UPDATED FALL 2013 Patient Handbook - QCH - Home 18.pdfQCH is a patient-centred and family-focused...

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Queensway Carleton Hospital is a Smoke-Free and Scent-Free Environment UPDATED FALL 2013 Patient Handbook

Transcript of UPDATED FALL 2013 Patient Handbook - QCH - Home 18.pdfQCH is a patient-centred and family-focused...

Queensway Carleton Hospitalis a Smoke-Free and Scent-Free Environment

UPDATED FALL 2013

Patient Handbook

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Welcome to Queensway Carleton Hospital

To our patients, their families and visitors:

On behalf of the staff, physicians, students and volunteers, welcome to Queensway Carleton Hospital.

QCH is a patient-centred and family-focused Hospital where we are committed to providing care in an environment where patient safety is our first priority. We want your experience at Queensway Carleton Hospital to be a positive one which is best achieved through a partnership based on two-way respect, responsibilities and accountabilities.

Our dedicated team of health care professionals serve an ever-changing and growing population. Over the past several years, our Hospital has grown significantly in response to the needs of our community and it’s our goal to continue to be the hospital of choice where patients receive exceptional patient care and where health care professionals choose to deliver that care.

We invite you to read through this Patient Handbook at your convenience and familiarize yourself with what you can expect during your stay in hospital. Being informed and involved ensures that you play an active role in your own health care journey.

Sincerely,

Tom Schonberg President and CEO

Tom Schonberg President and CEO

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Table of ContentsQCH Vision and Mission Statement ...... 4QCH Values .......................................... 4Patient Bill of Rights and Responsibilities ..................................... 5Protecting the Privacy of Your Personal Health Information ......... 7What to bring for your stay .................... 8Patient Safety begins with YOU – Your health care, be involved ................ 9Clean Hands Protect Lives ................. 10Antibiotic Resistant Organism (Bacteria / Germ) Admission Screening Patient Information Sheet ....................12Preventing blood clots (Deep Vein Thrombosis and Pulmonary Embolism) in Hospital ............................................13

Hospital InformationAdmissions ......................................... 14Allergy Alert – Fragrance Sensitive Environment ........................................ 14Bank Machine ..................................... 15Cafeteria ............................................ 15Call Centre .......................................... 15Cellular and Digital Phones ................ 15Clinical Pathways ................................ 16Community Care Access Centre (CCAC) ............................................... 16Consent for Treatment ........................ 16Discharge Information ......................17Electrical Appliances ...........................17Finance Cashier ................................. 18Fire Alarms and Exits ......................... 18Flowers – Fragrance Sensitive Environment ........................................ 18Food Services .................................... 18Geriatric Day Hospital ......................... 19Gift and Book Cart .............................. 19The QHC Gift Box .............................. 19Hairdressing and Barber Services ...... 19

Please note: We are constantly changing to meet your needs. Information presented in this directory may be subject to change.

ID Bracelets ........................................ 20Infection Prevention and Control......... 20Information Desk ................................ 20Living Will ........................................... 21Lost and Found Items ......................... 21Mutual Respect and Tolerance .......... 21Newspapers and Magazines .............. 21OC Transpo ........................................ 21Parking ............................................... 22Patient E-Mail ..................................... 22Patient Mail ......................................... 22Patient Telephone and Television Rental Service ................... 23Patient Transportation ........................ 24Pet Visitation ....................................... 24Protection Services............................. 25Recovery Connections ....................... 25Satisfaction Surveys and Comment Cards .......................... 25Smoke-Free Environment ................... 26Spiritual Care ..................................... 26Taxi Service ....................................... 27Tim Hortons ........................................ 27Vending Machines .............................. 27Visiting Hours ..................................... 27Volunteers ........................................... 29Washrooms......................................... 29

Your Health Care Team ...................... 32Queensway Carleton Hospital Foundation .......................................... 35Champions of Care Donation Form .................................... 33What You Need to Know About Health Care Costs at QCH ............................. 34

Community Supporters .................35

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OUR VISION We will be the hospital of choice, recognized for our exemplary patient care, people and performance in an environment of innovation and strategic partnerships.

OUR MISSION As a patient and family-centred hospital:

• We provide a broad range of acute care services to the people of Ottawa and the surrounding region.

• We respond to the needs of our patients and families through our commitment to exemplary performance, accountability and compassion.

• We partner with other health care and community service organizations to ensure coordinated and integrated care.

• We actively promote a learning environment in which our staff, physicians, students and volunteers are progressive and responsive.

• We are an active teaching partner with colleges, universities and other healthcare programs.

Our Cornerstone Programs are: • Emergency Services • Medical Services • Surgical Services • Geriatric Services • Acute Rehabilitation Services • Childbirth Services • Mental Health Services

OUR VALUES • Accountability • Innovation • Respect

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Patient Bill of Rights Queensway Carleton Hospital’s Patient Bill of Rights and Responsibilities represents important guiding principles and behaviors that our staff will strive to achieve in their relationships with patients, their families and representatives. We will respect your right to:

Information about you:• Receive all your health care information in a clear, accurate and complete way.• Review your health record should you wish, following established procedures

and within a reasonable timeframe.• Be clearly informed of the expected outcome, benefits and risk of each treatment

option and test.• Be informed as quickly as possible of any incident which has occurred during the

delivery of services which has resulted in unintended implications to your health and well being and the measures that the hospital intends to put in place to avoid a recurrence of such an incident.

• Protect your information consistent with the laws governing privacy in Ontario.

Delivering quality care, with dignity and respect:• Receive the best care that we are capable of providing.• Know the names and functions of the members of your health care team.• Be treated with courtesy and respect.• Be free from discrimination and harassment.• Be an active participant in your own care.• Be listened to and have time to ask questions or express concerns without anxiety. • Be screened for multi-resistant organisms (germs) for your own safety and that

of others.

Choice:• Accept or refuse any medications or treatment once you have received all the

necessary information you need to make an informed decision.• Change your mind, start or stop treatment.• Participate in the decision making process to decide your plan of care.• Choose a Substitute Decision Maker of your choice and according to legislation,

who will speak and act on your behalf, if for any reason you become unable to act for yourself.

Patient Bill of Rights and Responsibilities

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Support:• Receive social, emotional and spiritual support of your choice within the hospital

setting.• Be accompanied by persons of your choice within the restrictions of safety.

Respecting your privacy:• Receive your treatment in as private a setting as is possible within the hospital. • Have the collection, use and disclosure of your personal health information

handled in a secure and confidential manner.• Be asked to sign a consent form if your personal information needs to be shared

with any party other then those listed on our privacy signage, posted throughout the hospital.

Patient ResponsibilitiesTo Patients, Families, and Representatives:

• Mutual respect and cooperation are essential to the delivery of quality health care. In order to successfully meet your health care needs, we ask that you and/or your representative(s) please:

• Provide all necessary information as requested by your health care team and notify them of any changes. Ask questions about your illness and treatment and let us know if the answers are unclear.

• Provide the hospital with a copy of a written advance directive if you have one. • Follow your treatment or care plan to the best of your ability. Ask for whatever

information is necessary to make an informed choice and share your decision with people close to you. Keep in mind that “best care” does not always mean “the most aggressive treatment available”.

• Be prepared for medical tests and understand that they may not be carried out if preparatory instructions were not followed.

• Respect the rights of others to access hospital care when required and cooperate with the healthcare team to arrange for a prompt discharge once the physician and health care team determine that you no longer require the services of the hospital

• Respect the rights of others for quiet and privacy and be courteous and respectful of the staff and other patients who you come into contact with.

• Keep appointments and pay applicable fees for missed appointments or services that are not covered by OHIP or your private insurance.

• Provide the necessary medical insurance or other coverage information so that the hospital may appropriately apply necessary charges.

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We understand that health information about you is personal and must be protected.

For these reasons we will:• Provide the best possible level of confidentiality around the collection, use and

disclosure of your personal health information;

• Collect only necessary information and use that information solely for the care and treatment you are seeking;

• Disclose only information necessary for the delivery of your care and the management of the health care system. This could include sharing information with your Family Doctor, a laboratory, another health care provider, your health insurance plan or regional/provincial electronic patient records system. This could also mean disclosing information to comply with legal and regulatory requirements (i.e. the Mental Health Act), research requests, patient satisfaction surveys, internal QCH fundraising and teaching or statistical requirements;

• Ask your permission before disclosing any of your information for purposes not related directly to the above. We will also respect your right to withdraw your consent to use your information for purposes not required for legal or regulatory requirements;

• Recognize your right of access to your health information when you request it and provide copies for a fee;

• Recognize your right to review your personal health information with a member of our staff during your stay;

• Respond to your questions or concerns about the way we handle the privacy of your personal health information

Chief Privacy Officer 613-721-2000 Ext. 2915

Protecting the Privacy of Your Personal Health Information

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Personal belongings including visual aids and eyeglasses, dentures, hearing aids and personal physiotherapy devices such as canes and walkers, should be labeled with the patient name prior to admission to the hospital. Please Note: There is a “What to Pack” list provided in the Childbirth Centre Handbook.

Clothing: You may bring your own pajamas and dressing gown, but they should be washable and worn well above the ankles so you do not trip or fall. We suggest you wear hospital gowns if you have drains or tubes. When out of bed, non-slip, full-back slippers or walking shoes are recommended.

Personal Care Items: We suggest you bring your own toothbrush, toothpaste, hairbrush, shaving supplies, makeup, lotions, soap and shampoo. Please Note: Unscented personal care products are recommended due to patient and staff sensitivities.

Medications: Please bring all the medications you are currently taking (including prescription, over the counter and herbal) in the original packaging or bottles. During your hospital stay, only medications prescribed by your hospital physician may be taken. Patients will be requested to use their own inhalers, eye drops, ointments and creams while they are in hospital. Please note: Any patient who has received a blood transfusion Medical Caution Card from a Lab, please present the card upon admission or to a member of your health care team.

Valuables: Please leave your valuables such as jewelry and watches at home. If you find yourself admitted to hospital unexpectedly, have a loved one take your valuables home. Patients should carry their Health Card as well as a credit card to aid in payments as well as telephone and television rental. Small change for personal gift shop or cafeteria purchases may also be needed.

Please note: Electrical appliances such as hairdryers, curling irons and electric heating pads and blankets are not permitted. Please see the section titled “Electrical Appliances.”

What to Bring for your Hospital Stay

Queensway Carleton Hospital is proudly designated a NICHE (Nurses Improving Care for Healthsystem Elders) hospital, demonstrat ing our commitment to excellence in providing care to older adults. To find out more about NICHE, visit http://nicheprogram.org/ or ask a member of your health care team.

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Our Hospital is committed to safe, quality care for patients. It’s important for patients and their family members to know it is possible to be harmed by hazards in the physical environment, during the course of care delivery and by breakdowns in communication. Keeping you safe is our priority. As professional and careful as we are, we want and need your help in ensuring your safety.

1. Be involved in your health care. Be an active member of your care team by taking part in every decision about your care. Ask a member of your team if you have questions so that you can make informed choices. It means coming prepared for your medical treatment and knowing what to do when you go home. It also means getting support from friends and family if needed.

2. Tell a member of your care team about your past illnesses and your current health condition, including how you are feeling and recent hospital of physician visits, any medications, ongoing medical problems and any family history of illnesses.

3. Bring all your medicines with you when you go to the hospital or for a medical appointment. Some medications, when combined, can cause reactions. Bring medications, even over the counter ones such as vitamins and herbal remedies, with you in their original packaging or bottles. Be sure to tell your care team if you take prescriptions from more than one physician.

4. Tell a member of your care team if you have ever had an allergic reaction to any medication or food. Reactions can include rashes, headaches, breathing trouble and feeling sick and can be a result of components of a medication, food or even anaesthetics during surgery. You can be tested for allergies and even wear ID bracelets such as MedicAlert™.

5. Make sure you know what to do when you go home from hospital or from a medical appointment. Ask as many questions as you can to make sure you understand. These could include questions about medications, plans for home care and follow-up appointments.

6. Preventing fall in hospital is important. Falling is a risk when you are unwell and in unfamiliar surroundings. Let the care team know if you have ever had a fall or are unsteady on your feet. Ask for help when walking and use handrails, walkers and wheelchairs where available. Wear non-slip footwear and rubber soles while in hospital.

Patient Safety begins with YOU – Your health care, be involved

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Hand cleaning is one of the best ways you and your health care team can prevent infections from spreading.

Did you know that the main way germs can spread is by hand?

Keeping hands clean is the best thing you and your health care team can do to prevent infections from spreading to others. That’s so important in hospitals and other places where the risk of infection is high.

In Canada, one in nine patients gets an infection while in hospital.

Sometimes patients get infections when they are in hospital. Thousands of times a day, members of your health care team handle things that could have harmful germs. Without good hand cleaning, these germs can spread to patients and cause infection.

Your health care team works hard to keep their hands clean.

Your health care team plays a big role in preventing the spread of infection. They are committed to giving you clean, safe care.

There are important moments when your health care team should clean their hands, such as:

• After touching objects in a patient’s room and going to another room• Before and after treating patients• Before and after special procedures such as giving a needle• After contact with body fluids such as blood or urine

When should your health care team wear gloves?Wearing gloves does not prevent germs from spreading from patient to patient. So, don’t expect your health care team to always wear gloves. But, do expect them to clean their hands at the right time in the right way.

There are times when your health care team should wear gloves. For instance, they wear gloves when they are treating open wounds or taking blood. They may also wear gloves when taking care of a patient in isolation *in a room by themselves.) These patients need special care and protection. If you are visiting a patient in isolation, you may also have to wear special protection such as gloves, a mask or a gown.

Once your health care team is finished with a task, they will throw the gloves away. They clean their hands carefully both before and after using the gloves.

When you come to a hospital, hand cleaning is your job too.

Whether you are a patient or a visitor, do your part to prevent germs from spreading.

Clean Hands Protect Lives

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Think about the times that you would clean your hands at home, such as:

• Before and after eating• After using the washroom• After sneezing or coughing

Make sure you clean your hands at these times and even more often when you are in the hospital.

There are two ways to clean hands.You can clean your hands by using:

1. Hand rub provided throughout the hospital2. Soap and water using the soap in the dispensers at the sink

After cleaning, make sure your hands are dry before touching anything. This is very important when you use the hand rub.

Visitors who do not feel well should not come to see you.

When you are in hospital, don’t be shy about telling visitors to stay home if they are not feeling well. That’s another big way we can keep infections from spreading in the hospital.

As a patient, you have the right to ask your health care providers, including your physician, if he/she has washed their hands. Hand hygiene is everyone’s responsibility.

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Antibiotic Resistant Organism (Bacteria / Germ) Admission Screening Patient Information Sheet

Because there has been an increase in the number of resistant bacteria in our community the Queensway Carleton Hospital has a policy to screen (test) all medical service patients and other patients such as surgical patients who have been in a health care institution for 24 hours or more in the last 12 months for antibiotic resistant bacteria before or on admission to the Hospital.

What is an Antibiotic Resistant Organism?Antibiotic Resistant Organism is a strain of bacterium (germ) that has developed the ability to resist many antibiotics. The common antibiotics that are normally used to kill it do not kill the bacteria when it carries this resistance. Just like “normal” bacteria, it can live harmlessly in our noses, rectum and on our skin. However, if it causes an infection to develop, we need different, often-stronger antibiotics to kill it.

For these reasons, we need to make sure that this bacterium does not spread to other patients. People who are already sick would be more likely to get an infection from resistant bacteria than healthy people would, so in the hospital it is very important that we control the spread of these bacteria. In order to control the spread, we need to know who might be carrying the bacteria.

What test is preformed to detect Antibiotic Resistant Organism?The test involves collecting nose and rectal swabs from each patient. One swab is placed into each one of your nostrils; two swabs are obtained from your rectal area. It does not hurt. If someone is found to have resistant bacterium (germ), he or she is placed in a private room and put on special precautions to ensure that the bacteria cannot be spread to other people.

If one of your swab results is positive for a resistant bacterium that you are tested for, your doctor or nurse will inform you.

The majority of people will not have Antibiotic Resistant Organisms (germs) but the Ontario Ministry of Health and Long Term Care’s Provincial Infectious Disease Advisory Committee recommends that all hospitals have a process to screen patients for Antibiotic Resistant Organisms (germs) to control the spread of infection. All Ottawa area hospitals have adopted this infection prevention and control policy.

Your cooperation in having the samples collected is appreciated, and is necessary for us to make sure that we keep Antibiotic Resistant Organisms (germs) in control

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Preventing blood clots (Deep Vein Thrombosis and Pulmonary Embolism) in Hospital

Admission to hospital for certain surgeries or medical illnesses can increase your risk of developing blood clots. The risk may be greater if you have a history of blood clots, a family history of blood clots, cancer, recent surgery, recent travel, birth control pill or hormone replacement therapy.

Deep vein thrombosis (DVT) is a blood clot formed in a deep vein in the leg or pelvis that can cause leg swelling and pain. Sometimes the clot can become loose and reach your lungs. This is called a pulmonary embolism (PE) which can cause chest pain and sudden shortness of breath, and can be very serious.

If you develop any of the following symptoms during your hospital stay or after discharge, please seek medical attention immediately:

Possible signs and symptoms of DVT:• pain in your leg• swelling in your leg• warm and/or discoloured skin

Possible signs and symptoms of PE:• new shortness of breath • pain in your chest and/or ribs which is worse when you take a deep breath• coughing up blood

Your doctor will take steps to reduce your risk of developing a blood clot while you are in the hospital. These may include one of the following:

• Blood thinning medication in the form of a daily injection • Compression stockings to improve circulation and reduce the risk of clots.• Sequential compression devices which are leg wraps (from your ankle to your

thigh) that can improve blood flow with gentle pressure on the leg.

To reduce your risk of developing a blood clot while in hospital:• Ask your doctor or nurse if they have taken steps to reduce your risk of getting a

blood clot.• Expect to receive an injection which reduces the chances of abnormal clotting of

the blood• Resume physical activity and walking as soon as your doctor permits it• Drink plenty of fluids if permitted.• Report any chest pain, shortness of breath, or pain or swelling in your leg to a

member of the health care team immediately.

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AdmissionsPatient Registration/Admitting is located on the main level near the main entrance. Volunteers in the front lobby will direct you to the desk.

You will be asked:• Your name and current address• Your family physician’s name• Provincial health card number • Method of payment (i.e. credit card number) • Details specific to your health insurance coverage if you are requesting semi-

private or private accommodations• Name and contact information of your substitute decision maker (if applicable)• Religious preferences (so that your clergy/faith group may visit)

You will also be informed about our Mixed Gender Bed Assignment Policy which ensures the efficient use of our inpatient beds. Patients may be admitted or transferred to a bed in a room where the other patient(s) are of the opposite sex. You will be informed by your nurse if this situation should occur

Allergy Alert – Fragrance Sensitive EnvironmentQCH promotes a scent-free environment. We all have the right to breathe clean air and not to suffer unnecessary health problems brought on by chemical fragrances. Patients, visitors and staff are asked to refrain from wearing perfumes, colognes and personal care products that are highly scented such as deodorants, aftershave, hair products, body powders and lotions.

Hospital Information

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Bank MachineThere are two Automate Teller Machines (ATMs) available 24 hours a day located at the Main Entrance (adjacent to the Parking Machine) and one located next to Tim Hortons. A portion of the ATM transaction fee is donated to patient care at the hospital.

Cafeteria The Cafeteria is located on Level 1 and provides breakfast and lunch service, Monday to Friday, from 6:30 a.m. to 2 p.m. The Cafeteria features a wide selection of hot and cold breakfast options, soups, short-order service, daily entrée and pizza specials, Panini (toasted sandwich) bar, snacks and healthy food choices as well as a fully stocked salad bar and fresh deli bar. Throughout the summer months, the Cafeteria also features barbecue days on the patio.

If you’re looking for snacks outside Cafeteria hours, vending machines are located throughout the hospital and are accessible 24-hours in the Childbirth Centre, the Emergency Department and in the Cafeteria. (See also Tim Hortons and Vending Machines).

Call CentreThe Call Centre is the Telecommunications hub of the hospital located around the corner from the Main Entrance (past the Information Desk and to the left, adjacent to The QCH Foundation.) Call Centre Agents are available to assist visitors when the Information desk is closed.

Cellular and Digital PhonesThe use of radio frequency transmitting devices (i.e. cell phones, video games and wireless communication devices such as Blackberrys) are permitted in corridors and public areas of the hospital such as waiting rooms. Please note: These devices are not permitted in patient care or diagnostic rooms and must be turned off in these locations. We ask that you refrain from using these devices in close-proximity to patients being transported through public areas.

Cell phones capable of image capture or video transmission can only be used with the consent of the individual(s) who image is captured. Cell phones must not be used to record conversations without express consent of the individuals involved. For more information, contact the QCH Privacy Officer at 613-721-2000 ext. 2915.

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Clinical PathwaysYour hospital stay may follow a plan of care called a “Clinical Pathway”. It has been prepared so that you, your family, and all members of your health care team know your plan of care, including what tests, treatments and diet you require as well as the education and planning necessary for discharge. The patient version of your Clinical Pathway gives you an idea of what to expect from when you get to the hospital until discharge. Once you and/or your family have read the information, please feel free to ask your nurse or other members of the health care team any questions.

Community Care Access Centre (CCAC)CCAC is a Ministry of Health and Long-Term Care funded program which arranges home care services, aids placement into long-term care homes such as nursing homes, and provides information about community services. CCAC is a non-profit organization which supports in-home and in-school health services for children, adults and seniors.

CCAC case managers are available at QCH and will access clients for eligibility according to Ministry criteria. Services include case management, nursing, personal care, physiotherapy, occupational therapy, social work, nutritional counseling and speech language pathology. There may be a wait list for some services.

Ask a member of your health care team for more information on the CCAC or contact the onsite team at 613-721-2000 ext. 3765. To reach the main CCAC office, call 613-745-5525 or visit the web site at www.champlain.ccac-ont.ca

Consent for TreatmentYou will be asked to sign a consent form for certain tests, procedures and treatments. Information regarding the benefits, risks and options must be provided by the health care practitioner providing your care, this is called Informed Consent. You have the right to refuse treatment, and it is important that you understand the implications of your decision. If you are unable to consent to treatment for any reason, you must appoint a Substitute Decision Maker. At Registration, you are required to give the name of your substitute decision maker. Information regarding Substitute Decision Makers and Power of Attorney kits are available through Social Work, located on the main level or by calling 613-721-2000 ext. 3750.

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Discharge Information Discharge time is 10 a.m. for most patients. Discharge time for Childbirth Centre patients vary between 48 and 72 hours after admission.

Your physician or nurse will inform you of your discharge date and time so a friend or family member can assist you in going home. Early departure is key to helping us accommodate the next patient. Your care team can provide information and costs regarding private transfer services and taxis if necessary. When you prepare to leave, please be sure that you have all your belongings, your blue hospital card as well as any aftercare instructions, prescriptions and return appointment information as needed.

To help ensure you are safe after you leave the hospital, it is important that you understand all the instructions regarding your medications, diet, activity and return appointments. If you have any questions, ask a member of your health care team before you leave.

Electrical AppliancesQCH only allows the use of battery-operated appliances. Small battery powered devices such as clocks, radios and tape players (not including battery chargers) will be permitted as long as they do not disturb other patients or QCH staff. For safety reasons, plug-in appliances such as electric shavers and hair dryers are not permitted. Only QCH approved grooming appliances will be permitted and are available from your nursing team. Appliances must be unplugged while not in use and hair dryers should not be used in the bathroom.

The following devices are prohibited:• Portable televisions (bedside TVs are available for rent for a nominal daily fee) • Heating devices of any type including electrical heating pads and blankets,

space heaters, curling irons, coffee pots/coffee makers and personal hair dyers• Although it is extremely unlikely, a patient’s appliance could interfere with the

operation of a nearby medical device. Computerized devices (i.e. personal computers, video games) may be the most likely sources of interference. If an appliance appears to be interfering with the operation of a medical device, inform a member of your care team and turn off or unplug the appliance – normal device operation should resume. It may be necessary to turn some devices off and then on to resume normal operation.

Please note: You must discuss any medical device you bring into the hospital with your attending physician or member of your health care team.

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Finance CashierIf you plan to make hospital payments in person using Interac (debit card), cash or credit card, please visit the Finance Cashier between 8:30 a.m. and 4 p.m., Monday to Friday. The cashier is located just past the Information Desk and to the left..

Fire Alarms and ExitsFire exits are clearly marked on each floor. During a fire alarm, all fire doors are closed on your unit until there is an ALL CLEAR announcement on the speaker system. Upon hearing a fire alarm, please return to your room with any family or visitors. Staff on your unit will inform you if any action becomes necessary. If you are in the Cafeteria, please stay there until an ALL CLEAR is announced. Please note that the elevators do not work during a fire alarm.

Flowers – Fragrance Sensitive EnvironmentFlower arrangements sent to you during your stay will be hand-delivered to your room by staff or volunteers. Visitors are also invited to visit the Gift Shop on the main level to purchase or order flowers. When ordering flowers, consult with the Florist to choose a low-scent variety. The following flowers are no longer accepted within QCH: freesias, lilacs, lavenders, hyacinths, peonies and lilies including day, tiger, Easter, lily-of-the-valley and star gazers

Food ServicesFood Services staff are committed to providing you with meals that are nourishing as well as appetizing. A varied menu, based on Canada’s Food Guide and specific dietary requirements, is provided daily during your stay, with Food Services staff visiting mid-morning and again mid-afternoon to take your food order. Meals are delivered approximately 8 a.m., 12 noon and 5 p.m. Nourishments are available between meals for those with special dietary requirements.

QCH provides kosher meals upon request to any Jewish patient. Families and caregivers who find themselves in hospital over the Jewish Sabbath or in emergencies where they find themselves unprepared, are invited to speak with the Dietitian about access to The Kosher Pantry.

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Geriatric Day HospitalThe Queensway Carleton Geriatric Day Hospital is an inter-professional, specialized geriatric outpatient service helping seniors gain and maintain a healthy and independent lifestyle.

The Geriatric Day Hospital serves people 60 years of age and older, who live in the community and require assessment, rehabilitation, and treatment to help them remain independent. We take pride in the care we give to our seniors in our community. We are located off site from the main hospital at 39 Robertson Road, 613-721-3808. Please contact us if you feel we can be of help.

Gift and Book CartDuring a patient’s stay, QCH volunteers will visit patient care areas with the Gift (tuck) Cart which contains magazines, personal items and snacks for purchase. The Book Cart offers books and magazines that you may borrow during your stay, or even take home with you. Items from the Gift Cart are also available from the QCH Gift Shop located on the main floor.

The QHC Gift BoxYou are invited to visit The QCH Gift Box gift shop located at the Main Entrance. The Gift Box, operated by Volunteer Services, carries a wide variety of items including gifts for every occasion, newspapers, magazines, fresh flowers, cards, personal care items, confectionary and newborn products. All proceeds raised support the hospital and its programs.

Hours of Operation:Monday - Friday 9 a.m. to 4 p.m. 5 p.m. to 8 p.m.

Saturday and Sunday 12 noon to 4 p.m.

Hairdressing and Barber ServicesPatients can enjoy the convenience of an in-hospital visit from a local hairstylist. For more information and a list of available stylists and barbers, enquire at the ACC Desk (main desk) on your unit. You or your family members are responsible for contacting the salon, setting the appointments and providing payment for the service.

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ID BraceletsA wrist bracelet will be given to you upon admission for day surgery or a hospital stay. You are required to wear it at all times while at the hospital. A more involved identification band system is in place in the Childbirth Centre which the staff will explain upon admission.

Infection Prevention and ControlQCH is committed to the health and safety of its patients and visitors as well as hospital staff and volunteers.

• Please ensure that your family members and visitors follow hand hygiene procedures when entering and exiting a patient room.

• Some patients may require special infection control precautions and their visitors and health care team may be required to wear gowns and masks to prevent the spread of the infection. Please ensure that your visitors adhere to any and all precautions as directed.

• Please inform your family and visitors that they should not visit if they are feeling “sick or unwell” or even if they feel that they are “coming down with something”

• Family members and visitors are also asked to refrain from using the washrooms in a patient room. Public washrooms are available on each unit.

Please note: Hospitals can be infectious zones. Please ensure that those with babies and young children visiting keep visits very brief, do not let babies or toddlers out of your arms or strollers and that children are supervised at all times. Do not let children sit on hospital beds or crawl on the floor.

As a patient, you have the right to ask your health care providers, including your physician, if he/she has washed their hands. Hand hygiene is everyone’s responsibility.

(See also Clean Hands Protect Lives at the beginning of this Handbook)

Information DeskLocated at the Main Entrance, the Volunteers at the Information Desk are available to assist patient and visitors Monday to Friday, 8 a.m. to 4 p.m. If you or a family member are here to visit any of the hospital’s clinics, the Volunteers can direct you to the correct location. During off –hours, the Call Centre Agents (located past the Information Desk and to the left, adjacent to The QCH Foundation) are available to assist.)

People First. Caring Always. 21

Living WillIf you have prepared a Living Will, have an Advanced Directive or signed a donor card, please inform the Admitting/ Registration staff when you are admitted to the hospital. It is important to ensure that your family members are aware of your health decisions.

Lost and Found ItemsIf you have misplaced a belonging during your recent stay, inform a member of your nursing team or contact ext, 1701. Found items will be kept for a period of two months.

Mutual Respect and Tolerance QCH values compassion, tolerance and mutual respect. We are committed to providing a safe, violence-free environment for patients, visitors, staff and volunteers. Aggressive behaviour and/or coarse language will not be tolerated. Any person who is physically or verbally abusive, or destroys hospital property, may be reported to the police. We recognize that visits to the hospital can be stressful and patients often have complex needs. Our staff is here to help you deal with difficult situations. Please ask our staff if you need to talk or have privacy.

Newspapers and MagazinesDaily papers can be purchased from the boxes located outside the hospital’s main entrance. Newspapers, along with a variety of magazines, are also available through the Gift Shop on the main floor.

OC TranspoThe hospital is serviced by OC Transpo routes 97, 118 and 152. Visit OC Transpo online and use the Travel Planner to plan your visit.

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ParkingHospital visitors will access the easy-to-use automated parking system by following these steps:

1) Entry Station: Retrieve a ticket as you enter the parking lot. You are asked to carry this ticket with you as you will require it at the pay station, or if you choose, you may pay directly at the exit gate with a credit card.

2) Pay Station: A climate-controlled booth centrally located at the front of the lot enables visitors to access the two available pay station units. There is also a pay station located at the hospital’s main entrance. Visitors insert their ticket at the station and pay the amount shown by coins, bills, or credit card. The pay station machine issues an exit ticket required to leave the lot.

3) Exit Station: Visitors will insert their exit ticket at the exit station. There is also an option at the exit station to pay by credit card, bypassing a stop at the pay station

* Daily passes can also be purchased at the pay stations by following the clear and simple touch-screen options.

* Weekly and Monthly passes may be purchased from the Finance Cashier or the Security Office between 8:30 a.m. and 4 p.m. They are located just past the Information Desk and to the left.

Patient E-MailPatients can receive personal emails and well wishes from family and friends through the hospital’s Patient E-Mail service. Visit the hospital web site at www.qch.on.ca and click on the Patient E-Mail button. Complete the online form and your emails will be directed to Volunteer Resources and hand-delivered by the volunteers.

Patient MailIncoming mail will be delivered directly to your room by a QCH volunteer. Please inform friends and family to address your mail as follows:

Your Name (and Unit/Room number)c/o Queensway Carleton Hospital3045 Baseline RoadOttawa, ON K2H 8P4

*Please ensure there is a valid return address

Outgoing mail should be deposited in the Canada Post box located outside the main entrance. Stamps are available in the Gift Shop located on the same level.

People First. Caring Always. 23

Patient Telephone and Television Rental ServiceEvery patient bedside is equipped with a phone that can dial within the hospital only. Patients are only charged for phone service if it is activated by the patient or their family member(s) through the Hospitality Network’s Automated System (described below) or through the onsite representative.

The Hospitality Network offers an Automated Rental System to order service at your convenience.

How to order:Activation & payment with Visa or Mastercard:

• From patient’s bedside phone, dial extension 2200 and follow the easy voice instructions to activate service.

• The telephone/television service will begin automatically within a few minutes after you call is completed.

• At any time if you require assistance, your call will be connected to a live representative who will assist you.

• A complimentary headset for the television can be found in the patient’s bedside stand.

Activation & payment with cash or cheque:• From patient’s bedside phone, dial extension 2200 and follow the easy voice

instructions to activate service. • At any time if you require assistance, your call will be connected to a live

representative who will assist you.• The onsite Hospitality Network representative will collect payment in person

during regular coverage hours (excluding statutory holidays.) Please refer to Channel 77 on your TV for more information.

Prices: Please note: Prices are subject to change without notice. Please refer to the most recent Hospitality Network Pricing Guide available on each patient unit or by calling the onsite Hospitality Network representative at ext. 4740.

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Patient Transportation Patients may require transportation for tests or consultations outside the hospital and upon discharge. Transport by ambulance (Emergency Medical Services) is only for emergency situations or when a paramedic is needed.

Non-urgent transportation can include: private vehicle (friends or family); taxi/wheelchair accessible taxi; ParaTranspo and private transport companies. Hospitals use the services of private companies with trained personnel and specially designed vehicles for non-urgent transport of patients.

Hospitals are required to pay for transport when the transfer is from one hospital to another or for medical appointments at another facility. Hospitals DO NOT pay for transfer to other locations such as retirement homes.

Please note: Patients must arrange for transportation before their discharge. The hospital recommends that patients plan a ride home with family or friends. If this is not possible, the hospital will assist a patient to arrange for transportation. If a special vehicle is required, a private company is contacted. Patients will be required to pay for this service and payment must be made directly to the transport company. Ask your care team or Discharge Planner for more information.

Pet VisitationQCH recognizes that pet therapy can be instrumental in the recovery of illness and will seek to accommodate requests for pet visitation while maintaining quality care and safety for all. For family pets to be permitted, several guidelines MUST be followed. Failure to comply will result in the owner being asked to promptly remove the animal from hospital property.

• Pets are limited to dogs and cats and they must be house pets• Visits are restricted to between 30 and 60 minutes• The patient must be acutely ill with an extended hospital stay• There must be no potential threat to other patients or staff• All visitation must be pre-approved by the Nurse Manager on the unit and a

permission slip completed (available at the main desk on the unit.) This slip should be produced when requested by hospital personnel.

Pet visitation is available in acute care areas when permitted including the Geriatric Unit, Alternate Level of Care (ALC), Rehabilitation and Mental Health.

Animals are NOT permitted in Intensive Care (ICU), operating rooms, labour and delivery, newborn nursery, pre/post anaesthesia surgery, rooms with isolation precautions, storage/preparation areas for food, medications or sterile supply rooms and rooms with persons at increased risk of infection or patients with allergies.

People First. Caring Always. 25

Protection ServicesSecurity is on duty 24 hours a day and can be contacted through your nursing team should you have any security-related problems or concerns. Please report any personal property loss or suspicious activity.

QCH participates in Hospital Watch a program that relies on staff, volunteers, physicians and patients being the “eyes and ears” of the hospital. We ask that anyone report any suspicious activity to staff. An example may be a suspicious person with no hospital I.D. who is going in and out of patient rooms. We recommend that items of value such as wallets, jewelry, and money be left at home or given to loved ones for safekeeping.

Security is available for escorts to personal vehicles for those with any security concerns. If you require an escort, please have the nursing team in you area page Security through the Call Centre.

You will see our uniformed Security personnel completing regular patrols throughout the hospital. Feel free to stop and speak with an officer at anytime if you have any concerns.

Recovery ConnectionsThis regional program, with support from Psychiatric Survivors of Ottawa, is intended to provide family peer support to those accessing the inpatient Mental Health unit at the hospital. To find out more, contact 613-721-2000 ext. 2860.

Satisfaction Surveys and Comment CardsAt QCH, our goal is to provide family and patient-centred care. With our Patient Satisfaction Surveys, Comment Card and Kudos Card Programs, the hospital can obtain ongoing feedback from patients. It is a good opportunity for you to reflect on your experience in hospital.

You may be asked to complete a Patient Satisfaction Survey during or shortly following your stay at QCH. Your opinions and ideas are important to our continual quality improvement. In addition, patients and their families are encouraged to provide feedback through the Comment Cards and return boxes located on each patient care unit. Please be assured that privacy is respected and your responses will remain anonymous unless you indicate otherwise. Your feedback is appreciated.

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Smoke-Free EnvironmentQCH promotes a smoke-free environment. Smoking is NOT PERMITTED anywhere on hospital property, including personal vehicles parked on the property. As a health care institution, QCH has an obligation to ensure that those who work, visit or receive services at our hospital, are not harmed by second-hand smoke.

As a patient or visitor, we ask that you help us make this policy work. Please:• Leave tobacco products at home or ask a family member to bring them home.• Ask your family and visitors to refrain from smoking while on hospital property.

Patient Smoking Cessation ProgramQCH is a participating member of the Champlain Network of Hospital-Based Smoking Cessation Programs, and as such, uses a common approach to identify and provide an intervention to avoid nicotine withdrawal and offer support for patients who want to quit during their stay in hospital. Ask you health care team for more information.

Spiritual Care Your spiritual well-being is important. The Spiritual care office on the main level is open Monday to Friday from 8 a.m. to 4 p.m. and can be reached by dialing ext. 6600. Ecumenical and Perinatal Chaplains are on-call 24-hours-a-day to provide care and support in emergency situations. Roman Catholic Chaplains are available most days from 8 a.m. to 10 p.m. Your health care team can make these contacts for you.

*Sacred Space has been set aside for anyone who requires a quiet place to reflect and concentrate on your spiritual needs. Located on the main floor adjacent to the Spiritual Care Office, the sacred space is a non-denominational retreat accessible 24 hours a day, 7 days a week. Please ask your nurse or a volunteer for directions.

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Taxi Service There are direct taxi line telephones to connect you with area taxi services. The phones are clearly marked and located adjacent to the Patient Registration area at the main entrance and in the Emergency Department.

Tim HortonsIn addition to the hospital’s Cafeteria services, a full-service Tim Hortons kiosk is located on the main floor adjacent to the Emergency Department. (See also Cafeteria)

Hours of operation:Monday to Friday 6:30 a.m. to 9 p.m.Saturday, Sunday and Holidays 7 a.m. to 8 p.m.

Vending MachinesVending machines are located in the Emergency Department waiting area, the Childbirth Centre waiting area and the Cafeteria. Change machines are located in these areas.

Visiting HoursPatient recovery can be enhanced by visits from family members, but remember, recovery is also aided by plenty of rest. Please have consideration for your fellow patients regarding the number of visitors coming to see you. Patients and their families are asked to adhere to the posted visiting hours as well as the overhead pages reminding you of when visiting hours begin and end.

• Follow proper Hand Hygiene when entering the hospital and patient rooms.• Children are the responsibility of the visitor. Hospitals can be infectious zones.

Ensure that those with babies and young children visiting keep visits very brief. Do not let babies or toddlers out of your arms or strollers and ensure children are supervised at all times. Do not allow children to sit on hospital beds or crawl on the floor.

• Only two visitors at patient bedside at one time. • Floral arrangements or fruit baskets may not be appropriate for certain patients.

Please check with the nursing unit beforehand. • If your visit coincides with a time when a physician or other health care

professional is with the patient, please allow them to complete their duties before entering the patient room.

Visitors should NOT visit if they are unwell with signs and symptoms of possible infections such as fever, cough, runny nose, vomiting, diarrhea, rash, flu-like symptoms or conjunctivitis.

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Childbirth Program:

Intensive Care Unit (ICU) A3: 11 a.m. to 1 p.m. and 4 p.m. to 7 p.m. *Immediate family only in this unit.

• Only two visitors at patient bedside with maximum four visitors each day. Limit visits from young children to immediate family only and please keep all visits brief.

• Visits are limited or extended at the discretion of the health care team and the patient’s needs.

• For Infection Control reasons, NO FLOWERS are permitted in the ICU patient rooms.

In-Patient Mental Health: Weekdays 4 p.m. to 8 p.m. Weekends 11:30 a.m. to 2 p.m. and 4 p.m. to 8 p.m.

• Patients in this area do not have telephones in their room. If you would like to speak with a patient, please call 613-726-9877.

Medicine, Surgery and Geriatrics – Level 3 and 411:30 a.m. to 2 p.m. and 4 p.m. to 8 p.m.

• Only two visitors at patient bedside at one time. Limit visits from young children to immediate family only and please keep all visits brief.

Who Can Visit Birth Unit Mother Baby Unit Special Care Nursery

Gynecology/ Surgery

Partner/primary support person

Any time day or night. Any time day or night.

Parents any time day or night, except during daily report times of 7 am to 7:30 am and 7 pm to 7:30 pm.

Grandparents and siblings of new baby

15 minute visit after baby is delivered day or night.

10 am to 8 pm. Siblings must be accompanied by an adult.

10 am to 8 pm except 7 pm to 7:30 pm during report time.

Family and friends

No general visiting other than designated support people.

3 pm to 8 pm 3 pm to 8 pm except 7 pm to 7:30 pm during report time.

11:30 am to 2 pm and 3 pm to 8 pm

Number of people at the bedside

3 including partner and 2 other support people during labour and delivery. No switching of support people.

3 including partner. Please considerate of other patients in the room when visiting.

2 including 1 parent with Baby bracelet.

3 visitors

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Rehabilitation Unit (A4): 11:30 a.m. to 2 p.m. and 4 p.m. to 8 p.m.

VolunteersOur hospital volunteers are a valuable resource and help serve the needs of patients by complementing the efforts of the staff. Volunteers support many areas of the hospital and are easily recognizable in their royal blue smocks and royal blue shirts. Our regular and student volunteers contribute an average of 40,000 hours each year and are also involved in fundraising, donating profits to enhance the quality of patient care at the hospital. If you are interested in becoming a volunteer, please contact Volunteer Resources at 613-721-4709.

WashroomsPublic washrooms are located throughout the hospital for your convenience and clearly designated by signage. Please note: family members and those visiting patients are asked to use the public washrooms located on each unit and NOT to use washrooms located in patient rooms.

Washrooms at QCH are designated senior-friendly and are fully accessible by those in walkers, wheelchairs and other assistive devices. Washrooms located near the main entrance as well as those in the Childbirth Centre and Emergency Department are equipped with diaper changing stations.

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Your Health Care Team Patient care is our top priority at Queensway Carleton Hospital and we work as a team with our patients. There are many employees who may assist in your care. All staff are required to wear their identification name tags at all times which include their picture, name and title.

There are a number of departments within the hospital which offer supervised training for students/interns/residents seeking credentials in various professions and you are advised that a student/intern/resident may be involved in your care. Of course, your care will remain the responsibility of your doctor(s) and other care team members, but we encourage you to ask whatever questions you might have about the involvement of our students/interns/residents in regards to your care.

Attending Physician: Your doctor arranges for your admission to the hospital and is responsible for your care while you are here. You may also be under the care of “consultant” doctors, depending on your medical needs. Physicians are available for family conferences if required.

Clinical Nurse Specialist: This member of the team may be asked to assist you or your family in assessing problems related to aging, as well as in planning treatment and evaluating your progress.

Dietitian: As part of your treatment, you may be prescribed a special diet or have particular nutrition requirements. Clinical Nutrition Services will provide individual and family counseling for patients with restricted or special dietary needs. Dietitians are available Monday to Friday. During your hospital stay if you have any dietary concerns about the meals that you are receiving, please speak to either your nurse or a Food Service Aide and a Clinical Diet Technician will visit you to discuss your specific needs.

Environmental Services: The Environmental Services Aides are committed to keeping your hospital room, furniture and other areas clean in an efficient and unobtrusive manner. You will likely see them in your area a number of times each day.

Laboratory Technician and Medical Radiation Technologists: As part of the diagnosis and treatment process, you may require an x-ray or blood tests. A Medical Radiation Technologist will either bring the x-ray equipment to your room, or you will be escorted to the X-ray Department. A Venipuncture Technician or a nurse may collect blood samples. These samples will be taken to the Lab for testing by Laboratory Technologists.

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Nursing: Our Registered Nurses (RN) and Registered Practical Nurses (RPN) are an integral part of the multi-disciplinary team of care givers who develop your plan of care while you are in the hospital. They are present 24/7 to ensure ongoing assessment and to monitor your plan of care.

Occupational Therapist: Our registered occupational therapists (OT) assist you to gain and maximize your independence with functional activities. OTs may recommend physical changes to your home to increase your safety and independence, or suggest equipment to increase your mobility such as ramps or wheelchairs. OTs may recommend devices such as a long handled reacher so that you can dress yourself independently, and teach memory strategies to assist you with daily activities. OTs also assist you to maintain your independence in your work and leisure activities. Our OTs can be found on our rehabilitation unit, surgical and medical units and our mental health in-patient and out-patient programs.

Palliative Care Team: Palliative care is an approach that concentrates on reducing the severity of disease symptoms and improving the quality of life of patients and their families for people facing severe, complex illness. The interprofessional palliative care team identifies and treats pain and other symptoms, including physical, psychosocial, and spiritual. It is offered in conjunction with curative and all other appropriate forms of medical treatment.

Pharmacist: All hospital medication orders are reviewed by Pharmacists who are involved in monitoring your medication treatment during your hospital stay. Pharmacists are available to discuss your medications with you.

Physiotherapist: Registered physiotherapists (PT) assess, treat and prevent physical problems, injuries and pain, to restore movement, function and health status. Our PTs can be found in the ICU assisting with recovery of respiratory function, on the rehabilitation unit assisting to regain mobility after a stroke, on the surgical unit guiding mobility after a total joint replacement, and on the medical unit assisting with balance exercises and recommending mobility aids

Porters: These members of our staff transport you to and from departments if you require any tests during your stay.

Rehabilitation Assistant: Rehabilitation assistants work closely with our occupational therapists and physiotherapists to assist you with regaining your mobility and function. Rehabilitation assistants provide care under the direction of PT and OT and may assist you with functional activities such as retraining for dressing after surgery, increasing how far you are walking, or working on exercises to regain your strength and endurance.

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Respiratory Therapists: These healthcare professionals assist physicians with the diagnosis and treatment of lung disorders. During the course of your stay, an RT may be called to support the care team in certain situations. RT’s may provide assistance in: airway maintenance for patients in areas that include ER, ICU or Maternal Newborn; CPR and support; life support including mechanical ventilation; high risk births; stabilizing high-risk patients being moved by ground ambulance; administering inhaled drugs and medical gasses; conducting lung function tests and guiding patient education on managing lung diseases such as asthma and COPD

Social Work/Discharge Planner: This department assists you, your family and friends, in finding solutions to social, emotional or economic problems connected with illness or disability. Home care services are arranged through this department if your doctor deems this is a necessity. On admission, you will receive a letter fully explaining our discharge protocol. Please take a few minutes to read it carefully.

Speech Language Pathologist: Registered Speech Language Pathologists (SLP) identify, assess and treat communication and swallowing disorders. SLPs also provide education and counselling to patients and their families for management of their communication and swallowing difficulties. They work closely with other professionals as part of a multidisciplinary team, in providing a coordinated program of care. Services are provided throughout the hospital on the Medical, Surgical, ICU, Rehab and Awaiting Placement Units; as well as for outpatients in our community.

YOUYou are a very important part of our team and play an active role in your recovery process and patient safety. We encourage you to speak openly to members of your health care team if you should have any questions or concerns. (See also Patient Bill of Rights and Responsibilities.)

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Queensway Carleton Hospital Foundation plays a vital role in providing our hospital with resources necessary to enhance patient care and purchase medical equipment. Our mission is to improve and save lives by working with our donors, our hospital and our community to encourage philanthropic gifts in support of patient care.

Your donation to Queensway Carleton Hospital Foundation goes directly back to our hospital, supporting the healthcare needs of our rapidly growing community. Many people are surprised to learn that equipping our hospital is 100% the responsibility of our community. The government helps cover the cost of maintaining and operating the equipment once it’s here, but it’s up to the community to get it through the doors.

There are a variety of ways for you to donate and make a difference at our hospital:

Champions of Care DonationDid an employee, physician or volunteer make a difference for you or your loved ones during your stay with us? You can recognize and thank them by making a Champions of Care donation in their honour. Your Champion will receive a commemorative pin to wear with pride and letter of acknowledgement.

Tribute DonationHonour the memory of a loved one or friend or celebrate a special occasion like the birth of a child by making a tribute donation in their honour.

A Gift in Your WillIncluding a bequest in your will is a thoughtful way to create a legacy that will support patient care at Queensway Carleton Hospital for generations to come.

General DonationYour general donation will help support the healthcare needs of our rapidly growing community. We offer the option of making a regular monthly donation as part of our Circle of Friends Monthly Giving program or a one-time gift.

How to Donate:• In Person – visit the Foundation on Level 2 near the Main Entrance• By Phone – call 613-721-4731• Online – www.qch.on.ca/donate• By Mail – use the form in this handbook to send your donation to: Queensway Carleton Hospital Foundation 3045 Baseline Road Ottawa, ON K2H 8P4

For more information about how your gift makes a difference or other giving options, please contact Queensway Carleton Hospital Foundation by phone at 613-721-4731 or email [email protected].

Queensway Carleton Hospital Foundation

A tax receipt will be issued for donations of $10 or more.     Charitable Registration No.  13725 3571 RR 0001   

Champions of Care Donation Form   My Champion’s full name:  ___________________________________________Title:  ________  Department/location:  ___________________________________________________________  Message for Champion:  __________________________________________________________  ______________________________________________________________________________ 

 

 My name is:  ______________________________________________________Title:  ________  Address:  ______________________________________________________________________  City:  _______________________________ Province:  ________   Postal Code:  _____________      Telephone:  ____________________________________________________________________  Email:_________________________________________________________________________  I wish to make a gift in the amount of:  

 $50     $100    $250    $500    Other:  $  __________________  

  I have enclosed a cheque payable to:  Queensway Carleton Hospital Foundation  

  I prefer to charge my gift to:  

                   Card Number:  _____________________________________  Expiry Date:  ________/________  Name on card:  _________________________________________________________________  Signature:  _____________________________________________________________________  Mail to:   Queensway Carleton Hospital Foundation 3045 Baseline Road Ottawa, ON     K2H 8P4  Fax:  613‐721‐4755