagealsphincter.

5. Inflate the cuff using an air-filled syringe attached to the valve at the end of the pilot tube.

6. Secure the LMA

D. Evaluate heart rate.

1. If heart rate less than 100 start bag and mask ventilation with 100% oxygen or intubate infant.

2. If heart rate is between 60 and 80 increasing continue to ventilate infant.

3. If heart rate is between 60 and 80 and not increasing or less than 60, begin chest compressions asper AAP-NRP Guidelines.

E. Place radiant warmer temperature probe as soon as possible.

F. Place infant on Cardio respiratory monitor and O 2 sat monitor as soon as possible.

G. Place IV or assist physician with umbilical artery catheter (UAC) placement.

H. Administer appropriate drugs as needed and per physician order.


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1. Narcan should NOT be given to infants of narcotic addicted mothers, which may result in severeseizures.

I. Documentation:

1. Neonatal Resuscitation Form

2. Code Evaluation Form

• Radiant Warmer• Stethoscope• Suction Equipment

◦ wall or machine suction◦ bulb syringe◦ suction catheters (14fr., 12fr., 10fr., 8fr., 6.5fr.)

• Oxygen Equipment◦ ability to deliver 100% O 2◦ flow meter◦ oral airway (No. 00 and 0)◦ Anesthesia bag or self inflating bag with oxygen reservoir, pressure manometer◦ masks; premature and term sizes◦ meconium adapter

• Intubation Equipment◦ ET tubes – 2.5, 3.0, 3.5, and 4.0◦ Laryngoscope◦ Blades size 0 and 1◦ Stylet◦ Tape◦ Non-bacteriostatic saline

• Umbilical Vein Catheter (UVC) / UAC Supplies◦ Umbilical line catheters (5fr. and 3.5fr.)◦ stopcock◦ blunt needle◦ 4.0 suture◦ sterile gloves◦ umbilical catheterization tray◦ heparin solution◦ Betadine solution◦ IV fluids for line as per physician order.

• Emergency Drugs (kept in top drawer of nursery crash cart )◦ Calcium Gluconate 10% injection 10ml concentration◦ Dextrose 10% bag 500ml◦ Dopamine HCL 400 mg in Dextrose 5% 250ml bag (1600mcg/ml)◦ Epinephrine 1:10,000 10ML syringe◦ Naloxone◦ Sodium Bicarbonate 4.2% syringe 5Meq/10ml◦ Sterile Water for Injection 10ml vials◦ Sodium Chloride 0.9% 10ml vials preservative free

Equipment:


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• Cardio-resp. monitor• O 2 saturation monitor• Assorted sizes of syringes and needles• Cord clamp• Glucometer• Gavage tube (5fr. and 8fr.)• Newborn Resuscitation Record




Health and HospitalCommittee








Maternal Child HealthDepartment (MCH)



MCH Director Louise Fry: Maternal Child Health Director 5/25/2018

Owner Laura Guido: Cardiopulmonary Services & Wound Care Center Direc 9/21/2017

Textbook of Neonatal Resuscitation (6th ed.). (2011). American Academy of Pediatrics and American HeartAssociation.

LMA Insertion Technique. (2013, May 1). Retrieved March 19, 2015, from tube.medchrome.com/2013/05/laryngeal-mask-airway-lma-insertion.html


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Original: 6/1/2012Last Approved: N/ALast Revised: 10/23/2019Next Review: 3 years after approvalOwner: Brittney Slibsager: Medical Staff

Services ManagerPolicy Area: Organization-Wide

Competency Guidelines: Moderate (Conscious,Moderate) Sedation Written Exam

POLICY:

SCOPE:

PROCEDURE:1. In accordance with JCAHO requirements, all new and current members of the medical staff who request

moderate sedation privileges will demonstrate current competency and training in the following areas:

A. An overview of the sedation process

B. Patient assessment

C. Airway management

D. Medication administration

E. Patient monitoring to include identification and management of abnormal rhythm strips

F. Documentation requirements

2. New Applicants/Reapplicants to the Medical Staff: Successful completion (minimum 75% passingrate) on the Moderate Sedation Competency Written Exam is required of all new applicants/reappointeesto the medical staff before privileges will be granted in moderate sedation.


Attachments:

To provide the Medical Staff Services Department with guidelines for administering the written ModerateSedation Competency Exam to new applicants and current members of the St. Louise Regional HospitalMedical Staff who request moderate sedation privileges in order to maximize patient safety and quality of care.

This policy applies to all new applicants to the medical staff and all current medical staff members who requestmoderate sedation privileges. Medical staff members who request moderate sedation privileges must showcurrent competency to perform the requested procedure and complete the written exam at the time of theprivilege request.

Competency Guidelines: Moderate (Conscious, Moderate) Sedation Written Exam. Retrieved 11/20/2019. Official copy athttp://verity-saintlouise.policystat.com/policy/4659842/. Copyright © 2019 St. Louise Regional Hospital

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Approval Signatures








Pharmacy & SurveillanceCommittee (P&S)




Chief Executive Officer (CEO) John Hennelly: Chief Administrative Officer 3/30/2018

Mark Ahn, M.D.: Anesthesia Medical Director 3/2/2018

Anesthesia Medical Director Mark Ahn, M.D.: Anesthesia Medical Director 3/2/2018

Owner Brittney Weltz: Medical Staff Services Manager 3/1/2018

Competency Guidelines: Moderate (Conscious, Moderate) Sedation Written Exam. Retrieved 11/20/2019. Official copy athttp://verity-saintlouise.policystat.com/policy/4659842/. Copyright © 2019 St. Louise Regional Hospital

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Original: 4/1/2002Last Approved: N/ALast Revised: 11/13/2019Next Review: 3 years after approvalOwner: Liesel Short: Employee Health

NursePolicy Area: Employee Health

Associate On-Duty Contact with an Infectious orCommunicable Disease

POLICY:

PROCEDURE:1. It is the sole responsibility of the Department Director, Clinical Manager, or Supervisor to notify the

Employee Health Service and Infection Control Department immediately when a suspected on-dutyexposure to an infectious or communicable disease occurs.

2. It is the responsibility of the Infection Control Department to determine that contact with an infectious orcommunicable disease has actually occurred. Employee Health Service will receive a list of all exposedassociates from Infection Control. This must be completed within 24 hours of the suspected exposure bythe department's individual supervisor.

3. The Infection Control Department will investigate the exposure and will determine the extent of actualcontact and which individuals will require follow-up.

4. Employee Health Services will be responsible for arranging any treatment and follow-up as necessarywith the associate.

5. The Employee Health Nurse renders first aid and follow-up for associates with industrial exposure orillness as determined by written policies, professional knowledge, and practice.

6. Records of treatment will be maintained in each Employee Health File.

7. The Employee Health Nurse will follow the List of Work Restrictions as adopted by the Infection ControlCommittee.

8. In the event associates are to receive medications according to the Employee Health Medical Directives:

a. Employee Health will coordinate with the Medical Director and/or ED physician on duty as neededand submit a "Confirmed Contact" List to St. Louise Regional Hospital Pharmacy.

In order to ensure adequate health of all personnel it is essential that health care procedures be followedcarefully and within given time limits.

In case an associate or volunteer has on-duty contact with an infectious or communicable disease, it is theresponsibility of the Department Director, Clinical Manager, or Supervisor to see that the associate follows theprocedures as outlined below.

Associate On-Duty Contact with an Infectious or Communicable Disease. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/4901651/. Copyright © 2019 St. Louise Regional Hospital

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b. St. Louise Regional Hospital Pharmacy will dispense medication in individual prescriptions accordingto "Confirmed Contact" list to Employee Health Office or directly to associates presenting after EHoffice hours.

c. Employee Health will evaluate each "Confirmed Contact" on the list and evaluate their exposure withinput from the Medical Director and/or ED physician on duty as needed. If the individual meets thecriteria identified in the "Management Exposure policy, then the individual will be given themedication. If the individual does not meet the criteria, the medication will be returned to thePharmacy.

d. Non-associates will be notified of their possible exposure and advised to seek medical evaluation.Those individuals may register in the St. Louise Regional Hospital Emergency Department to beevaluated as private patients. They will not receive prophylactic medications from Employee HealthServices.

e. In the absence of Employee Health, a "Confirmed Contact" list will be initiated by Infection Control orNursing Supervisor and the EHS Medical Director and/or ED physician on duty will be consulted.

f. Employees may be referred to Workers' Compensation provider or other medical provider asnecessary or warranted.












Infection Preventionand CaseManagement Director

Pam Holmquist: Infection Prevention and Case Management Director 9/6/2018


Chief ExecutiveOfficer (CEO)

John Hennelly: Chief Executive Officer 5/10/2018

Human ResourcesDirector

Jillian Madison: Director, Human Resources 5/2/2018

Owner Liesel Short: Employee Health Nurse 5/2/2018

Associate On-Duty Contact with an Infectious or Communicable Disease. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/4901651/. Copyright © 2019 St. Louise Regional Hospital

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Original: 6/1/2015Last Approved: N/ALast Revised: 6/1/2015Next Review: 3 years after approvalOwner: Pam Holmquist: Infection

Prevention and CaseManagement Director

Policy Area: Infection Prevention & Control

Pandemic Influenza Plan

TABLE OF CONTENTS

1. DECISION MAKING

2. HOSPITAL SURVEILLANCE

3. INFECTION CONTROL

4. HOSPITAL RISK COMMUNICATIONS

5. EDUCATION AND TRAINING

6. PATIENT TRIAGE

7. CLINICAL GUIDELINES

8. VACCINES AND ANTIVIRAL DRUGS

9. SURGE CAPACITY

10. SECURITY – FACILITY ACCESS

11. OCCUPATIONAL HEALTH

12. RECOVERY OF OPERATIONS

ST. LOUISE REGIONAL HOSPITALEMERGENCY MANAGEMENT PLANPANDEMIC INFLUENZA MANAGEMENT

INTRODUCTION

EXECUTIVE SUMMARY – Pandemic Influenza Action Table

Attachments

ATTACHMENT 1: Tool 10 – SCC Physician Alert Case Definition Avian Influenza

ATTACHMENT 2: Tool 12 – SCCPH Informational No: 2005-4 Laboratory Community Update (2005-4)

ATTACHMENT 3: Tool 21 – Home Isolation Checklist

ATTACHMENT 4: Tool 28 – Pocket Website Reference Tool

ATTACHMENT 5: Tool 29 – Figure 1, Clinical Algorithm for Case Management Alert Period

ATTACHMENT 6: Tool 30 – Figure 2, Clinical Algorithm for Case Management Pandemic Period

ATTACHMENT 7: Tool 32 – Clinical Triage Guidelines - Pandemic Critical Resource Stage

ATTACHMENT 8: Tool 37 – Patient Home Care Handout

Pandemic Influenza Plan. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/4822987/.Copyright © 2019 St. Louise Regional Hospital

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INTRODUCTION

1. A limited number of patients infected with pandemic influenza virus, or other novel strain of influenza, as part ofnormal operations

2. An overwhelming increase in the number of patients in the event of escalating transmission of pandemic influenza.

PLANNING ASSUMPTIONS1. The number of ill people requiring outpatient medical care and hospitalization will overwhelm the local health care

system.

2. St. Louise Regional Hospital will maximize the medical surge capacity and capability. However, when hospitalcapacity is exceeded, Influenza Care Centers (ICCs) will be needed for patients who can safely be managedoutside of the acute care setting; hospitals will be reserved for patients needing the most sophisticated care.

3. The increased healthcare demands associated with pandemic influenza cannot be managed by healthcarefacilities alone. An effective pandemic response must include cooperative strategies that use a variety ofhealthcare entities including hospitals, clinics, long-term care facilities, private practice physicians, and homehealth care providers.

4. Hospitals and other healthcare entities will likely experience staffing shortages throughout the pandemic periodand into the subsequent recovery period. Under specific emergency conditions, volunteers, retired healthcareprofessionals, and trained unlicensed personnel may be used to provide patient care in a variety of healthcaresettings.

5. Current resources for mass fatality care at all levels, including healthcare facilities, the county morgue andmortuaries, may be inadequate to meet the challenges posed by pandemic influenza.

6. To maximize healthcare resources and achieve the optimal benefit for the most people, traditional standards ofcare may need to be altered. "Sufficiency of care," medical care that may not be of the same quality as thatdelivered under non-emergency conditions but that is sufficient for need, may be the standard of care during aninfluenza pandemic.

ATTACHMENT 9: Tool 42 – Household Flu Preparedness Checklist

ATTACHMENT 10: FluSurge 2.0

ATTACHMENT 11: Employee Health Service Pandemic Flu Symptom Review Questionnaire

ATTACHMENT 12: Influenza Care Center (ICC) location check list

ATTACHMENT 13: Outbreak Weekly Survey Report

The ability of St. Louise Regional Hospital, (SLRH), to develop a coordinated health care strategy to effectivelyprepare and provide for pandemic influenza patients is a critical capacity. Because of the nature of influenza virusesand their natural ability to mutate and become more or less of a threat to humans, there remains uncertainty as to whenand how a pandemic will evolve, and its effect on local conditions that will influence decision-making within thehealthcare system. St. Louise Regional Hospital must be prepared for the rapid pace and dynamic characteristics ofpandemic influenza. (Also reference Pandemic Influenza Surge Event 2-23 in Emergency Operations Plan, (EOP).

St. Louise Regional Hospital should be equipped to care for:

The hospital is committed to: identifying and isolating all potential patients with pandemic influenza; implementinginfection control practices to prevent influenza transmission; providing medical treatment to patients; and ensuring rapidand frequent communication within the hospital, with other healthcare facilities, and with the Santa Clara County PublicHealth Department (SCCPHD).

EXECUTIVE SUMMARY – Pandemic Influenza Action Table


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PANDEMIC INFLUENZA PLAN – ACTION TABLESection Alert Period (first confirmed transmission in

U.S.)Pandemic Period (first confirmedtransmission in Bay Area)

Page#

Action Responsible Action Responsible1. DecisionMaking

• HICS implementedfor Pandemic FluPlan

• Administrator/ IncidentCommander

• Pandemic plansauthorized

• Administrator/IncidentCommander

10

• Determine locationfor pandemic flu unitand assign(volunteer) clinicalmanager

• Administrator/ IncidentCommander /

• InfectionControl

• Consider whetherpandemic flu unitneeds expansion


2. HospitalSurveillance

• Initiate influenza-likeillness surveillanceas required bySCCPHD

• EmergencyDepartment,Laboratory

• Send statusreports throughEMSystemmessaging, case-level or batched,as requested bySCCPHD

• InfectionControl staff

10

• Initiate procedure forsafe transport oflaboratory specimensto SCCPHL

• Laboratory

• Initiate monitoring foremployee absences

• EmployeeHealth

3. InfectionControl

• Ensure that respiratorfit-testing program isin place fordesignated clinicalstaff

• EmployeeHealthServices

• Screening of allthose enteringhospital

• EmployeeHealth,EmergencyDepartment,Security

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• Ensure thatrespiratory HygieneStations are placedat all hospitalentrances


• Instruct all withrespiratorysymptoms to usemasks, tissues,gels atrespiratoryhygiene stations

• All Staff,InfectionControlNurse

• Implement procedurefor acquiringadditional supplies

• Materials/Purchasing

• Track supplyvolumes andcontinue to orderas needed

• Materials/Purchasing

• Educate staff on • Education • Separate • All Clinical


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prevention oftransmission ofdisease

Dept,InfectionControl

persons withrespiratoryinfections incommon areas ifpossible

Areas

• Train ED onSCCPHD triagescreeningguideline, Tool#32

• InfectionControls

• Clinical triagescreening usingSCCPHDguideline

• EmergencyDepartment

• Appoint triageofficer

• IncidentCommander/Administrator

• Set up triagetent(s)decontaminationzone

• Facilities

• Designateentrance foremployees, staff,volunteers. Allwill be screenedand designatedcoded dot placedon ID badge.

• EmployeeHealth

• Designate ED asonly entrance forpatients andvisitors. Novisitors allowedunless necessaryfor patient well-being


• Implementsecurity presenceat the entrances

• Security

• Educate staff, ptsand families onproper use ofPPE including


• Education


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removal anddisposal &adequate handhygiene.

• Implementcohorting of ptswith pandemic flu& cohorting staffwith flu pts.

• Staffsupervisors

• ClinicalManagers

• Monitor ICpractices of staff


• Place pandemicflu patients onrespiratoryisolation for 14days from onsetof symptoms

• MDs

• Implementpatienttransportationprotocol


• Considerrelocatingportable X-raymachine topandemic unit

• Radiology• Pandemic

unit staff

• Screen visitors &utilize those whocan provide carefor the pts

• Emergency,EHS

• Stop all non-pandemic fluadmissions andelective surgeriesif wide-spreadhospital-acquiredtransmissionoccurs


4. Hospital RiskCommunications

• PIO will be thesingle-source contactwith the SCCPHD

• PIO • Follow sameprocedures andchannels as forAlert Period

15

• Determine plan for • PIO, Liaison • Distribute • PIO


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distributinginformation to public:consider Hospitalwebsite, printedbulletins, recordedmessages on hotline,radio

officer,InfectionControl,HumanResourcesVicePresident

information topublic as planned

• Use hot line,recorded messages,hospital website, "AllSLRH" e-mail,printed bulletins, FAQsheets for internaldistribution ofinformation

• PIO, LiaisonOfficer,HumanResourcesVicePresident

5. EducationAnd Training

• Identify infectioncontrol practices,isolation, quarantine,and home care asappropriate orneeded usinginformation fromSCCPHD andInfection ControlExposure ControlPlan to respond to apossible flu pandemic


• Follow sameprocedures as forAlert Period.

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• Instruct staff, patientsand visitors on theuse of PPE todecrease diseasespread

• EducationDept

• EmployeeHealth

• Begin cross-trainingof Clinical and Non-clinical staff who arenot currently directcaregivers to providecare as needed

• EducationDept

• Safety Officer

• Provide updatededucational materialson how to preventand treat influenzafrom SCCPHD topatients, familymembers and visitors

• EducationDept


• PublicRelations

6. Patient Triage • Set up triage and • Infection • Lock down all • Administrator/ 15


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stock triage/screening area for allpatients and visitors.This could be in tentsset up in Decon.Zone

Control• Safety Officer• Facilities

Engineers

entrances tohospital.

• Disable badgeaccess to allexterior doors.

IncidentCommander(HICSactivated)

• SecuritySupervisor

• Set up screeningarea for all staffentering the hospital


• EmployeeHealth

• Direct all personsentering hospitalto the appropriatescreening areas:

• Employees –Employee health

• Visitors, Patients,Family – TriageTents

• SecurityOfficers

• Labor Poolassignments

7. ClinicalGuidelines

• All clinical guidancefrom SCCPHD &CDHS will be faxedto all MDs.

• Med StaffOffice

• All clinical staffwill follow theSCCPHD ClinicalGuidelines

• Med Staff 17

8. Vaccines AndAntiviral Drugs

• Increase the numberof HealthcareWorkers and patientsreceiving theseasonal influenzavaccine

• EmployeeHealth

• InfectionControl Staff

• Will followSCCPHDguidelines onestablishingpriority groups forvaccination.

• EmployeeHealth

• InfectionControl Staff

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• Increase the numberof pneumovaccinesgiven to patients

• Clinical Staff,InfectionControl Staff

• Continue to offervaccine topatients topreventsecondarybacterialpneumonia

• Clinical Staff,InfectionControl Staff

• Use antiviral drugsaccording toestablishedstandards of care.

• Physicians • Follow SCCPHDguidelines on useof antiviralsduring apandemic.

• Physicians

9. SurgeCapacity

• Develop plan for staffhousing

• Administrator/incidentCommander

• Implement staffhousing plan

• StaffingOffice

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• Implement RapidDischarge Plan

• Clinical Units • Authorizetemporarycancellation ofelective surgeries

• Administrator/incidentCommander


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• Open pandemic FluUnit (trigger is firstnovel flu case atSLRH)


• Open PandemicFlu Unit if notalready open

• Administrator/Incidentcommander

• Identify volunteerstaff for PandemicUnit


• EmployeeHealth

Regulate fooddistribution

• NutritionServices

• The assumption isthat staffingavailability will largelydetermine surgecapacity

Consider using staffrecovered frompandemic flu to workin Pandemic flu unit

• EmployeeHealth

• Staffing office

10. MortuaryIssues

• Increase monitoringof Morgue censusreconciliation to daily

• NursingSupervisor/Bed control

• Contact SCCwhen 2 bodies inmorgue for helpwith removal

• NursingSupervisor/Bed Control,

• Clinical units

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• Contact SCC when 2bodies in morgue forhelp with removal

• Stack bodies inmorgue ifnecessary

11. Security –Facility Access

The hospital CommandCenter (HCC,willbe activated.

• Administrator/ IncidentCommander

• Code Triage willbe activated

• IncidentCommander

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• Access to theHospital will berestricted.

• Security• Incident

Commander

• HCC-Securitylock-down Planwill be initiated.

• Security• Incident

Commander

• Additional securitystaff will be broughtin as needed.

• SecuritySupervisor orDirector ofFacilities

• All hospitalentrances shallbe secured.

• Card key accessto all externaldoors will be shutoff.

• Security shall beposted at allentrances.

• Only staff thathas beenscreened byEmployee HealthServices will beallowed entry.

• Security• Labor Pool

• A screening area forall patients and

• Facilities• EVS

• A screening areawill be set up for

• Facilities• Employee


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visitors will be set upoutside the mainhospital buildings.This may be in a tent,parking structure orother area.

The area will havelighting, power andequipment asneeded.

• Materials all employees,separate from thepatient/visitorscreening area.(See Section 3 -Infection Control,A. Methods.)

HeathServices

12. OccupationalHealth

• Renew efforts tovaccinate all staff andextended staff withthe seasonal humaninfluenza vaccine



• All staff andextended staffwill be screenedfor influenza-likesymptoms beforeentering SLRHfacility.

◦ MainHospital: asingleentrance willbe madeavailable forall Healthcare workersof mainhospitalfacility.



24

• EHS will screen allstaff that havetraveled in the past10 days by airplaneor high-risk area (asdefined by InfectionControl) before theyreport to work.



• Screening criteriashall include:

◦ Temperature• Symptom review

questionnaire(seeATTACHMENT11 "SLRHPandemic FluSymptom ReviewQuestionnaire").



• All staff who becomeill shall:

◦ Seek medicalcare.

◦ Notify EmployeeHealth Services

◦ Stay home until24 hours after

• SLRH Staff• SLRH

ExtendedStaff

• "Cleared" staffwill be providedwith a colored"dot" to be placedon their SLRHbadge to signifythat they havebeen met the




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resolution offever unless oneof the followingapplies:

▪ Analternativediagnosis isestablished.

• Diagnostic tests arenegative forinfluenza.

criteria for beingable to report forduty that day.

• Any health careworker whobecomessymptomaticwhile on duty willbe required todon a surgicalmask and reportto EHS for amedicalevaluation

• SLRH Staff• SLRH

ExtendedStaff

• EAP will beavailable forcounseling forany employee ofSLRH.

• EmployeeHeathServices

• HumanResources

• Rest and mealbreaks will beprovided throughthe labor pool.

• Staff SupportUnit Leader

13. Recovery OfOperations

• Evaluate need toadapt Code Triagerecovery plan forPandemic Flu


• ImplementRecovery Planwhen allpandemicpatientsdischarged fromhospital


25

1. DECISION MAKING

A. Alert Period

1. Unless directed otherwise by the SCCPHD, St. Louise Regional Hospital shall enter the Alert Period asoutlined in the subsequent sections of this plan upon notification by the SCCPHD of the first confirmedcase of the pandemic influenza in the United States.

2. Upon entering the Alert Period, the hospital shall convene an emergency pandemic influenza task forceto review/revise this plan that includes:


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a. Use of the Hospital Incident Command System (HICS) for a sustained continuity of hospitaloperations and patient care services:

1. Specific pandemic influenza planning strategies that incorporate current local, state and federalguidance

2. Triggers for activating the hospital's internal pandemic emergency plan

3. Assignment of authority and responsibility for aspects of the pandemic plan and responsewithin the facility

4. Patient triage systems

B. Pandemic Period

1. St. Louise Regional Hospital shall implement the Pandemic Period plans outlined in the subsequentsections when the first confirmed case of pandemic influenza upon either the notification of SCCPHD, orthe awareness of a sudden surge of influenza patients during the initial phases of the pandemic withinthe Bay Area.

2. HOSPITAL SURVEILLANCEThe goal of influenza disease surveillance is to serve as an early warning system to detect an increase ininfluenza-like-illness in the hospital & community.

A. MethodsMonitor influenza–like-illness (ILI) in Santa Clara County. ILI is defined as temperature greater than 100.4 andat least one upper respiratory symptom (cough, runny nose, sore throat).

1. St. Louise Regional Hospital ED participâtes in syndromal surveillance. Information is captured byIBEX and sent automatically to ESSENCE.

2. ESSENCE is a computer syndromal surveillance system which is available to hospitals for automaticreporting.

B. Alert Period

1. SCCPHD may require:

a. Laboratory confirmed influenza- associated hospitalizations to be placed on the reportable diseaselist.

b. Specimens from patients meeting the case definition for suspect avian influenza H5N1 infection aresent to the SCCPHL, (Santa Clara County Public Health Lab).

2. St. Louise Regional Hospital Lab has a procedure in place for safe transport of specimens to SCCPHL.

3. The following procedure for monitoring employee absenteeism will be implemented.

a. All employees calling in sick with ILI (influenza- like –illness) will be required to leave a voice mailmessage with Employee Health in addition to following their normal department sick callprocedures.

b. The employee will be asked to provide the following information:

1. Name

2. Department where they work

3. Contact telephone number

4. ILI symptoms they are exhibiting

5. Duration of symptoms.

c. The call offs will be monitored by the Employee Health Services Department on a daily basisMonday through Friday and by the Nursing Supervisor on Saturday and Sunday.


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d. A tally sheet of the number of ILI sick calls will be filled out daily and faxed to the Infection ControlDepartment for review and correlation with the Emergency Department data.

C. Pandemic Period

1. St. Louise Regional Hospital will provide status reports through the EMSystem messaging. Early in thisperiod, case level reporting will be done. As the pandemic spreads, batch reporting will be done.SCCPHD reporting forms are provided in the county plan.

3. INFECTION CONTROLThe goals of infection control are:

◦ To limit transmission of pandemic influenza from infected patients to non-infected patients and staff

◦ To provide infection control guidance to the hospital on managing pandemic influenza patients.

Since a vaccine for pandemic influenza will not be available immediately, and antiviral drugs may be in limitedsupply, the ability to limit transmission will depend upon the use of appropriate infection control measures

A. Methods

1. Alert Period

a. St. Louise Regional Hospital has a respirator program in place for designated clinical staff. N95masks are worn by staff when providing care for a patient with a suspect or known airbornetransmitted disease. Records of N95 fit testing are kept in EHS.

b. Materials Management will order additional supplies of PPE to maintain an adequate supply for theaverage daily census. The estimated minimum quantities are five sets of PPE used per day for eachinfluenza patient. See Section 9 for additional information on surge capacity. A procedure foracquiring additional supplies in an emergency will be developed.

c. All staff is educated on the importance of containing respiratory secretions to prevent thetransmission of disease during employee orientation. Emphasis is also placed on staff beingprepared at home with emergency supplies which include gloves and masks.

d. Respiratory hygiene etiquette signs and masks are available at the main entrances to the hospital

2. Pandemic Period

a. Detection of persons entering the hospital with suspect or known pandemic influenza

b. Instruct persons with signs of respiratory illness to use respiratory hygiene etiquette. This includes:

1. Respiratory hygiene stations with supplies of masks, tissues and gel and posted signs inappropriate languages with instructions to immediately report symptoms of respiratoryinfections as directed.

2. Instructions on the proper use and disposal of masks and tissues, and the use of antimicrobialgels after contact with respiratory secretions. Emphasis on covering the nose/mouth withtissues or with an arm when coughing and sneezing

c. Spatial separation of persons with respiratory infections in common areas if possible.

d. Clinical triage screening using the SCCPHD clinical triage guideline shall be implemented-in theEmergency Department, (ED). ED staff shall receive training on this guideline. A triage officer will beappointed to manage flow. The triage area will be set up in the hospital decontamination zone.

e. Entrances to the hospital shall be limited to ED for patients and visitors and to a separate,designated entrance for employees.

f. A designated area will be used for daily screening employees for influenza symptoms. This willinclude monitoring temperature and signs & symptoms of influenza.


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g. A designated colored dot will be placed on staff badges once influenza is ruled out. The color of thedots will change every day.

h. Security will be available at the entrances

i. Visitors will be screened for signs and symptoms of influenza before entry into the hospital. Anyonesuspicious for influenza will not be permitted inside the facility.

j. Family members who accompany patients with influenza are assumed to be exposed and shouldwear masks.

k. Only visitors who are necessary for the patient's well being and care shall be allowed in the hospital.

l. Non infected visitors will be instructed on proper use of PPE and hand hygiene before entering andleaving a patient's room.

B. Management of infectious patients

1. Patient placement

a. Limit admission to influenza patients with severe complications of influenza who cannot be cared foroutside the hospital.

b. These patients should be placed on airborne precautions for a minimum of 5 days to 14 days fromonset of symptoms. Immuno-compromised patients may be placed on isolation for the duration oftheir illness.

c. A pandemic flu unit shall be established within the hospital.

d. This should be done early in the course of a local outbreak.

e. Personnel assigned to cohorted patient care units should not float to other units. The number ofpersonnel entering this unit should be limited to those necessary for pt care and support.

f. Health care workers should be vigilant to avoid:

1. Touching their eyes, nose or mouth with contaminated hands (gloved or ungloved):

2. Adjusting PPE after contact with infected patient.

3. Improper removal of PPE.

4. Contaminating environmental surfaces that are not directly related to the patient (door knobs,light switches, etc.)

g. Health care workers should practice careful hand hygiene.

2. Personal Protective Equipment (PPE)

a. Masks

1. Staff taking care of infected patients will wear a N95 mask when in close contact with aninfected patient. Ideally the mask should be worn once and discarded. If in short supply, thismay be changed. If patients are in a common area, one mask may be worn for multiplepatients over a short period of time.

2. Change masks when they become moist.

3. Do not leave a mask dangling around the neck.

4. After touching or when discarding the mask, perform hand hygiene.

b. Gloves

1. Gloves should be worn for contact with all body fluid s including respiratory secretions.

2. Remove and discard after contact with a patient. Perform hand hygiene.

3. If gloves are in sort supply, priorities for glove use may need to be established.


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c. Gowns

1. Wear an isolation gown if soiling of clothes is anticipated. Most patient contact does not requirethe use of a gown. Procedures that involve close contact with the patient or the generation ofaerosols require the use of a gown.

2. Gowns should be used only once and then properly disposed of and hand hygiene performed.If gowns are in short supply, priorities for their use may need to be established.

d. Goggles or face shields

1. If sprays or splatters of infectious material are likely, goggles or a face shield should be worn.

2. Eye protection should be properly disposed of and hand hygiene performed.

3. Patient transport

a. Limit patient movement and transport outside the isolation area. Consider having a portable X-raymachine for use with the area

b. If transport is essential, patient must wear a regular mask and perform hand hygiene before leavingthe area.

4. Standard precautions are used for:

a. Disposal of wastes

b. Handling contaminated linen (linen cart kept in room)

c. Handling dishes and eating utensils

d. Handling and reprocessing used patient –care equipment

e. Environmental cleaning and disinfection

5. Cleaning and disinfection of an occupied room or area

a. Wear gloves according to hospital policy and wear an N95 mask. Gowns are not necessary forroutine cleaning.

b. Keep areas around pt free of unnecessary supplies and equipment

c. Use any EPA approved disinfectant.

d. Pay special attention to frequently touched surfaces.

6. Cleaning and disinfection after discharge or transfer

a. Follow standard precautions

b. Postmortem care-follow standard precautions

7. Employee Health Issues

a. Implement a system to educate personnel about employee health issues related to pandemic flu

b. Screen all personnel for influenza like symptoms before they come on duty.

c. Personnel who are at high risk for complications of pandemic flu (pregnant women, immuno-compromised persons) should be informed about their medical risk and offered a job away frominfectious patients

8. Control of hospital-acquired influenza transmission

a. If limited hospital-acquired transmission is detected, appropriate controls should be implemented.These may include:

1. Cohorting of patients and staff on affected units

2. Restriction of new admissions to the affected areas


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3. Restriction of visitors to affected areas

4. If wide spread hospital-acquired transmission occurs, these controls:

5. Restrict all nonessential persons

6. Stop admissions not related to pandemic and stop elective surgeries.

4. HOSPITAL RISK COMMUNICATIONS

A. Information Sources

1. Information regarding a pandemic and the planning for it is available from a variety of sources, including,but not limited to:

a. Federal Government - www.pandemicflu.gov

b. Centers for Disease Control (CDC) - CDC's Emergency Communication System –http://www.pandemicflu.gov

c. California Department of Health Services - California Health Alert Network (CAHAN)

d. Santa Clara County Public Health Department (SCCPHD) - http://www.sccgov.org/portal/site/phd/

2. To reduce the likelihood of conflicting or confusing messages during Alert and Pandemic periods acrossthe healthcare system, St. Louise Regional Hospital will coordinate all external media content with theSanta Clara County Public Health Department (SCCPHD) and other area hospitals. The SCCPHD -Public Information Officer (SCCPHD PIO) will take the lead in development of public health and medicalrisk communication materials for release to the public, business community, schools, and criticalinfrastructure including healthcare facilities. The hospital Public Information Officer (PIO) shall maintain aclose working relationship with the SCCPHD PIO.

B. Alert Period

Upon activation of the Hospital Command Center (HCC) and implementation of Hospital Incident CommandSystem (HICS), the following procedures will be put into place:

1. External Communication to Health Agencies

a. The hospital PIO shall be the single-source contact with the SCCPHD PIO. The hospital PIO shallbe assigned by the Incident Commander under the hospitals HICS plan.

b. The hospital Infection Control will assist with the tracking of local transmissible respiratory diseases,case definitions, and new epidemiological findings.

2. External Communication to Public

a. The PIO shall work with the SCCPHD, HCC and Public Relations to create appropriate messagesfor staff, patients, and the general public.

b. Possible resources for distributing information could be

1. Recorded Messages on special hot line

2. Hospital Website

3. Printed bulletins

4. Radio – KCBS (740 AM)

3. Internal Communication to Staff

a. Education and training shall be provided to all staff and volunteers. See Section 5 – Education andTraining of this plan.

b. Information and messages for staff and volunteers including updated information on the hospitalstatus, staffing needs, and other pandemic flu information provided by the SCCPHD shall be


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http://www.pandemicflu.gov/



http://www.sccgov.org/portal/site/phd/


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distributed using appropriate channels.

1. The content of the communications shall be determined by

a. PIO

b. Liaison Officer/Public Relations

c. Infection Control

d. Human Resources Vice President

c. Possible resources for distributing information can include:

1. Recorded Messages on special hot line

2. Hospital Website

3. "All St. Louise Regional Hospital" email

4. Fax

5. Printed bulletins

6. FAQ

C. Pandemic Period

During the pandemic period, the hospital PIO will:

1. Maintain a single source of contact with SCCPHD PIO, ensuring information is updated, as needed.

2. Maintain internal and external communications as outlined during the Alert Period.

5. EDUCATION AND TRAINING

A. Information Sources

1. Offering information and education prior to an event can be addressed by designating a local educationalleader who will plan, conduct and execute training and educational opportunities on topics such as:Topic Responsible

PartyStatus/Action

Awareness of global or local transmissible respiratoryinfectious diseases

▪ EducationDept

▪ SafetyOfficer

▪ InfectionControl

▪ See SCCPHD"Preparing forPandemic FluGuide"

▪ Documentationfrom CDC

▪ See InfectionControlExposureControl Plan

Identification of infection control practices, isolation,quarantine, and home care as appropriate or needed torespond to a possible flu pandemic


▪ EmployeeHealth




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Awareness of comprehensive standard precautionspolicies incorporating hand and respiratory hygieneprotocols to be practiced at all times as a means ofgeneral infection control and prevention



▪ Ongoingrevisions andupdates asnecessary

Use of PPE to decrease disease spread and how toassist patients and visitors on PPE use


▪ EducationDept

▪ EmployeeHealthServices

▪ Ongoing

Cross-training of Clinical and Non-clinical staff who arenot currently direct caregivers to provide care as needed

▪ EducationDept

▪ SafetyOfficer


▪ Uponnotification ofAlert Status bySCCPHD

▪ Town HallMeetings

▪ Additionaltraining

Education of patients, family members and visitors ▪ EducationDept


▪ Education

▪ CommunityRelations


▪ Develop a St.LouiseRegionalHospitalspecificPandemic Flumemo.

B. Additional Resources from SCCPHD Pandemic Influenza Plan

1. Attachment 3: Tool 21 – Home Isolation Checklist

2. Attachment 4: Tool 28 – Pocket Website Reference Tool

3. Attachment 8: Tool 37 - Patient Home Care Handout

4. Attachment 9: Tool 42 - Household Flu Preparedness Checklist

6. PATIENT TRIAGE

A. Pandemic Flu Triage Supply ListItem Description Quantities*


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▪ Monitors; O2 Sat, 2

▪ N95 Masks 2000

▪ Surgical Masks 2000

▪ Oxygen tanks 4

▪ Oxygen Masks 4

▪ Antimicrobial Hand Gel 24 bottles

▪ Antimicrobial Wipes 10 containers

▪ Medium/Large Gloves 720 boxes

▪ Isolation gowns 450

▪ Tympanic Thermometer 2

▪ Thermometer covers 1000

▪ Emesis Basins 250

▪ Signs to explain how to fill out self history 2-4

▪ Tents 2

▪ Chairs 4

▪ Heaters 4

▪ Garbage Cans 2

▪ Wheelchairs 2

▪ Copies of SCCPHD Tool #21 – Home Isolation Checklist 100, Copy as needed

▪ Copies of SCCPHD Tool #37 – Patient Home Care Handout 100, Copy as needed

*The numbers represent estimated supplies for 150 people for 3 days.

B. Additional Resources from SCCPHD Pandemic Influenza Plan

1. Attachment 7: Tool 32 – Clinical Triage Guidelines during Pandemic Critical Resource Stage

7. CLINICAL GUIDELINESSt. Louise Regional Hospital is utilizing the clinical guidelines as outlined by the Santa Clara County Public HealthDepartment in the Pandemic Influenza Preparedness and Response Plan.

Note: Refer to SCCPHD website for current revision: http://www.sccgov.org/portal/site/phd/.

A. Overview

Refer to Chapter 7 - Clinical Guidelines and Disease Management for a complete description of guidelinesfor healthcare providers.

The CDHS "Pandemic Influenza Preparedness and Response Plan" acknowledges, "The management ofinfluenza is based primarily on sound clinical assessment and management of individual patients as well asan assessment of locally available resources such as rapid diagnostics, antiviral drugs and vaccines, and


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hospital beds.

Healthcare providers play an essential role in detecting an initial case of novel or pandemic influenza in acommunity. Early detection through heightened clinical awareness of disease and swift action for isolationand initiation of treatment can benefit the individual patient and may slow the spread of influenza within thecommunity. Rapid diagnosis and intervention with clinical care can potentially avert severe complications."(from the California Department of Health Services Pandemic Influenza Preparedness and Response Plan,Draft. Appendix 5, January, 2006.)

The SCCPHD distributed a Physician Alert dated December 9, 2005 (Tool 10) (see Attachment 1), whichaddresses the diagnosis of novel influenza infections. Additionally, the SCCPHD Laboratory has providedinformation on criteria for influenza A (H5N1) diagnostic testing, who to contact regarding clinical consultation,procedures for safe handling and collection of clinical specimens (as well as submittal and case historyforms), where to send specimens, and resources for additional information that may be useful to clinicians(Tool 12) (see Attachment 2).

B. Alert Period

1. Hospital Pandemic Influenza Plans should include a defined process for ensuring that clinical guidancereceived from SCCPHD and CDHS is shared with clinical staff.

2. SCCPHD has developed "Figure 1: Clinical Algorithm for Case Management- Alert period" (SeeAttachment 5), that should be used by all SCC clinicians in evaluating and diagnosing a novel Influenza.This includes both clinical criteria and epidemiological criteria.

C. Pandemic PeriodSCC Hospitals should implement plans to assure that clinical guidance received from SCCPHD and CDHSare shared with all clinicians.

8. VACCINES AND ANTIVIRAL DRUGSSt. Louise Regional Hospital is utilizing the Vaccines and Antiviral Drugs section as outlined by the Santa ClaraCounty Public Health Department in the Pandemic Influenza Preparedness and Response Plan..Note: Refer to SCCPHD website for current revision: http://www.sccgov.org/portal/site/phd/

A. Overview

Refer to Chapter 7—Clinical Guidelines and Disease Management for a complete description of the useand administration of vaccines and antiviral drugs during an influenza pandemic.

Once the characteristics of a new pandemic influenza virus are identified, the development of a pandemicvaccine will begin. Recognizing that there may be benefits to immunization with a vaccine prepared beforethe pandemic against an influenza virus of the same subtype, efforts are underway by the federal governmentto stockpile vaccines for subtypes with pandemic potential. As supplies of these vaccines become available, itis possible that the federal government will recommend that some healthcare personnel and others critical toa pandemic response will be vaccinated to provide partial protection or immunological priming for a pandemicstrain. HHS has not finalized policies for the use of pre-pandemic vaccine. During a pandemic, theserecommendations will be updated, taking into account populations that are most at risk.

Antiviral drugs effective against the circulating pandemic strain can be used for treatment and possiblyprophylaxis during influenza pandemic. Decisions regarding whether to prioritize use of antivirals fortreatment over prophylaxis, or for prophylaxis over treatment, will be determined, to the extent possible, onthe basis of demonstrated efficacy of the antiviral agents against novel and pandemic influenza strains.

B. Alert PeriodSCC hospitals will:


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1. Monitor updated HHS information and recommendations on the development, distribution, and use of apandemic influenza vaccine (http://www.pandemicflu.gov).

2. Work with SCCPHD on plans for distributing pandemic influenza vaccine. The SCCPHD is currentlyfinalizing a Mass Prophylaxis Plan.

3. Provide estimates of the quantities of vaccine needed for hospital staff and patients using SCCPHDcriteria.

4. Develop a hospital pandemic influenza vaccination plan.

C. Pandemic PeriodSCC hospitals will:

1. Follow SCCPHD guidelines for use and administration of antiviral drugs for prophylaxis measures andtreatment, if available.

2. Implement the hospital pandemic influenza vaccination plan, as directed by SCCPHD.

9. SURGE CAPACITY

A. Policy Summary:"Medical surge capacity" refers to the ability to evaluate and care for a markedly increased volume of personsthat exceeds normal operating capacity within a healthcare system. "Medical surge capability" is the ability tomanage patients requiring unused or specialized medical evaluation and care, which includes expertise,information, procedures, equipment or personnel. According to Joint Commission, Resources, entitled "SurgeHospitals: Providing Safe Care in Emergencies," a healthcare system should have the ability to expandquickly beyond normal services to meet an increased demand for medical care.

B. Policy and Procedure:

1. Purpose

a. The purpose of the Pandemic Surge Capacity Plan is to provide an organized and safe response toa pandemic situation such as influenza. The intent of this plan is to minimize serious illness andoverall deaths and to minimize disruptions of normal services to patients.

C. Alert PeriodUpon notification that the hospital has entered an Alert Period, as defined by the Santa Clara County PublicHealth Department, the following will occur:

1. Utilize HIC's plan and medical directives for Rapid Discharge Plan.

a. Expedite discharge of patients no longer needing higher levels of medical/surgical inpatient care.

2. Temporary cancellation of all elective surgical procedures.

a. The trigger for this action will be the 1st pandemic flu case in the hospital.

b. The VP of Patient Care and Clinical Services/CNE will be notified of the trigger case preceding thenotification of patients and OR staff.

3. A "Pandemic Flu Unit" will be created.

a. A designated area will become the designated pandemic flu unit.

b. Patients will not cohabit rooms unless avian flu cases are laboratory-confirmed, or capacity forisolating is exhausted.

4. Volunteer staff will be used for the Pandemic Flu Unit.

5. Nutrition Services will begin stepped up ordering of food supplies. See Section D below.

6. Material Management will begin stepped up ordering of extra supplies. See Pandemic Flu Triage SupplyList. See page 19 of Pandemic Flu Plan.


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7. Environmental Services will ensure enough Alcohol-Base hand rub, germicidal, disinfectants, linens, etcin stock and re-order as necessary.

D. Pandemic Period

1. Every attempt will be made to separate the location of pandemic flu patients from the non-avian fluhospital patients.

2. Review and revise admissions criteria as provided by SCCPHD when bed capacity is limited. See"Patient Surge Bed Capacity" below.

3. Food distribution will be regulated during this period.

E. Patient Surge Bed Capacity

1. Maximum Census

Med/Surg =44

Mother Baby = 16

Labor and Delivery = 6

Critical Care = 8

Emergency = 9

TLC = 10

Wound Care = 6

Total beds = 93

F. Surge Capacity Plan for Meal Services

1. Upon notification of the Alert Period, Nutrition Services shall follow the procedures outlined in NutritionServices.

▪ Upon entering the Pandemic Period, Nutrition Services staff will follow the guidelines set forth in thenutritional services Disaster Policy and procedure.

2. The Hospital Command Center (HCC) will arrange and allocate storage spaces

3. During the Pandemic Period, the HCC will initiate "rationing" of food.

a. Rationed meals will be served to only patients and on-duty employees.

b. There will be no meal service to visitors.

G. Additional Resources

1. Attachment 8: Tool 28 – Pocket Website Reference Tool

2. Attachment 10 – FluSurge 2.0 (http://www.cdc.gov/flu/flusurge.htm). This includes screen shots ofestimates for St. Louise Regional Hospital.

10. MORTUARY ISSUES

A. Alert PeriodUpon notification that the hospital has entered an Alert Period, as defined by the Santa Clara County PublicHealth Department, the following will occur to prepare for the possibility of mass fatalities during influenzapandemic:


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1. Current St. Louise Regional Hospital capacity for refrigeration of deceased persons is 2 bodies.

2. Current disaster plan for managing remains and temporary morgue overflow includes capacity for total of2 bodies

3. Modified plans to address potential need to manage contaminated remains for days would involvestacking bodies in morgue when there is excess of 2 bodies

4. Threshold of 2 bodies in morgue will initiate request to Santa Clara County for refrigerated truck(coordinated between the Bed Control and Materials)

5. Keep supplies (i.e. body bags) in stock

B. Pandemic PeriodSt. Louise Regional Hospital will:

1. Activate overflow morgue capacity plan (refrigerated morgue truck from SCC or stacking bodies inmorgue as needed)

2. Receive and use guidance from the SCC Coroner regarding disposition of deceased (morgue sites)

11. SECURITY – FACILITY ACCESS

A. Alert PeriodUpon notification that the hospital has entered an Alert Period, as defined by the Santa Clara County PublicHealth Department, the following may be enforced:

1. The Hospital Command Center (HCC) shall be activated.

a. The HCC shall direct all actions of the hospital, including:

1. Decisions regarding the temporary closure of the hospital to new admissions and transfers.

2. Restricting hospital access to employees, patients, and essential visitors only.

a. Essential visitors include family members, care-givers of patients, vendors deliveringessential supplies, and those approved by the HCC.

b. Non-essential visitors will not be allowed access.

2. SecurityUpon notification that the hospital has restricted access Security shall:

a. Lock all exterior hospital doors. Access will be by card key only.

b. Contract additional security staff to assist with and enforce lockdown of the facility.

c. Follow directions from the HCC. (Security lock-down plan)

3. FacilitiesUpon notification that the hospital has restricted access Facilities shall:

a. Coordinate with the HCC to define and set up a screening area for all patients and visitors to thehospital. Specifics will be determined by the HCC.

1. This space may be external to the main hospital buildings, such as

a. 3 Large tents and decon tent set up in the south parking lot

b. North parking lot

c. South field area

d. Other space deemed appropriate.

2. This space will require lighting, electrical power, chairs, cots, tables, gurneys, and otherequipment requested by the clinical staff.

a. EVS and Distribution will assist with providing and setting up of equipment.


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b. Facilities will arrange for the leasing of equipment, as needed.

B. Pandemic PeriodUpon notification by the HCC that the hospital has entered a pandemic period the following additionalmeasures will be taken.

1. HCC

a. Code Triage will be called.

2. Security

a. Follow the Emergency Security Plan under the direction of the HCC.

b. Card key access to all external doors will be shut off.

c. All hospital entrances shall be secured.

1. Officers/designees shall be posted at all entrances.

2. Security may request additional assistance from the Labor Pool.

d. Only staff that has been screened by Employee Health Services will be allowed entry.

3. Facilities

a. Facilities will assist in setting up a screening area for all employees.

1. This entrance will be separate from the patient/visitor screening area.

b. Any employee must be approved for entry by Employee Health Services.

12. OCCUPATIONAL HEALTHInfluenza can often have an explosive impact in the health care setting and preventing transmission is animportant concern for the protection of staff and patients and to ensure that St. Louise Regional Hospital canmaintain its core functions.

A. Alert PeriodUpon notification that the hospital has entered an Alert Period, as defined by the Santa Clara County PublicHealth Department, the following will occur:

1. All staff and extended staff involved in the care of patients should be vaccinated with the most recentseasonal human influenza vaccine.

2. All staff and extended staff who have traveled within the past 10 days by airplane or from an areaconsidered high-risk by Infection Control shall be screened by Employee Health Services beforereporting to work.

3. All staff and extended staff will need to be vigilant for symptoms of influenza for up to one week aftertheir last exposure to an infected patient.

4. All staff and extended staff who become ill should do the following:

a. Seek medical care but prior to arrival notify their healthcare provider they may have been exposedto influenza.

b. Notify Employee Health Services

c. Stay home until 24 hours after resolution of fever unless one of the following applies:

1. An alternative diagnosis is established that explains the health care worker's illness

2. Diagnostic tests are negative for influenza

d. While at home, ill persons should practice good respiratory and hand hygiene to lower the risk oftransmitting the virus to others.

B. Pandemic Period


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1. All staff and extended staff will be screened for influenza-like symptoms before they are allowed to enterany St. Louise Regional Hospital facility.

a. Main Hospital: a single entrance will be made available for all Health Care workers to be screenedfor clearance to work.

2. Screening criteria will include:

a. Temperature

b. Symptom review questionnaire (see ATTACHMENT 11 "Employee Health Service Pandemic FluSymptom Review Questionnaire")

3. Each "cleared" staff will be provided with a colored "dot" to be placed on their St. Louise RegionalHospital badge to signify that they have been met the criteria for being able to report for duty that day.

a. Health care workers will not be allowed to enter St. Louise Regional Hospital facility without theappropriate colored "clearance dot".

4. Any health care worker who becomes symptomatic while on duty will be required to don a surgical maskand report to Employee Health for a medical evaluation.

5. Hospital EAP will be available for counseling for any employee of St. Louise Regional Hospital.

6. Rest and meal breaks will be provided through the labor pool. This will be coordinated through the HICSstaff support unit leader.

13. RECOVERY OF OPERATIONSThis section has not yet been drafted.

ATTACHMENTS

PANDEMIC INFLUENZA PREPAREDNESS &RESPONSE PLAN

Attachment 1 Santa Clara County Physician Alert Case Definition - Avian Influenza

Attachment 2 Santa Clara County Public Health Informational No: 2005-4 Laboratory Community Update(2005-4)

Attachment 3 Home Isolation Checklist

Attachment 4 Pocket Website Reference tool

Attachment 5 Figure 1, Clinical Algorithm for Case Management Alert Period

Attachment 6 Figure 2, Clinical Algorithm for Case Management Pandemic Period

Attachment 7 Clinical Triage Guidelines during Pandemic Critical Resource Stage

Attachment 8 Patient Home Care Handout (to be developed)

Attachment 9 Household Flu Preparedness Checklist

Attachment10

Flu Surge 2.0

Attachment11

Employee Health Service Pandemic Flu Symptom Review Questionnaire

From

Santa Clara County Public Health Department

Refer to SCCPHD website for current revision: http://www.sccgov.org/portal/site/phd/.


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Attachment12

Influenza Care Center Location Check List

Attachment13

Outbreak Weekly Survey Report

All revision dates: 6/1/2015

Attachments:

01: Tool 10 – SCC Physician Alert Case Definition AvianInfluenza02: Tool 12 – SCCPH Informational No: 2005-4Laboratory Community Update (2005-4)03: Tool 21 – Home Isolation Checklist04: Tool 28 – Pocket Website Reference Tool05: Tool 29 – Figure 1, Clinical Algorithm for CaseManagement Alert Period06: Tool 30 – Figure 2, Clinical Algorithm for CaseManagement Pandemic Period07: Tool 32 – Clinical Triage Guidelines - PandemicCritical Resource Stage08: Tool 37 – Patient Home Care Handout09: Tool 42 – Household Flu Preparedness Checklist10: FluSurge 2.011: Employee Health Service Pandemic Flu SymptomReview Questionnaire12: Influenza Care Center (ICC) location check list13: Outbreak Weekly Survey Report

Approval Signatures








Pharmacy & Surveillance(P&S) Committee


Safety Committee Geoffery Tull: Health and Safety Security Manager 7/19/2018

Patient Safety Committee Mary Drottz: Director of Quality & Regulatory Affairs 6/6/2018

Health & Safety SecurityManager

Geoffery Tull: Health and Safety Security Manager 6/4/2018


Owner Pam Holmquist: Infection Prevention and Case Management Director 5/21/2018


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ATTACHMENT 1: SCC Physician Alert Case Definition Avian Influenza

ATTACHMENT 2: SCCPH Informational No: 2005-4 Laboratory Community Update (2005-4)

ATTACHMENT 3: Home Isolation Checklist

Page 1 of 2

HOME ISOLATION CHECKLIST A person with influenza may continue to be infectious (able to spread illness) for at least 5 and up to 14 days after the first day they had symptoms. Please follow this checklist to help limit the spread of illness in your home.

1. Limit physical contact between those with influenza and those without. The ill household member(s) with influenza needs to be physically separate from non-

ill persons living in the home. Pick one room in the house where the ill person(s) can stay for their entire infectious period. If more than one person in the home has influenza, all ill persons can share the same room. The ideal room for ill person(s):

o Has windows that open to increase air circulation. o gets natural light (UV light can kill influenza virus) o Has a door that closes. o Has a bathroom attached or nearby so the ill person isn’t sharing bathroom

space with those who aren’t ill. One person in the home should be the designated caregiver; all others should have

limited to no contact. The designated caregiver can bring meals, beverages and medicines to the room of the ill person.

Ill persons should not leave their room or the home during the period when they are most likely to be infectious (5 days after onset of symptoms, and potentially longer). When travel outside the home is necessary (e.g. for medical care), the ill person should cover the mouth and nose when coughing and sneezing and should wear a mask.

If contact between infected and not infected cannot be avoided (e.g. during transport in a car), place a surgical or procedure mask over the nose and mouth of the ill person (or the well persons if the ill person cannot tolerate a mask), and open the windows to increase air circulation.

2. Contain the respiratory secretions of the ill. All persons with signs and symptoms of a respiratory infection, regardless of presumed cause, should: Cover their nose and mouth when coughing or sneezing Use tissues to contain respiratory secretions Dispose of tissues in the nearest waste receptacle after use Perform hand hygiene after contact with respiratory secretions and contaminated

objects/materials

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HOME ISOLATION CHECKLIST

3. Protect the well with personal protective equipment (PPE) and hand hygiene. The primary caregiver, or anyone who cannot avoid contact with the ill household member, can protect themselves by: Wear a surgical or procedure mask when in close contact (< 3 feet) with an infectious

person. Masks should be changed and discarded when they become moist. Wash hands or use alcohol based hand rub after touching or discarding a mask.

Wear gloves if there is likely to be contact with respiratory secretions. Discard gloves immediately after use.

If hands are visibly soiled, wash them with warm water and soap If hands are not visibly soiled, use an alcohol-based hand rub (these products are

preferred over soap and water in this situation because they don’t dry the skin) Clean hands after contact with a person who may be ill, after removing mask or

gloves, or after touching items or surfaces that may be soiled.

4. Keep environment clean Tissues used by the ill person and other waste should be placed in a bag and disposed

of with other household waste. Laundry may be washed in a standard washing machine with warm or cold water and

detergent. It is not necessary to separate soiled linen and laundry used by a patient with influenza from other household laundry. Care should be used when handling soiled laundry (i.e. avoid “hugging” the laundry) to avoid self-contamination. Clean hands after handling soiled laundry.

Soiled dishes and eating utensils should be washed either in a dishwasher or by hand with warm water and soap. Separation of eating utensils for use by a patient with influenza is not necessary.

Environmental surfaces in the home can be cleaned using normal procedures. An EPA registered hospital disinfectant can be used according to manufacture’s instructions, but is not necessary. There is no evidence to support the widespread disinfection of the environment or the air.

5. Prevent illness among household members Persons who have not been exposed to pandemic influenza and who are not essential

for patient care or support should not enter the home while persons are actively ill with pandemic influenza.

Household members should monitor closely for the development of influenza symptoms and contact a telephone hotline or medical care provider if symptoms occur.

ATTACHMENT 4: Pocket Website Reference Tool http://www.cdc.gov/flu/professionals/treatment/0506anti-viralguide.htm CDC guidelines for the use of influenza anti-viral medications for the 2005-2006 influenza season http://www.cdc.gov/flu/professionals/treatment/ CDC information about anti-viral medications http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm CDC Information on infection precautions that should be implemented for all respiratory illnesses (Respiratory Hygiene and Cough Etiquette) http://www.cdc.gov/flu/avian/professional/infect-control.htm CDC information on infection control recommendations http://www.cdc.gov/travel/other/avian_influenza_se_asia_2005.htm CDC website for travel advisories and precautions http://www.fda.gov Food and Drug Administration prescribing information for oseltamivir for pediatric prophylaxis http://www.hhs.gov/pandemicflu/plan/ HHS Pandemic Flu Plan http://www.hhs.gov/pandemicflu/plan/pdf/S01.pdf HHS Pandemic Flu Plan Surveillance Section http://www.hhs.gov/pandemicflu/plan/pdf/S02.pdf HHS Pandemic Flu Plan Lab Diagnostics Section http://www.hhs.gov/pandemicflu/plan/sup1.html#app3 CDC Novel Influenza Case Report Form http://www.oie.int.downld/AVIAN%20INFLUENZA/A_AI-Asia.htm World Health Organization of Animal Health (OIE) WebPage on Avian Influenza (type H5) in Animals www.pandemicflu.gov Federal government provides background information and frequent updates for healthcare professionals http://www.pandemicflu.gov/plan/tab3.html Federal government provides guidance for families and individuals http://www.osha.gov/Publications/OSHA_pandemic_health.pdf Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers www.redcross.org Information to make your own emergency preparation plan and kit www.sccphd.org Santa Clara County Public Health Department www.vaers.hhs.gov Vaccine Adverse Effects Reporting System www.who.int World Health Organization provides information about the international progress of the pandemic http://www.who.int/csr/disease/avian_influenza/en/ For an updated listing of countries with cases of human infections

http://www.cdc.gov/flu/professionals/treatment/0506anti-viralguide.htm

http://www.cdc.gov/flu/professionals/treatment/

http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm

http://www.cdc.gov/flu/avian/professional/infect-control.htm

http://www.cdc.gov/travel/other/avian_influenza_se_asia_2005.htm

http://www.fda.gov/

http://www.hhs.gov/pandemicflu/plan/

http://www.hhs.gov/pandemicflu/plan/pdf/S01.pdf

http://www.hhs.gov/pandemicflu/plan/pdf/S02.pdf

http://www.hhs.gov/pandemicflu/plan/sup1.html#app3

http://www.oie.int.downld/AVIAN%20INFLUENZA/A_AI-Asia.htm


http://www.pandemicflu.gov/plan/tab3.html

http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

http://www.redcross.org/

http://www.sccphd.org/

http://www.vaers.hhs.gov/

http://www.who.int/

http://www.who.int/csr/disease/avian_influenza/en/

ATTACHMENT 5: Tool 29 – Figure 1, Clinical Algorithm for Case Management Alert Period

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Tool 29 – Figure 1 Clinical Algorithm for Case Management Alert period (footnotes)

Footnotes to Figure 1:

1. Updated information on areas where novel influenza virus transmission is suspected or documented is available on the CDC website at www.cdc.gov/travel/other/avian_flu_ah5n1_031605.htm and on the WHO website at www.who.int/en/.

2. For persons who live in or visit affected areas, direct contact includes touching live poultry (well-appearing, sick or dead) or touching or consuming uncooked poultry products, including blood. For animal or market workers, it includes touching surfaces contaminated with bird feces.

3. Close contact includes direct physical contact, or approach within 3 feet (1 meter) of a person with suspected or confirmed novel influenza.

4. Standard and Droplet Precautions should be used when caring for patients with novel influenza or seasonal influenza (refer to Module III, “Health Care” for a detailed discussion of these precautions). Droplet precautions should be continued for a minimum of 14 days, unless there is full resolution of the illness or another etiology has been identified before that period has elapsed. Information on infection precautions that should be implemented for all respiratory illnesses (i.e., Respiratory Hygiene/Cough Etiquette) is provided at: www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm

5. The decision to hospitalize a patient in the alert period should be based on all clinical factors, including the potential for infectivity and the ability to practice adequate infection control. If hospitalization is not clinically warranted, and treatment and infection control is feasible in the home, the patient may be managed as an outpatient. The patient and his or her household should be provided with information on infection control procedures to follow at home (see attachment titled “Home Isolation Checklist”; see also Module IV, “Limiting the Spread of Disease”). The patient and close contacts will be monitored for illness by local public health department staff.

6. Guidance on how to report suspected cases of novel influenza is provided on page 95 of this module.

7. The general work-up should be guided by clinical indications. Depending on the clinical presentation and the patient’s underlying health status, initial diagnostic testing might include: • Pulse oximetry • Chest radiograph • Complete blood count (CBC) with differential • Blood cultures • Sputum (in adults), tracheal aspirate, pleural effusion aspirate (if pleural effusion is present)

Gram stain and culture • Antibiotic susceptibility testing (encouraged for all bacterial isolates) • Multivalent immunofluorescent antibody testing or PCR of nasopharyngeal aspirates or swabs

for common viral respiratory pathogens, such as influenza A and B, adenovirus, parainfluenza viruses, and respiratory syncytial virus, particularly in children

• In adults with radiographic evidence of pneumonia, Legionella and pneumococcal urinary antigen testing

http://www.who.int/en/


of 3

Tool 29 – Figure 1 Clinical Algorithm for Case Management Alert period (footnotes)

Footnotes to Figure 1 (Continued):

• If clinicians have access to rapid and reliable testing (e.g., PCR) for M. pneumoniae and C. pneumoniae, adults and children >5 yrs with radiographic pneumonia should be tested.

• Comprehensive serum chemistry panel, if metabolic derangement or other end-organ involvement, such as liver or renal failure, is suspected.

8. Instructions for collecting specimens for novel influenza virus testing can be found on pages 86 of this module.

9. Strategies for the use of anti-viral drugs are discussed on pages 86-88 of this module.

10. Guidelines for the management of contacts in a healthcare setting are provided in Module III.

11. Given the unknown sensitivity of tests for novel influenza viruses, interpretation of negative results should be tailored to the individual patient in consultation with the local health department. Novel influenza directed management may need to be continued, depending on the strength of clinical and epidemiologic suspicion. Anti-viral therapy and isolation precautions for novel influenza may be discontinued on the basis of an alternative diagnosis. The following criteria may be considered for this evaluation:

• Absence of strong epidemiologic link to known cases of novel influenza

• Alternative diagnosis confirmed using a test with a high positive-predictive value

• Clinical manifestations explained by the alternative diagnosis

12. Guidance on the evaluation and treatment of suspected post-influenza community-associated pneumonia is provided in Tools 32 and 33.

ATTACHMENT 6: Tool 30 – Figure 2, Clinical Algorithm for Case Management Pandemic Period

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Tool 30 – Figure 2 Clinical Algorithm for Case Management Pandemic Period (footnotes)


1. This clinical case definition presumes that pandemic influenza will present with a clinical respiratory illness, as does seasonal influenza and novel influenza infections with avian influenza H5N1. Novel or pandemic strains of influenza A may produce clinical syndromes that differ from seasonal or avian influenza. If this happens, this case definition will be updated accordingly.

2. Standard and Droplet Precautions should be used when caring for patients with novel influenza or seasonal influenza (refer to Module III, “Health Care” for a detailed discussion of these precautions). Droplet precautions should be continued for a minimum of 5 days, unless another etiology has been identified before that period has elapsed. Information on infection precautions that should be implemented for all respiratory illnesses (i.e., Respiratory Hygiene/Cough Etiquette) is provided at: www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm

3. Routine laboratory confirmation of clinical diagnoses will be unnecessary as pandemic activity becomes widespread in a community. The SCCPHD will work with the CDC and the California Department of Health Services to conduct virologic surveillance to monitor antigenic changes and anti-viral resistance in the pandemic virus strains throughout the Pandemic Period.

4. Healthcare providers should base the decision to hospitalize a patient on a clinical assessment, following existing community standards of care. When hospital beds and healthcare resources become critically short in supply, the SCCPHD will develop and communicate standardized clinical criteria for triage of patients to care in the inpatient acute-care setting vs. Influenza Care Centers vs. the home. See algorithm titled “Clinical Triage Guidelines during Pandemic Critical Resources Stage” for details.

5. See Module III, “Heatlhcare,” for further information on cohorting.

6. The general work-up should be guided by clinical indications. Depending on the clinical presentation and the patient’s underlying health status, initial diagnostic testing might include:

• Pulse oximetry

• Chest radiograph

• Complete blood count (CBC) with differential

• Blood cultures

• Sputum (in adults), tracheal aspirate, pleural effusion aspirate (if pleural effusion is present) Gram stain and culture

• Antibiotic susceptibility testing (encouraged for all bacterial isolates)

• Multivalent immunofluorescent antibody testing or PCR of nasopharyngeal aspirates or swabs for common viral respiratory pathogens, such as influenza A and B, adenovirus, parainfluenza viruses, and respiratory syncytial virus, particularly in children


of 3

Tool 30 – Figure 2 Clinical Algorithm for Case Management Pandemic Period (footnotes)


• In adults with radiographic evidence of pneumonia, Legionella and pneumococcal urinary antigen testing

• If clinicians have access to rapid and reliable testing (e.g., PCR) for M. pneumoniae and C. pneumoniae, adults and children >5 yrs with radiographic pneumonia should be tested.

• Comprehensive serum chemistry panel, if metabolic derangement or other end-organ involvement, such as liver or renal failure, is suspected.

7. See “Patient handout for use in the home care setting” for the home isolation checklist and sample home care instructions.

8. Healthcare providers should ensure that patients triaged to home have adequate medication and supplies for the management of comorbid conditions, such as asthma or diabetes.

ATTACHMENT 7: Clinical Triage Guidelines - Pandemic Critical Resource Stage

Page 1 of 2

Clinical Triage Guidelines during Pandemic Critical Resource Stage

Clinical Triage Guidelines during Pandemic Critical Resources Stage Santa Clara County

Notes:

1. Influenza symptoms: High fever (T > 38) plus sore throat, cough or shortness of breath. Other symptoms: weakness, myalgias, abdominal symptoms, epistaxis, conjunctivitis, nasal congestions, chills, headache.

2. Pandemic flu triage protocol: Available resources: vital signs, examination, pulse oximetry Patient: wears respiratory mask on presentation Personnel: respiratory and universal precautions Evaluation: age, living conditions, functional status, sick contacts

of 2 Clinical Triage Guidelines during Pandemic Critical Resource Stage

Other comorbid medical conditions

A. Adults and teens >12 years of age: modified pneumonia severity index (PSI) calculation

Characteristic Points assigned Age Number of years Significant comorbid illness +10 Physical exam Altered mental status +20 Respirations >30 +20 Systolic BP<90 +20 Pulse >125 +20 Pulse oximetry <90% +20

(1) Admission to hospital: Score > 90 or a. Toxic appearance or rapid decompensation (especially important in

adolescents and in pregnant women) b. Significant hypoxia – O2 saturation < 88% c. Patients whose level of disability or medical complexity (e.g., on dialysis,

severe quadriplegia, dementia, etc.) would overwhelm the ability of assigned staff to provide basic care for other patients at Influenza Care Centers

(2) Admission to Influenza Care Center: Score < 90 and a. Needs closer monitoring and nursing care (for example, IV fluids, IV

antibiotics, etc.), or b. Unable to care for self or return if symptoms worsen, or c. No hospital beds available

(3) Discharge to home: a. Score > 90 with poor prognosis and unlikely to benefit from hospitalization,

or b. Score < 90 and able to care for self or has caregiver, and able to return if

symptoms worsen. B. Children 12 yrs of age and younger:

Indications for hospital admission include any of the following a. Fever and age < 2 months b. Significant tachypnea c. Hypoxia on pulse oximetry d. Chest retractions, cyanosis, intermittent apnea, nasal flaring e. Toxic appearance

3. PPE: respiratory masks, antiseptics, bleach for household surfaces 4. Isolation: Keep separated from other family members as much as possible, use hand

washing, and dispose of tissues in plastic bags. Wear respiratory mask when outside the home. Patient should remain isolated from other persons for at least 7 days after the onset of symptoms. [Refer to the “Home Isolation Checklist” Tool 21]

5. 911: EMS: The ability of EMS to deliver patients to a non-hospital location will require changes in current state statutes, which may come about in the context of a declaration of emergency

ATTACHMENT 8: Tool 37 – Patient Home Care Handout This Tool has been developed and will be distributed by SCCPHD.

ATTACHMENT 9: Household Flu Preparedness Checklist

Household Flu Preparedness Checklist As many as 1 in 4 people could get sick during a pandemic, with many of them seriously ill. Services and supplies we count on everyday may not be available. Every individual and family could be on their own, without care, for quite a while. This makes being prepared even more important. Make sure you have these items to prepare for a pandemic flu. HOUSEHOLD FLU PREPAREDNESS CHECKLIST TO PLAN FOR A PANDEMIC

Two weeks worth of food for you and your family. This should be food that does not need refrigeration (canned meats and fish, beans, soups, fruits, and dry goods like flour, salt and sugar)

Two weeks of water in sealed, unbreakable containers. If water service is disrupted, plan on one gallon for each person for each day, for up to two weeks.

Two weeks worth of prescription medicines

Two weeks worth of ibuprofen or acetaminophen (Tylenol) for each person in the house for fever and pain

Two weeks supply of other non-prescription drugs and health supplies such as cough and cold medicine, stomach remedies, and vitamins for each person in the house

Rehydration solution (such as Pedialyte for children and Gatorade for adults and teens)

Thermometer TO LIMIT THE SPREAD OF GERMS AND PREVENT INFECTION

Teach your children to wash hands frequently with soap and water, and model the correct behavior.

Teach your children to cover coughs and sneezes with tissues, and be sure to model that behavior.

Teach your children to stay away from others as much as possible if they are sick. Stay home form work and school if sick.

Supply of face masks for each person in the house Supply of plastic gloves for each person in the house Soap, disinfectants, and chlorine bleach for routine cleaning and disinfecting OTHER EMERGENCY SUPPLIES Cell phone and charger Flashlight Portable radio and batteries Manual can opener Garbage bags Tissues, toilet paper, disposable diapers

ATTACHMENT 10: FluSurge 2.0 Flu Surge is a spreadsheet-based model which provides hospital administrators and public health official’s estimates of the surge in demand for hospital-based services during the next influenza pandemic. FluSurge estimates the number of hospitalizations and deaths of an influenza pandemic (whose length and virulence are determined by the user) and compares the number of persons hospitalized, the number of persons requiring ICU care, and the number of persons requiring ventilator support during a pandemic with existing hospital capacity. With FluSurge 2.0, users can change variables that impact estimates of the number and duration of influenza-related hospitalizations. Variables that can be altered by the user include the assumed average length of hospital stay for an influenza-related illness, and the percentage of influenza-related hospital admits that will require a bed in an Intensive Care Unit (ICU). The user can also change the total number of persons requiring hospitalization. To run FluSurge, go to: http://www.cdc.gov/flu/flusurge.htm A. FluSurge Data for Saint Louise Regional Hospital

Below are screen shots of Saint Louise Regional Hospital created in June, 2007. Population data was adapted from the Santa Clara County 2000 census (www.wickipedia.com) by Mary Cwynar. The numbers include only the near-geography cities served by Saint Louise Regional Hospital. This was done to correct for the population served by other hospitals in the county.

Census of Wide-Geography Cities Served By Saint Louise Regional Hospital Santa Clara

County Mtn Vw Sunnyvale Cupertino Los AltosLos Altos

HillsSanta Clara Milpitas Total Average

Population 1682585 70708 131760 50546 27693 7902 102361 62698 453668under 18 24.7 18 20.4 26.6 23.7 23.6 19.9 24.6 101622 22.418-24 9.3 8.3 7.7 5.2 3.5 4 11.3 9.5 32081 7.125-44 35.4 43.4 41.3 33 24.5 19.6 39.1 38 154830 34.145-64 21 19.8 19.9 24.1 29.1 35.8 19.1 20.9 109334 24.118-64 65.7 71.5 68.9 62.3 57.1 59.4 69.5 68.4 296245 65.3over 65 9.5 10.5 10.6 11 19.3 17 10.6 7 55736 12.3Total 453603 100

Census of Near-Geography Cities Served By Saint Louise Regional Hospital

Santa Clara

County Mtn Vw Sunnyvale Cupertino Los AltosLos Altos

Hills Total AveragePopulation 1682585 70708 131760 50546 27693 7902 288609under 18 24.7 18 20.4 26.6 23.7 23.6 64822 22.518-24 9.3 8.3 7.7 5.2 3.5 4 16566 5.725-44 35.4 43.4 41.3 33 24.5 19.6 93394 32.445-64 21 19.8 19.9 24.1 29.1 35.8 74288 25.718-64 65.7 71.5 68.9 62.3 57.1 59.4 184248 63.84over 65 9.5 10.5 10.6 11 19.3 17 39482 13.7Total 288551 100 •Seasonal high ED census =700 /week (Typical ED census =500 /week)

http://www.cdc.gov/flu/flusurge.htm

http://www.wickipedia.com/

•FluSurge2.0_initial assumptions: ○ Near-geography population base ○ 15% attack rate, 8 week duration ○ 53% non-ICU capacity staffed ○ 60% ICU capacity staffed ○ 60% total ventilators available

FLU SURGE 0.2

ATTACHMENT 11:

Employee Health Services Pandemic Flu Symptom Review Questionnaire

M

Employee Health Services Pandemic Flu

Symptom Review Questionnaire

Date: _______________________ Time: ___________________ Name: ___________________________________________________________

please print Department: ______________________________________________________ During the Pandemic Period all associates and extended staff will be screened for influenza like symptoms before they are allowed to enter any SLRH facility.

1. Temperature:________________ 2. Have you had any of the following symptoms in the last 24 hours?

• Fever greater than 100?...................... Yes No

• Aching muscles?................................... Yes No

• Cough?.................................................. Yes No

• Headache?............................................. Yes No

• Joint Aches?.......................................... Yes No

• Eye pain?............................................... Yes No

• Feeling very cold or shaking chills?...... Yes No

• Feeling very tired?................................. Yes No

• Sore Throat?.......................................... Yes No

• Runny or stuffy nose?............................ Yes No

Cleared to work:…… Yes No Sent home:………… Yes No Other: ________________________________________________________________ By: __________________________________________________________________

ATTACHMENT 12 INFLUENZA CARE CENTER (ICC)

LOCATION CHECKLIST

DATE: _____________________ LOCATION: __________________________ PERSON IN CHARGE____________________ CONTACT INFORMATION: ____________________________________________________________ ANTICIPATED NUMBER OF PATIENTS: ______________________________________ # OF ROOMS IN LOCATION TO BE USED FOR PATIENTS: _____________________ # AND TYPE OF BEDS: HOSPITAL BEDS _______________________________________________ COTS __________________________________________________________ MATTRESSES ON FLOOR _______________________________________ BARE FLOOR SPACES ___________________________________________ BED\COT PLACEMENT ALLOWS AT LEAST 3FT BETWEEN PATIENTS? YES [ ] NO [ ]

• if no, consider another location for cases If no, are there portable or other barriers that can be erected\used to prevent droplet spread? Or are there other methods that can be used, e.g. placing patient beds head – to –toe. (Describe)_______________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ # OF PATIENTS PER BATHING LOCATION (TUBS OR SHOWERS) ________________________________________________________________________ If inadequate, what alternatives will be used? (Describe) ________________________________________________________________________ # OF PATIENTS PER TOILET ________________________________________________________________________ If inadequate, what alternatives will be used? (Describe) _________________________ ________________________________________________________________________ ________________________________________________________________________ # OF SINKS FOR HANDWASHING ____________________________________________ If inadequate what alternatives will be used, e.g. alcohol hand rinse? (Describe) _______________________________________________________________________________________________________________________________________________

(ICC checklist continued) FRESH\POTABLE WATER SUPPLY (Describe, e.g. well, city water, etc.) (If necessary, contact Facilities: 2548) If inadequate what alternatives will be used? (Describe) ________________________________________________________________________ ________________________________________________________________________ STORAGE FOR CLEAN OR STERILE SUPPLIES: (Describe) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ If inadequate what alternatives will be used? (Describe) __________________________ ________________________________________________________________________ ________________________________________________________________________ STORAGE FOR SOILED LINEN, GARBAGE, CONTAMINATED ARTICLES (Describe) ________________________________________________________________________________________________________________________________________________________________________________________________________________________ If inadequate what alternatives will be used? (Describe) __________________________ ________________________________________________________________________ ________________________________________________________________________ METHODS AND SCHEDULES TO CLEAN OR MAINTAIN SURFACES (Describe) FLOORS ________________________________________________________________________________________________________________________________________________ WALLS ________________________________________________________________________ BEDS (DESCRIBE FOR BOTH COVERING AND FRAME) ________________________________________________________________________ OTHER FURNITURE ________________________________________________________________________ VENTILATION SYSTEM AND TYPE OF AIR HEATING\COOLING\ HUMIDIFICATION (if necessary, contact Facilities: 2548): (Describe) ________________________________________________________________________ Describe required modifications to current system: ________________________________________________________________________ (ICC checklist continued)

FOOD STORAGE AND REFRIGERATION: (Describe) ___________________________________ Describe required modifications to current system ______________________________ MEDICATION\VACCINE STORAGE: (Describe) ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Describe required modifications to current system ________________________________________________________________________ STERILIZATION/DISINFECTION CAPABILITY: (Describe) ________________________________________________________________________ Describe required modifications to current system _______________________________________________________________________ DISH/UTENSIL CLEANING: (Describe) _______________________________________________________________________ Describe required modifications to current system _______________________________________________________________________

ATTACHMENT 13 OUTBREAK WEEKLY SURVEILLANCE REPORT

Complete and fax weekly as requested by CA Department of Health Services. CA DHS Contact person __________________________________ Fax: _________________________ Phone: __________________________ Number of employees at facility during this period: _________________ Count the number of patients and staff who are diagnosed using the current case definition. Attach working case definition (most updated version).

Date Day # Emergency Department Visits* E = ER, T = triage

# Admissions H = admitted to

hospital; A = admitted to alternate care

# Hospital-Acquired

Cases

# Staff diagnosed

Total No.

Total # meeting case definition Total No.

# meeting case

definition

__/__/__

Sunday T= ER=

H= A=

__/__/__

Monday T= ER=

H= A=

__/__/__

Tuesday T= ER=

H= A=

__/__/__

Wednesday T= ER=

H= A=

__/__/__

Thursday T= ER=

H= A=

__/__/__

Friday T= ER=

H= A=

__/__/__

Saturday T= ER=

H= A=

TOTAL T= ER=

H= A=

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Original: 10/1/1989Last Approved: N/ALast Revised: 3/1/2012Next Review: 3 years after approvalOwner: Gloria Dela Merced: Hospital

ExecutivePolicy Area: Surgical Services - Anesthesia

Intraoperative Evaluation / Documentation,Anesthesia

POLICY:

PROCEDURE:A. The Anesthesiologist/Anesthetist administering anesthesia shall be responsible for completion of the

Anesthesia Record with ASA classification.

B. Intraoperative anesthesia documentation shall contain at least:

1. Name, dosage, time and route of administration of all drugs and anesthetic agents used.

2. IV fluids administered including additives, time and amount.

3. Blood/blood products administered including identification numbers.

4. Oxygen flow rate.

5. Continuous recording of patient status noting blood pressure, heart rate, respiratory rate,temperature, end tidal CO2, pulse oximetry for oxygen saturation and physiological monitoring data.

6. Documentation of all pertinent events including induction, maintenance of anesthesia, emergencefrom anesthesia and checking of equipment function.

C. Appropriate completion of the Anesthesia Record will be monitored as a routine part of the QualityManagement Program for Anesthesia Services with identified problems/opportunities to improve servicesreferred to the Medical Director of Anesthesia Services for follow-up.




Health and Hospital Kristy Takeda: Health Care Program Analyst pending

There will be appropriate guidelines for the evaluation/documentation of patient responses to anesthesia andpertinent events occurring during surgical procedures requiring administration of anesthesia.

Intraoperative Evaluation / Documentation, Anesthesia. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423018/. Copyright © 2019 St. Louise Regional Hospital

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Committee (HHC)







Anesthesia MedicalDirector


Owner Gloria Dela Merced: Director, Critical Care, Supervision, & Volunteer 9/19/2018

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Medical Director, Anesthesia ServicesPOLICY:















The Anesthesia Service operates under the direction of the Medical Director of the Anesthesia Services.

Medical Director, Anesthesia Services. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423028/. Copyright © 2019 St. Louise Regional Hospital

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Nonflammable Anesthetics: Safety RegulationsPOLICY:

PROCEDURES:A. The term Nonflammable Anesthetizing Location shall mean any anesthetizing location permanently used

for or intended for the exclusive use of nonflammable anesthetizing agents.

B. No electrical equipment shall be utilized in any anesthetizing location unless judged by the EngineeringDepartment as being in compliance with NFPA 56A and 76B-M.

C. When a physician wishes to use his personal electrical equipment, it shall first be inspected by theEngineering Department and labeled as being in compliance with NFPA 56A and 76B-M.

D. Photographic lighting equipment shall be totally enclosed or constructed to prevent the escape of sparksor hot metal particles.

E. The use or storage of flammable anesthetic agents shall be expressly prohibited in all nonflammableanesthetizing locations.

F. If cautery, electrosurgery or other hot or arcing device is to be used during a procedure, flammablegermicides or flammable fat solvents shall not be applied for preoperative preparation of the skin.

G. When the ground-contact signal (red light) and/or the audible warning sounds, the EngineeringDepartment shall be contacted to locate improperly functioning electrical equipment. Following completionof the procedure, the OR in which the signal was detected shall not be used until a report has beenreceived from the Engineering Department that the electrical defect has been repaired/remedied.

H. Transportation of a patient while an inhalation anesthetic is being administered by means of a mobileanesthesia machine shall be prohibited unless deemed essential for the benefit of the patient in thecombined judgments of the surgeon and the anesthesiologist.


Attachments:

There will be established guidelines for the safe administration/use of nonflammable anesthetic gases in allareas of the Hospital providing Anesthesia Services.

Nonflammable Anesthetics: Safety Regulations. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5422847/. Copyright © 2019 St. Louise Regional Hospital

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Approval Signatures













Nonflammable Anesthetics: Safety Regulations. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5422847/. Copyright © 2019 St. Louise Regional Hospital

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Objectives of Anesthesia ServicesPOLICY:

PROCEDURES:A. The Anesthesia Services will implement operational standards, which facilitate attainment of objectives

and will monitor/evaluate activities and outcomes to determine level of objective attainment/maintenance.

B. Provide Anesthesia Services, which are responsive to the needs of all patients within the Hospital.

C. Maintain and improve whenever possible existing high levels of patient safety and quality of care in theprovision of Anesthesia Services.

D. Provide appropriate consultative services to members of the Medical Staff and to Hospital personnelregarding patient care concerns.

E. Provide appropriate direction/supervision/training of all personnel in the OR, Recovery Room, and Pre-opclinic to maximize the quality of patient care services provided.

F. Provide appropriate management of material and human resources in the provision of patient careservices for maximum utilization effectiveness.

G. Ensure implementation of an effective Quality Management Program in the monitoring and evaluation ofAnesthesia Services throughout the Hospital.








The Anesthesia Services will implement operational standards which facilitate attainment of objectives and willmonitor/evaluate activities and outcomes to determine level of objective attainment/maintenance.

Objectives of Anesthesia Services. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5422789/. Copyright © 2019 St. Louise Regional Hospital

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Objectives of Anesthesia Services. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5422789/. Copyright © 2019 St. Louise Regional Hospital

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ExecutivePolicy Area: Surgical Services

Pneumatic TourniquetPOLICY:

PROCEDURE:

1. Before use, the pneumatic tourniquet should be inspected and tested for cleanliness, integrity andfunction.

2. The cuffs, tubing, connectors, and gauges will be in good working condition.

3. Reusable cuffs and bladders should be cleaned, rinsed and dried according to the level of contamination.

4. All connecting tubing shall be wiped with a hospital grade chemical germicide and dried.

5. The tourniquet cuff shall be protected adequately form contamination during surgery.

6. The tourniquet cuff length and width should be individualized to the shape and size of the patient's limb.The widest cuff possible for the appropriate length should be used.

a. The cuff should overlap at least three (3) inches but not more than six (6) inches.

7. The tourniquet cuff should be applied to reduce risk to the skin integrity.

a. Padding should be soft, wrinkle free and wrapped smoothly around the limb as high on the extremityas possible, being careful not to pinch the skin folds where the tourniquet is applied.

b. Once inflated the cuff should not be readjusted. (Some tourniquet technology may not requirepadding-see manufacturer's instructions.)

c. Upper arm and thigh tourniquet cuffs should be positioned on the limb at the point of maximumcircumference. Consider presence of superficial nerves in unprotected areas.

d. Provide protection from fluids from collecting under the tourniquet cuff.

e. The use of a rubber bandage (Esmark) may be used to assist exsanguination of the limb.

f. When the cuff is inflated the pressure gauge should be clearly visible and monitored. Tourniquet

It is the policy of the SLRH operating room to use the AORN standards of care for the use of the pneumatictourniquet as outlined below. The pneumatic tourniquet includes an inflatable cuff, pressure source, pressureregulator, connective tubing and a pressure display.

The pneumatic tourniquet will be tested, maintained, inspected and cleaned according to the manufactureswritten instructions.

Pneumatic Tourniquet. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423026/.Copyright © 2019 St. Louise Regional Hospital

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inflation should be kept to a minimum.

g. Tourniquet pressure is determined and monitored by the surgeon and anesthesiologist. Theminimum pressure should be used to produce a bloodless field. Basic guidelines are:

▪ For the upper extremities; add 70mm to the patient's systolic pressure.

▪ For the lower extremities; multiply the patient's systolic blood pressure by two.The surgeon shall be informed of the duration of the tourniquet time at frequent, established intervalsby the anesthesiologist.

h. Documentation shall include:

▪ Cuff location

▪ Skin protection/padding stockinet

▪ Cuff pressure

▪ Time of inflation/deflation

▪ Skin and tissue integrity under the cuff before and after the use of the pneumatic tourniquet

▪ Assessment and evaluation of the entire limb.

▪ ID/serial # of tourniquet

▪ Identification of person who applied the cuff

REFERENCES:













AORN (2015) Guidelines for Perioperative Practice. Denver, CO: The Association of PeriOperative RegisteredNurses, Inc.

Pneumatic Tourniquet. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423026/.Copyright © 2019 St. Louise Regional Hospital

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Personnel Authorized to Enter SurgeryRATIONALE:A. Association of Operating Room Nurses' standards recommends limited traffic flow in the operating room

to assure maintenance of the sterile field.

B. The American Hospital Association Patient's Bill of Rights states "The patient has the right to everyconsideration of his privacy... (And) that all communications and records pertaining to his care should betreated as confidential."

Policy:Persons who may be authorized to enter the Operating Room Suite are divided into the followingcategories:

1. Medical personnel who are members of the Medical Staff of the St. Louise Hospital.

2. Hospital employees normally assigned to work in the Operating Room Suite.

3. Hospital employees normally assigned to work in other areas of St. Louise Hospital, but who areoccasionally required to enter the Operating Room Suite to do appropriate work.

4. Appropriate Allied Health Professionals approved to perform duties in the operating room.

5. Students: Medical, Nursing, Related Subjects.

6. Sales persons or technical advisors at the request of the surgeon, Operating Room Manager, ordesignee for the specific purpose to provide technical advice on the use and function of theequipment provided by them.

Participation is limited to verbal direction or equipment handling. Touching the patient is prohibitedwithout specific request and guidance by the physician.

C. Observers not allowed in the Operating Room.

1. Physician's relatives and friends.

2. Patient's relatives and friends, except support person during Cesarean section under spinalanesthesia.

3. Any observer during emergency procedures.

4. No more than two observers for any procedure.

Personnel Authorized to Enter Surgery. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423034/. Copyright © 2019 St. Louise Regional Hospital

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Regardless of all considerations, the primary surgeon has the ultimate decision to deny admission of anyperson to the Operating Room.

PROCEDURES:A. Patient consent will be obtained by the physician requesting.

B. The name and function of people observing in surgery will be recorded on the O.R. Record under "other".

All persons entering the Operating Room Suite are subject to the appropriate rules of dress, decorum,techniques of asepsis, etc. as outlined in the policies and procedures of Surgical Services for St. LouiseRegional Hospital.













Personnel Authorized to Enter Surgery. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423034/. Copyright © 2019 St. Louise Regional Hospital

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Positioning of the Surgical PatientPOLICY:

PROCEDURE:1. The perioperative RN will conform that appropriate positioning equipment is available and in working

condition before the patient arrives in the OR.

2. The RN will confirm the patient's position with the operative surgeon.

3. Anticipates positioning equipment needed for specific operative procedure.

4. Perioperative personnel will initiate action when necessary to ensure that an adequate number ofpersonnel will be used to safely transport, move, lift, and position patients during all phases of care.

5. Preoperative assessment for positioning needs should be made before transferring the patient to theprocedure bed.

The assessment shall include, but not be limited to:

◦ Preoperative neuropathies, preexisting conditions, and/or disease;

◦ Physical limitations

◦ Age

◦ Height and weight

◦ Skin condition

◦ Nutritional status

◦ Procedure type and position.

6. The RN will maintain patient dignity and privacy for the patient during transport, transfer and positioning.

It is the Policy of SLRH Operating Room to follow the AORN recommended guidelines for positioning thesurgical patient. The patients' position should provide optimum exposure for the procedure while providingaccess to IV lines and monitoring devices. Attention must be paid to patient comfort and safety, as well ascirculatory, respiratory, musculoskeletal and neurological structures. Equipment used for positioning isdetermined by the procedure, surgeon preference and patient condition. Working as a team, the surgeon,anesthesiologist, and perioperative nurse can minimize the risk of perioperative complications related topositioning.

Positioning of the Surgical Patient. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423032/. Copyright © 2019 St. Louise Regional Hospital

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7. During positioning the perioperative nurse will monitor the patient's body alignment and skin integrity.

8. The Perioperative RN will ensure that patient jewelry and body piercing accessories are removed beforetransferring onto or positioning the patient on the OR bed.

9. The Perioperative RN will actively participate in positioning the patient under the direction of the surgeonand in collaboration with the anesthesia provider.

REFERENCES:













AORN (2012), 12th edition. Perioperative Standards and Recommended Practices for Inpatient andAmbulatory Settings. Denver, CO: The Association of PeriOperative Registered Nurses, Inc.

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Pre-Operative HoldingPOLICY:

PROCEDURES:A. All patients will be admitted 1 – 1½ hours prior to the scheduled procedure.

B. A registered nurse will document a pre-operative nursing assessment on each patient including the vitalsigns and any allergy history or other significant health problems.

C. The patient will be dressed in appropriate attire for the procedure and made comfortable.

D. All diagnostic studies will be checked for completion and identification of any possible abnormalities whichmay impact on the procedure.

E. The consent form(s) will be checked for completion – correct time, date, procedure, physician, and patientsignature – and determine that patient fully understands. .

F. All pre-operative orders will be completed prior to transporting the patient to the operating suite











There will be appropriate pre-operative/pre-procedure care provided for all patients admitted to surgicalServices.

Pre-Operative Holding. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423013/.Copyright © 2019 St. Louise Regional Hospital

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Pre-Operative Holding. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423013/.Copyright © 2019 St. Louise Regional Hospital

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Pre-Operative RequirementsPOLICY:

PROCEDURES:A. It is required that any surgeon scheduling a surgical procedure shall be a member in good standing of the

St. Louise Regional Hospital Staff, have been granted surgical privileges, and that documentation of suchprivilege is available to the Operating Room personnel (See Medical Staff By-laws for process).

Except in cases of extreme emergency where delay would imperil the life of a patient, so stated in writingby the attending physician, no patient will be brought to surgery for operative procedure until the followingrequirements have been fulfilled:

B. History and Physical Examination (and surgical consultation if obtained) are recorded on the chart. Mustcontain the following:

1. Patient Identification

2. Date

3. Procedure to be rendered

4. Evidence that the patient understands the possibility of risk and complication, and has been given anexplanation of alternate treatment.

5. Each patient scheduled for surgery will have a completed History and Physical recorded within 30days of the scheduled procedure

6. Preoperative diagnosis is written and signed by the surgeon. Physician preoperative orders mustinclude the exact wording of the surgical procedure(s) to be written on the patient's operative permitprior to signing.

C. Preanesthetic medication orders are written and examination notes are recorded by the Anesthesiologist.

D. Consents

1. A specific consent form properly executed and signed by the patient is the responsibility of theattending nurse.

2. Hysterectomy

To maintain a high level of quality patient care, the following pre-operative requirements are in effect at St.Louise Regional Hospital. These standards conform to the recommendations of the Joint Commission

Pre-Operative Requirements. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423016/.Copyright © 2019 St. Louise Regional Hospital

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Patients scheduled for hysterectomies are required to sign the following:

a. "Hysterectomy – Informed Consent" form which is executed by the physician or physician'sdesignee and provided to the hospital upon admission.

b. A St. Louise Regional Hospital "Consent for Surgery" will also be signed on admission to thehospital. No hysterectomy will be performed as an elective sterilization on any patient.

E. Pre-operative work-up:

1. A lab work, EKG and radiology procedure is at the discretion of the physician/anesthesiologist, basedon the patient's condition.













Pre-Operative Requirements. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423016/.Copyright © 2019 St. Louise Regional Hospital

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ExecutivePolicy Area: Organization-Wide

Propofol Management and CarePURPOSE:

POLICY:A. Propofol (Diprivan) is indicated for use only in intubated mechanically ventilated adult patients.

Administration of Propofol (Diprivan) is to be performed only by staff who have been educated on itsspecific considerations/properties, who have successfully completed ACLS training, and who are skilled inthe management of critically ill patients.

B. Continuous Propofol infusion will be administered only in the Medical/Surgical ICU and it may also beadministered in the PACU.

C. Propofol will not be administered to patients who:

a. Have known allergies to Propofol, soybean oil, egg, lecithin, or glycerol.

b. Are 12 years of age or less.

c. Are pregnant or lactating mothers.

d. Are NOT intubated AND mechanically ventilated (unless a member of the Anesthesia Dept. ispresent).

D. Caution will be used in patients with:

a. Hyperlipidemia or those at risk to develop hyperlipidemia.

b. Patients who are concurrently receiving TPN/Lipids.

NOTE: When Propofol is initiated, the physician will need to reduce the amount of lipids the patient isreceiving, as 1ml of Propofol contains approximately 0.1g of fat (1.1 Kcal). Nutrition consultsuggested.

c. Patients with pancreatitis.

d. Patients who are hypotensive, hypovolemic, or hemodynamically unstable.

E. Prior to initiating Propofol infusion, the nurse will:

a. Validate physician's desired level of sedation on the Propofol Protocol. (The physician must specify

To establish criteria for the management and nursing care of a patient undergoing continuous Propofol infusionin the hospital setting.

Propofol Management and Care. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5278894/. Copyright © 2019 St. Louise Regional Hospital

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the desired level of sedation if different from a Richmond Agitation Sedation Scale (RASS) of -3.)

b. Perform a baseline assessment for:

1. LOC/anxiety

2. Vital signs

3. Baseline triglyceride level

c. Assess patient's level of pain; ensure concomitant IV analgesia has been ordered.

F. A Bolus of Propofol may be administered by an anesthesiologist, CRNA, or critical care pulminologist/intensivist.

NO BOLUS of Propofol will be given by an RN. RNs may administer Propofol by continuous IV infusion,via infusion pump through a dedicated line. Though a central line is preferred, it can be infused via aperipheral site. If a dedicated line is not possible, Propofol may be given with TPN and intralipids as longas a separate pump with a three way stopcock is utilized.

PROCEDURE:A. Strict aseptic technique must be maintained during handling, as Propofol contains no antimicrobial

preservatives. The vial rubber stopper will be disinfected using 70% isopropyl alcohol prior to spiking thebottle with a sterile vent spike and sterile tubing. Infusion must commence immediately.

B. The Propofol infusion will be initiated at 5mcg/kg/min.

a. No increase in the infusion rate will be made during the first 5 minutes of infusion. Assess the patientfor hemodynamic response and level of sedation.

b. If the patient is hemodynamically stable, increase the infusion rate at 5mcg/kg/min. no faster thanevery 5 minutes until the desired level of sedation (specified by the physician) is attained. Most adultpatients require maintenance rates of 5-50 mcg/kg/min. to maintain adequate levels of sedation. Ifpatient is requiring more than 50 mcg/kg/min. notify the physician and reassess sedation options.

C. Upon initiation of Propofol, vital signs will be documented as follows:

a. Every 15 minutes x 2, every 30 minutes X2, then everyone (1) hour if patient is hemodynamicallystable throughout the infusion.

b. Pulse oximetry will be monitored continuously and documented every one (1) hour and PRN in theelectronic medical record (EMR) or a vital sign flowsheet.

c. Should the patient become hemodynamically unstable, call the M.D.

D. Any unused Propofol and the IV tubing MUST BE discarded after 12 hours . As with other lipidemulsions, the number of IV line manipulations should be minimized.

E. Recommended: A wake-up assessment will be carried out every 24 hours throughout the infusion, unlessotherwise contraindicated. This requires an MD order for the "Wakeup assessment" .This dailyassessment allows for the evaluation and assessment of: CNS function, pain management, and anxietylevel. This ensures that the patient receives the lowest effective dose of Propofol necessary to achievethe desired level of sedation.

a. Avoid abrupt discontinuation of Propofol. (Do not just turn off the infusion). Rapid awakening maycause agitation and/or asynchrony with the ventilator due to the sudden influx of stimuli occurringduring the transition from deep sedation to full consciousness.


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b. Adjust the infusion rate to maintain a light level of sedation. For patients maintained at a RASS of -3or higher, decrease the infusion rate in 5 mcg/kg/min in increments of 5 minutes interval until a RASSof 0 is reached, or to the desired level specified by the physician. Once the patient has reached alightly sedated level, determine the level of orientation appropriate for that patient, then discontinuethe infusion. Within 10-15 minutes the patient usually will be completely awake (assuming the patientcan achieve full consciousness).

c. After evaluation, titrate to a deeper level of sedation by increasing the infusion rate in 5 mcg/kg/minin 5 minutes intervals until the desired level of sedation specified by the physician is attained.

F. Weaning from the ventilator:

a. Once the physician initiates the weaning process, all paralytic agents will be discontinued.

b. Gradually decrease the Propofol infusion rate until the patient reaches a light level of sedation. It isrecommended that the Propofol infusion be continued in order to maintain a light level of sedationthroughout the weaning process until 10-15 minutes prior to extubation,at which time the infusion canbe discontinued.

DOCUMENTATION:a. Propofol will be recorded in mcg/kg/min. in the Vital Sign Flowsheet of the EMR or a vital sign flowsheet

(during downtime).

b. The patient's level of sedation as indicated by the RASS will be recorded with each titration and then atleast every two hours once stable (and more often as patient condition warrants) on the Vital SignFlowsheet of the EMR under the short name RASS.

c. Richmond Agitation Sedation Scale (RASS):+4 Combative+3 Very agitated+2 Agitated+1 Restless0 Alert and calm-1 Drowsy-2 Light sedation-3 Moderate sedation-4 Deep sedation-5 Unarousable

d. Propofol will be recorded in the Intake & Output Flowsheet of the EMR under Propofol

REFERENCE(S):


Attachments:

American College of Critical Care Medicine (ACCM), (2013). Clinical Practice Guidelines for the Managementof Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Society of Critical Care Medicine.Retrieved from http ://www.ashp.org/doclibrary/bestpractices/tgpad.aspx


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Approval Signatures








Surgery Department Brittney Weltz: Medical Staff Services Manager [KT] 4/4/2019

Medicine Department Brittney Weltz: Medical Staff Services Manager [KT] 4/4/2019

Pharmacy Director Norman Fox: Pharmacy Director 4/4/2019

ICU AssistantManager

Tyler Johnston: ICU Assistant Manager 3/19/2019








Norman Fox: Pharmacy Director 9/21/2018


Gloria Dela Merced: Director, Critical Care, Supervision, & Volunteer 9/19/2018

Owner Lori Katterhagen: VP Patient Care & Clinical Services / CNE 8/14/2018


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Reprocessing of Single Use DevicesPOLICY:

PURPOSE:

BACKGROUND:• Many single use devices can be reprocessed and reused upon 510k clearance by the FDA. These

devices are produced with durable components, thus allowing them to be reprocessed several times.• Due to the advancement of industrial cleaning and sterilization techniques, these products are cleaned,

sterilized and tested for functionality under strict FDA guidelines.• Each device undergoes 100% quality inspection before being returned to the facility.• Reprocessing allows for a device to be re-used without compromising the quality, outcome, or patient

safety.• Reprocessing has been endorsed by many leading medical professional organizations (AORN, JCHAO,

AAMI, AHA and others).• The results are a continuation of each hospital's standard of excellence regarding patient care while

maximizing utilization of facility supplies and increasing operation efficiencies.• The device manufacturer for reprocessing, maintains all product liability for the products with their label.

This includes ancillary devices such as hand pieces or other products used in conjunction with areprocessed product.

• At the conclusion of each procedure all approved single use devices will be reprocessed according toFDA policy and procedures and the facilities reprocessing policy. Hospital personnel will follow theirinfection control policy for handling devices contaminated with blood, tissue, or body fluids.

• Reprocessed products are safe and therefore it is the expectation of the facility that all associates willcollect SUD's and use reprocessed products in accordance with the facilities reprocessing policy.

• Devices collected at the SLRH for reprocessing will be the only devices returned for reuse to SLRH

Approved Single Use Devices, ("SUD") will be reprocessed for reuse. Reprocessing of approved devices willnot be reprocessed on site, but shall be achieved by an external contractor. All associates will be givenappropriate education and orientation to the practice of reprocessing and are expected to fully participate bycollecting devices for reuse and utilize reprocessed items before the use of new ones.

To establish and implement a program for safe, FDA regulated reuse of single use devices, "SUD" which willuphold the Daughter's of Charity Mission for environmental and fiscal responsibility.

Reprocessing of Single Use Devices. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423015/. Copyright © 2019 St. Louise Regional Hospital

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1. Open but not used, all devices and items.

2. Compression device sleeves

3. Pulse oximeter probes (adhesive type)

4. Laryngeal Mask Airways

ENDOSCOPY DEVICES:

5. Biopsy forceps (hot and cold)

6. Jag Wires/Glide/Guide wires(retain protective sheath for reprocessing)

7. Snares

ORTHODPEDIC AND ENT DEVICES:

8. Drill bits

9. Burrs

10. Saw blades

11. Chisels

12. Taps

13. Rasps

14. Reamers

15. Shavers

16. Radiofrequency probes

17. Tourniquet cuffs(Sterile)

GENERAL/GYN/URO

18. Trocars

19. Harmonic scalpels

20. Laparoscopic Instruments-COLD: (Ethicon and AutoSuture graspers, babcocks, scissors, and dissectors

21. Laparoscopic Instruments-HOT:Valley Lab=Ligasure Atlas.Auto Suture= mini-shears, scissors, dissectors. Ethicon=dissector, scissors, macro jaw bipolar forceps.Gyrus/Everest=Bipolar cutting forceps, Molly forceps, macro jaw bipolar forceps, Lyons dissectingforceps.***DO NOT CUT ANY WIRES OR CORDS ON ANY DEVICE***

22. Multiclip appliers

23. Linear Staplers /GI open linear staplers. (This will be returned empty, ready to load)

24. TURP loops and electrodes

25. Stone retrieval baskets

The approved list of single use devices for reprocessing are:

Who is responsible for collection of single use devices for reprocessing?


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• Used and contaminated (used during the surgical procedure on the patient)• Open, clean and unused (opened and unused). Segregated on the back table or passed off to prevent

contamination.

• All personnel handling contaminated items must follow strict adherence to use of personal protectiveequipment to avoid exposure to potentially infective material on the devices. Use appropriate gloves,gown and eye protection and mask.

• Whenever possible, open unused items should be passed off the field. If the item was on the back tableit should be considered contaminated and treated accordingly.

• All items collected shall be taken to the decontamination area in sterile processing and rinsed free ofdebris. It is preferable that the devices used during the procedure be rinsed on the back table with waterto avoid bioburden build up. Do not cut any cords that are part of a single use device. When in doubt if thedevice should be collected for reprocessing, the associate will not discard the device.

• The devices will then be either ultrasonically cleaned or run through the washer/sterilizer. Sterileprocessing staff will be responsible for device cleaning and placement into the collection containers.Collection containers will be located in the decontamination area of central processing. This is a restrictedarea and is accessible only to personnel within the surgical department

• Items which were used and decontaminated will be placed in designated container for these items with aRED biohazard symbol on the outside.

• Opened and unused items which were never in contact with potentially infectious material (ie. patient'sfluids), will be placed in designated container for these items.

• There will be a separate smaller container with the biohazard symbol on the outside which shall be usedonly for endoscopy items. (Biopsy forceps, snares etc), which will be located at the point of use withinthe endoscopy suite.

• All protective sheaths or housings that devices are packaged in, such as guide wires, snares, etc., shouldalso be retained and returned along with the SUD.

• Used sequential compression device sleeves will be stored in a designated hamper . This storagehamper will be located in PACU.

All surgical department associates are responsible for collection of SUD's.

What types of items are collected for reprocessing?There are two types of collected items:

How are items collected, decontaminated, and stored?

Who will be responsible for collecting the containers?The onsite technician will regularly collect the bins and replace them with new ones. The on site technician willbe responsible for the safe handling and return of the items for reprocessing

How are items returned to inventory and used?The time frame for each type of device is variable. Materials Management will be able to track what devicesare in process and when they will be available for shipment. The Inventory Control clerk will place reprocesseditems on the shelf with new ones.

When selecting supplies, always choose the reprocessed devices before selecting new ones.Reprocessed devices will be on the shelf in front of new ones. The packaging will be clear see thru plasticwithout cardboard outer boxing. The labeling will identify the device and load number from sterilization. If noreprocessed devices are available, then choose a new one. When this occurs, notify the charge nurse and/orinventory control clerk. This inventory problem will tracked


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• Vendors will not speak negatively to any surgeon or associate about SUD reprocessing while on hospitalproperty.

• Vendors will not distribute any materials about SUD reprocessing or other information discreditingreprocessing to any associate. No method of communication for this purpose will be tolerated.

• Vendors will not move, remove, or redistribute processing product in any of the surgical department'ssupply without approval of the OR director

• Vendors who violate this policy will result in immediate and permanent expulsion from this facility. Inaddition, products purchased from this vendor will be scrutinized for purchase from another vendor.

• Associates who witness behavior from any vendor that is not consistent with our policy for reprocessingsingle use devices, should immediately report the violation to their supervisor, director of surgicalservices, and/or materials management.

• Immediately notify your supervisor/director/materials management.• Retain all packaging related to the device.• Notify Risk Management of the incident.













How should associates address original equipment manufacturer vendor disruption?

What is the process to report a device inquiry in the event of product failure at the point of use?In the case of a reprocessed device failure that does not result in patient injury, the device will be saved alongwith the packaging for quality assurance review.

In the case of a reprocessed device failure that DOES RESULT in a patient injury:

Who is liable in the event of product failure? The reprocessing company assumes all responsibility forliability related to failure of reprocessed devices.

How are patient costs affected? Overall, patient and hospital costs will be reduced. Patient charges willreflect a reduction for all devices whether new or reprocessed.


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Safety Policies for the Operating RoomPOLICY:

RATIONALE:

PROCEDURES:ACTION RATIONALE

1. Do not block access to equipment. 1. Access to fire safety equipmentmust never be blocked.

2. Hallways must be kept clear at all times and necessaryequipment should only be placed on one side of the hallway.

2. Pathways should not be blockedto prevent movement of people orequipment.

3. Gas cylinders must be properly cleaned and supported, emptytanks labeled, and storage should be in areas wheretemperatures are constant.

3. Improperly stored tanks maypose a threat of explosion.

4. Side rails must be up on occupied gurneys. 4. Patients may fall if side rails arenot up.

5. Dispose of all soiled linens in the appropriate manner 5. Avoid possible contaminationfrom linen to personnel.

6. Dispose of sharp objects in authorized containers. 6. Avoid risk of injury from sharpobjects improperly disposed of.

7. Narcotics are stored in locked cupboard. 7. Access is limited to authorizedstaff and supplies are counted andcounts documented at the changeof each shift.

8. Toxic liquid chemicals are poured in vented areas located neareye washing facilities.

8. Toxic fumes pose a risk topersonnel.

9. Utilize good body mechanics at all times. 9. Use of proper body mechanics

A safe environment will be provided for employees, hospital staff, patients and visitors.

The safety of all those entering the operating rooms at St. Louise Hospital will be guaranteed.

Safety Policies for the Operating Room. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423014/. Copyright © 2019 St. Louise Regional Hospital

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decreases the risk of injury due tostress and strain on muscles.

10. Personnel safety will be emphasized during cleaningprocedures such as floor washing.

10. Containing water may preventunnecessary slips and falls.

11. Flammable products will not be used in the operating room. 11. Prevent fires which may eruptduring use of flammable products.

12. Injuries involving patients will be documented on an IncidentReport Form.

12. Documentation regardinginjuries is imperative.

13. Injuries involving employees will be documented and reportedto the Employee Health Department.

13. Documentation regardinginjuries is imperative.

14. Scalpels shall be passed to the surgeon in an emesis basinwhenever possible. (Eye cases and others involving the use ofmicroscope are the exception.) Scalpels shall be placed back inthe emesis basin by the surgeon to be passed off the field.

14. Only one set of hands shall beon the sharp at one time todecrease the likelihood of "cutting"someone as the sharp is pulledaway.













Safety Policies for the Operating Room. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423014/. Copyright © 2019 St. Louise Regional Hospital

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ManagerPolicy Area: Pharmacy

IV Levothyroxine Therapeutic HoldPURPOSE:

POLICY:

A.

B.

C.

D.

PROCEDURE:A.

B.

◦

C.

D.

◦

◦

To provide a clinically safe and economic medication hold alternative when intravenous levothyroxine idordered.

An automatic five day hold on IV Levothyroxine order shall be placed when a patient previously receiving POtherapy becomes NPO during hospital admission. Levothyroxine has a half-life of 6-7 days which allows for aperiod of time after the last oral dose before the transition to intravenous dosing is needed. Exceptions to thisrecommendation are:

Myxedema

Pediatrics/adolescents<18 years of age

Organ donation

Prescriber indicating on order instructions not to hold IV Levothyroxine therapy

Review the patient’s history for any exclusion criteria (myxedema, pediatrics/adolescents, organ donation,and/or prescriber indicating to not hold IV Levothyroxine)

Schedule the IV levothyroxine dose to begin 5 days from last dose (Dose starts on day 6)

Note: The initial parenteral dosage should be 50% of the previously established oral dosageof levothyroxine.

Pharmacy will write an order in patient’s chart - “IV levothyroxine temporarily on hold to begin on (Date)per P&T protocol”

Monitor patient daily assessing NPO status. Initiate an IV to PO interchange when patient meets all of thefollowing criteria:

Evidence of clinical improvement

Patient is receiving medications or diet orally or via enteral tube

IV Levothyroxine Therapeutic Hold. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/4824893/. Copyright © 2019 St. Louise Regional Hospital

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◦

◦

REFERENCES:












VP / CNE Gloria Dela Merced: Dir. of Nursing, Critical Care & Nursing Admin. [KT] 9/23/2019


Patient does not have persisting nausea, vomiting, or diarrhea

Patient does not have pending NPO order

Reason for Recommendation of Hold:

As a cost-savings initiative, the pharmacokinetic properties of levothyroxine’s extended half-life do not requireimmediate transition from oral to intravenous route in the NPO setting, unless clinical manifestations ofhypothyroidism occur.

IV Levothyroxine Therapeutic Hold. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/4824893/. Copyright © 2019 St. Louise Regional Hospital

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Labeling of MedicationsPOLICY:

DEFINITIONS:

• Prescription medications• Sample medications• Herbal remedies, nutriceuticals, vitamins, and over the counter medications• Vaccines• Contrast agents• Parenteral nutrition• Blood derivatives• Intravenous solutions either plain or with electrolytes or drugs• Chemicals and reagents such as formaline, saline, sterile water, Lugol's solution, radiopaque dyes,

gluteraldehyde, and chlorhexidine• Any agent classified by the FDA as a drug

PROCEDURE:A. The nurse or person administering the medication will insure that all medication containers are properly

labeled whenever medications are prepared but are not immediately administered.

B. At a minimum, all medications prepared in the hospital are correctly labeled with the following:

1. Medication name, strength, and amount (if not apparent from the container).

Medications and medication containers are labeled in a standardized manner consistent with applicable lawand regulation and standard of practice. Anytime one or more medication(s) are prepared but not immediatelyadministered, the medication container must be labeled.

Medication denotes any of the following:

Immediately administered is defined as an uninterrupted process between the time medication is prepared tothe time it is administered to a patient.

Medication container is defined as any storage device such as a plastic bag, syringe, bottle, or box, whichcan be labeled and secured in such a way that it can readily be determined that the contents are intact andhave not expired.

Labeling of Medications. Retrieved 11/14/2019. Official copy at http://verity-saintlouise.policystat.com/policy/6104187/.Copyright © 2019 St. Louise Regional Hospital

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2. Expiration date when not used within 24 hours.

3. Expiration time when expiration occurs in less than 24 hours.

4. The date prepared and the diluent for all compounded intravenous admixtures and parenteralnutrition formulas.

C. When preparing individualized medications for multiple specific patients or the person preparing themedication(s) is not the individual administering the medication, the medication must be labeled as notedabove. The label must also include:

1. The patient's name

2. The location where the medication is to be delivered.

3. Directions for use and applicable accessory and cautionary instructions.

D. All medications should be secure and controlled. Before administration of a medication, the personadministering the medications shall verify the two patient identifiers and ensure the patient's FIVERIGHTS (the right drug, right dose, right mode, right time and right patient) before administration of anymedication.

E. Unlabeled, outdated, damaged, or contaminated medication must be discarded and will not be given tothe patient. All unopened solutions or medications that have been discontinued or have exceeded theirexpiration date must be returned to the Pharmacy Department.

F. A multiple-dose container is any medication intended by the manufacturer for more than one use from thesame container. These medications include, but are not limited to, ophthalmic solutions, otic solutions/ointments, and injectable multiple-dose vials with preservatives. Multi-dose containers or multi-doseinjectable vials, such as insulin, must be labeled with the date opened and stored appropriately. Onceopened, discard multiple use containers or multiple dose vials within 28 days.

G. Intravenous admixtures for immediate use may be prepared outside the pharmacy, but the establishedguidelines must be followed:

1. The Pharmacy Department will compound all compounded sterile preparations except in urgentsituations in which a delay could harm the patient or when the product's stability is short or the use ofadmixture connecting systems, such as vialmate adaptors, minibag plus, or advantage bags. Theseconnecting systems must be activated prior to administration.

2. Staff use clean or sterile technique and maintain clean, uncluttered, and functionally separate areasfor product preparations to avoid contamination of medications. Hand washing is required beforeeach IV preparation. The area used for the admixture should be cleaned with 70% isopropyl alcoholbefore the admixture procedure is started. All supplies required for the admixture should beassembled prior to admixture (syringes, needles, alcohol swabs, drug(s) to be added, IV solution,etc).

3. All admixtures ports of the IV solution or drug containers (diaphragms of the vials or neck of glassampules) must be swabbed with 70% solution of alcohol prior to penetration of the container with anyadditives or admixture connecting devices. Filter needles should be used for all glass ampules.

4. During the preparation staff visually inspects the medication for particulates, discolorations, or otherloss of integrity.

5. The intravenous (IV) admixture or sterile product will not be used after 24 hours after preparation. Allunopened solutions which have been discontinued or have exceeded their expiration date must bereturned to the Pharmacy Department.


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6. Intravenous admixtures that are not labeled must be discarded.

7. All light-sensitive solutions must be wrapped in such a manner as to shield them from any lightsource.

H. Labeling of medications and solutions on and off a procedural or sterile field are addressed under aseparate policy "Labeling of Medications and Solutions on the Operative Field".

REFERENCES:








Pharmacy & TherapeuticsCommittee (P&T)


VP / CNE Gloria Dela Merced: Dir, Critical Care, Supervision, Surgery, SPD 3/11/2019

Owner Norman Fox: Pharmacy Director 3/6/2019

The Joint Commission Medication Management Standard MM.05.01.09. MM.05.01.07


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Electrical SafetyPOLICY:

PROCEDURES:A. Defective electrical equipment shall be replaced or removed from service and Biomedical Engineering

contacted if:

1. Equipment has been dropped, abused, or if liquid has been spilled into it.

2. Anyone has received a shock with its use.

3. Any wire or cord shows evidence of being frayed, cut, worn, or burned.

4. Evidence of overheating by touch or smell.

5. Any plug is bent, loose, or broken.

B. The National Fire Prevention Association (NFPA) does not permit use of portable electric heaters.

C. Use of two prong adapters is not permitted.

D. Extension cords, obtained through the Maintenance Department only, may be used in the facility.

E. Use of personal electrical medical equipment is not allowed. When valid medical reasons exist for the useof electrical medical equipment not owned by the hospital, the equipment shall be inspected, approvedand labeled by Biomedical Engineering. If equipment is found unsafe, it will be removed from hospitalpremises.

F. Before use, all electrical medical equipment purchased, borrowed or rented by the hospital will bechecked and approved by Biomedical Engineering. Copies of all equipment information/instructions willbe maintained by the Maintenance Department or CuraCare.

G. Service reports for equipment covered under contract agreement will be maintained by BiomedicalEngineering.


Attachments:

To maintain a safe working environment within the surgical services area, so that staff will detect, report andremove faulty or defective electrical equipment.

Electrical Safety. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5761995/. Copyright ©2019 St. Louise Regional Hospital

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Approval Signatures









Owner Gloria Dela Merced: Dir, Critical Care, Supervision, Surgery, SPD 1/24/2019

Electrical Safety. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5761995/. Copyright ©2019 St. Louise Regional Hospital

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Management of Hazardous Materials and WastePOLICY:

RATIONALE:












Hazardous materials and waste will be managed according to hospital policy.

All hospital departments will comply with hospital policies and procedures.

Management of Hazardous Materials and Waste. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5422949/. Copyright © 2019 St. Louise Regional Hospital

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Medical GasPOLICY:

RATIONALE:

PROCEDURE:ACTION RATIONALE

1. For problems with medical gas, contact PlantOperations.

1. Plant Operations is responsible formedical gas.












Medical gas systems will be maintained by members of the Engineering Department.

Medical gases will be maintained in order to provide an adequate and safe supply of non-flammable medicalgases for hospital use.

Medical Gas. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5422956/. Copyright ©2019 St. Louise Regional Hospital

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Nerve and Muscle Biopsy for Outside InstitutionsPOLICY:

PROCEDURE:

1. If a differential diagnosis of peripheral neuropathy is entertained, the specimen should be handled in amanner which, in addition to paraffin sections, permits the preparation of teased fibers, plastic sections,and if necessary, eventual electron microscopy.

2. Santa Clara Valley Pathology department to be notified at least 24 hours before impending biopsy, ifpossible. Please call Santa Clara Valley Medical Pathology if the biopsy is cancelled.Telephone (408) 885-6554 or 885-6550Santa Clara Valley Medical CenterDepartment of Pathology751 South Bascom AvenueSan Jose, CA 95128

3. The Surgical coordinator will notify Santa Clara Valley Pathology department and arrange transportationof the specimen.

4. The following guidelines will be followed in handling/preparation of the specimen:

A. Optimal length of nerve: 3.0 cm

▪ Please handle nerve as atraumatically as possible.

▪ Please do not inject anything into the portion of nerve which is to be removed.

B.

▪ Wrap nerve in saline-dampened gauze.

▪ Place in a closed container.

▪ Transport the closed container on wet ice. (Not gel refrigerant, i.e.: "cold ice", not dry ice) tothe address above as quickly as possible.

Specimens for Muscle and Nerve biopsy require different methods of handling, storing and preservation inorder that the tissue sample arrives to the lab in a manner that is conducive for proper analysis to becompleted.

Muscle/Nerve biopsy (For outside Institutions)

Nerve and Muscle Biopsy for Outside Institutions. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5738995/. Copyright © 2019 St. Louise Regional Hospital

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5. Notify Dr. Herrick that biopsy has been performed and forward specimens.

6. Fill out form "Information to be transmitted with Nerve Biopsy" completely.


Attachments: Information to be Transmitted with NerveBiopsy

ST. LOUISE REGIONAL HOSPITAL

INFORMATION TO BE TRANSMITTED WITH MUSCLE BIOPSY


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https://pstat-live-media.s3.amazonaws.com/attachments/public/f6a8bac1e8af20543f05d8fef45397d231290884bd34e751dad8f09f/Nerve%20and%20Muscle%20Biopsy%20for%20Outside%20Institutions%202015.doc

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Approval Signatures











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Patient Transportation from HospitalPOLICY:

PROCEDURES:A. Each patient having procedures scheduled through Surgical Services is responsible for providing patient

transportation to and from the Hospital.

B. Patients receiving general, regional or IV sedative anesthesia must have a responsible adult accompanythem home. These patients will be transported from the unit/ hospital by wheelchair.

C. Patients having local anesthesia only will be permitted to ambulate upon discharge unless their post-operative status warrants a wheelchair/escort.

D. Patients having endoscopic procedures without general anesthesia or IV sedation may be dischargedhome unaccompanied when the following conditions are met:

1. Patient remains in the Hospital for at least 30 minutes following the procedure.

2. Physician performing the procedure writes appropriate discharge order.











There will be established guidelines for the provision of safe patient transportation.

Patient Transportation from Hospital. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423027/. Copyright © 2019 St. Louise Regional Hospital

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Patient Transportation from Hospital. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5423027/. Copyright © 2019 St. Louise Regional Hospital

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Visiting Policy for Outpatient Admissions/PARPURPOSE:

POLICY:

1. Pediatric patients will be allowed to have one parent in attendance while in PACU and OutpatientAdmissions (Pre-operative Holding area.)

2. One responsible adult will be allowed in Outpatient Admissions Pre-op only when the patient has aspecific impairment (i.e. hearing impairment, language barrier) preventing him/her from providing all of therequired information.

3. One responsible adult will be allowed in the Pre-operative area immediately prior to patient beingtransferred into the Operating Room.

4. When there is only one patient in Outpatient Admissions, one responsible adult may remain with thepatient and at the discretion of the nurse.

5. One responsible adult will be allowed into PACU to receive discharge instructions with the patient only atthe time of discharge.








To establish guidelines for traffic pattern in the perioperative practice areas by limiting patient's visitors in thePre-op holding and Post Anesthesia Care Unit (PACU).

In order to maintain safety and effectiveness in care given for patients in Pre-op and PACU, it is the policy ofSt. Louise Regional Hospital that visitors are limited in these areas with the following exceptions:

Visiting Policy for Outpatient Admissions/PAR. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5762008/. Copyright © 2019 St. Louise Regional Hospital

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Visiting Policy for Outpatient Admissions/PAR. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5762008/. Copyright © 2019 St. Louise Regional Hospital

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Original: N/ALast Approved: N/ALast Revised: N/ANext Review: 3 years after approvalOwner: Louise Fry: Maternal Child

Health DirectorPolicy Area: Maternal Child Health

Amniotomy, AssistingPURPOSE:

POLICY:

PROCEDURE:Equipment

• Fluid-impermeable pads• Soap and water• Washcloth or peri-bottle• Towel• External electronic fetal heart rate (FHR) monitoring equipment or a fetoscope or Doppler stethoscope• Sterile gloves• Clean gloves• Sterile amniotomy hook or finger cot• Hospital-grade disinfectant• Thermometer

In amniotomy, a practitioner uses a sterile amniotomy hook or an amniotomy finger cot to artificially rupture apatient's amniotic membranes.According to the American College of Obstetrics and Gynecologists, routineamniotomy need not be performed in females with normally progressing labor and no evidence of fetalcompromise unless required to facilitate fetal monitoring. Amniotomy can also be performed with an oxytocininfusion to treat slow labor progress. Amniotomy, used in combination with oxytocin administration, has shownto modestly reduce the duration of labor and cesarean birth rates when compared to expectant management.

When deciding whether to perform amniotomy, the practitioner considers such factors as fetal presentation,position, and station; degree of cervical dilation and effacement; contraction frequency and intensity;gestational age; existing complications; and maternal and fetal vital signs. Amniotomy shouldn't be performedroutinely and should be performed only in a labor and delivery area equipped to handle an emergency.Amniotomy is contraindicated when there's a contraindication to vaginal delivery, when the presenting fetalpart is unengaged, or if there's known or suspected vasa previa.

Amniotomy, Assisting. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5216686/.Copyright © 2019 St. Louise Regional Hospital

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Preparation of Equipment

Implementation• Verify the practitioner's order.• Gather and prepare the equipment at the patient's bedside.• Confirm that written informed consent has been obtained and is in the patient's medical record.• Perform hand hygiene.• Confirm the patient's identity using at least two patient identifiers.• Provide privacy.• Reinforce the practitioner's explanation of the procedure, and answer the patient's questions.• Raise the bed to waist level during the procedure to prevent caregiver back strain.• Perform hand hygiene.• Assist the patient into a dorsal recumbent position for easier vaginal access.• Place fluid-impermeable pads under the patient.• Obtain the patient's temperature to have a baseline for comparison during the procedure.• Immediately before the practitioner performs the amniotomy, assess the FHR and characteristics to

evaluate fetal status. Use external fetal monitoring throughout the procedure; alternatively, use afetoscope or Doppler stethoscope before and after the procedure. (See the "Fetal heart rate monitoring,auscultation" and the "Fetal monitoring, external" procedures.)

• The practitioner performs a sterile vaginal examination to palpate for the umbilical cord and determinefetal station and presentation.

• Using sterile no-touch technique, open the amniotomy hook or finger cot package.• Wearing sterile gloves, the practitioner removes the amniotomy hook or finger cot from the package.• If ordered, apply pressure to the uterine fundus as the practitioner inserts the amniotic hook or sterile

gloved hand with the amniotomy finger cot applied over the index or middle finger, vaginally to thecervical os. This pressure helps keep the fetal presenting part engaged and reduces the risk of cordprolapse.

• Carefully avoiding contact with the fetal presenting part, the practitioner ruptures the amniotic membraneat the internal os.

• Assess the electronic fetal monitor tracing for variable decelerations in the FHR that suggest cordcompression. If these FHR changes occur, notify the practitioner, who will perform a vaginal examinationto check for cord prolapse. If external electronic fetal monitoring equipment isn't available, use afetoscope or Doppler stethoscope to assess the FHR for at least 60 seconds after the amniotic membraneruptures to detect bradycardia or other changes in FHR.

• Perform hand hygiene.• Put on gloves to comply with standard precautions.• Clean and dry the perineal area. When necessary, replace the fluid-impermeable pads under the patient's

buttocks to promote comfort and hygiene.• Inspect the amniotic fluid for meconium and blood. Note the color, consistency, amount, and odor of the

fluid.• Return the bed to the lowest position to prevent falls and maintain safety.• Discard used supplies in the appropriate receptacles.

Inspect all equipment and supplies; if a product is expired, its integrity is compromised, or it's defective,remove it from patient use, label it as expired or defective, and report the expiration or defect as directed byyour facility.


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• Remove and discard your gloves.• Perform hand hygiene.• Obtain the patient's temperature at a frequency determined by your facility and according to the patient's

condition to detect possible infection.Notify the practitioner if the patient's temperature rises to 100° F(37.8° C).

• Continue to monitor uterine contractions, FHR, and labor progress; watch especially for fetal tachycardia,which is commonly an early indicator of maternal infection.24 Make sure that alarm limits are setappropriately for the patient's condition and that the alarms are turned on, functioning properly, andaudible to staff.29Perform hand hygiene.

• Clean and disinfect the external electronic fetal monitoring equipment, fetoscope, or Doppler stethoscopeaccording to the manufacturer's instructions to prevent the spread of infection.

• Perform hand hygiene.• Document the procedure.

Special Considerations• During vaginal examination after amniotomy, maintain strict sterile technique to prevent uterine infection.

For the same reason, perform vaginal examinations only when necessary.The evidence to guide thetiming of amniotomy in patients who are receiving intrapartum prophylaxis for group B streptococcalinfection is insufficient.

• The Joint Commission issued a sentinel event alert concerning medical device alarm safety becausealarm-related events have been associated with permanent loss of function or death. Among the majorcontributing factors were improper alarm settings, alarm settings turned off inappropriately, and alarmsignals not audible to staff. Make sure alarm limits are set appropriately, and that alarms are turned on,functioning properly, and audible to staff. Follow facility guidelines for preventing alarm fatigue.

Complications

Documentation

REFERENCES:

Umbilical cord prolapse and rupture of a vasa previa, which are life-threatening potential complications ofamniotomy, are emergencies requiring immediate cesarean delivery to prevent fetal death. Umbilical cordprolapse occurs when amniotic fluid gushing from the ruptured sac sweeps the cord down through the cervix.The risk of prolapse is higher if the fetal head isn't engaged in the pelvis before rupture. Rupture of a vasaprevia during the procedure can cause fetal blood loss.

Intrauterine infection can result from failure to use sterile technique for amniotomy or from prolonged laborafter amniotomy. Other complications include cord compression causing variable decelerations in fetal heartrate and minor scalp trauma.

Record the FHR before and immediately after amniotomy. Document the time at which the membranes wereruptured. Note any meconium or blood in the amniotic fluid. Document the color, consistency, amount, andodor of the fluid. Record maternal temperature every 2 hours and labor progress as appropriate.

American College of Obstetricians and Gynecologists (ACOG). (2009, reaffirmed 2015). ACOG practicebulletin number 107: Induction of labor. Obstetrics and Gynecology, 114, 386–397. (Level VII)

Lippincott Procedures, (2018, February) Amniotomy, assisting. Retrieved from: http://procedures.lww.com/lnp/


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All revision dates:










Owner Louise Fry: Maternal Child Health Director [MD] 1/24/2019

view.do?pId=4367281


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Original: 7/13/2018Last Approved: N/ALast Revised: 7/13/2018Next Review: 3 years after approvalOwner: Louise Fry: Maternal Child


Birthing Balls: Guidelines for Labor Supportduring the Intrapartum Phase

PURPOSE:

GUIDELINES:I. General

1. Standard precautions including personal protective equipment (PPE) to be used when risk forexposure to any blood, body fluids, liquids, or chemicals is anticipated.

2. Proper body mechanics to be used when lifting, bending, or positioning any equipment or patient.

3. The birthing ball can be used with both external and internal electronic fetal monitoring equipment.

4. The patient should wear slip-resistant shoes, slippers, or socks or has the option of bare feet.

5. The birthing balls are to be covered prior to patient use with the white extrasorb disposable chux.

6. The birthing balls are not to be used in the shower or near wet floor surfaces.

7. The birthing balls will be cleaned in between each patient using the antimicrobial wipes allowing todry (per instructions), placed in a plastic bag, and returned to the appropriate storage area.

8. Periodic cleaning during single-patient use may be necessary.

9. The birthing balls are to have proper inflation maintained based on manufacturer'srecommendations.

TYPES OF BIRTHING BALL:A. Round birthing ball

1. Round birthing balls are designed for use while the laboring patient is out of bed, with limited use inbed.

2. Determine the proper size of the round birthing ball based on manufacturer's recommendations.

3. Support is provided behind and on the sides of the birthing ball.

4. The birthing ball can be placed on the floor, a fixed stable chair, or the bed.

To provide clinicians with guidelines to ensure the safe and effective use of birthing balls in the intrapartumsetting.

Birthing Balls: Guidelines for Labor Support during the Intrapartum Phase. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5761260/. Copyright © 2019 St. Louise Regional Hospital

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5. A support person should remain positioned next to the patient to provide additional stability andsupport.

6. Instruct the patient to sit on the ball with her hips and knees bent at a 90° angle.

7. For use in bed, position ball at the head of the bed with both siderails up and locked with pt leaningon hands and knees with arms positioned over the ball

B. Peanut ball

1. Peanut balls are generally designed for use while the laboring patient is in bed, with limited use whenthe patient is out of bed.

2. Peanut balls can be used for patients with or without an epidural/anesthesia in place who arerequired to stay in bed.

3. Position the peanut ball based on patient position and comfort, manufacturer's suggestions, andpatient safety.

4. Assist the patient to reposition every 30-60 minutes while in labor.

5. When used while the patient is out of bed a support person should remain positioned next to thepatient to provide additional stability and support.

CONTRAINDICATIONS:A. Documented predetermined gait instability.

B. Medical indications affecting the hip, pelvis, or symphysis.

REFERENCES:











Premier Birth Tools (2015). Tip sheet on peanut balls.

Rosebud Doula Services, LLC. (2016). Peanut Ball & Labor Coping Skills [DVD].

Tussey, C. M., Botsios, E., Gerkin, R. D., Kelly, L. A., Gamez, J., & Mensik, J. (2015). Reducing Length ofLabor and Cesarean Surgery Rate Using a Peanut Ball for Women Laboring With an Epidural. The Journal ofPerinatal Education, 24(1), 16–24. http://doi.org/10.1891/1058-1243.24.1.16


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Breastfeeding Mother, Nipple ShieldsPURPOSE:

POLICY:1. All staff will be educated on when it is appropriate to introduce a nipple shield to the nursing dyad.

2. All staff will be educated on how to assess the effectiveness of a nipple shield.

3. Mothers will be counseled on the potential negative effects of long-term nipple shield use. (Difficultyweaning, risk for insufficient milk supply due to decreased nipple stimulation and decreased infant intake)

4. Nipple shield should not be worn to prevent nipple soreness but only to temporarily bringing outthe nipple.

PROCEDURE:1. Equipment

a. Standard (Medela) Nipple Shield

2. Assess

a. Mother's nipples (flat or inverted)

b. Positioning of mother and baby at the breast

c. Ability of baby to maintain latch and suckle at the breast

d. History of bottle supplementation

e. Mother's understanding of the potential for decreased milk supply with use of breast shield.

3. Implementation

a. Wash hands

b. Center the nipple, and place the rim firmly against the breast and while supporting the breast in the"C," holds at the edges of the shield rim.

c. It may be helpful to place a small amount of water or mother's milk under the rim to facilitateplacement.

In order to provide infants with an ineffective latch an opportunity to suckle at the breast, all maternal child staffwhen utilizing a nipple shield will follow the following guidelines.

Breastfeeding Mother, Nipple Shields. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5761092/. Copyright © 2019 St. Louise Regional Hospital

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d. After baby has latched, and into a nutritive suck, detach baby and quickly remove shield, and re-attach baby to breast. If baby will not re-attach to the breast, replace nipple shield and finish feeding.Repeat this routine at each feeding until baby latches onto breast without the aid of the nipple shield.(May take up to one week to wean from shield)

e. After feeding have mother use (Medela) breast pump for 10 minutes to protect milk supply.

f. Notify Lactation Educator when mom is discharged with a nipple shield so appropriate follow-up canbe made.

g. Instruct mom to record all feeding attempts along with all of baby's voids and stools while baby isusing the nipple shield.

h. Wash nipple shield after each use with hot soapy water and place on clean towel to dry.

4. Teaching

a. Mother understands the potential risk for insufficient milk supply with the use of a nipple shield.

b. Mother understands the importance of follow-up.

c. Mother will be instructed to keep record of breastfeeding attempts, and baby's voids and stools whilebaby is using nipple shield.

d. Mother understands importance of pumping to ensure adequate milk production.

5. Documentation

a. Reason for nipple shield use.

b. Infant's response.

c. Mother's teaching and response and verbal acknowledgement of risk of decreased milk production.












Breastfeeding Mother, Nipple Shields. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5761092/. Copyright © 2019 St. Louise Regional Hospital

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Care During the Recovery Phase After a VaginalBirth

POLICY:

PROCEDURE:A. After a vaginal delivery blood pressure (B/P), pulse, respirations, fundus height and vaginal bleeding

should be assessed every 15 minutes times 1 hour, then every 30 minutes times one hour, or more oftenif indicated.

B. Patient's temperature should be monitored as indicated.

C. Facilitate maternal/infant bonding. Mother should remain skin to skin with her baby throughout recovery ifmother is alert and baby is stable. Initiate breastfeeding while baby is skin to skin according to patient'spreference and if maternal and newborn status allows.

D. Review and follow postpartum orders.

E. Recovery documentation should be completed according to the Recovery Record in the electronicmedical record.

F. Review and record fluid volume status.

G. A complete report should be given by an RN with the transfer of care or the transfer of the patient toanother unit.

REFERENCES:


Attachments:

The recovery phase after birth is a critical time of physiological adjustment and initial recovery from the stressof labor. Patients should have their vital signs and obstetric parameters assessed taking into considerationmaternal condition and analgesia/anesthesia or absence of anesthesia. The nursing assessment should alsoinclude a body systems assessment.

American Academy of Pediatrics & American College of Obstetricians and Gynecologists. (2002). Guidelinesfor Perinatal Care (5th ed.). Elk Grove Village, IL: Author.

Care During the Recovery Phase After a Vaginal Birth. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5146143/. Copyright © 2019 St. Louise Regional Hospital

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Approval Signatures










Care During the Recovery Phase After a Vaginal Birth. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5146143/. Copyright © 2019 St. Louise Regional Hospital

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Cleaning in the Obstetric Practice SettingPOLICY:

At the End of Each Birth/Surgical Procedure:A. Personal protective equipment should be used to handle any contaminated disposable and reusable

items.

B. Contaminated, disposable items should be placed in a leak-proof, tear-resistant container.

C. Reusable items that are grossly contaminated with blood and body fluids should be placed in a leak-proofcontainer and labeled as biohazardous. Spray instruments with Bio-Zolve Instrument Presoak Spray Gel.Containers should be transported in a closed, washable cart.

D. All sharps should be placed in designated puncture-resistant containers that are labeled as biohazardousmaterial.

E. Visibly soiled equipment and furniture should be cleaned with a facility-approved agent at the end of eachbirth or procedure.

F. Walls, doors and surgical lights should be spot-cleaned if soiled with blood or body fluids.

G. At the end of a birth or procedure, a minimum of a 3-foot to 4-foot perimeter area around the floor shouldbe cleaned. The perimeter should be extended as necessary.

H. Transport vehicles should be cleaned with a facility-approved agent.

Daily Terminal Cleaning:A. All horizontal surfaces should be dusted daily with a clean lint-free cloth that is moistened with a facility-

approved agent to reduce airborne contaminants.

B. The entire floor in each birth room should be cleaned.

C. Surgical suites and surgical scrub/utility areas should be cleaned daily with a facility-approved agent.

Additional Cleaning:A. Accidental spills of blood and body fluids should be cleaned as promptly as possible using a lint-free cloth

Anything that has been in contact with blood, tissue or body fluids is considered potentially contaminated withmicroorganisms.

Cleaning in the Obstetric Practice Setting. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5146181/. Copyright © 2019 St. Louise Regional Hospital

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saturated with a facility-approved agent.

B. Refillable liquid soap dispensers should be disassembled and cleaned before refilling.

C. All areas and equipment in the surgical setting should be cleaned on an established schedule.












Cleaning in the Obstetric Practice Setting. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5146181/. Copyright © 2019 St. Louise Regional Hospital

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Dress CodePOLICY:

GUIDELINES:A. Personnel must wear service-approved scrubs in the Mother Baby unit and not worn from home. Hospital

laundered scrubs are required for Labor and Delivery unit.

B. If a jacket/coat is needed for warmth, all staff may wear any color coat/jacket, so long as a professionalappearance is maintained. Impermeable gowns are worn for their intended purpose only, not for warmth.A solid white, short sleeved T-shirt may be worn under the scrub top for warmth.

C. Shoes should be kept neat and clean. Securely fit shoes are recommended clogs are not recommended.Stockings or socks must be worn with shoes.

D. All personnel must wear an identification badge with picture visible.

E. A vigorous scrub to the elbows with germicidal soap is required before contact with infants. Rings shouldbe removed, with the exception of a wedding band or significant ring. Watches and bracelets should beremoved. All other jewelry must be appropriate and should not interfere with the performance of duties.Artificial nails may not be worn.

F. Hair must be secured above the shoulders and away from the face.

G. All surgical garb (caps, masks, shoe covers) should be removed before leaving the operative areas.

H. Unit coordinators are expected to look neat and professional in appearance. No jeans, sweat suits orshorts are to be worn while working. Only the approved warm-up jacket may be worn.




Health and Hospital Kristy Takeda: Health Care Program Analyst pending

Attire and appearance should project a professional image. Compliance with the dress code is expected, andfailure to comply will result in disciplinary action.

Dress Code. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5063652/. Copyright © 2019St. Louise Regional Hospital

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Committee (HHC)







Dress Code. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5063652/. Copyright © 2019St. Louise Regional Hospital

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Health DirectorPolicy Area: Nursing

Infant and Newborn - Bulb Syringe SuctioningPURPOSE:

POLICY:

PROCEDURE:Considerations:1. AVOID stimulating gag reflex by NOT placing syringe in back of mouth.

2. Suction MOUTH BEFORE NARES to prevent possible aspiration of secretions from back of mouth wheninfant cries, gasps or struggles.

3. Suction nostril quickly, as prolonged suctioning can interfere with breathing.

4. Too frequent suctioning creates swollen mucous membranes, which increases the need for suctioning.

Equipment:• Bulb Syringe• Burp Cloth

Procedure Steps1. Turn infants head to side and stabilize it.

2. With free hand, squeeze bulb syringe to expel air.

3. Insert tip of syringe along side of mouth.

4. Slowly release bulb while moving tip of syringe around sides of mouth and tongue to avoid adherence tomucous membranes.

5. Remove tip of syringe from the mouth and squeeze several times to remove secretions onto burp cloth,blanket, etc.

6. Repeat Suctioning as needed to clear infant's/child's mouth.

To remove secretions from the mouth and nose of pediatric patients.

The nurse will remove secretions from the mouth and nose.

Infant and Newborn - Bulb Syringe Suctioning. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5218884/. Copyright © 2019 St. Louise Regional Hospital

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7. To suction nose, use bulb syringe in same manner inserting tip into one nostril until it fits snugly withoutforcing it. Repeat in other nostril.

8. Bulb syringe in each crib.

9. Instruct parent(s) on use of bulb syringe.

10. Document bulb syringe teaching.











MSP Director Leighan Perales: Medical, Surgical, Pediatric Director 1/24/2019


Infant and Newborn - Bulb Syringe Suctioning. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5218884/. Copyright © 2019 St. Louise Regional Hospital

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Intrapartum Nursing PracticePOLICY:

PROCEDURE:A. Initiate and use the care plan during labor and birth.

B. Discuss the birth plan with the patient and supporting family.

C. Obtain and complete the primary care provider's orders.

D. Perform continuous or intermittent monitoring as ordered. Assess and document fetal status and uterineactivity.

E. Assess and document maternal vital signs.

1. Blood pressure, pulse and respiration should be recorded as ordered, as determined per patientclinical condition or at a minimum of every 4 hours.

2. Temperature should be recorded every 4 hours or every 2 hours if membranes are ruptured or if thetemperature is elevated.

3. After initiation or rebolus of a regional block, including patient-controlled anesthesia, blood pressuremay be assessed every 5 minutes for the first 15 minutes.

4. Assess and document the progress of labor.

5. Perform a vaginal examination when indicated by the woman's physical condition, emotional status,and changing trends in the fetal heart rate pattern or as ordered by the primary care provider.

F. Encourage the woman to change positions every 30–60 minutes or as needed to optimize uteroplacentalblood flow, comfort, body alignment and fetal descent.

G. Maintain adequate hydration of the woman and assess elimination.

1. Assess and document bladder status/elimination.

2. Document intake and output as ordered or as indicated for the clinical condition.

H. Assess, evaluate and document the woman's level of comfort.

Nursing care will be provided according to the patient's/support person's birth plan, individual beliefs, values,maternal–fetal condition, and stage of labor. Supportive care includes physical care, emotional care,instruction/information and advocacy.

Intrapartum Nursing Practice. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5146113/.Copyright © 2019 St. Louise Regional Hospital

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1. Provide interventions according to the woman's birth plan, maternal–fetal status and primary careprovider orders.

2. Reevaluate the effectiveness of interventions within 1 hour.

I. Explain and document the rationale for the plan of care and interventions.

1. Assess and document the woman's knowledge level and learning needs.

2. Document the patient's or family's response.

J. Communicate the results of the assessment of maternal–fetal status to the primary care provider.

1. Document the primary care provider's response.

K. Support or assist the woman's natural pushing efforts.

L. Ensure support resources are available for neonatal resuscitation if necessary.

M. Coordinate the provision of the appropriate equipment and environment for birth.

N. Assist with patient positioning and preparation for birth as indicated.

O. Initiate stabilization and immediate care of the newborn while skin to skin with Mom.

P. Complete birth documentation.

Q. Assess for and document maternal stabilization.

R. Promote newborn/maternal/family bonding with skin to skin.

S. Complete newborn transitional assessment documentation.

T. Process specimens obtained according to policy.

Notes:1. Vital signs should be recorded at regular intervals, at least every 4 hours. This frequency may be

increased, particularly as active labor progresses according to clinical signs and symptoms. (AmericanAcademy of Pediatrics, American College of Obstetricians and Gynecologists. [2002]. Guidelines forPerinatal Care [5th ed.], p. 133. Elk Grove Village: Authors.)

2. Assess maternal blood pressure after the initiation or re-bolus of a regional block, including PCEA[patient-controlled epidural anesthesia]. Blood pressure may be assessed every 5 minutes for the first 15minutes. More or less frequent monitoring may be indicated based on consideration of factors such astype of analgesia/anesthesia, route and dose of medication used, the maternal–fetal response tomedication, maternal–fetal condition, the stage of labor or facility protocol. (Association of Women'sHealth, Obstetric and Neonatal Nurses. [2001]. Nursing care of the woman receiving regional analgesia/anesthesia in labor [Evidence-Based Clinical Practice Guideline], p. 13. Washington, DC: Author).







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Maternal TransportsPOLICY:

Appropriate Transfer

Role of the Transferring PhysicianA. The physician evaluates the risk status to determine the required level of specialized care.

B. The physician considers third-party/insurance payer coverage when designating appropriate level-II orlevel-III facility.

C. The physician initiates transports to a level-III facility when risk factors for preterm delivery are firstidentified and while maternal–fetus status is stable. Transport should not be delayed until maternal–fetalcondition has deteriorated.

Role of the Transferring HospitalA. The hospital provides medical treatment that minimizes the risks to the health of the woman and fetus

(es).

B. The hospital sends the patient's medical records related to the condition, including available prenatalrecord, history, documentation of signs or symptoms, preliminary diagnosis, results of diagnostic studiesor telephone reports of such studies, treatment provided, results of any tests, consent forms, certificationfor unstable transports and other records as soon as available after the transfer.

C. The hospital arranges for qualified personnel and transportation equipment. Delivery and neonatal

Women and fetuses at high risk may be transferred to a facility that provides the required level of specializedcare. The American Academy of Pediatrics' and American College of Obstetricians and Gynecologists'Guidelines for Perinatal Care recommends that women and fetuses at risk for complications that may affectperinatal outcome be referred or transported during the antepartum period.

A woman may be transferred via ambulance or helicopter during the antepartum, intrapartum orpostpartum period for specialized care. The woman and fetus (es) should be stable during transport.The attending physician from the transferring hospital will determine whether the woman and fetus(es) are stable. Stable condition is defined as such: No deterioration of the medical condition is likely,within reasonable medical probability, to result from or occur during the transport of the woman andfetus (es) from one facility to another.

Maternal Transports. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5761292/. Copyright© 2019 St. Louise Regional Hospital

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resuscitation supplies should be taken if the delivery may be imminent.

Role of the Receiving FacilityA. The receiving facility agrees to accept the transfer and to provide appropriate medical treatment. The

receiving hospital may not refuse to accept the patient if it has the capacity to treat the woman and/orfetus (es). The facility can refuse if the patient does not require any treatment beyond the capabilities andfacilities available at the transferring hospital or the mother and/or fetus (es) is/are determined medicallyunstable.

B. The on-call perinatologist at the receiving facility is notified of request for transfer and given report on thepatient from the attending physician. The perinatologist should call the patient's attending physician forany additional information, as well as to authorize the transport. The perinatologist should also confirmwho will be the patient's attending physician at the receiving hospital.

Unstable Transport

• The patient requests the transport in writing and includes the reason for the transport request as well asdocumentation that the patient is aware of the risks and benefits of the transport. This request should beincluded in the medical record.

• The physician documents that the benefits of the transfer outweigh the risk. The medical benefitsreasonably expected from the provision of appropriate medical care at another facility should outweighthe increased risks to the woman and/or fetus (es).

• A competent labor and delivery nurse or obstetrician or both will accompany the patient during transport.St. Louise Regional Hospital Nurses do not accompany patients during transports. Some level III facilitieshave maternal transfer teams available to accompany patients in route.

Patient Refuses to Consent to Transport

A. Offer to transport the patient to another medical facility.

B. Inform the patient of the risks and benefits of the transport.

C. Obtain written informed refusal including documentation that the patient has been informed of the risksand benefits of the transport and the patient's reason for the refusal.

D. Document in the medical record a description of the proposed transport and the refusal.

Reporting Inappropriate Transports


Hospitals should not transport an unstable patient except in the following situations:

The obstetrician should take the following steps:

Federal regulations require that a hospital report within 72 hours any time it has reason to believe it may havereceived an individual who has been transferred in an unstable emergency medical condition from anotherhospital in violation of the requirements of the Emergency Medical Treatment and Labor Act. An emergencymedical condition is defined as a medical condition such that the absence of immediate medical attentioncould reasonably be expected to result in placing the health of the mother and/or her fetus (es) in seriousjeopardy or there is inadequate time to effect a safe transfer to another hospital before a delivery or thattransfer may pose a threat to the health or safety of the mother and/or her fetus (es).


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Newborn Thermoregulation Guidelines

• Increased respiratory rate• Poor perfusion

* Notify Primary Care Provider If Low Temperature Is Associated With:

Newborn Thermoregulation Guidelines. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5220500/. Copyright © 2019 St. Louise Regional Hospital

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• Lethargy


Attachments: Newborn Thermoregulation Guidelines

Approval Signatures










Nursing May Notify the Primary Care Provider at Any Time with a Concern

Newborn Thermoregulation Guidelines. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5220500/. Copyright © 2019 St. Louise Regional Hospital

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Operative Obstetric Nursing Aseptic Technique

PROCEDURE:A. The integrity of sterile packs should be checked.

B. The sterile field should be established and maintained as close as possible to time of use.

C. Sterile items should be handed to scrubbed person or place securely on sterile field.

D. The sterile field should not be covered.

E. The surgical team should face and never turn their backs on the sterile field.

F. The sterile field should be monitored to maintain sterility including a sterile barrier of one foot.

G. Unguarded sterile field should be considered contaminated.

H. Corrective action should be taken when the sterile field is not maintained.

I. When gown or glove is contaminated:

1. Contaminated person should step away from field.

2. Gown should be untied by circulating nurse.

3. Circulating nurse pulls gown towards her and off the contaminated person. The gown is removed firstand then the gloves to prevent cross contamination of gown onto scrubbed hands. The hand shouldbe completely covered by cuff of the gown so the gown will not be contaminated.

4. New gown and/or gloves should be applied. Avoid touching gown of scrub nurse. If contaminationoccurs, gloves and gown should be removed.


Attachments:

Policy:

The principles of aseptic technique include isolating the operative site from the unsterile physical environment,creating and maintaining a sterile field in which surgery may be performed and preventing contamination of thesterile field. Appropriate surgical scrubs, protective eye wear, cap, and mask should be worn by any person inthe OR area. All hair, including facial hair should be covered.

Operative Obstetric Nursing Aseptic Technique. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5208953/. Copyright © 2019 St. Louise Regional Hospital

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Approval Signatures










Operative Obstetric Nursing Aseptic Technique. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5208953/. Copyright © 2019 St. Louise Regional Hospital

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Operative Obstetric Nursing Practice: Counts forInstruments, Sharps, and Sponges

PROCEDURE:A. The initial count of all instruments, sharps, and sponges should be completed simultaneously by the

circulating RN and the scrub personnel prior to incision. RN and scrub tech must visualize eachinstrument while counting and use proper names for instruments. Inventory list must be used insequence and there must be agreement between RN and scrub tech before moving on to the next item inthe sequence.

1. At the time additional instruments, sharps, or sponges are added during the procedure, asimultaneous count of added items should be completed by the circulator and scrub person.

2. Instrument, sharp, and sponge counts should be completed prior to any cavity closure.

a. 1st Count: cavity within a cavity (i.e., uterus)

b. 2nd Count: closure of the next cavity (i.e., peritoneum)

c. 3rd Count: closure of the skin (sharps and sponges only)

3. Counts should match the initial count recorded plus any additional instruments, sharps, and spongesadded during the case.

B. If the number of needles/sponges in the pack does not correspond with the number stated on thepackage, the needles/sponges should be:

1. Handed off the field

2. Contained in a plastic bag

3. Labeled with the number

4. Not included in the count

5. Remain in the operating room

6. Notify management for tracking of lot numbers

Policy:

Counts for instruments, sharps and sponges should be taken before and during all operative procedures in theOR by a circulating RN and scrub personnel. In emergency situations, the circulating RN should check with theattending as to whether or not an initial count should be taken.

Operative Obstetric Nursing Practice: Counts for Instruments, Sharps, and Sponges. Retrieved 11/20/2019. Official copy athttp://verity-saintlouise.policystat.com/policy/5218511/. Copyright © 2019 St. Louise Regional Hospital

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C. Broken or disassembled instruments, sharps, or sponges should be accounted for in its entirety with eachcount. No deliberate alterations should be made in the integrity of counted sponges (i.e., sponges are notused for dressings).

D. Instruments with more than one piece should be counted by the piece (i.e., Cesarean forceps, 2 parts).

E. Instruments, sharps (needle package front may be used for count and verified upon opening), andsponges should be opened fully, removed from packaging and counted by scrub and circulatingpersonnel concurrently and recorded on the white board.

F. Sponges should be discarded from the sterile field as they become soiled and placed into plastic linedbuckets. All sponges should remain visible for all counts.

G. If a permanent change of staff occurs, all instruments, sharps, and sponges should be countedsimultaneously by all circulating and scrub personnel.

H. Counts begin at the operative site, proceeding to the Mayo, then to the back table, and finally off thesterile field.

I. Each count should be reported to the surgeon(s) as correct or incorrect. There should beacknowledgement of each count by the attending surgeon(s).

J. In the case of an incorrect count, the following will occur:

1. The count should be rechecked.

2. The surgeon should be alerted.

3. Scrubbed personnel should check the sterile field.

4. Circulator should check all areas and containers of the room.

5. If the count continues to be incorrect, an x-ray should be taken in the OR.

6. The patient should remain in the OR until the results of the x-ray are reported. The physician shouldbe notified of the results.

K. If the procedure is an emergency and time does not permit counts, an x-ray should be taken at the end ofthe procedure.

L. Counts should be recorded in the appropriate section of the OR record.












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Operative Obstetric Nursing Practice: Draping ofa Patient for Surgical Procedures

POLICY:

PROCEDURE:A. General Guidelines

1. Organize drapes in order of application

2. Gloved hands should not come in contact with the patient's prepped skin.

3. Drapes should not extend beyond the sterile field or touch the ground.

4. Drapes should not be moved once they are placed.

5. At completion of the procedure, drapes should be rolled from head to foot of the patient and placedin the proper container.

B. Abdominal

1. Towels should be folded lengthwise, one at a time, and handed to physician and/or assistant ifapplicable.

2. Position lap sheet with marker to the head of the patient and hand to physician.

3. With hand cupped under drape, move top portion of drape towards the head of the patient and holdup for anesthesiologist to clamp to IV poles.

4. In the same manner as in step #3, move the lower portion of the drape towards the patient's feet anddrop over end of the bed.

5. Open the sides of the drape and drop towards the floor.

C. Vaginal

1. Place hands in cuff of perineal drape and secure under patient buttocks.

2. With hands cupped under leg drape, move drape over patient's foot, up the leg and drop over knee.

3. Repeat step #2 for the opposite leg.

Draping creates a sterile field during a procedure. Patients undergoing a procedure requiring a sterile fieldshould be appropriately draped.

Operative Obstetric Nursing Practice: Draping of a Patient for Surgical Procedures. Retrieved 11/20/2019. Official copy athttp://verity-saintlouise.policystat.com/policy/5121959/. Copyright © 2019 St. Louise Regional Hospital

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4. Place abdominal drape over patient's abdomen, instructing patient and family to keep hands underthe drapes.












Operative Obstetric Nursing Practice: Draping of a Patient for Surgical Procedures. Retrieved 11/20/2019. Official copy athttp://verity-saintlouise.policystat.com/policy/5121959/. Copyright © 2019 St. Louise Regional Hospital

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Operative Obstetric Nursing Practice: Procedurefor Use of Electrosurgical Unit

PROCEDURE:A. The grounding pad should be applied to patient to maintain uniform body contact. The thigh is usually the

preferred site. The patient's skin integrity at the pad site should be evaluated before and after theelectrosurgical unit use. Document both evaluations in the perioperative nursing notes.

B. During the procedure, the active electrode (pencil) should be placed in the case provided with each unit.

C. The power settings should be confirmed for coagulation and/or cutting with the physician.

D. The electrosurgical unit should not be used in the presence of flammable agents.

E. Document placement of the electrosurgical unit and the electrosurgical unit identification number in theperioperative nursing notes.

F. If grounding pad becomes wet, the unit should be turned off immediately and the grounding pad shouldbe replaced and then resume use.










Policy:

Proper use of the electrosurgical unit (ESU) promotes patient safety, prevents injury, and extends the life onthe ESU.

Operative Obstetric Nursing Practice: Procedure for Use of Electrosurgical Unit. Retrieved 11/20/2019. Official copy athttp://verity-saintlouise.policystat.com/policy/5218598/. Copyright © 2019 St. Louise Regional Hospital

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Operative Obstetric Nursing Practice: Procedure for Use of Electrosurgical Unit. Retrieved 11/20/2019. Official copy athttp://verity-saintlouise.policystat.com/policy/5218598/. Copyright © 2019 St. Louise Regional Hospital

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Operative Obstetric Nursing Practice: ProperPositioning of the Patient in the Operating RoomPOLICY:

PROCEDURE:A. For Abdominal Surgery

1. The patient should be assisted to OR table and centered on the table.

2. A wedge should be placed under her hip to obtain lateral tilt for Cesarean birth. Obstetricianpreference may require removal of wedge prior to draping patient.

3. The knee strap should be placed above the knees.

4. Each arm should be placed and secured on an arm board.

B. For Vaginal Procedure

1. The patient should be assisted to the OR table and placed so her perineum reaches the break in thetable. The head attachment should be placed at foot of table before the case so legs are supportedwhen extended.

2. Place stirrups into holders.

3. At the direction of anesthesia, both legs should be placed simultaneously into stirrups.

4. Legs should be secured in stirrups.

5. The table head attachment should be removed and the foot of bed lowered.

6. At conclusion of the procedure legs should be removed from the stirrups simultaneously.


Attachments:

Proper positioning of the patient on the OR table provides maximum safety for the patient; maximizes thepatient's respirations and circulation; minimizes pressure on nerve sites; provides a visible and accessibleoperative site for the surgeon; and decreases postoperative discomfort. The proper position for the patientshould be confirmed with the physician and anesthesia personnel and readjusted as necessary. Thecirculating nurse should document the proper patient position on OR record.

Operative Obstetric Nursing Practice: Proper Positioning of the Patient in the Operating Room. Retrieved 11/20/2019. Officialcopy at http://verity-saintlouise.policystat.com/policy/5218603/. Copyright © 2019 St. Louise Regional Hospital

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Approval Signatures










Operative Obstetric Nursing Practice: Proper Positioning of the Patient in the Operating Room. Retrieved 11/20/2019. Officialcopy at http://verity-saintlouise.policystat.com/policy/5218603/. Copyright © 2019 St. Louise Regional Hospital

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Operative Obstetric Nursing Practice: SkinPreparation of the Perioperative Patient

PROCEDURE:A. Hair Removal

1. Hair removal should be performed as close to the time of surgery as possible. Hair should beremoved in an area outside the room where the procedure will be performed to avoid contaminationof sterile fields with airborne dispersal of loose hair.

2. Clippers should be used to remove hair. Clippers should have a disposable head. The method of hairremoval should be documented on the perioperative record.

3. Any cuts, abrasions, moles, warts, or other skin conditions should be reported to the physician.

B. Skin Prepping

1. Any patient allergies noted to iodine or other prep agents planned for use should be reported to thephysician.

2. Refer to physician preference sheet for proper prepping agent to use. Prepping agents should beapplied using sterile technique.

3. The guiding principle for scrubbing and painting the incision areas is to "prep from clean to dirty". Theprep should begin at the incision site and extend outward to the periphery of the area to be prepped.Towels used to pat dry scrub solutions should be removed without contamination of the areaprepped.

4. Care should be taken to avoid prep solutions dripping from the periphery of prep toward the incisionsite. Sterile towels or drapes should be used to avoid pooling of solution under the patient. Wetantimicrobial agents may cause skin irritation or chemical burns. The prep solution should be allowedto dry prior to incision, especially when electrocautery is planned.

C. Vaginal/Perineal Prep Using Iodophor Solution

1. Using aseptic technique, the prep should begin over the pubic area, scrub downward over vulva,perineum, and anus and then discard sponges.

2. With new sponges, start at labia majora and scrub outward over inner aspects of upper third of the

Policy:

Skin preparation reduces the risk of surgical site infection with the least amount of skin irritation.

Operative Obstetric Nursing Practice: Skin Preparation of the Perioperative Patient. Retrieved 11/20/2019. Official copy athttp://verity-saintlouise.policystat.com/policy/5121935/. Copyright © 2019 St. Louise Regional Hospital

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thighs, discard sponges.

3. Cleanse vagina and cervix as requested by physician.

4. Sterile water should be used to rinse.

5. Follow with Betadine rinse if applicable.

6. Special Note: If both abdominal and vaginal preps are required, the vaginal prep should beperformed first so that the abdomen remains the cleanest area and is not contaminated by splashingor aerosolization from a vaginal prep. This is an exception to the "clean to dirty" principle.

D. C-Section Skin Prep Using ChoraPrep™

The following steps should be used to apply a single coat of ChoraPrep™ on area to be prepped, avoidpooling of solution.

1. Using aseptic technique, break seal on ChoraPrep™ applicator sponge.

2. Soak cotton swabs with ChoraPrep™ and apply to umbilicus site in circular motion, starting at thecenter, moving to the periphery. Discard cotton swabs.

3. Using the applicator sponge, move to site, prep incision line with repeated back and forth swipes forabout 30 seconds and move upward to prep abdomen.

4. Next, prep to 6 inches from pubis and to bed line.

5. NOTE: The person performing the prep should move around table and not reach over sterile field toprep the other side.

6. Move to thighs, prep 6 inches down each thigh.

7. Prep should go downward so the incision line is not contaminated.

8. Pubis should be prepped last.

9. Discard ChoraPrep™ solution and remove gloves.

E. Cesarean Skin Prep Using Ioban™ Drape

1. Apply Ioban™ drape to thoroughly dry skin. Grasp edges of film firmly and peel off paper liner until"stop" symbol appears. Hold film a few inches above skin.

2. Using a sterile towel, press down firmly on the film, first contacting the skin along the intendedincision line to ensure good skin contact. Firmly smooth film into place without tension, working awayfrom the intended incision line to achieve wrinkle-free adhesion.

F. At the End of the Procedure

1. When appropriate, at the end of the procedure and before application of the tape to secure thedressing, care should be taken to assess and remove any excess prep solutions, which may causeirritation or discomfort to the patient.

2. The method of skin preparation should be documented on perioperative record.


Attachments:


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Approval Signatures











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Operative Obstetric Nursing Practice: SterileGown and Glove Technique

POLICY:

PROCEDURE:A. Gowning and Gloving Closed Method:

1. Set up sterile gown and gloves on separate field.

2. Perform surgical hand scrub.

3. Pick up gown at neckline, gently shake folds of gown, and do not create flapping movement.

4. Slide hands into sleeves to sleeve cuff.

5. Grasp cuff between thumb and forefinger.

6. Circulating nurse adjusts and secures back of gown.

7. Glove dominant hand first. Keeping hands inside sleeves, place glove on dominant hand sleeve,thumb down, fingers pointing toward elbow and wrist edge of glove level with sleeve cuff seam.

8. Grasp glove cuff with covered fingers and thumb of hand to be gloved.

9. Grasp under edge of the glove cuff with the sleeve covered fingers of the opposite hand.

10. Pull glove opening down and completely over gown cuff of the hand being gloved.

11. Grasp glove cuff and gown cuff and pull both cuff and glove on at the same time.

12. With gloved hand, pick up the other glove and follow the same procedure for gloving the other hand.

B. Gloving Open Method:

1. With hands extending through sleeves, fold back paper wrapper of gloves.

2. Pick up the first glove by the folded cuff and slide hand in without unfolding the cuff.

3. Pick up the second glove by placing fingers under the turned back cuff and put it on, pulling cuff up

The sterile gown and glove technique is used to provide protection for the patient, to prevent bacteria on thescrubbed person's hands and clothing from being transferred to the operative wound and to protect thescrubbed person from bacteria in the patient or in the atmosphere. All scrubbed hospital personnel are to wearappropriate surgical apparel and protective eye wear.

Operative Obstetric Nursing Practice: Sterile Gown and Glove Technique. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5218680/. Copyright © 2019 St. Louise Regional Hospital

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over gown cuff.

4. Adjust cuff on first hand over gown cuff.

C. Gowning and Gloving Another Scrubbed Person:

1. Person who is gowned and gloved opens sterile towel and lays one end of it over the person'soutstretched hand.

2. Pick up gown and allow gown to unfold, holding it at the neck band with the outside toward you.

3. Keep hands on the outside of the gown, under a protecting cuff made by the neck band andshoulders. Hold the gown towards the person being gowned and slip arms into the sleeves. Releasethe gown.

4. The person being gowned holds arms out to permit the circulator to pull the gown on.

5. Scrub nurse grasps the glove firmly with fingers under the turned back cuff, thumbs extended widelyto the side.

6. Pull glove cuff up over sleeve as hand is inserted into the glove.

7. Repeat for the other hand.












Operative Obstetric Nursing Practice: Sterile Gown and Glove Technique. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5218680/. Copyright © 2019 St. Louise Regional Hospital

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Operative Obstetric Nursing Practice: SurgicalAttire

PROCEDURE:A. Individuals entering the semi-restricted and restricted areas of the surgical suite should wear freshly

hospital laundered surgical attire. Surgical attire should be made of reusable woven fabric or single-use,nonwoven, low-lint fabric.

B. Surgical attire should be replaced with fresh, clean surgical attire on a daily basis or whenever it becomesvisibly soiled, contaminated, or wet.

C. Surgical attire contaminated with visible blood or body fluids should remain at the facility and belaundered by the hospital or a hospital-contracted commercial laundry.

D. A clean, low lint surgical head cover or hood should confine all hair in the semi-restricted and restrictedareas.

E. A clean single surgical mask should be worn in areas where open sterile supplies or when scrubbedpersons are present. Masks should cover both the mouth and the nose and be secured.

F. If shoe covers are worn for personal protection, they should be changed if they become torn, wet, orsoiled.

G. Shoes should be clean with no visible soiling. Shoes should have closed toes and low heels.

H. Persons from other departments entering the semi-restricted or restricted areas may wear a surgicalgown to cover outside apparel.

REFERENCES:


Policy:

Scrub attire should be worn in the semi-restricted and restricted areas of the operative area to promote a highlevel of cleanliness and hygiene. The semi-restricted area includes the support areas of the surgical suite suchas storage for clean and sterile supplies, work areas for storage and processing of instruments. Operatingrooms are considered a restricted area.Cross Reference: Operative Obstetric Nursing: Sterile Gown and Glove Technique

AORN Standards, Recommended Practices, and Guidelines 2005

Operative Obstetric Nursing Practice: Surgical Attire. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5218683/. Copyright © 2019 St. Louise Regional Hospital

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Operative Obstetric Nursing Practice: Surgical Attire. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5218683/. Copyright © 2019 St. Louise Regional Hospital

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Operative Obstetric Nursing Practice: TrafficPatterns

POLICY:A. Patients entering the surgical area should wear clean gowns, covered with clean linens, and have their

hair covered.

B. Surgical team members should minimize the need for excess movement or activity during procedures.

C. Door to the operating rooms should be closed except when needed to move patients, personnel, supplies,and equipment.

D. Talking and number of people present should be minimized during procedures.

REFERENCES:











Policy Statement:

Traffic control practices protect personnel, patients, supplies, and equipment from potential sources of cross-contamination.

AORN Standards, Recommended Practices, and Guidelines 2005

Operative Obstetric Nursing Practice: Traffic Patterns. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5121940/. Copyright © 2019 St. Louise Regional Hospital

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Operative Obstetric Nursing Practice: Traffic Patterns. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5121940/. Copyright © 2019 St. Louise Regional Hospital

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Radial Arterial Puncture of the NeonatePURPOSE:

POLICY:

QUALIFICATIONS/TRAINING PROGRAM:

1. Current California Registered Nurse (RN) license

2. Current Neonatal Resuscitation Program Provider Card

3. Successful completion of annual competencies

4. Successful completion of two neonatal radial arterial punctures observed by a physician or RN trainer.

1. Successful completion of annual competencies

2. Performance of two successful radial arterial puncture on a neonate in the previous year

3. Completion of the Radial Arterial Puncture quality assurance form (Attachment A) annually

1. See attached form to be completed by the performing RN after completion of the procedure.

2. The Department Director and the trainer RN will review competencies upon completions and annually.

To obtain arterial blood gas for an accurate assessment of oxygenation in infants.

A qualified registered nurse (RN) may perform a radial arterial puncture with a physician (MD) order. QualifiedRN's must follow the procedure for radial arterial puncture. Evaluation of collateral circulation by performing amodified Allen test will be done prior to the radial arterial puncture. The puncture will not be done if the Allentest is negative. When possible the puncture will be performed when the infant has been in a quiet state for 10minutes.

Education and performance requirements:

Competency Maintenance:

Evaluations:

Written Record:

A list of RNs qualified to perform will be kept on file in the Director's office and in the Charge Nurse binder andit will be updated at least annually.

Radial Arterial Puncture of the Neonate. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5220513/. Copyright © 2019 St. Louise Regional Hospital

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CONTRAINDICATIONS:1. Coagulation defects

2. Circulatory compromise in the extremities

3. Inadequate collaterals

4. Infection in the sampling area

5. When cannulation of the vessel is anticipated

PROCEDURE:

1. Check MD order and identify the patient using two patient identifiers before drawing blood.

2. Perform Procedural Time out

3. Assemble equipment

4. Maintain thermal regulation

5. Perform pain assessment and document results

6. Select puncture site

◦ Avoid awkward positioning; hyperextension may obliterate the pulse.

◦ Palpate arteries and select one that appears to have the best blood flow

7. Provide the infant with a pacifier and 0.5 milliliter (ml) of the sterile sucrose solution. If not contraindicated.

8. Perform modified Allen test for collateral circulation

◦ Elevate infant's hand

◦ Passively clench hand while both the radial and ulnar arteries are simultaneously compressed untilthe hand is blanched.

◦ Release the ulnar artery while maintaining compression on the radial artery and note the degree offlushing of the hand. Color should return to the hand in less than 10 seconds if adequate collateralcirculation is present.

◦ DO NOT PUNCTURE THE ARTERY IF COLOR RETURN EXCEEDS 15 SECONDS

9. With middle or index finger relocate the radial artery through palpation.

10. Don sterile gloves.

Equipment:

Alcohol wipesBetadine swabs2x2 sterile gauzeHeparinized syringesAdhesive bandageSterile sucrose solutionPacifierGloves

Procedure Steps:


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11. Prepare puncture site with betadine and allow to dry for 1 minute.

12. Wipe off dried betadine with an alcohol wipe and dry with sterile 2x2 gauze.

13. Hold the needle with the bevel up at a 30-45 degree angle for a deep artery. Keep angle of entry shallowfor superficial vessels, 15-25 degrees.

14. Insert needle slowly and advance until blood appears, then stop.

15. If no blood returns, slowly withdraw needle and redirect for blood supply.

16. Note Oxygen (O2) saturation at time of draw.

17. Arterial blood will fill the butterfly tubing. Withdraw the needle and apply firm pressure for at least 5minutes.

18. Expel air from sample and cap. Rotate syringe to mix sample with heparin. Place sample on ice.

19. Label sample with patient sticker and include date, time, and collector's initials to label.

20. Call Respiratory Therapist (RT) to pick up sample. Enter order into Electronic Medical Record. Resultsshould print to local printer.

21. Check peripheral circulation after applying pressure for 5 minutes.

22. Perform and document pain assessment.

DOCUMENT:

• Time of draw, puncture site.• Amount of blood withdrawn• Oximetry reading at time of sample collection• Allen's test results• Infant's tolerance of the procedure• Peripheral circulation assessment after the procedure

REFERENCES:

On the Nursery Flow sheet

Fletcher, M.A., & MacDonald, M.G. (1997). Atlas of procedures in neonatology (2nd ed.).Philladelphia: Lippincott.Kenner, C., & Lott, J.W. (Eds.).(2003). Comprehensive neonatal nursing: A physiologic perspective (3rd ed.).Philadelphia: Saunders.Association of Women's Health, Obstetric, and Neonatal Nurses; National Association of Neonatal Nurses;American Association of Critical Care Nurses; Verkian, T.; & Walden, M. (2004). Core curriculum for neonatalintensive care nursing (3rd ed.). Philadelphia: Elsevier.


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Attachments: Competency for RN: Arterial Puncture inNeonate


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Approval Signatures











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Visitor Guidelines for Family & Friends

A. Parents are participants in their hospitalized infant's care. Other family / friends / support people arevisitors.

B. In recognition of the developmental changes occurring within a childbearing family, opportunities forperinatal patients to visit with family members and friends is encouraged.

C. Visiting periods and individuals are based upon patient preferences with consideration for privacy, safety,and protection of mothers and newborns.

GENERAL GUIDELINES:A. Visitors should be determined by the mother.

B. Children should be 14 years old or older unless they are siblings. Sibling visitation is highly encouraged toassist in the maintenance of family cohesiveness.

C. Children should be accompanied and supervised by a responsible adult.

D. Children of staff and physicians are not permitted in nursing areas.

GENERAL HEALTH GUIDELINES:A. Family and friends should refrain from visiting if they are febrile, have diarrhea, or have symptoms of an

upper respiratory infection. Cold sores should be covered with a mask until lesion is dry / scabbed.

B. Children who have had the chicken pox vaccine must wait greater than or equal to 30 days from the timethe vaccine was administered.

C. Mothers who have received Rubella vaccine present no risk when visiting infants.

D. All visitors should wash their hands and forearms in the patient's room before handling the baby.

TRIAGE AREA / EXAM ROOM / LABOR &DELIVERY:

Policy Statement:

The visiting guidelines above apply to all maternity units. Listed below are details specific to visitationon the individual nursing units.

Visitors should be determined to meet the needs of the mother / fetus. The mother / family may determine who

Visitor Guidelines for Family & Friends. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5760752/. Copyright © 2019 St. Louise Regional Hospital

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MOTHER BABY UNIT MBU:A. Visitors should be determined by staff and the mother, whenever possible, during a stay on MBU so that

quality care may be provided to both the mother and her infant. Decisions may be changed by the motheror any member of the health care team at any time.

B. The needs of a roommate should be taken into consideration when the father or significant other visits theother patient in the room.

C. Over-night accommodations can be arranged for one person. A private room is required for a sleepoverguest.

NURSERY:A. All visitors should perform a 3-minute scrub to the elbows with antiseptic soap and instructed to follow the

hand washing policy.

B. Visitors should have permission from the parents to visit the baby when the parents are not present.Parents may designate several support people who may visit alone.

C. Two people are permitted at the infant's bedside at a time.

D. If the parents are not married and concerns are expressed regarding the father visiting the baby, the staffshould inform the mother that the father has the same visitation rights as the mother when the mother hasacknowledged the man as the father of the baby.

E. The parents should be informed that information about their infant is confidential and will only be given tothem.

F. If the infant is taken to the mother's room on another unit for a visit the following will apply:

1. Infant should be taken via isolette if mother / infant condition permits.

2. The mother should wash her hands with antiseptic soap or use alcohol-based hand rub beforeholding / touching her infant.

3. Staff should stay with the mother and baby during the visit.

4. The clinical status of mother / infant may require modification of these procedures. Staff shouldinstruct / educate the family / friends about the rationale for the modification.

INFANTS VISITING HOSPITALIZED MOTHERS:A. Infants visiting their hospitalized mother should be accompanied by a responsible adult.

B. The infant's family should provide supplies for the infant's needs.

C. The MBU can provide a bassinet for the mother's room.

D. Continuation of breast-feeding is encouraged. Lactation Services is available for consultation.

All revision dates: 11/1/2015, 5/1/2012, 5/1/2009, 8/1/2007

may visit based on their desires. During a physician visit or delivery, there will be a limit of 2 visitors. Inaddition, a member of the healthcare team may request that visitors be limited during certain stages of thechildbearing continuum or until transfer to postpartum to facilitate adequate patient access for care. Requestsby staff members to limit the number of visitors and/or length of visit should include information / education thatassist the family and friends to understand the patient's needs.


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Original: 2/1/2010Last Approved: N/ALast Revised: 2/1/2010Next Review: 3 years after approvalOwner: Brittney Slibsager: Medical Staff

Services ManagerPolicy Area: Medical Staff

Medical Staff Vincentian Spirit AwardPOLICY

PROCEDURE1. Eligibility

a. All Medical Staff members who have completed 5 years of service on the St. Louise RegionalHospital Medical Staff are eligible.

2. Criteria

a. A Medical Staff member who consistently exemplifies the Mission and Values of St. Louise RegionalHospital and the Verity Health System.

b. A physician should be known for outstanding patient care and a collaborative manner with allmembers of the health care team.

c. S/he must have active participation in his/her responsibilities as a Medical Staff member.

d. The Medical Staff member has demonstrated his/her interest and contributions to community healthand wellness.

e. A Medical Staff Member may be nominated for outstanding practice of one or more Vincentianvalues of respect, compassionate service, simplicity (honesty), advocacy for the poor, andinventiveness to infinity.

3. Selection Process

a. Nominations should be made by using the attached nomination form.

b. The award ceremony will be held at the annual Medical Staff dinner each year in December.

c. Three months prior to the event, the Chief of Staff requests nominations from the Medical StaffDepartment Chairs. Other Medical Staff Members may also submit nominations.

St. Louise Regional Hospital's Medical Staff recognition program provides a method to formally recognizeMedical Staff members for outstanding achievement and service in carrying out the Hospital's and VerityHealth System's Mission and Values. Medical Staff members nominate fellow physicians for this award.Nominations may also be considered from Nursing and Administration. The Chief of Staff appoints an ad hoccommittee (Vice President of Mission Integration automatically sits on this Committee), to review thenominations and make the final selection.

Medical Staff Vincentian Spirit Award. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5760621/. Copyright © 2019 St. Louise Regional Hospital

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d. Three months prior to the event, nominations will also be requested from Nursing and Administration.

e. Nominations are due in the Medical Staff office two months prior to the award ceremony.

f. The Chief of Staff appoints an ad hoc committee to review the nominations submitted.

g. Members of the ad hoc committee shall include, but not limited to:

▪ Chief of Staff

▪ Two additional representatives from the Medical Staff

▪ Representatives from Administration

▪ Representative from the Community

▪ Vice President of Mission Integration

h. The ad hoc committee meets and makes the final selection. The Chief of Staff informs the recipientand confirms his/her attendance at the event.

i. The selection is kept confidential until the annual Medical Staff award ceremony.


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Attachments: SLRH Medical Staff “Vincentian Spirit Award”

Approval Signatures








Chief Executive Officer (CEO) John Hennelly: Chief Executive Officer 1/9/2019


Owner Brittney Weltz: Medical Staff Services Manager 1/7/2019


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Original: 7/1/2000Last Approved: N/ALast Revised: 6/1/2012Next Review: 3 years after approvalOwner: Robert Schambach: Emergency

Department & Urgent CareCenter Director

Policy Area: Emergency Services

Dept - Performance Improvement - EmergencyDepartment (PC)

POLICY:

EMERGENCY DEPARTMENT MONITORINGPROGRAM:1. Documentation and Appropriateness of Care:

◦ Daily review of documentation.

◦ Random review of representative charts for appropriateness of care based on chief complaint anddiagnosis.

2. Diagnostic Test Review:

◦ Daily review of variant x-rays and lab cultures.

3. Patient Relations

◦ Ongoing review of patient complaints with a summary report quarterly to the Emergency MedicineCommittee

4. Occurrence/Outcome Screens:

◦ Monthly Review of:

▪ Patient transfers

The Emergency Department (ED) is designed, equipped and staffed to provide the patient community servedby St. Louise Regional Hospital with prompt, courteous, high-quality, cost-effective emergency services.

The Emergency Department Performance Improvement activities are directed to identify real or potentialopportunities for improvement related to patient care. Monitors are utilized to observe, check and track patientcare progress. Objective criteria are selected to reflect current knowledge and clinical experience.Appropriateness of care as well as quality is assessed. All clinical activities and practitioners are evaluated onan ongoing basis. The evaluation of patient care and practitioner's performance is emphasized rather than justlooking at documentation on the chart.

The Emergency Department Director will be ultimately responsible for overseeing the PerformanceImprovement activities of the Department.

Dept - Performance Improvement - Emergency Department (PC). Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5239223/. Copyright © 2019 St. Louise Regional Hospital

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▪ Patients leaving AMA

▪ Patients receiving CPR

▪ DOA's, deaths in the Emergency Department or within 24 hours of admission

5. Blood Usage:

◦ Reported quarterly

6. Charts Referred from other Committees or from St. Louise Regional Hospital Medical Staff Members:

◦ Reviewed quarterly

7. Notification Forum:

◦ Reviewed monthly

8. Focused Studies:

◦ As needed

SUMMARY OF THE PROCESS IMPROVEMENTPROCESS:1. Identify a problem area where patient care can be improved.

2. Obtain data with selected criteria.

3. Analyze the data to determine the cause and extent of the problems.

4. Develop a plan of action.

5. Implement the plan.

6. Test the plan to see if the problem is resolved.


Attachments:

Each identified process improvement will result in an assessment, a conclusion, and a plan of action designedto correct or eliminate the problem.

Implementation of plans of action designed to eliminate patient care issues will be the responsibility of theEmergency Department Manager. In most instances, this can be accomplished through educational activities,changes in policies, guidelines, and procedures. When necessary, recommendations for the addition, deletionor alteration of equipment will be made.

Follow-up studies as well as a continuous review of patient care activities by the Emergency DepartmentManager will ensure that the plans of action have achieved the desired results.

Documentation of the entire Performance Improvement program and its effectiveness will be presented at thequarterly Emergency Medicine meeting and will be included in the minutes.


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Approval Signatures

StepDescription

Approver Date

Health andHospitalCommittee(HHC)


MedicalLeadershipCommittee(MLC)


MedicalExecutiveCommittee(MEC)


EmergencyDepartmentMedicalDirector

Brian Saavedra, M.D.: Emergency Department Medical Director 1/10/2019


Owner Robert Schambach: Emergency Department & Urgent Care Center Director 12/18/2018


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Dept – SafetyPOLICY:

PROCEDURE:1. Side rails on gurneys should be kept up at all times.

2. Restraints should be used only when necessary, and after other less restrictive options have failed. (Referto Restraint Policy.)

3. Smoking is not permitted anywhere on the campus.

4. Spills will be cleaned up promptly.

5. Every patient will have an identification band in place.

6. Defective or broken equipment is promptly removed from service.

7. Needles and syringes are properly disposed into provided "sharps" containers.

8. Biomedical engineering regularly checks defibrillator and monitor equipment.

9. Principles of good body mechanics are practiced by all employees.

10. Gurney/wheelchair wheels should be locked at all times.

11. Gurneys should be in lowest position, or returned to lowest position after procedures.

12. Foot stools are provided to assist patients onto gurneys, if needed.

13. Crowding of all passageways is to be avoided.

14. All staff must:

◦ Report all unsafe conditions to the manager if it is something that cannot be corrected immediately.

◦ Participate in safety programs.

◦ Be knowledgeable of and use good body mechanics.

◦ Dispose of glass or sharp objects in the proper manner.

◦ Assure that internal and external medications are stored in separate cabinets.

15. Written medication orders (not verbal orders) will prevent medication errors. Telephone orders are to be

It is the responsibility of ED personnel to prevent injury or accident to patients, co-workers and themselves byfollowing all safety guidelines.

Dept – Safety. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5239228/. Copyright ©2019 St. Louise Regional Hospital

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written on the proper form, read back, and later signed off by ordering physician.

16. Portable O2 tanks are secured in the following manner:

◦ Held in portable cart.

◦ Secured beneath gurney with appropriate gauges for position of tank.

17. Call lights are available in patient restrooms and patients are instructed in their use.

18. Emergency equipment and availability of supplies are the responsibility of every shift and should bechecked as early in the shift as possible. Any malfunction of equipment should be reported immediately tothe ED Manager.

19. The Risk Hotline should be called for all patient and visitor incidents related to patient safety.

20. See Infection Control Policy and Procedure Manual for safety against infection and cross-contamination inED.



StepDescription

Approver Date











Dept – Safety. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5239228/. Copyright ©2019 St. Louise Regional Hospital

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External Jugular (EJ) Vein Intravenous (IV)Access

PURPOSE:

SCOPE:

POLICY:1. External Jugular (EJ) IV access is appropriate for adult patients that do not have other suitable peripheral

sites and require IV therapy. EJ's are considered a peripheral IV and can be placed by a RN that hasproven knowledge of the anatomy of the neck and then demonstrates competency through proctored EJIV starts. To demonstrate competency the RN will complete 3 proctored EJ starts. These starts will beplaced in the presence of, and signed off by, an Emergency Department Physician with privileges topractice at St. Louise Emergency Department (ED). The knowledge and proctoring will be documented asa specific Nursing Competency.

2. Registered Nurses with prior experience placing EJ IVs may challenge the knowledge based portion ofthe competency with the Emergency Department Director and then demonstrate competency through 3proctored EJ starts with an Emergency Department Physician who has privileges to practice at St. LouiseED.

3. Only one side of the neck can be used to attempt placement of the EJ. Two attempts is the maximumnumber of attempts. Both attempts must be on the same side of the neck. After the first attempt an MDmust authorize the second attempt while at the bedside to help prevent airway impairment fromhematoma development.

4. The use of topical anesthetic cream can be used prior to insertion.

5. EJ's will be labeled EJ on the dressing so as not to be confused with central line access. EJ IVs can stayin place for no more than 24 hours.

6. EJ IV's will not be used for IV contrast, due to potential airway compromise.

7. Vesicants such as vasopressors can be used in an EJ IV only in an emergency situation and with an MD

Provide temporary peripheral intravenous (IV) access in patients requiring urgent and emergent IVintervention.

Emergency Department Registered Nurses

External Jugular (EJ) Vein Intravenous (IV) Access. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5239218/. Copyright © 2019 St. Louise Regional Hospital

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order that specifically directs administration of the vasopressor via EJ.

REFERENCES:1. Infusion Nurses Society, Ins Position Paper March 20, 2008

2. Medscape Reference, author: Gil Z.Shiamovitz, MD, FAAEM; Chief Editor: Vincent Lopez Rowe MD.External Jugular Vein Cannulation. May 22, 2013.



StepDescription

Approver Date











External Jugular (EJ) Vein Intravenous (IV) Access. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5239218/. Copyright © 2019 St. Louise Regional Hospital

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Patient – 24 Hour LogPOLICY:

PROCEDURE:

1. ED registration number

2. Insurance designation

3. Name

4. Age

5. Sex

6. Time of registration

7. Method of arrival: Ambulatory, Carried, Wheelchair, or Ambulance (Code 2 or 3)

8. Physician attending the patient

9. Discharge diagnosis

10. Disposition

11. Time of discharge

12. Discharge category and priority.


Attachments:

The Emergency Department maintains a 24 hour log providing an accurate and chronological record of allpatients seen in the Emergency Department. The Emergency Department log is maintained electronically, andthe can be produced on request.

All patients who are admitted into the ED registered in the ED log. The computerized log includes the followinginformation:

Patient – 24 Hour Log. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5239235/.Copyright © 2019 St. Louise Regional Hospital

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Approval Signatures

StepDescription

Approver Date











Patient – 24 Hour Log. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5239235/.Copyright © 2019 St. Louise Regional Hospital

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Original: 11/1/2002Last Approved: N/ALast Revised: 8/1/2007Next Review: 3 years after approvalOwner: Leighan Perales: Medical,

Surgical, Pediatric DirectorPolicy Area: Nursing

Hemodialysis Catheter – Initiating IV Fluids andConversion to Heparin Lock

PURPOSE:

EQUIPMENT:1. IV fluids if initiating fluids

2. Syringe to aspirate Heparin if initiating fluids

3. 10ml syringe filled with normal saline if converting to Heparin Lock

4. Syringes with 1.5ml of 5,000 units/ml of Heparin lock solution per Lumen if converting to Heparin lock

5. Injection cap

6. Alcohol wipe

PROCEDURE:

1. Wash hands.

2. Stop infusion, clamp central venous access device.

3. Wipe connecting site with alcohol.

4. Disconnect tubing, unclamp, and flush with normal saline and clamp.

5. Unclamp, flush with Hep-lock flush.

6. Cap off with injection cap.

7. Document procedure.

To maintain use and maintain patency of hemodialysis catheter.

NOTE: DO NOT USE HEMODIALYSIS CATHETER FOR IVs WITHOUT APPROVAL OF NEPHROLOGIST.NEVER USE HEMODIALYSIS CATHETER WITHOUT ASPIRATING 2ml FROM LUMEN PRIOR TO USE.AFTER INSERTION OF IV, INSTILL 1.5ml OF 5,000 units/ml OF HEPARIN INTO EACH LUMEN.

To Convert to Hep Lock

To Initiate IV Fluids

Hemodialysis Catheter – Initiating IV Fluids and Conversion to Heparin Lock. Retrieved 11/20/2019. Official copy athttp://verity-saintlouise.policystat.com/policy/5761226/. Copyright © 2019 St. Louise Regional Hospital

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1. Obtain authorization from Nephrologist.

2. Wash hands.

3. Assure device is clamped.

4. Use a syringe to aspirate 2 ml from lumen to be used.

5. Flush catheter with 10 ml of Normal Sterile Saline.

6. Clamp off device.

7. Wipe Hemodialysis cap with alcohol.

8. Luer lock new tubing into catheter or place new injection cap on catheter tubing and clip InterLink levellock cannula into injection cap.

9. Place tubing on infusion pump, unclamp catheter and begin infusion.

10. Document procedure.











Owner Leighan Perales: Medical, Surgical, Pediatric Director 1/24/2019

Hemodialysis Catheter – Initiating IV Fluids and Conversion to Heparin Lock. Retrieved 11/20/2019. Official copy athttp://verity-saintlouise.policystat.com/policy/5761226/. Copyright © 2019 St. Louise Regional Hospital

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Nursing - Age-Specific Standards of Care(Adolescence to Geriatric)

STANDARDS OF CARE STANDARDS OF PRACTICENURSING PROCESS

All patients can expect their careassessment, delivery and monitoringaccomplished via the nursing process.

• All nurses are expected to demonstrate assessmentskills according to policy and procedure on both aninitial and ongoing basis.

• All nurses are expected to demonstrate planningskills to include nursing diagnosis and dischargeplanning; individualized approach to planning care,including physical, psychosocial, and age specificneeds in collaboration with other health care membersand family.

• All nurses are expected to demonstrateimplementation skills according to basic andadvanced competency requirements for given areas ofpractice.

• All nurses are expected to evaluate care planned andimplemented through ongoing assessment and makeadjustments when necessary.

COMFORT MANAGEMENT

Patients can expect their discomfort to bemanaged within tolerable limits.

Nurses are expected to assess patient's discomfort atappropriate intervals and will provide treatment/interventions in a timely manner.

PATIENT SAFETY

Patients can expect to be cared for in asafe environment while in our facility.

Nurses are expected to assess and monitor the patient andthe environment for potential hazards for injury. Nurses willtake appropriate preventive and corrective actions toensure patient safety.

NUTRITIONAL SUPPORT

Patient can expect to have adequate Nurses are expected to assess the nutritional needs of

Standards of Practice are based on the nursing process.

Nursing - Age-Specific Standards of Care (Adolescence to Geriatric). Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5761394/. Copyright © 2019 St. Louise Regional Hospital

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nutritional support during their hospitalstay.

patients. Interventions will be directed at providing foridentified nutritional needs in the most efficacious manneras required by their changing levels of wellness or withinallowable limits.

SKIN INTEGRITY

Patients can expect to have their skinintegrity maintained to the extent theirdisease process allows.

Nurses are expected to assess for factors that contribute tobreakdown in patient's skin integrity. Interventions will bedirected at minimizing risks and preventing breakdown.

MEDICATION ADMINISTRATION

Patients can expect to receiveappropriate prescribed medications fromqualified care providers.

• Right Medication• Right Dose• Right Route• Right Patient• Right Time

TREATMENTS AND PROCEDURES

Patients can expect to receive theirtreatments or procedures in a safe andtimely manner from a qualified careprovider.

Nurses are expected to implement treatments andprocedures in a safe and competent manner as defined bypolicies, procedures and protocols. Interventions will betimely. Nurses will be judicious and cost-effective in theiruse of supplies and equipment when providing treatmentand performing procedures.

INFECTION CONTROL

Patients can expect to receive caredirected at preventing hospital-acquiredinfections.

Nurses are expected to utilize universal precautions whenproviding care. Nurses will be alert to signs/symptoms ofinfection and will implement appropriate infection controlprotocols specific to identified issues/problems in a timelymanner.

CRITICAL EPISODE MANAGEMENT

Patients can expect timely and safeinterventions in the event of a criticalepisode.

Nurses are expected to anticipate and recognize potential/impending critical episodes and will respond appropriately.Interventions will be efficacious and timely, directed atpreventing undue crisis to the extent possible given thepatient's condition.

PATIENT EDUCATION

Patients can expect that they, with theirfamily/significant other, will be included inteaching that will facilitate theirunderstanding of health care needs.

• Assess the learning needs of patients and theirsignificant others;

• Utilize available resources and established teachingplans in providing the information required to meetidentified needs;

Nurses are expected to follow the policies and proceduresthat facilitate the safe and appropriate administration ofmedications. Basic to safe Administration:

Nurses are expected to:


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• Assess the patient's/significant other's understandingof information provided;

• Initiate referrals as needed to facilitate learning.

PSYCHOSOCIAL SUPPORT

Patients and their families/significantothers can expect to have theirpsychosocial needs addressed in asupportive environment.

Nurses are expected to be accepting of the patient's belief,culture, and socioeconomic background as they pertain tothe patient's status. Nurses will implement interventionsand utilize resources that are support the patients to theextent allowed by the patient's condition and within thelimits of hospital policies and procedures.

DISCHARGE PLANNING

Patients and their families/significantothers can expect that their dischargeneeds will be addressed. Upon the timeof discharge, patients and significantothers can verbalize their understandingof arrangement for post-hospital care.

Nurses are expected to, on admission; begin to identify thepatient and significant other's needs for assistance withpost-hospital care to facilitate timely discharge of patients.

ADOLESCENT PATIENT STANDARDS OF CARE

STANDARDS OF CARE STANDARDS OF PRACTICEPSYCHOLOGICAL SUPPORT The nurse is expected to:

The adolescent can expect that the careprovided will be knowledgeable of theirspecial growth and development needs.

1. Recognize that forming an identity is the major taskof adolescence.

2. Be aware of controlling behaviors exhibited byadolescent, e.g.,

◦ non-compliance with meds/treatments.

◦ not eating (s/sx of anorexia/bulimia).

3. Other positive reinforcement for compliance.

4. Allow for increasing independence but maintainsuitable limit-setting for the adolescent's well-beingand safety.

◦ offer choices within limits.

5. Focus on normal aspects of appearance -

◦ assist with adapted to disease related self-image changes, i.e., hair loss, scars,medication induced weight changes.

6. Allow time for venting of feelings to limit episodes ofacting out.

7. Encourage peer visits and phone calls.

(ADOLESCENT: INDIVIDUALS BETWEEN ON-SET OF PUBERTY AND ADULTHOOD)


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8. Allow private time by self and with friends, separatefrom parental visits.

9. Encourage return to normalization within physicalcapabilities (school work).

10. Offer opportunities for the parents to express theirfeelings and support them through this experience.

11. Allow adolescent to create an environment, whichallows them to feel comfortable (within safety limits),e.g., radio, posters, food, clothing from home.

12. Document the adolescent's behaviors and/orchoices given and/or limits.

PATIENT EDUCATION The nurse is expected to:

The adolescent can expect to receiveinformation to meet age-specific needs.

1. Provide the adolescent with straight-forward adviceand information in answer to their questionsregarding sensitive matters.

2. Focus care on disease process as well asfacilitation of optimum growth and development.

3. Document the adolescent's response to patienteducational interventions.

All revision dates: 5/10/2018, 5/1/2015, 8/1/2009, 9/1/2007












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Procedure - Surgery - NPO PriorPOLICY:

PROCEDURES:1. NPO prior to surgery means nothing by mouth including oral medications unless the physician order

states "except medications" or gives specific orders to give certain medications.

2. Any conflicts between the physician order and anesthesiologist order must be resolved by them.

3. Nursing will follow the attending anesthesiologist and/or Surgeon's order in regard to the statedclarification of NPO prior to surgery.












Patients are made NPO by Physician Order. If the patient is made NPO less than six (6) hours before surgeryor not per specific order the anesthesiologist and ordering physician must be contacted.

Procedure - Surgery - NPO Prior. Retrieved 11/20/2019. Official copy at http://verity-saintlouise.policystat.com/policy/5761782/. Copyright © 2019 St. Louise Regional Hospital

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