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NEW HORIZON SURGICAL CENTER LLC

COMPETENCY MANUAL/ANNUAL INSERVICES 2010


This has been developed to help employees meet some of the basic requirements of mandatory education.
If you have any questions while reading this packet please contact the Director of Nursing.
Table of Contents:
• Body Mechanics
• OSHA/Safe needle law
• Radiation Safety
• Sexual Harassment
• Corporate Compliance
• Customer Service
• Risk Management/Pt Safety
• Electrical Safety
• Medical Gas Safety
• Reporting and Treatment of Work-related injuries
• Patient Safety
• Unexpected Outcomes
• Loss of Electrical Power
• Lock Out/Tag Out
• Medical Device Reporting
• Hazardous Materials
• Emergency preparedness
• Codes used in the Center
• Fire Safety
• Bioterrorism
• Evacuation
• Advance Notice Requirements
• Patient’s Rights
• Non-Discrimination
• Confidentiality/HIPAA
• Advance Directives
• Age Specific Growth and Development
• Impaired staff member
• Abuse and Neglect
• Latex Allergy
• Surgical Hand Scrub/Chain of Infection/Handwashing guidelines
• Blood borne Pathogens/Infection Control
• Exposure Control Plan/Sharps
• TB
• Workplace Violence
• Cultural Diversity/Cultural Competency
• Look-alike Sound-alike Drugs
• Pain Competency
• Blood bank
• Skills Checklist
• Prevention of Patient Falls
• Contingency Plan
• Surgical Site Universal Protocol
• High Alert Medication List
• Propofol
• Nosocomial infections
• Abbreviations not to use
• Event Related Sterility
• Patient Safety Act/Incident Reporting
• MRSA & MDRO
• Evacuation Policy
• Sharps Injury/Phebotomy
• Identity Theft
• Housekeeping Review
• Drug Competency
• CLIA Waived Testing
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• Patient Safety Act Risk


Name: ______________________________________ Date: ______
Score: _________________
Retake Score: __________Signature of employee: _____________________________
Signature of Nursing Director: _______________________

BODY MECHANICS AND ERGONOMICS:

Objective: To be aware of the most common causes of back problems.


To learn how to avoid back injuries.
To be aware of arranging your work environment to fit you and your
body.

In 1984 nurses were found to be fifth among workers in all occupations who
claimed workers compensation for back injuries.
Only heavy laborers ranked higher.
Not only is there a need for education and training with a focus on body mechanics.
There is also a need to develop alternative methods to decrease the stress that
causes overexertion injuries. If a task produces undue stress this should be
communicated to the Director of Nursing. If this is done, an alternative method
may be found in order to decrease the chances of injury.

It is what we do to our body’s everyday that is the cause of most back problems.
Back problems are usually the result of:

 Poor Posture
 Poor Every Day work Habits
 Poor Body Mechanics
 Insufficiently Flexibility
 Lack of Strength and Endurance

The following are triggers that have been found to affect back pain or injuries in the Nursing or
O.R. setting:
• Standing for long periods of time
• Lifting and holding patients’ extremities
• Holding retractors for extended periods of time
• Transferring patients on and off of OR beds
• Reaching, lifting, and moving equipment; and
• Repositioning patients on OR beds

Posture:
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Posture is important no matter what position (standing, sitting or lying down) you are in and at all
times whether you have an injury or not. To be in a balanced posture means that you are handling
the forces of gravity in the most efficient way possible. To be unbalanced places chronic stress on
ligaments, muscles, and other structures, so that over a period of time they may fail.

Normally, the low back has an inward curve, as does your neck. The upper back has a slight
outward curve. Too little curve or too much curve can be harmful.
The curves need to be balanced in order for the spine to function as a good shock absorber and to
ensure that no structure takes too much load.
Problem Postures:

Standing:
A flat low back places increased load on the disc. A low back unbalanced in this way is a poor
shock absorber because all of the curves that are above it are diminished also.
An exaggerated curve in the low back places increased load on the little joints of the back that are
located between the vertebrae. The abdominal muscles are lax so there is poor support to the
spine from the abdomen.

Sitting:
Sitting itself places increased load on the discs of the low back. Slumped sitting makes it worse.
It also causes the head to move forward that strains the neck. If this is constant, muscles and
ligaments shorten and flexibility is lost so that proper posture can no longer even be achieved.

Lying Down:
A sagging mattress or one that is too hard can cause you to get up and feel stiff or in discomfort.
Therefore:

 Stand with your knees relaxed, your shoulders over your hips and hold the back of your
head high. If you must stand to work, your work height should not require you to bend
forward. If you must stand still, having one foot up on a low rail or a block is relieving.

 Sit with your feet on the floor, your knees and hips both at 90 degree angles, a small
support at your low back so the curve is maintained, and hold the back of your head high.
The depth of the seat should be such that your hips are all the way back in the seat and
your thighs are supported to within two inches from the crease at your knee. Have your
work at the proper height. In sitting, this might mean that you need to adjust your chair.
Support your feet on a stool if they do not reach the floor. Your arms should rest on your
desk, without pushing your shoulders up or causing you to slump.

 If you work at a computer, the keyboard should be close enough so that your upper arms
are by your sides. Your forearms should be parallel to the floor and your wrists straight.
In this position, your hands will “float” over the keyboard.
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 Your document holder should be at eye level so that you do not need to move your head
very much when looking from screen to copy. The top two inches of the screen should be
at eye level so that your eyes can scan down easily.

 Sleep on a mattress that supports you in good alignment, but conforms to all of your
curves.

 Change your position if you work overhead often, you need to crouch or bring your knees
to your chest periodically in order to restore flexibility in the opposite direction. If you sit
or drive for a long period of time, stop, stand up and bend backwards a little to restore
flexibility in that direction. Position changes help relieve stress.

Postural and Body Mechanics Mistakes:

 Habitual unbalanced postures.


 Lifting with the back forward bent and legs straight. If lifting is repeated in this way it can
damage the back over time without a person’s knowing it. Standing and working with the
back forward bent.
 Holding a load too far away from the body.
 Twisting the back, especially when bent forward.
 Reaching high overhead to lift a heavy load. (This increases the arch in the low back).
 Trying to manage a load that is too heavy.
 Poor Planning
 Using fast, jerky motions.
 Failing to modify the environment so that you do not have to sit and stand in stressful,
unbalanced ways or work with safety hazards present.

What to do when lifting:


 Plan your move before you begin.
 Get help (mechanical or human) if the load to lift is too heavy.
 Bring the load as close to you as possible.
 Place your feet into a wide base of support.
 Maintain a slight inward curve to your low back and tighten your lower abdominal
muscles by pulling them in.
 Keep your head and shoulders up
 Lift with your legs
 Pivot your feet, do no twist.
 Move as smoothly as possible.

o Keep your feet apart when lifting. A wide base of support keeps the load centered
over your base of support.
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o Pivot or turn with your feet instead of twisting or turning with your body.
Twisting and turning can weaken and increase pressure on discs and supporting
structures.
o Plan and practice whether you are able to handle the load safely.
o Lift with your legs. Leg muscles are powerful muscles that are designed for power
activities. As you perform the lift, keep your back erect and squat with your legs
to perform the lift.
o Approach the lift close to your body. Keep the load as close to your body as you
are able. A load held at arm’s length would be much harder to lift than a load held
close to the body.
o Keep your head up while you are lifting. Keeping your head up and level helps
keep the spine in its normal curves.
o Tighten the stomach muscles as you lift. This will add support to your back as you
lift.
o Move slowly and easy when lifting. Quick jerky movements can cause more strain
on muscles, joints, ligaments and bones.

Workstation Ergonomics

The following 5 easy steps to good ergonomics can help you assess your work station and make
simple adjustments that can improve your comfort and safety on the job.
1. Assess how comfortable you are at your workstation.
2. Adjust your chair- your chair affects your comfort more than anything else in your work
environment.
3. Reorganize your work area. A well organized and properly adjusted workstation can
improve efficiency and help prevent injury.
4. Check the lighting. Proper lighting can reduce eyestrain and help avoid headaches.
5. Make lifestyle changes. Regular exercise and getting enough sleep will go a long way
toward helping you feel better and work more comfortably.

Adjusting Your Chair and Workstation

1. Backrest: The backrest should fit snugly against your lower back. If it doesn’t, adjust the
backrest until your back is fully supported. If you can’t adjust the backrest, use a small
pillow to support the lower back.
2. Arm and Keyboard Position: With fingers on the middle row of your keyboard, your
forearms should be parallel to the floor. Your wrists should be straight and relaxed.
3. Foot Position: Your feet should rest firmly on the floor with 3-6 inches of leg room
between your lap and desk or keyboard tray. Your knees should be bent to 90-100 degree
angle. If your chair is not adjustable, and your feet do not touch the floor, use a foot stool
to support feet.
4. Screen Position: The top of the monitor should be at or below eye level. The screen should
be 18-30 inches from your eyes, or about arm’s length.
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5. Workstation: Arrange things most commonly used within easy reach. Document holders
should be at same height and distance as monitor. Your workstation should be free of
glare from light coming through outside windows, and overhead lighting should not create
glare on your screen.

OSHA:
OSHA’s 1999 Compliance Directive to protect US health care workers follows the California bill
passed on September 30, 1998.

Failure of health care facilities to implement and use safe needle devices puts health care workers,
especially nurses, at serious risk for contracting life-threatening diseases. This type of
occupational risk is unnecessary and preventable.

OSHA’s blood borne pathogen standard: The bill requires sharps prevention technology to be
included as engineering or work practice control, excepting technology that does not promote
employee or patient safety or that interferes with a medical procedure.

Requires exposure control plans to be updated, reflecting progress in implementing sharps


prevention technology.

Requires documentation and recording of exposure incidents.

Employees should:

Refuse to use unsafe needle or sharps devices


Always use universal/standard precautions
Wear proper face coverings
Wear gloves
Respect sharps: recap needles only if absolutely necessary, and then, use a resheathing device or
one-handed scoop method.
Properly dispose of sharps after use
Get immunized against Hepatitis B
Immediately report all exposures.
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Comply with post exposure follow-up.


Support your peers
Help mitigate the problem
Be a change agent (Be open to new products or practices that could prevent exposure)

PERFORM ANNUAL OSHA TRAINING WITH EMPLOYEES


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RADIATION SAFETY:

Two ways that you can encounter radiation in the healthcare environment are through
external beam sources or x-rays and radioactive materials that are put inside patients’ bodies to
treat disease.

You should avoid any possible harmful effects of exposure by:

• Minimizing your time exposed to the radiation source


• Using shielding and protective clothing when appropriate
• Never touch anything with a radioactive warning label unless you are trained and
authorized to do so.
• Whenever caring for patients who are being treated with radioactive materials, dispose of
syringes, radioactive liquid and other waste properly.

It is the employee’s responsibility to read the Radiation Safety Manual. The Manual will be kept
in the Nursing Station with the Policy and Procedure Manual.

If you have any questions or are unsure of something, ask your Nursing Director or Radiation
Safety officer.

RADIATION SAFETY FOR FLUOROSCOPIC PROCEDURES


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Fluoroscopy has proven to be an integral part of diagnosis and treatment of patients with various
clinical conditions. However, in 1994 the Food and Drug Administration (FDA) became
concerned with serious radiation induced skin injuries from fluoroscopic procedures and issued
various public health advisories concerning this. As more and more procedures move to the
ambulatory setting, it is important for the healthcare worker to understand ways to minimize
fluoroscopic exposure and to monitor that exposure.
With fluoroscopy, there is a continuous beam of radiation from the x-ray tube delivered to the
patient, which produces a real time radiographic image. This allows the physician to monitor the
exam/procedure “live” in order to provide accurate treatment.
The fluoroscopic unit is composed of an image intensifier, fluorescing screen, film, and an x-ray
tube producing the x-ray beam. The image intensifier increases the image brightness without
increasing the radiation exposure by converting the x-rays transmitted into a brighter light image
for viewing.
Fluoroscopic procedures can be diagnostic or interventional, with the latter providing the greater
doses.
Sources of Radiation Dose:
Three main sources of radiation dose to patients and personnel during fluoroscopy are primary,
leakage, and scatter.
Primary dose is the radiation from the useful beam used to produce the image. Therefore careful
attention to the fluoroscopic design and setup in the room is important. Controlling the input and
direction of the primary beam and thus the resultant scattered radiation, can reduce the radiation
risk to the patient and staff in the room.
Secondary radiation during fluoroscopy is scatter and leakage radiation. Scatter radiation results
when the primary beam interacts with the patient or other objects. In general, the intensity of the
scatter radiation equals 0.1% of the useful beam at a distance of 1 meter from the patient.
Leakage radiation occurs when the beam is activated. X-rays pass through the tube’s housing.
This occurs as long as x-rays are produced within the tube, but this radiation falls well below the
regulatory level.
Dose Exposure:
Absorbed dose is the amount of ionizing radiation absorbed per unit per mass at a certain point
within irradiated matter. Some of the largest doses to patients in medical imaging and intervention
occur with fluoroscopy. The largest dose occurs at the skin, where the radiation enters the patient.
The radiation absorbed dose unit is the rad or Gray. One Gy equals 100 rads.
National dose limits for exposure to ionizing radiation for workers and the general public have
been set by various regulatory agencies. No legal maximum doses have been set for patients due
to the great variability in patients and the types of procedures they need. However, it is the
clinician’s responsibility to limit the volume of exposed tissue and to keep the total dose to the
minimum necessary to complete the procedure to protect the patient.
Permissible doses for healthcare workers have been set, but the ALARA principle (as low as
reasonably achievable) is emphasized as the most important mechanism when handling
occupational exposure to radiation.
Radiation injury to the skin does not occur at low doses, but when a certain threshold is resulted
(~2 Gy); it can result in errythema and hair loss and progress to chronic skin ulceration. The
severity increases with increasing dose above the threshold dose. Genetic susceptibility to
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radiation as well as previous high doses from earlier procedures increases the risk of fluoroscopic
skin radiation injury.
While time between doses to the skin permits the skin to recover somewhat, it may not fully
recover. Large patients, especially those with connective tissue disease, diabetes mellitus,
homozygosity for ataxia telengiectasia or previous high dose fluoroscopes are at a greater risk for
skin injuries.
Before 1990, few reports of radiation skin injury occurred. However, in the 1990’s, the number of
cases reported increased due to lengthy high dose interventional procedures. Most were related to
cardiac catheter ablation and other cardiac procedures.
Minimizing Exposure by Personnel:
Overall, dose limit for imaging personnel is 5 REM per year. In addition, a maximum permissible
dose of 50 REM per year is for skin, hands, and feet.
Dosimeters should be worn by all personnel participating in fluoroscopic procedures per
established policies and physicist recommendations.
All personnel should use ALARA principle to minimize dose.
All personnel should wear protective garments such as aprons, thyroid collars, lead gloves, and
lead eyeglasses. Type of garment is dependent upon types of procedures performed.
Keeping Fluoroscopic Radiation Exposure to a Minimum:
The most basic and important way to reduce dose is to reduce time, increase distance from the
source, and use protective shielding.
Other ways to keep the radiation dose down is to keep the field of view smaller by adjusting the
collimators. Use the last image hold or “freeze framing” mechanism so that decisions can be made
on this static image and not while the beam is on. Make sure that the radiation is not continuously
turned on, but rather use an on and off routine instead.
During interventional procedures, care should be given to ensure that extraneous body parts such
as arms and breasts are not exposed to the beam. Periodically rotating the fluoroscope around a
center within the area of interest will distribute the total dose over a larger area of skin and thus
decreases chance of injury.

References:
Teresa G. Norris, B.A., Radiation Safety in Fluoroscopy. Radiologic Technology.
2002, 73: 511-533

Bushong, S.C. Radiologic Science for Technologists. Physics, Biology, and


Protection. 6th ed. St. Louis, Mo: Mosby Yearbook, Inc; 1997

United States Food and Drug Administration, Centers for Devices and Radiologic
Health. FDA Public Health Advisory: Avoidance of Seriously X-ray
Induced Skin Injuries to Patients During Fluoroscopically Guided
Procedures. Rockville, Md: Food and Drug Administration; September 30,
1994.
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SEXUAL HARASSMENT:
It is the policy of the Center to maintain a working environment free of all forms of sexual
harassment or intimidation. Sexual harassment includes, but is not limited to, sexual advances,
unwelcome sexual jokes, propositions, commentary about an individual’s body, sexual ability or
sexual deficiencies, touching, pinching or assault, obscene comments or gestures, requests for
sexual favors, display in the workplace of sexually suggestive objects or pictures, and other verbal
or physical conduct of sexual nature. Sexual harassment in any form is a serious violation of this
policy and will not be condoned.

Sexual harassment of employees is not permitted.

Definition of Sexual Harassment:

Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a
sexual nature, when
1. Submission to such conduct is made either explicitly or implicitly
a term/condition of
employment, or;
2. Submission to or rejection of such conduct is used as the basis of
employment decisions; or
3. Such conduct unreasonably interferes with an employee’s work
performance or creates an
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intimidating, hostile, or offensive working environment.

For example, sexual harassment can include, among other things, unwelcome propositions,
flirtations and requests, whether express or implied, for sexual favors. It can also include other
unwelcome verbal visual or physical conduct of a sexual nature, such as unnecessary touching of
an individual, graphic or verbal commentaries about an individual’s body, sexually degrading
verbal abuse, a display in the workplace of sexually suggestive objects or pictures, sexually
explicit or offensive jokes and physical assault.

Any employee who feels that he or she has been the subject of sexual harassment from a
coworker, manager, patient, or any other person in connection with employment at the Center
should immediately report the behavior in question to the Nurse manager or designee. The
Director of Nursing or designee will obtain from the employee a signed statement describing the
harassment.
Appropriate collective action will be taken when a report of sexual harassment is validated. Such
corrective action may include a counseling report, observation period, suspension and / or
termination. In the event that the offending individual is not an employee, the Director of
Nursing in consultation with the Administrator will
take action necessary to prevent a recurrence of the incident in the workplace. The Center
prohibits retaliation against an employee who complains of sexual harassment. An employee who
knowingly makes a false report of sexual harassment or who provides false information will be
subject to disciplinary action, which may include termination.

CORPORATE COMPLIANCE

Compliance means the willingness to follow guidelines prescribed by regulatory authorities in


treating patients, documenting patient services and billing for patient services. The Handbook is a
supplemental tool to policies established by the Center. This handbook is not able to cover every
situation the staff may encounter.
The Center realizes that Compliance is the business of all Center staff. The effectiveness of this
handbook depends upon the willingness and ability of the staff to bring compliance issues to the
attention of their supervisors. If there is uncertainty about an issue the staff must err on the side
of reporting the issue to their supervisor or to the Compliance Officer/Director of Nursing or
designee .

Why do we need a Center Compliance Program?


The Center needs a Compliance program because it is in our best interest and the best way to
helping abide by government regulations.
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What are the six parts of the Compliance Program?

1. Staff Screening
The Center will not employ any person who the Center knows has been convicted of a criminal
offense related to healthcare or has been excluded from the Federal program participation.

2. Patient referrals

The Center does not pay for patient referrals


Gifts to patients to influence their use of the Center are prohibited.
The staff will not accept gifts from vendors, suppliers or other providers in exchange for patient
referrals.
The Center will not waive coinsurance or deductibles for any patient.

3. Billing
The Center will bill only for services that are medically necessary
The Center will bill only for services provided under proper supervision and by a licensed
physician.
Correct billing codes will always be used and the billing standards will be followed.
Medical records will be maintained that support billing codes.
The Center will not bill separately for services included in the composite rate.
Claims will not knowingly be up-coded or submitted in duplicate unless the duplicate is a
resubmission and marked as such
Billing errors will be promptly corrected and overpayments returned.

4. Patient records
Patient records will be kept in accordance with all Federal, State and local laws.
The staff will follow the Medical Records policy.

5. Medicare enrollment standards


The Center will ensure that every effort will be made that the contents of all applications to
Medicare for enrollment or re-enrollment be complete and correct.

6. State licensure and Medicare certification


Center will comply with all requirements of State licensure
Medicare Certification where applicable.

Center Director’s Role


The Director of Nursing/Coordinator of the Compliance Program will report to the Managers
regarding all Center compliance issues. All employees and physicians will have annual training
regarding Corporate Compliance.
Corrective action will be implemented for all compliance standard violations.
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Center Director Implementation Documents:


Compliance Manual
Acknowledgement forms
Report to be prepared for the Managers three times/year regarding any deviations from the
compliance standards
Complaint box for anonymous complaints
Review and follow-up on all complaints
Annual financial and billing chart audits
Review documentation provided by the Center
Complaint forms

Managers
Oversees the Compliance program
Reviews of the Compliance checklist three times/year to ensure that the standards are met
Ensuring resolution of any deficiencies found or any complaints filed.

Complaints:
Violations will be reported to the Director of Nursing.
The Complaint form will be completed and given immediately to the Corporate Compliance
Officer/Director of Nursing.
The Director of Nursing and the Managers will decide what corrective actions to take.
If the person reporting the violation wishes to be anonymous they may leave an anonymous
complaint in the complaint box.
The Center will not tolerate retaliation against staff that report violations of the Center’s Policy.

Government Investigations:
The Center will comply with any government investigation
If a search warrant is presented ask for a copy and their business card of the agent.
Request an inventory of any items taken and have the agent sign.

Conclusion:

The Center is committed to monitoring and documenting the Center’s compliance with
appropriate Federal, State and local laws and regulations.

All staff members and physicians associated with the Center must acknowledge understanding of
the compliance program and comply with these standards.
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CUSTOMER SERVICE:

It is important to create a positive first impression.


• A customer forms impressions about you and your organization within seconds of contact.
• Your attitude is the key to customer satisfaction
• You affect the success of the Center
• Try to think of how you can make the customer happy that they talked to you
• Remember you never get a second chance to make a first impression
Remember to keep in mind how much you should appreciate customers:
Think to yourself when they speak with you:
• Thank you for paying my salary so that I can pay my mortgage, buy a car, send my kids to
college, etc.
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Make the customer happy that they called.


• Be patient and personal.
• Pretend that you are talking to your best friend. (You are)
What will please customers most?
• No hassle
• Someone who listens
• Verbal feedback
• Immediate action
• Using his/her name
To be successful when faxing or using e-mail and voice mail:
• Use the customer’s name
• Give your name and reason for the request
• Ask for the name of the person who will handle the request
• Give your number and best time to reach you
• State the urgency
• Back up a fax with phone call
• Verify that someone is taking care of the request
• Have a return fax receipt if possible
Telephone techniques to use when answering the phone:
• Offer to help
• Be polite
• Get caller’s name and number
• Take a message and write it down or immediately transfer the call
• Ensure that the message was picked up
• Do not leave the call on hold for extended periods of time. Offer to take down the caller’s
phone number and have the call returned.

Think about what you are saying and how you say it.
Say Don’t Say
May I ask who is calling? Who’s calling?
He’s not in the office at the moment. He hasn’t come in yet. (In the morning)
She’s away from her desk at the moment. She’s on her coffee break.
He’s out of the office today He left early today.
She’s not in the office today She’s sick today.
He’s out of the office for the next two He’s on vacation for two weeks.
weeks
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Customers want to form a partnership with you.


• Try to break the communication barrier, if one exists
• Build good rapport with your customer, not resistance
• Put aside your feelings and all judgments
• Concentrate on the data
• Focus on facts
• Acknowledge their emotions
• Take ownership and solve the problem

Don’t Say Say


I don’t know Let me find out for you
I’m new here Although I’m new, I’ll get someone to help
you.
I just got here How may I help you
We do not have it. If we do not have it I will order it or try to
find it.
I’m not sure if I can help you. If I can’t help you, I know who can or if I
can’t help you I’ll find the right person.
I don’t think I can do that. I’ll do whatever it takes.
Your refund will take about six weeks. I’ll personally handle your refund to get it
when you need it.
The doctor will be right with you. Dr. W. is looking forward to seeing you in
about 15 minutes.
There is nothing I can do about it, it’s the Our policy is written to protect your
Company policy. privacy and safety, but here is what I can
do.
I don’t have anything to do with your To solve the problem……..
problem.

Try to understand the other person.


• How do they feel?
• What did they say?
• What do they want to say?
Remember that people are more persuaded by your attitude than by logic.

Give customers what they want:


Special treatment
Choices
High quality care

Evaluate whether you are a good listener?


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• Do you let people finish what they are trying to say before you speak?
• If the person hesitates do you try to encourage him or her rather than start your reply?
• Do you withhold judgment about the person’s idea even if you do not like the person?
• Can you listen fully even though you think you know what he/she is about to say?
• Do you stop what you’re doing and give full attention when listening?
• Do you question the person to clarify his/her ideas more fully?
• Do you restate/paraphrase what’s said and ask if you got it right?

A good listener:
 Does not judge but listens for feelings and facts
 Pays attention to the content of the conversation
 Listens completely first because this often makes people feel valued
 Listens for the main idea
 Avoids getting off the subject
 Keeps good eye contact
 Listens carefully, gives feedback, and asks for confirmation that they have understood the
situation correctly
 Makes positive statements
 Maintains patience while listening
When on the phone with a customer avoids:
o Arguing
o Rationalizing
o Defending
o Complaining
o Reacting
o Emotionalizing
o Promising
o Insuring
Explain how the customer can complain further:
Give a phone number and a name
Avoid using irritating words, including:
Can’t
Can’t help you
You should have
All we can do
It is company policy
You have to
Instead, ask what they want:
• What would you like for us to do?
• What will work best for you?
Be courteous and caring:
• Let me take care of that for you
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• Would you like to use our telephone?


• Please forgive me, but I must ask again
Take responsibility:
• Give me a few minutes/days/week and I’ll get to the bottom of this.
• I apologize for that misinformation, here’s what I can do
• Our hands are tied by law, but here’s what I can do
How to say no or explain policy:
• Empathize with the customer- I understand how you feel.
• Acknowledge emotions- I see/hear how concerned and upset you are
• Suggest alternative- tell what you can do
• Decline with reason- explain safety/privacy/etc.
• Use self-disclosure-I have felt like that too
• Ask open-ended questions-How will that work for you?
• Use the broken record technique-repeat what you’ve said
Remember Our Customers Are:
The most important people who will ever be in the Surgical Center
VIP’s who call on the phone
Not interruptions of our work but are the reasons why we have work
Individuals with names and feelings
Not people you should argue with
The reasons we all have jobs
Not always right, but they are always the customer.

Reference: 1995, Fred Pryor Seminars, “How to Deliver Exceptional Customer Service.”

RISK MANAGEMENT/PATIENT SAFETY:


NEW HORIZON SURGICAL CENTER LLC

The Center promotes patient safety through the recognition and acknowledgement of risks to
patients, visitors and staff safety and the initiation of actions to reduce these risks. The Center
recognizes that the need for improvement is rarely the fault of an individual; therefore our
improvement activity focuses on the processes and systems of care and services that may be
changed to provide high quality of care in the safest environment.

At the Center all individuals are responsible for providing the highest quality of care and services
and maintaining a safe environment. Each individual that provides care in the Center must be
active in identifying all quality and safety concerns or ideas for improvement to the Director of
Nursing or designee. You will be asked to participate in specific improvement activities in the
Center to make every effort to ensure quality of care continues to be provided in the Center.

Electrical Safety:

Everyone needs to understand the hazards of electricity and to follow safety precautions.
Unsafe use of electricity can cause fire explosion, shock, and burns. This can result in injury,
disability, and death.
All electrical equipment used for patient care in the Center must be inspected by the biomedical
department before it is used in the Center.

Electrical Safety Tips:

Always grasp the plug, not the cord when removing it from a socket.
Keep all electrical lights and equipment clean and free of dust, paper or anything that could
possibly start a fire.
Check all cords for fraying and loss of insulation.
Do not use extension cords.
All electrical devices should be properly grounded with 3-prong plugs.
Avoid sparks in oxygen-rich environments as oxygen supports combustion.
Do not handle electrical equipment with wet hands. Never touch an electrical device and
plumbing at the same time.
Disconnect any electrical device that sparks, smokes, smells, stalls, blows a fuse or gives you a
shock.
Remove defective electrical devices from circulation and report it to the biomedical technician
immediately.
In a case of electrical shock, Do not touch the person, equipment or wire causing the shock
hazard. This could result in a shock to you. First, turn off the current from the main source.

Medical Gas Safety:

All gas cylinders are color coded when they arrive to the Center. Green is oxygen, yellow is air,
black is nitrogen, gray is CO2, and blue is nitrous oxide.
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Never interchange regulators that are not intended for use with that specific gas or gas blend.
Do not attempt to modify or repair cylinders.
Always store cylinders in an upright position in a cylinder container or chained to the wall. If no
cylinder container is available, the cylinder may be placed lengthwise on the floor. Open valves
on cylinders or regulators slowly. Cylinder valves should remain in the closed position when not
in actual operation. Know your job responsibilities for working with medical gases. The Medical
Gas room is used for storage of all large supply tanks. It is kept locked at all times. The Director
of Nursing or designee will be responsible for switching over all main supply tanks. You are
responsible for reporting any alarms on the medical gas alarm panel immediately to the Director
of Nursing or designee. Knowing the location of all shut off valves in the Center is your
responsibility. Shut off valves are only used with prior authorization of the Director of Nursing or
designee.

Reporting and Treatment of Work-related injuries:

Report all work-related injuries to your supervisor immediately.


The Manager/Supervisor and employee must complete an incident form.
In the case of a needle-stick or other sharps injury, this will also be logged in on the sharps injury
log form and on the OSHA log form. If there is a work-related injury that requires immediate
attention the employee is to report to the hospital emergency room for care.
The infectious disease specialist is available for all follow-up care regarding sharps injuries or
blood borne pathogens.
See employee handbook for further details.

Patient Safety:
Patient safety is everyone’s responsibility. Ways to keep patients safe includes:

• Verifying a patient’s identity at least two ways, (i.e. name and birthdate or name and
medical record number) before going ahead with any interaction.
• Washing hands between each patient encounter to prevent the spread of infection.
• Reporting abnormal lab values to an appropriate person.
• Repeating any verbal orders back to the prescriber to ensure the communication was
accurate.
• Reporting any environmental hazard immediately to the person in charge.
• Knowing what to do in an emergency.

Unexpected Outcomes:
Unexpected outcomes and events can result in the patient, employee or visitor being injured,
damaged equipment, loss of time at work and expense to the Center. Whenever an event occurs
that is in any way out of the norm it is important to report the occurrence so that the Center can
learn from it and prevent it from happening again. In order to facilitate this, the Center has a
reporting system of such occurrences. Everyone is accountable to report these unexpected events.
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If you are a State licensed center, serious preventable adverse events need to be reported by
calling 609-633-7759. See Revised Mandatory Patient Safety Reporting Requirement
Booklet for specific guidelines/definitions.

A confidential incident report must be completed whenever there is a patient or visitor occurrence
that is not consistent with the accepted routine of the Center which either did or could have
resulted in injury or loss to a patient/visitor or which might otherwise give rise to a claim against
the Center, employee of the Center or a member of the staff. Individuals discovering an incident
must initiate, process and deliver an incident report to the Director of Risk Management within 24
hours of the occurrence, if a patient/visitor should have an incident, which is not witnessed by an
employee, the person who is notified of the incident should complete the incident report.
Serious preventable adverse events need to be reported via faxing a completed form to 609-
984-7707 within 5 business days after the facility discovers the occurrence of the event.
“Reported” means completion of the event form and receipt of the form by Patient Safety
Initiative. Fax confirmation will be sent upon receipt.

Medication Occurrence Report:


An incident report must be completed for every variation in the medication system. This
is given to the Director of Nursing or designee. All variations in the medication process are to be
reported even if the variation was caught and corrected before it reached the patient.
You may contact the Consultant Pharmacist if you have any questions regarding a medication
occurrence.
If you are State licensed center, this may a reportable event. See Revised Mandatory Patient
Safety Reporting Requirements Booklet for specific guidelines/definitions.

Report of Employee injury


An incident report of an employee injury must be completed and sent to the Director of Nursing
or designee. This immediate report is important to ensure timely and appropriate treatment of the
employee injured and to address the safety concerns that contributed to the injury so that no other
person is placed at risk.
Contact the Director of Nursing if you have any questions regarding an employee injury or
illness.

Always remember that the purpose of reporting is to determine facts- not fault.

Loss of Electrical Power


All life-sustaining equipment should be plugged into the emergency outlets (red covers) at all
times.
Emergency power will be restored within 10 seconds of interruption in all patient areas.
During regular business hours, contact the Director of Nursing.

Lock Out/Tag Out


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Be aware that an encounter with a lock or tag on an electrical switch or device indicates the
equipment is “out of service” and should not be used. Only the authorized person who affixed the
lock or tag may remove it.

Medical Device Reporting:


To comply with the Safe Medical Devices act of 1990, this Center shall report any failure in
Medical Devices.

Procedure:
It is part of the Center’s policy to provide continuous ongoing monitoring and evaluation of all
medical devices and equipment utilized in patient care.
Any mechanical electrical device utilized by this Center that results in death, serious injury, or
illness to any individual shall be reported to the manufacturer of said device if known and Food
and drug Administration FDA
Depending on the severity of the event, immediate telephone (or fax) contact will be made with
the manufacturer and the FDA
In all cases, written, detailed documentation shall be prepared by the Center and submitted to the
manufacturer and the FDA
Summaries from incident reports and medical records shall be provided as appropriate.
When possible and appropriate pictures shall be taken of the event

Hazardous Materials:

Healthcare workers use chemical substances every day. Some chemicals may be life-saving (such
as pharmaceuticals), but other s may put you and your co-workers at risk.

KNOW THE RISKS

Hazardous Substances include:


• Compressed gases.
• Anesthesia gases
• Cleaning and sterilizing agents
• Hazardous drugs
• Radioactive materials
• Infectious substances
You can reduce the risk of injury due to hazardous material by:
Reading all the warning labels:
Every chemical or hazardous material that is used in the Center must have a warning label. Read
the label and follow the directions.

Knowing where to find Material Safety Data Sheets:


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Material Safety Data Sheets (MSDS) provides detailed information on chemicals and their
hazards, and what to do in case of a spill or injury. There is a MSDS book located at the Nurse’s
Station that includes all of the chemicals stored and used. These chemicals are in alphabetical
order and also are divided in alphabetical order by location.

Using Personal Protective Equipment:


Protect yourself when working with chemical or hazardous materials by using safe work practices
and by wearing personal protective equipment (PPE). PPE includes gloves, gowns, masks and
goggles. Know the correct method of applying and removing PPE to prevent contamination to
you or to the environment. Dispose of sharps in the provided sharps containers. Dispose of
infectious waste in the red trash bins.

Reporting all unsafe conditions:


Report all unsafe conditions to the Administrator/Director of Nursing or designee.

Participating in all safety inservices


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EMERGENCY PREPAREDNESS:

In the event of an internal or external disaster the Center has a plan of action to follow.
The Policies are located in the Emergency section of the Policy and Procedure Manual.

Internal Disaster is an unexpected occurrence within or immediately outside of the Center which
would render the Center unstable or unsafe for patient care.

External Disaster is a situation which occurs out in the community and involves the Center
receiving causalities.

The Code for Disaster is “Disaster Plan is in effect”. When this code is called you should report
to the Director of Nursing or designee for specific instructions.

The Administrator/Director of Nursing or designee is responsible for the overall direction of the
Center in case of a disaster.

Codes used in the Center:

CODE “B” Bomb Threat

Any employee who receives a telephone bomb threat should immediately call the
Administrator/Director or Nursing or designee who will contact the Police Department with the
specific details concerning the threat. If you receive the call you should report everything
possible about the call, tone of voice of the caller, time and location of the explosive device. See
the Policy on Bomb Threat located in the Emergency section of the Policy and Procedure Manual
for more information.

Hit intercom 32*


and Call Code “B” overhead and the location X 3
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Refer to the Policy on Code “B” in the Emergency section of the Policy and Procedure Manual
for further instructions.

CODE BLUE

An emergency situation in which an individual in the Center stops breathing and or has no
palpable pulse.

Hit intercom 32* and announce CODE BLUE and give your location 3 times.

If you are the first person on the scene:


Do not leave the person alone
Call out for assistance or use the nearest telephone to initiate the Code Blue
If you are trained in CPR start CPR

Refer to the Policy on Code Blue located in the Emergency section of the Policy and Procedure
Manual for further instructions.

CODE “5”

This is an emergency situation in which assistance is needed to control the behavior of someone
who is endangering themselves or others.

Hit intercom 32*


and Call Code “5” overhead and the location X 3

Refer to the Policy on Code “5” in the Emergency section of the Policy and Procedure Manual for
further instructions.

CODE “DISASTER DRILL IS IN EFFECT”

This is an emergency situation in which assistance is needed either internally due to an internal
disaster in the Center or for an external emergency in which assistance may be needed to care for
individuals who have been injured in the Community.

Hit intercom 32*


and Call Code “DISASTER DRILL IS IN EFFECT” overhead and the location X 3

Refer to the Policies on “DISASTER” in the Emergency section of the Policy and Procedure
Manual for further instructions.

CODE “T”

This is an emergency situation in which there is a Tornado.


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Hit intercom 32*


and Call Code “T” overhead and the location X 3

Refer to the Policy on Code “T” in the Emergency section of the Policy and Procedure Manual for
further instructions.

CODE “H”

This is an emergency situation in which there is a Hurricane.


Hit intercom 32*
and Call Code “H” overhead and the location X 3

Refer to the Policy on Code “H” in the Emergency section of the Policy and Procedure Manual
for further instructions.

FIRE SAFETY:

Fire safety is an important part of your job. Fire is a serious threat to health care facilities. All
employees must know how to respond appropriately if a fire occurs.

Four causes of fires are faulty electrical equipment, pressurized oxygen, flammable liquids and
gases and smoking. The Center has a no smoking policy. Smoking within the facility or by any
of the entrance areas will result in disciplinary action or termination.

How to report a fire:

Activate the nearest pull station located at the entrance or exit doors of the building
Hit intercom 32* and call the code overhead X 3 “Code Red” and the location of the fire.
Example:
“Code Red Soiled Utility Room O.R. Corridor”
“Code Red Soiled Utility Room O.R. Corridor”
“Code Red Soiled Utility Room O.R. Corridor”

Participate in all fire drills held at least quarterly in the Center.


Know the location of fire extinguishers, fire alarm boxes (pull stations), oxygen shut-off
valves, and fire exits.
Know how to use the fire alarm boxes and fire extinguishers.
Know how to shut-off oxygen and other piped gases.
Know evacuation routes
Keep all fire doors closed and clear of any equipment.

Responding to a Fire emergency


NEW HORIZON SURGICAL CENTER LLC

R=Rescue anyone in immediate danger.


A=Activate the alarm
C=Contain the fire by shutting the doors.
E=Extinguish, only if it can be done safely

Use of the Fire Extinguisher

P=Pull the pin.


A= aim at the base of the fire
S=Squeeze the handle
S=Sweep from side to side.

How to Activate the Fire Alarms:


Go to the nearest fire pull box. Pull the handle down until you hear a click. Leave the pull handle
in the down position. Pulling the handle automatically notifies the Fire Department that there is a
possible fire. It is essential that the alarm is activated even in a drill. If a drill is performed the
Director or Designee will inform the Fire alarm Company before the alarm is pulled that a drill is
being performed. Include documentation on the Drill Report confirming receipt of the signal by
the Central Station.

Types of Extinguishers:

ABC Fire extinguishers are available in the Center. They are used on all types of fires.

If the threat of a real fire exists, a plan for the evacuation of patients must be initiated.
The evacuation policy is located in the Policy and Procedure Manual.

Never use elevators during a Fire


Never close the main oxygen valves unless you have received direct authorization form the
Administrator/Director of Nursing or designee or the Fire Chief.
Never open a door that feels warm or hot.
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ANNUAL HANDS ON FIRE EXTINGUISHER INSERVICE


NEW HORIZON SURGICAL CENTER LLC

POLICY: FIRE ALARM PULLS:


Purpose: To ensure that fire alarm pulls are functioning in the Center.

Procedure:

The Fire drills will be performed in the Center quarterly.


The alarm pulls will be sounded when the fire drill takes place, at least quarterly.
The fire department and the security company will be notified prior to starting the drill.
A fire drill report will be written and placed in the facility log. Documentation shall include
receipt of the alarm by the Central Station.
The Administrator/Director of Nursing will be responsible for reviewing all drills and ensuring
that staff members are performing appropriately.

If a fire alarm or sprinkler system is out of service for more than 4 hours, the fire authority is
notified and the building is evacuated, or an approved fire watch is established until the system is
brought back into service.

The Fire Alarm and Sprinkler systems are serviced and tested twice a year.
NEW HORIZON SURGICAL CENTER LLC

BIOTERRORISM:
When dealing with an act of bioterrorism the Disaster Plan will be put into effect. The
Evacuation Plan will be used if the act of bioterrorism is internal. If the act of bioterrorism is
external the Community Disaster Plan will be activated. It will be the responsibility of the
Director of Nursing or designee to contact proper authorities. This will be done to ensure that all
necessary actions are taken and to ensure that the building is deemed safe prior to re-entering the
facility.
First Call 911
Police will dispatch a police officer who will direct all further proceedings

In today’s society it is important to be prepared to respond to the potential of both a chemical


and/or biological act of terrorism.

CHEMICAL AGENTS: There are many chemical agents including Sarin, VX, Mustard gas,
Lewsite, CX (Phsogeneoxime) and Cyanide. A massive dose or close contact to the proximity in
which it is released will cause a very sudden and overwhelming reaction. Those who have a
minimal exposure will need treatment.
Most chemical agents will require some sort of decontamination. A person in contact with the
chemical agent may be required to just remove and bag their clothing. There might be cases
where complete decontamination will take place and require the use of personal protective
equipment by the Center staff. A specialized suit called a Tyvek suit, boots, gloves and a self-
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contained breathing apparatus PAPR will be used. It is necessary to be trained in the use of this
equipment. The Office of Emergency Management will instruct the Center on needed
decontamination.
BIOLOGICAL AGENTS
Anthrax is caused by a spore forming bacterium called Bacillus anthracis. It may occur in three
forms, cutaneous, inhalation and gastrointestinal. Person to person transmission is rare. Standard
precautions should be used. Disinfect surfaces with bleach and water 1:10 fresh dilution.

Plague is a bacterial infectious disease caused by Yersinia pestis. There are two types of plague:
bubonic and pneumonic. An intentional aerosol dissemination of Yersina pestis would produce
an outbreak of primary pneumonic plague. The incubation period is 1-4 days. Patient should be
placed on Droplet precautions. If the patient needs to be transported with in the Center a mask
will be applied to that patient.

Smallpox is caused by the variola virus. Skin lesions appear on the face and extremities
including palms of the hands and soles of the feet. It differs from chickenpox in that skin lesions
appear simultaneously all over the body. In chickenpox the skin lesions appear in waves of
vesicles.
Smallpox is transmitted by both airborne droplets and contact. Patients should be placed in a
negative pressure room (TB isolation rooms or use of HEPA filter). Disposable gowns and
gloves as well as a N95 respirator mask must be used. All personal protective equipment (PPE)
must be removed before leaving the patients room. Hands must be washed with either soap and
water or waterless soap. The small pox vaccine is the only known protection against smallpox.
Those caring for a smallpox patient should have been previously vaccinated and have a scar at the
vaccination site.

EVACUATION PROCEDURES:

Horizontal Evacuation:
Removing patients to a safe area on the same floor. Patients can be moved laterally by wheel
stretcher bed, non-wheeled stretcher, wheelchair, blanket or other conveyance to the nearest and
safest protected area on the same floor. Patients in immediate danger will be moved first,
including those who might be separated from safety if the danger should enter the area.
Ambulatory patients will move next to a safe area. Rooms will be searched for stragglers and all
doors closed when the rooms are vacated. A patient count should be made to insure that all
patients are accounted for.

Vertical Evacuation:
Removing patients to a safe area on a lower floor. Vertical evacuation or downward movement of
patients to a safe area on the floor below or out of the building may be necessary should danger
spread out of control. Ambulatory patients shall be instructed to line up outside the suite and
form a chain by holding hands and following a lead monitor. The monitor will lead ambulatory
patients to a safe area, stairway or exit. Non-ambulatory patients will be moved using the “carry
method” to a safe area.
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Under no circumstances will wheelchairs, stretcher or other wheeled transportation be used on a


vertical evacuation. Patients in the Operating Room will be handled according to the instructions
given by the attending physician.

Safety Precautions during evacuation

When traveling through smoke, keep low. Smoke and heat rises. Crawl along the floor if you
must, but remain low.
Do not run, or let anyone run in smoke filled areas.
When going through smoke, cover the patients face, as well as your own from the nose down.
Should evacuation be necessary through fire or extremely hot areas cover the patient with a wet
blanket.
Do not touch anything. Watch for falling debris, wires, etc.
Do not open a door into an area where a suspected fire might be. Even if the door is not warm, do
the following before opening the door. Should a fire be on the other side this will aid you in
closing the door instead of letting the fire blast through.

Brace your shoulder against the door.


Brace your foot against the base of the door
Place one hand on the doorknob.
Place one hand along the door opening about head level
Open the door slowly.
Make sure your face is turned away from the crack.
If smoke sweeps through, close the door immediately.
Place a blanket under the door to prevent smoke from entering the room.
Choose the safest way out.
Once you are out, do not let anyone return.
Remain calm. Do not panic. Follow all instructions issued.

Exit/Assembly Areas:

A primary and secondary area has been established and must be used as instructed.
Primary is the front exit and assembly in the parking lot .
Secondary is the back exit and parking lot.
See the Emergency Section of the Policy and Procedure Manual for further details.
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Review Evacuation Policy in the Policy and Procedure Manual

ANNUAL FIRE DRILL


ANNUAL DISASTER DRILL
ANNUAL BIOTERRORISM DRILL
ANNUAL MH DRILL
ANNUAL CODE DRILL
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POLICY: ADVANCE NOTICE REQUIREMENTS

According to 2009 State and Federal Requirements, patients have the right to receive information
on specific topics prior to the date of the procedure.
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PROCEDURE:

The following information will be provided to the patient:

A. Advance Medical Directive: The patient will be asked if he/she has an Advance
Medical Directive in effect that the Center should be aware of. The status of such
Advance Medical Directives shall be noted in a prominent place in the patient's
chart. The patient will be advised that the Center does not acknowledge Advance
Medical Directives. If the patient wishes to have Advance Medical Directives
acknowledged, the Center will assist the patient in finding a hospital that will be
able to provide the patient care.

B. Patients’ Rights and Responsibilities: The patient will receive a copy of the
Patient Bill of Rights and Responsibilities. This document will also be posted at
the Center in the Waiting Room and Holding/Pre-Op area.

C. Ownership/Out Of Network Election: consistent with the provisions of Section 3


of P.L. 1989, c. 19 (C. 45:9-22.6) Public law states that a physician is required to
inform patients of any significant beneficial interest in any healthcare services to
which patients are referred. The patient will be advised in writing of ownership
interest as well as whether any services or facility fees associated with the
provided services will be considered to be, and reimbursed at, out of network level
by the patient’s insurance carrier or other third party payer.

D. Exemption from Notification Requirement: Federal Conditions (CMS) are


allowing 2 exemptions from the notification requirement:

The procedure is scheduled the same day it is to be performed and

The referring physician indicates in writing that it is medically necessary


for the patient to have the surgery on the same day, and that surgery in
an ASC setting is suitable for the patient.

In such situations the ASC must provide the required notice prior to
obtaining the patient’s informed consent.
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POLICY: PATIENT RIGHTS AND RESPONSIBILITIES

All patients and staff shall be informed of and follow Patient Rights policies.

OBJECTIVE

To make every effort to ensure considerate and appropriate care with the patient's complete
understanding and cooperation.

PROCEDURE

A copy of the Patient Rights and Responsibilities:

Is provided to the patient or patient’s representative with verbal and written


notice of the patient’s rights, in advance of the date of the procedure, in a
language and manner that the patient or the patient’s representative
understands, unless the referral to the ambulatory surgical center for surgery
is made on that same date; and the referring physician indicates, in writing,
that it is medically necessary for the patient to have the surgery on the same
day, and that surgery in an ambulatory surgical center setting is suitable for
that patient. In such situations the ASC must provide the required notice
prior to obtaining the patient’s informed consent.

Is posted in a conspicuous place in the Surgical Center. (The waiting room and Holding/
Pre-op area.)

All staff shall:

Be oriented to Patient Rights annually and as part of orientation.


Apply and follow the Patient Rights.

In addition to this:

A sign will be posted regarding the address to file complaints about the
Center.

Any patient information brochures will contain information regarding the


complaint procedure.
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A complaint box will be placed in the waiting room for individuals to file
complaints.

Patient surveys will be placed beside the complaint box in order to facilitate the
filing of any positive or negative comments regarding the Center.
A complaint log will be kept in the Center to make every effort to ensure complaints are
investigated and addressed.

POLICY: PATIENTS’ RIGHTS


Patients at the Center have the following rights by state and Federal law and regulations. It is the responsibility of all employees to
ensure that the patients’ rights are complied with.
Patients are given a copy of the patients’rights.
The Patient’s rights are also posted in the Waiting and Holding Areas in the Center.

The patient or his/her representative, if applicable, has the right to:


o Be informed of these rights, as evidenced by the patient’s written acknowledgement, or
by documentation by staff in the medical record that the patient was offered a written
copy of these rights and given a written or verbal explanation of these rights, in terms
the patient or the patient representative could understand, in advance of the date of
the procedure, unless the referral to the ambulatory surgical center for surgery is made
on that same date; and the referring physician indicates, in writing, that it is medically
necessary for the patient to have the surgery on the same day, and that surgery in an
ambulatory surgical center setting is suitable for that patient. In such situations the
ambulatory surgical center must provide the required notice prior to obtaining the
patient’s informed consent.
o The Center must protect and promote the exercise of such rights. The facility shall have
a means to notify patients of any rules and regulations it has adopted governing patient
conduct in the facility;
o Be informed, where applicable, of physician financial interests or ownership in the
ambulatory surgical center facility. Disclosure of information must be in writing and
furnished to the patient in advance of the date of the procedure, unless the referral to
the ambulatory surgical center for surgery is made on that same date; and the referring
physician indicates, in writing, that it is medically necessary for the patient to have the
surgery on the same day, and that surgery in an ambulatory surgical center setting is
suitable for that patient. In such situations the ambulatory surgical center must provide
the required notice prior to obtaining the patient’s informed consent.
o Be provided, in advance of the date of the procedure with information concerning its
policies on advance directives, including a description of applicable State health and
safety laws, and if requested, official State Advance Directive forms, unless the referral
to the ambulatory surgical center for surgery is made on that same date; and the
referring physician indicates, in writing, that it is medically necessary for the patient to
have the surgery on the same day, and that surgery in an ambulatory surgical center
setting is suitable for that patient. In such situations the ambulatory surgical center
must provide the required notice prior to obtaining the patient’s informed consent.
o Documentation in a prominent part of the patient’s current medical record, whether or
not the individual has executed an advance directive.
o Be informed of services available in the facility, of the names and professional status of
the personnel providing and/or responsible for the patient’s care, and of fees and
related charges, including the payment, fee, deposit, and refund policy of the facility
and any charges for services not covered by sources of third-party payment or not
covered by the facility’s basic rate;
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o Be informed if the facility has authorized other health care and educational institutions
to participate in the patient’s treatment. The patient also shall have a right to know the
identity and function of these institutions, and to refuse to allow their participation in
the patient’s treatment and to change physicians if he or she so wishes;
o Receive from the patient’s physician(s) or clinical practitioner(s), in terms that the
patient understands, an explanation of his or her complete medical/health condition or
diagnosis, recommended treatment, treatment options, including the option of no
treatment, risk(s) of treatment, and expected result(s)/outcome(s). This shall occur
prior to any treatment being performed. If this information would be detrimental to the
patient’s health, or if the patient is not capable of understanding the information, the
explanation shall be provided to the patient’s next of kin or guardian. This release of
information to the next of kin or guardian, along with the reason for not informing the
patient directly, shall be documented in the patient’s medical record;
o Receive as soon as possible, the services of a translator or interpreter if you need one
to help you communicate with the Center’s health care personnel free of charge;
o Make informed decisions regarding care.
o Participate in the planning of the patient’s care and treatment, and to refuse medication
and treatment. Such refusal shall be documented in the patient’s medical record;
o Change primary or specialty physicians if other qualified physicians are available.
o Continuity of health care. The physician may not discontinue treatment of a patient as
long as further treatment is medically indicated, without giving the patient sufficient
opportunity to make alternative arrangements;
o Be included in experimental research only when the patient gives informed, written
consent to such participation, or when a guardian gives such consent for an
incompetent patient in accordance with law, rule and regulation. The patient may
refuse to participate in experimental research, including the investigation of new drugs
and medical devices;
o Voice grievances or recommend changes in policies and services to facility personnel,
the governing authority and /or outside representatives of the patient’s choice either
individually or as a group, and free from restraint, interference, coercion, discrimination,
or reprisal;
o Use the grievance procedure to document the existence, submission, investigation, and
disposition of a written or verbal grievance to the Center.
o Documentation by the Center of all alleged violation/grievances relating, but not limited
to, mistreatment, neglect, verbal, mental, sexual, or physical abuse.
o Have all allegations reported to the person in authority of the Center.
o Have substantiated allegations reported to the state authority or the local authority, or
both.
o Be provided with timeframes for review of the grievance and the provisions of a
response.
o Voice grievances and to investigation of all grievances made regarding treatment or
care that is (or fails to be) furnished.
o Written notice of the Centers decision which must contain the name of a facility contact
person, the steps taken to investigate the grievance, the results of the grievance
process, and the date the grievance process was completed.
o Exercise his/her rights without being subjected to discrimination or reprisal.
o Be fully informed about a treatment or procedure and the expected outcome before it is
performed.
o Have the person appointed under State law to act on the patient’s behalf if the patient
is adjudged incompetent under applicable State health and safety laws by a court of
proper jurisdiction
o Be free from mental and physical abuse, free from exploitation, and free from use of
restraints unless they are authorized by a physician for a limited period of time to
protect the patient or others from injury. Drugs and other medications shall not be
used for discipline of patients or for convenience of facility personnel;
o Appropriate assessment and management of pain. To education, including education
for the patient’s significant others (if applicable), regarding pain and symptom
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management in the discharge planning process; To expect and receive appropriate


assessment, management and treatment of pain as an integral component of that
person’s care .
o Information regarding credentials of healthcare professionals;
o Confidential treatment of information about the patient. Information in the patient’s
medical record shall not be released to anyone outside the facility without the patient’s
approval, unless another health care facility to which the patient was transferred
requires the information, or unless the release of the information is required and
permitted by law, a third-party payment contract, or a peer review, or unless the
information is needed by the New Jersey State Department of Health for statutorily
authorized purposes. The facility may release data about the patient for studies
containing aggregated statistics when the patient’s identity is masked;
o Be treated with courtesy, consideration, respect, and recognition of the patient’s
dignity, individuality, and right to privacy, including, but not limited to, auditory and
visual privacy. The patient’s privacy shall also be respected when facility personnel
are discussing the patient;
o Privacy and security of individually identifiable health information;
o Receive care in a safe setting and be free from all forms of abuse or harassment.
o Not be required to perform work for the facility unless the work is part of the patient’s
treatment and is performed voluntarily by the patient. Such work shall be in
accordance with local, State, and Federal laws and rules;
o Exercise civil and religious liberties, including the right to independent personal
decisions. No religious beliefs or practices, or any attendance at religious services, shall
be imposed upon any patient; and
o Not be discriminated against because of age, race, religion, sex, nationality, or ability to
pay, or deprived of any constitutional, civil, and or legal rights solely because of
receiving services from the facility.
o Have his/her rights exercised by the person appointed under State law to act on the
patient’s behalf.
if a patient is adjudged incompetent under applicable State health and safety laws by a
court of proper jurisdiction. If a State court has not adjudged a patient
incompetent, any legal representative designated by the patient in accordance with
State law may exercise the patient’s rights to the extent allowed by State law.

o The administrator shall provide all patients and/or their families upon request with the
names, addresses, and telephone numbers of the following offices where complaints
may be lodged:
The Office of Acute Care Assessment and Survey
Division of Health Facilities Evaluation and Licensing
New Jersey State Department of Health
PO Box 358
Trenton, New Jersey 08625-0358
Telephone: (800) 792-9770 (609) 292-9900
State of New Jersey
Office of the Ombudsman for the Institutionalized Elderly
PO Box 852
Trenton, New Jersey 08625- 0852
Telephone 1-877-582-6995
www.cms.hhs.gov/center/ombudsman.asp
The Administrator shall also provide all patients and or families upon request with the names and telephone numbers of offices
where information concerning Medicare and Medicaid coverage may be obtained.
Addresses and telephone numbers shall be conspicuously posted throughout the facility, including, but not limited to, the
admissions waiting area or room, the patient service area of the business, office and other public areas. The Center needs the
cooperation of its patients to ensure that efficient, safe and considerate care is available to all patients.
Patients are responsible for:
a. Providing physicians, center personnel and healthcare providers
with complete and accurate information about their medical
history and complete and accurate information related to their
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condition and care.


b. Informing healthcare providers about all the medications they
are taking as well as over-the counter products, herbal
remedies, and dietary supplements.
c. Adhering to the treatment plans recommended by their doctors.
d. Arranging for a responsible adult to take them home and remain
with them for 24 hours if required by their physician.
e. Telling his/her doctor about any living will, power of attorney, or
other advanced directives.
f. Being respectful of healthcare professionals, staff members, and
other patients.
g. Being responsible for medical consequences, which result from
refusing treatment or not following instructions of physicians
and surgery center personnel.
h. Being considerate of the Center’s staff that is committed to
excellence in patient care.
i. Supplying insurance information and paying bills promptly so
that the Center can continue to serve its patients effectively.
Agreeing to pay any expenses not covered by his/her insurance.

POLICY: NON-DISCRIMINATION/COMMUNICATION WITH SENSORY IMPAIRED


PATIENTS
It is the policy of the Center to provide services to all persons regardless of: race; creed; color;
ethnic origin; nationality; sex; handicap; age; affiliation with fraternal or religious organizations;
or cultural, economic, or educational background.

All services provided by the Center are available without distinction to all patients and visitors
regardless of race; creed; color; ethnic origin; nationality; sex; handicap; age; affiliation with
fraternal or religious organizations; cultural, economic, or educational background; or source of
payment for care.
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In addition, to all persons and organizations having occasion either to refer persons for services or
recommend the Center are advised to do so without regard to: race; creed; color; ethnic origin;
nationality; sex; handicap; age; affiliation with fraternal or religious organizations; cultural,
economic, or education background; or source of payment for care.

The Center will provide qualified sign language interpreters and other auxiliary aids to sensory
impaired persons and translators for individuals whose primary means of communication is not
the English language.

It is the responsibility of the attending surgeon to notify the Center in advance that a sensory
impaired or non-English speaking person has been scheduled for surgery and will require this
type of service so that arrangements can be secured.

Such interpreters and auxiliary aids will be made available at no cost to the patient.

RESPONSIBILITY:
The Administrator/Director of Nursing is designated to coordinate compliance with Title IX of
the Educational Amendments of 1972, Section 504 of the Rehabilitation ACT of 1973 (non-
discrimination against the handicapped), Title VI of the Civil Rights Act of 1964, and the Age
Discrimination Act of 1975.
PROCEDURES:
A. All new personnel are to be instructed to review this policy as part of their general
employee orientation.
B. When the facility is notified that a patient will require an interpreter and/or
auxiliary aids, the Nursing Director/Administrator will be notified so that
appropriate arrangements can be made with an outside source or a family member.
C. If a member of the patient’s family is available and willing to provide these
services for the patient, he/she will be permitted to do so, with the patients consent.
D. The admitting nurse will document on the consent form the interpreter’s name, and
if applicable, the type of auxiliary aids used.
E. An appropriate copy of this policy will be conspicuously posted in the Center.
F. This policy shall apply to all employment opportunities, Professional Staff
applications, patients, visitors, and Board of Director Memberships.
If an interpreter is not available on site, the ATT Language Line will be utilized to
communicate with the patient. The number is: 1-800-528-5888.
New Jersey Relay Service (NJRS) will be utilized to communicate with hearing impaired
patients. The number is 800-852-7897. 711 may also be dialed from most phones in New
Jersey.

CONFIDENTIALITY:

Patient confidentiality is making sure that you keep the information about the patients’ health care
private.
Confidentiality protects patients from embarrassment, disclosure of information to the wrong
people and discrimination. It also safeguards your patient’s right of privacy.

Confidential information includes information about a patient’s health and treatments.


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Examples include:
Details about their illness or condition
Information about treatments
Photographs or videos of a patient
Conversations between a patient and a health care provider
Patient information on a computer

You can protect patient confidentiality by:


Obtaining authorization form the patient before sharing medical information with any
unauthorized person or agency.
Obtaining the patients permission in writing.
Protecting all patient records by not leaving charts and flow sheets where unauthorized people
can see it.
Not talking about patients in public.
Using telephones and Faxes carefully and using faxes only when necessary.
An unauthorized person is someone who has no need to know. The person who is not
providing patient care or does not need the information to do their job. When giving
information to a friend or family member you need to have the patient’s approval before you
give the information to anyone.

POLICY: ADVANCE MEDICAL DIRECTIVES

Patients have the right to develop an Advanced Medical Directive.

PROCEDURE:
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A. Prior to the procedure and at the time of registration, the patient will be asked if
he/she has an Advance Medical Directive in effect that the Center should be aware of.
Advance Medical Directives address such issues as living wills and durable powers of
attorney. Patients will be provided, in advance of the date of the procedure, information
concerning policies on advance directives, including a description of applicable State
health and safety laws, and if requested, official State Advance Directive forms, unless the
referral to the ambulatory surgical center for surgery is made on that same date; and the
referring physician indicates, in writing, that it is medically necessary for the patient to
have the surgery on the same day, and that surgery in an ambulatory surgical center setting
is suitable for that patient. In such situations the Center will provide the required notice
prior to obtaining the patient’s informed consent.
If the patient does not have an Advance Directive, he/she will be offered
information regarding an Advance Directive and may fill one out in the Center, if
he/she wishes.

B. The existence of such Advance Medical Directives shall be noted on the patient's
chart. The Center does not acknowledge Advance Medical Directives. If the patient
wishes to have Advance Medical Directives acknowledged, the Center will assist the
patient in finding a hospital that will be able to provide the patient care.

C. The Center Administration shall periodically monitor the legal status of Advance
Medical Directives with the Center's attorney and track State and
Federal Regulations as they are modified.

Note: The patient has the right to documentation in a prominent part of the
patient’s current medical record, whether or not he/she has executed an
advance directive.

AGE-SPECIFIC GROWTH AND DEVELOPMENT:


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All employees as members of the health care team must establish relationships with the patient
and/or family member or significant other and take into consideration the age and developmental
stage of the individual.

Infancy (Birth to 1 year)

May exhibit separation anxiety.


Having familiar toys, and holding the child like the parent/caregiver does will help.
Keep frightening objects out of view.
Speak quietly and soothingly
Be careful to keep small objects away from the infant since infants like to put everything in their
mouth.

Toddler (1-3 years)

Keep physical contact to a minimum


Give choices when appropriate that allows the child to be included in their care.
Use distraction techniques when possible.
Allow the parent to be present if possible.
Toddlers are energetic and curious and this may lead to unsafe exploring so be watchful.

Pre-school (3-6 years)


Approach calmly and slowly to establish trust.
Allow parents to be involved if they wish.
Ask the child to help and give choices when appropriate.
At this age basic motor skills and limited comprehension makes the child prone to injury. Do not
leave equipment or tools unattended with the patient. Place equipment out of reach and monitor
their environment closely.

School Age (7-12 years)


Maintain normal/familiar routine as much as possible.
School age children fear loss of control and failure to live up to expectations.
Request self-undressing and respect privacy.
This age group fears bodily injury and disfigurement. Also they are afraid of the unknown.
Explain all procedures and treatments in simple terms that are understandable to them. Do not
leave equipment or tools in the room with the patient. Allow the parent or significant other to
stay if the patient wishes.

Adolescents (12-18 years)

Involve them in decision making and planning.


Respect their privacy
Encourage questioning regarding fear, options and alternatives.
Communicate directly to the adolescent.
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Be honest and nonjudgmental.


Remember that adolescents are willing to take risks and underestimate the probability of the risk.
Establish limits and boundaries.

Young Adulthood (18-25 years)


Middle Adulthood (25-65 years)

Be Aware that:
The adult has a need to be valued and a productive member of society
The economic responsibilities of the adult may cause denial of illness and resistance to
compliance with treatment and the discharge plan.
There is a need to be active in all aspects of the decision–making related to their care.
Be honest with them.
Encourage them to ask questions about their care.
Be complimentary, encouraging and interested.
There is an increased risk of stress related illnesses. There is a desire for independence.

Older Adulthood (65+ years)

Recognize fear of loss for self, spouse and friends that will influence their response to treatment.
Encourage them to be independent in their activities as much as possible.
Speak clearly and slowly with direct eye contact.
Speak with respect and utilize language appropriate for an adult.
Do not treat the older adult like a child.
Speak directly to the patient regarding their care.
Facilitate safety in their environment.
Allow the patient to express his/her feelings of anger, frustration, powerlessness or anxiety.
These patients are vulnerable to injury due to slower decision-making and responses to stimuli
reduced visual and hearing acuity and reduced balance and equilibrium. Maintain lighting and
make sure hallways are clear of obstructions. Remove unnecessary equipment from treatment
areas and patient’s rooms. Keep noise to a minimum.
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POLICY: IMPAIRED/INCAPACITATED PHYSICIAN OR STAFF MEMBER

Policy: To safeguard patients welfare by ensuring mechanisms are in place to prevent


impaired personnel from treating patients and by ensuring a procedure is in place
to handle an emergency incapacitation of a physician or staff member.

Procedure:
1. Any physician/staff member suspected of drug/alcohol impairment is to be
reported to the Nursing Director or her designee immediately

2. The Nursing Director or her designee, after speaking with the person, may deem
him/her unfit to function in their required capacity.

3. The Nursing Director will immediately notify the Medical Director of the situation
if it involves another physician. The Medical Director will speak to the physician in
question. In the meantime, the Nursing Director has the authority to postpone the surgery
until the Medical Director speaks to the physician.

4. If the person in question is a center employee, the Nursing Director will not allow
the person to work. The employee will be sent home as an unpaid day off. Arrangements
will be made to get the employee home safely. An incident report will be written and
follow-up disciplinary action will proceed when the employee reports to work next.

5. In the event that surgery has begun and a physician becomes incapacitated, the
PACU nurse will take the physician to PACU and take charge of caring for him/her while
the Nursing Directors will notify the Medical Director and any Professional Staff Member
that can be reached, to the degree permitted by his/her license, to do everything possible to
save the patient’s life or prevent serious harm.

6. In the event that surgery has begun and a Center employee involved in the case
becomes incapacitated, the person will be taken to PACU for care while the Nursing
Director will complete the surgical procedure.
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POLICY: ADULT/ELDER/CHILD ABUSE/NEGLECT

Policy: To provide guidelines to aid in identifying victims of domestic violence, child or


elder abuse and to provide guidelines for reporting suspected abuse.

GUIDELINES FOR IDENTIFYING VICTIMS OF DOMESTIC VIOLENCE


It is often difficult for nursing staff to identify domestic violence victims. Battering is usually an
ongoing problem which escalates in frequency and severity. By the time the victim has injuries
serious enough to require medical treatment, violence may be a long-established pattern. Center
staff should suspect domestic violence if any of the following is observed:

1. Patient admits to physical abuse

2. Patient presents with unexplained bruises, lacerations, fractures, or multiple


injuries in various stages of healing. Common sites of injury in domestic violence victims
are face, head, chest, breasts, abdomen and genitalia. Pregnant victims typically show
injuries to the breasts, abdomen, and genitalia.

3. Nursing assessment reveals untreated old injuries.

4. Nursing assessment reveals injuries on area of body normally covered by


clothing.

5. Injuries consistent with burns, whip-like bruises, etc.

6. Complaints of chronic pain.

7. Psychiatric, alcohol or drug abuse history in-patient or spouse.

8. Previous suicide gestures or attempts.

9. Bruising or laceration of lips from forced feeding. Wide bruises across


mouth from being gagged.

10. Spotty alopecia due to pulling hair.

When abuse is suspected, many victims will confirm the diagnosis when question in a
direct, non-threatening, non-judgmental manner.

For Example:

Have you ever experience a relationship in which you were hit, punched, kicked,
threatened or hurt in anyway? Are you in such a relationship now?
You mentioned your partner uses drugs/alcohol. How does your partner act when
drinking or on drugs. Is he verbally abusive? Is he physically abusive?
You mentioned that your partner loses her temper with the children. How are
things between the two of you.
Your seem to have some special concern about your partner. Can you tell me
more? Are you fearful? Has he ever hurt you?
Do your verbal fights include physical contact?
Many patients tell me that they had an argument with a partner and later state they
were beaten. Could this be happening to you? Are you being beaten?
Sometimes when a partner is overprotective and is jealous as you describe, they
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react strongly and use physical force. Is this happening in your situation?
I notice you have a number of bruises. Could you tell me how they happened?
Did someone hit you?

GUIDELINES FOR IDENTIFYING VICTIMS OF ELDERLY ABUSE

Health professionals need to be alert for signs and symptoms of elderly abuse and/or
neglect and to be aware of situations that provoke these incidents so that appropriate intervention
can result. The elderly person may openly admit that they have been abused or neglected, but
more often they deny the situation due to pride or fear of retaliation, isolation, abandonment, or
institutionalization. A thorough assessment is essential to identify subtle characteristics that
might suggest abuse/neglect is occurring.

Elderly patients may be misdiagnosed as having organic brain syndrome or senile


confusion, but abuse may be the cause of alterations in mental status. Once removed from this
environment, a patient may return to a normal or near-normal state. A patient’s statements or
disorientation should not be ignored until the possibility of abuse is ruled out. There are four
major types of elderly abuse:

Physical abuse, which includes beating, burning, rough physical handling


and sexual abuse;

When abuse is suspected, many elderly victims will admit to the abuse when asked questions in a
straightforward and non-judgmental way such as the following. Be sure to allow enough time for
the patient to respond:

Have you ever been hit, punched, kicked or hurt in any way?

Did someone give you this injury?

What is your relationship with your caregiver? How does she/he treat you?

Does your caregiver drink, use drugs or have a psychiatric history?

Does your caregiver verbally or physically abuse you or neglect your


needs?
You seem to have a special concern about your caregiver. Can you tell me
more? Are you fearful? Has she/he ever hurt you? Threatened to do so?

I have notice you have a number of bruises, could you tell me how they
happened?

Could you describe your routine day to me (i.e activities, hygiene,


bathing)??

What are your medications? How often do you take them?

How many meals a day do you eat? What do they consist of?

Neglect, which includes both willful and unwillful neglect, abandonment,


confinement, malnutrition, starvation, over-and-under medicating and
withholding of personal and medical care. This type of abuse is the most
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common but often is difficult t o detect.

NEGLECT SHOULD BE SUSPECTED WHEN NOTING:

• Malnutrition and dehydration


• Frequent or multiple decubiti
• Bleeding, tender gums or soreness or mouth
and tongue from mouth care neglect and/or
nutritional deficiencies.
• Poor personal hygiene.
• “Vacant stare”, passivity or unresponsiveness
due to physical or psychological abuse or
neglect.
• Withhold of drugs or non-compliance by
caregiver; over-medicating of patient.
• Report of withholding necessary adoptive
devises (e.g., hearing aid, eyeglasses, walker,
etc.)
• Psychological abuse, which indicates verbal harassment,
threats, enforced physical and emotional isolation, and any
behavior, which causes fear in the elderly. This often occurs
simultaneously with physical abuse and neglect; and
• Financial abuse, which includes withholding or stealing
funds and exploitation of personal property.

GUIDELINES FOR IDENTIFYING VICTIMS OF CHILD ABUSE

6. Physical abuse may be suspected if a child has unexplained bruises or welts on


face, lips, mouth, torso, back, buttock or thighs. If these bruises or welts seem to be
in various stages of healing or in clustered, patterned layouts.
7. Bruises or welts may resemble the article used to inflict the injury (electrical cord,
belt buckle)
8. Physical abuse may be suspected is assessment shows unexplained burns (cigar,
cigarette) especially on soles, palms, back or buttocks or immersion burns (sock-
like, glove-like doughnut shaped on buttocks or genitalia)
9. Physical abuse may be suspected if a child has unexplained fractures to skull,
nose, facial structure, multiple healing/healed fractures.
10. Physical neglect may be suspected if a child complains of continuous hunger, has
poor hygiene, inappropriate dress, chronic fatigue, listlessness, displays
unattended medical needs.
11. Sexual abuse may be suspected if a child has difficulty walking or sitting, has
torn, stain underclothing, pain or itching in the genitalia area, or bruises or
bleeding in external genitalia, vaginal or anal area.
12. Emotional maltreatment may be suspected if a child displays habit disorders
(sucking, biting, rocking, etc.) or conduct disorders (antisocial, destructive, etc.)
or neurotic traits (sleep disorders, speech disorders, etc.)
13. A child’s behavioral indicators that may be signs of abuse include fear of adult
contacts, apprehension when other children cry, behavioral extremes, frightened
of parents, afraid to go home, verbal reports of injury by parents/caregivers.
14. Behavioral indicators that may signal sexual abuse include withdrawal, fantasy or
infantile behavior. Child’s actions may display bizarre, sophisticated or unusual
sexual behavior or knowledge. Child may report sexual assault by
parent/caregivers.

REPORTING OF ABUSE / NEGLECT


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1. Child abuse/neglect must be reported to the Nursing Director or her designee who
will contact the Division of Youth and Family Services at 1-800-792-8610.
BY LAW, HEALTHCARE PROVIDERS MUST REPORT CHILD
ABUSE/NEGLECT.
2. Adult and Elder abuse/neglect must be reported to the Nursing Director or her
designee who will contact the appropriate social service. If the victim is from the
community, the Warren County Department of Citizen Services, Division of
Welfare would be contacted. Ask for Adult Protective Services. The telephone
numbers is 908-475-6591.
Somerset County Adult Protective Services: 908-526-8800.
Morris County Adult Protective Services: 973-326-7282.
3.
If the elder victim is from an institution (boarding home, nursing home), that
situation would be reported to the Office of Ombudsman, State of New Jersey
at 1-877-582-6995.

In addition to contacting the Social Worker and Protective Services call the local police
department for assistance.
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POLICY: SUSPECTED CHILD ABUSE

Purpose: To attempt to identify and/or report suspected child abuse to the proper authorities

Policy: Cases of suspected child abuse must be reported to the proper authorities

Procedure:
Questions parents as to possible cause if initial examination discloses bruises,
scratches, etc. Also note parents’ reactions to the questioning.

Record rapport between parents and child, post findings on patient’s chart and
report same to physician

Follow the procedure for reporting child abuse in New Jersey whether the
physician agrees with your findings or not.

Definitions of Child Abuse and Neglect:

Under the law an abused or neglected child is defined as any child under 18 years of age:
- Whose parent or guardian inflicts or allows to be inflicted upon the child
physical injury through other than accidental means which results, or
potentially could result, in a substantial risk of death, a serious prolonged
disfigurement, or impairment or loss of the function of any bodily organ;

- Whose physical, mental, or emotional condition has been impaired


or risks being impaired because of the failure of his or her parent or
guardian to provide adequate care and supervision, to supply adequate
food, clothing, shelter, education, medical or surgical care;

- Against whom a sex act has been committed by a person


responsible for his or her care or by someone else permitted to commit
such an act by the person responsible for the child’s care; or

- Who has been willfully abandoned by his or her parent or guardian.

Reporting Child Abuse in New Jersey

- In New Jersey, the Division of Youth and Family Services


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investigates reports of suspected child abuse and neglect.

- DYFS staff are available to receive referrals at the local district


office from 9 am to 5 pm and at the Office of Child Abuse Control
(OCAC) at ANY HOUR (800-792-8610). Calls received at OCAC during
normal working hours are immediately referred to the appropriate district
office.
- DYFS accepts all reports of suspected child abuse and neglect and
other referrals in writing, by telephone and in person from all sources
including...identified sources, news media, anonymous sources, sources
which have incomplete information, and referrals from the child or parent
himself.

Immunity from Civil or Criminal Liability

- Any person who reports abuse or neglect, pursuant to the law or


testifies in a child abuse hearing resulting from such a report, is immune
from any criminal or civil liability as a result of such action.

Penalty For Failure to Report

- Any person who knowingly fails to report suspected abuse or


neglect, pursuant to the law or to comply with the provisions of the law is a
disorderly person and subject to a fine up to $500.00 or up to six months
imprisonment, or both.

Any staff member who suspects a child is being abused must report this to the Nursing Director or
their designee immediately. It is the responsibility of the Nursing Director or designee to report
suspected cases of abuse to the appropriate authority.

54
LATEX ALLERGY:

Latex allergy or hypersensitivity is a recognized health problem and occupational risk for
healthcare workers. The risk of developing a latex allergy keeps rising because the more frequent
the contact with latex products the higher levels of the latex allergen you are exposed to.

People at highest risk are healthcare workers or any person whose job regularly requires them to
wear latex gloves and people who have had multiple surgeries.
Other people at high risk are people with certain food allergies such as banana, kiwi, avocado,
chestnut, and pineapple.

Types of Latex Reactions:

Contact Dermatitis: this is an irritant reaction to the chemicals used during the processing of the
latex or to the powder that’s added to the gloves. The usual symptoms are skin redness and
itching.

Type IV Hypersensitivity: a cell-mediated allergic reaction to the chemicals that are used during
the processing of latex, not the latex itself. This is not a true latex allergy. The symptoms are
redness, itching and possibly hives. If the powder is inhaled there may be red, itchy, runny eyes or
nose and coughing.

Type I Hypersensitivity- an IgE-mediated allergic response, which has the potential to be life
threatening. This is a true latex allergy. Symptoms may be localized or systemic and can include
hives, generalized edema, itching, rash, wheezing, difficulty breathing, diarrheas, nausea, low
blood pressure, rapid heart rate, feeling faint and in severe cases- respiratory or cardiac arrest.

What is the protocol for Patient’s with latex allergy

The admitting RN will assess all patients for a history of latex allergy during the pre-op phone
interview.
Patients identified with a latex allergy who are admitted to the Center will be provided with a
latex-free environment.
Patients with a latex allergy will be identified with an allergy sticker placed on the front of the
patient’s chart.

See Policy on latex allergies in the Policy and Procedure Manual

55
POLICY: SURGICAL HAND SCRUB PROCEDURE

Purpose: Although scrubbed members or the surgical team wear sterile gloves, the hands
and forearms should be cleaned preoperatively for every invasive procedure to
reduce the number of microorganisms in the event of glove tears. The purpose of
the hand scrub is:
1. to remove debris and transient microorganisms from the nails,
hands and forearms;
2. to reduce the resident microbial count to a minimum; and
3. to inhibit rapid rebound growth of microorganisms.

Policy: A surgical hand scrub shall be done by surgeons and scrub personnel prior to surgical
intervention

General information: Prior to each scrub, use A) a disposable pre-filled brush of Iodophor
Solution with detergent or a pre-filled brush of parachlorometaxylenol
(PCMX) cleansing solution or B) Chlorhexadine Gluconate 1% Solution
and Ethyl Alcohol 61% w/w (Avagard):

All jewelry must be removed from the hands and forearms

Fingernails should be free of polish and trimmed short. Cuticles should be in good
condition. Artificial nails should not be worn.

Hands and forearms should be free of open lesions and breaks in skin integrity.

Hair should be completely covered, mask is in place skirt tucked in pants.

Sleeves of scrub shirt should be above elbows.

Procedure A:

Adjust water to comfortable temperature

Thoroughly moistened hands and forearms should be washed using an approved scrub
agent before beginning the surgical scrub procedure.

Subungual areas should be cleaned under running water using a nail cleaner.

An antimicrobial agent should be applied with friction to the wet hands and forearms.

Fingers, hands and arms should be visualized as having four sides; each side must be
scrubbed effectively.

Hands should be held higher than the elbows and away from surgical attire.
56
Brushes or sponges used should be discarded appropriately.

57
Care should be taken to avoid splashing water onto the surgical attire.

A traditional, standardized anatomical timed scrub of at least three minutes should be


done initially and for every subsequent scrub.

Rinse each hand and arm with clear water being sure to hold hands above elbows, so that
the water from above elbow does not flow back onto arms. Caution must be taken
not to hit faucets during rinsing. Hold arms in upright position allowing most of
water to run off before entering operating room.

Procedure B:
1. Apply to clean, dry hands and nails.

2. For the first use of each day, clean under nails with a disposable, surgically
clean
(not sterile) nail cleaner.

3. Do not use water. Be sure hands are dry when using Avagard hand prep.

4. Pump #1: Dispense 1 pump (2ml) of Avagard antiseptic hand prep into the
palm of
One hand. Dip the fingertips of the opposite hand into the hand prep and work it
under the nails. Spread the remaining hand prep over the hand and up to just above the
elbow, covering all surfaces.

5. Pump#2: Using another 2 ml of Avagard antiseptic hand prep, repeat above


procedure with the other hand.

6. Pump #3: Dispense another 2 ml of Avagard antiseptic hand prep into


either hand and reapply to all aspects of both hands up to the wrist. Rub hand
prep briskly into hands until completely dry before donning gloves.

7. Wash hands with soap and water following surgical procedures.

58
THE CHAIN OF INFECTION:

Practices in infection control are aimed at breaking the “chain of infection”


There are three elements that are needed to spread an infection from one patient to another:
The organism
The host and the
Mode of transmission

The common modes of transmission in the Center are:

Contact Transmission: This is the route most common mode of transmission. There are two
forms of contact transmission.

Direct Contact: typically spread from staff to patients via unwashed hands.
Indirect Contact: Organisms spread on contaminated equipment used from patient to patient (i.e.
blood pressure cuff)

Airborne transmission: occurs when organisms are coughed, talked, or sneezed into the air by an
infected person. The organism is suspended on dust particles in the air and are then inhaled into
the body.

Droplet Transmission: This occurs when infectious organisms are coughed or sneezed into the
air by an infected person and immediately inhaled into the body by someone in the close vicinity.
An example of droplet transmission is meningococcal infection.

Hand washing is critical to prevent the spread of infection

According to the Centers for Disease Control and Prevention (CDC) hand washing is the single
most important procedure for preventing the spread of infection. This is because
microorganisms can enter your body by hand-to-hand, food-to-hand, and surface-to-hand
contact.

There are two acceptable methods of hand washing:

Waterless soap is quick and highly effective


Traditional 15 second soap and water wash
Traditional 15 second soap and water wash (for terms of patient teaching, this is about the time it
takes to sing the “Happy Birthday Song”)
59
POLICY: HANDWASHING
All personnel will be instructed in the hand washing procedure. It is generally considered to be
the single most important method for interrupting transmission of microorganisms and
preventing infections.

General Directions:

A. Hands must be washed with an approved antiseptic agent before preparing for the
first case of the day.

B. Hands must be washed after direct care of an individual patient, during


performance of duties (eating, handling dressings, specimens, using restroom etc.)

C. When washing hands, wet hands and wrist thoroughly holding them downward
over the sink so that the water runs toward the fingertips.

D. Rinse hands thoroughly keeping the hands higher than the elbows to keep water
from running down and contaminating the clean skin.

E. Dry wrist and hands thoroughly with paper towel.

Recommendations to improve hand hygiene practices of healthcare workers


and reduce transmission of pathogenic microorganisms to patients and
personnel.
1. Wash hands with a non-antimicrobial soap and water or and water when hands are visibly
dirty or contaminated with proteinaceous material.
2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for
routinely decontaminating hands.
3. Decontaminate hands after contact with a patient’s intact skin (as in taking a pulse or
blood pressure, or lifting a patient.)
4. Decontaminate hands after contact with body fluids or excretions, mucous membranes,
non-intact skin, or wound dressings, as long as hands are not visibly soiled.
5. Decontaminate hands if moving from a contaminated body site to a clean body site
during patient care.
6. Decontaminate hands after contact with inanimate objects (including medical equipment)
in the immediate vicinity of the patient.
7. Decontaminate hands before caring for patients with severe neutropenia or other forms of
severe immune suppression.
8. Decontaminate hands before inserting indwelling urinary catheters or other invasive
devices that do not require a surgical procedure.
9. Decontaminate hands after removing gloves.
10. To improve hand hygiene adherence among personnel where high workloads and high
intensity of patient care are anticipated, make an alcohol based waterless antiseptic agent
60
available in other convenient locations and in individual pocket-sized containers to be
carried by healthcare workers.
11. When decontaminating hands with a waterless antiseptic agent such as an alcohol-based
hand rub, apply product to palm of one hand and rub hands together, covering
manufacturer’s recommendations on the volume of product to use. If an adequate
volume of an alcohol-based hand rub is used, it should take 15 to 25 seconds for hands to
dry.
12. When washing hands with a non-antimicrobial or antimicrobial soap, wet hands first with
warm water, apply 3 to 5 ml of detergent to hands and rub hands together vigorously for
at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with
warm water and dry thoroughly with a disposable towel. Use towel to turn off the faucet.

Surgical hand antisepsis:


1. Surgical hand antisepsis, using either an alcohol-based hand rub or an antimicrobial soap,
is recommended before donning sterile gloves when performing surgical procedures.
2. To reduce the number of bacteria that may be released from the hands of surgical
personnel, while minimizing skin damage related to surgical hand antisepsis,
decontaminate hands without using a brush.

When selecting hand hygiene agents for the Center:


1. Provide hand hygiene products that have low irritancy potential.
2. Ask for input from care givers regarding the feel, fragrance, and skin tolerance of any
products under consideration. The cost of hand hygiene products should not be the
primary factor influencing product selection.
3. Evaluate dispenser systems to ensure that dispensers function adequately and deliver an
appropriate volume of product.
4. Do no add soap to a partially empty soap dispenser. This practice of “topping off”
dispensers may lead to bacterial contamination of soap.

Skin Care:
1. Healthcare workers should be provided with hand lotions or creams in order to minimize
the occurrence of irritant contact dermatitis associated with hand antisepsis or
handwashing.
2. Information should be requested from the manufacturer regarding the effects that hand
lotions, creams, or alcohol-based hand antiseptics may have on the persistent effects of
antimicrobial soaps being used in the Center.

Other:
1. Artificial fingernails or extenders should not be worn when providing patient care.
2. (Strongly recommended for implementation and strongly supported by well-designed
experimental, clinical, or epidemiologic studies.
3. Nails should be kept less than ¼ inch long.
4. (Suggested for implementation and supported by suggestive clinical or epidemiologic
studies or a theoretical rationale.)
5. Gloves should be worn when it can be reasonably anticipated that contact with blood or
other potentially infectious materials, mucous membranes, and non-intact skin will occur.
6. (Required for implementation, as mandated by federal and/or state regulation or
standard.)
7. Gloves shall be removed after caring for a patient. Do not wear the same pair of gloves
for the care of more than one patient, and do not wash gloves between patients.
8. Change gloves during patient care if moving from a contaminated body site to a clean
body site.

Healthcare worker educational and motivational programs:


1. Personnel shall be educated regarding the types of patient care activities that can result in
hand contamination and the advantages and disadvantages of various methods used to
61
clean their hands.
2. Hand hygiene practices should be monitored to provide personnel with information
regarding their performance.
3. Patients and their families should be reminded to decontaminate their hands.

Administrative measures:
Healthcare workers shall be provided a readily accessible waterless antiseptic agent such as an
alcohol-based hand rub product.

Outcome process measurements:


1. Handwashing in-service annually.
2. PPE assessment.
3. Monitor adherence to policies dealing with wearing of artificial nails.
4. When outbreaks of infection occur, assess the adequacy of healthcare worker hand
hygiene.

62
Competency for PPE
Employee name: ________________________________________________
Observation/Demonstration Competency met Competency not Comments
met
Verbalizes understanding
of Standard Precautions
Wears scrub attire in semi
restricted and restricted
areas.
Wears bouffant cap or hair
covering in designated
areas.
Wears shoe covers if
soiling of shoes is likely.
Wears goggles or face
mask when splashing is
possible.
Wears mask in restricted
areas.
Changes mask after use.
Does not leave mask tied
around neck for reuse.
Wears gown when
applicable
Wears gloves when
touching body fluids/ Uses
standard precautions.
Dons gown appropriately
Dons gloves appropriately
Dons mask appropriately
Removes PPE in correct
order and disposes of
properly.
Washes hands between all
patient encounters.
Washes hands after taking
off gloves.
Washes hands when gloves
are removed following
contact with body fluids.
Supervisor’s signature: ________________________________________
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Employee’s signature: _________________________________________ Date: _____

BLOOD BORNE PATHOGENS:

Blood Pathogens are diseases which are spread through direct contact with blood or other body
fluids. Examples of blood borne pathogens are HIV, Hepatitis B and C (HBV,HCV), syphilis
and Malaria.

OSHA is the Occupational Safety and Health Administration. They are responsible for
developing guidelines to protect workers form potential hazards in the workplace.

All employees who may come in contact with blood or blood products are at risk of contact with
blood borne pathogens.

Blood borne pathogens are spread through:


Needle stick injury
Cuts, scrapes or any open lesions
Splashes into eyes, nose or mouth
Oral vaginal or anal sex
Sharing of infected needles, syringes or razor blades

Standard Precautions means treating everyone’s blood, body fluids and excretions as infectious
at all times. If contact with blood or other body fluids or contaminated equipment is likely, you
must wear gloves. People infected with HIV, HBV and/or HCV are found in all age groups from
all socio-economic groups.

Personal Protective Equipment are items that are used to protect you from contact with
potentially infectious substances. The equipment includes gloves, masks, gowns, aprons, face
shields, goggles, resuscitation bags or other ventilation devices. If your job requires you to be
exposed to blood borne pathogens the Center will provide you with the appropriate protective
equipment at no cost to you.

OSHA requires that:


Employees are trained to use PPE properly
PPE must be appropriate for the task
Appropriate PPE must be used each time the task is performed.
PPE must be free of physical flaws that could compromise safety
Gloves must fit properly
64
If PPE is penetrated by blood or other infectious substances you should remove it as soon as
possible.
Before leaving the work area, all PPE must be removed properly and placed in the appropriate
receptacle. Always wash your hands.

Gloves:
Never use petroleum-based lubricants with latex gloves because it will break down the latex and
cause holes.
Cover any cuts or scrapes on your hands before putting on gloves
Inspect all gloves for holes or weakness and discard if necessary
Remove gloves so that the outer surface is turned inside out and discard appropriately.
Gowns, masks, Goggles, Face Shields:
Should be worn whenever blood or body fluids may be splashing.

Engineering Controls include:


All sharps are disposed of in the provided sharps container in the patient care areas.
Never bend or break off needles
Never recap syringe needles without an approved cap device
Place all specimens in a biohazard peel and seal bag
Dispose of all blood or body fluid soaked items in the appropriate red infectious waste containers
Liquid waste may be disposed of in a toilet or flush sink
Keep food and drinks out of refrigerators used for infectious waste
Do not apply cosmetics, lip balm or handle contact lenses in the work area
Do not touch broken glass with your hands. Use tongs or dustpan and broom
Wipe up blood spills with an approved hospital disinfectant or 1:10 bleach and water solution

If you are exposed to blood borne pathogens


Wash the area immediately with soap and water
Report the exposure to your supervisor as quickly as possible
Go to the Emergency Room at the hospital or the infectious disease specialist for the Center for
treatment.
The Center offers prophylactic treatment with anti-viral drugs according to CDC guidelines
through the Emergency Room at the Hospital or the infectious disease specialist for the Center.

65
The Exposure Control Plan can be found in the OSHA BOOK or in the Policy and Procedure
Manual under Infection Control/Blood borne Pathogens/ Exposure Control Plan.
New forms of Hepatitis have been determined and labeled Hepatitis D, Hepatitis E, and Hepatitis
G. These are more fully described in the Infection Control/Bloodborne Pathogen/Exposure
Control Plan in the Policy and Procedure Book.

Hepatitis B Vaccine:
Hepatitis is an inflammation of the liver which can be caused by a blood borne virus. Two
viruses are Hepatitis B and Hepatitis C

Hepatitis B is the most common blood borne pathogen a healthcare worker encounters. It can
last for months and mimics a flu illness.
Chronic carriers may not have any symptoms but can still p ass the virus to others. Long-term
effects are cirrhosis, liver cancer and death

Hepatitis C is another virus and when in the active stage may have similar symptoms to HBV.
Usually the symptoms are milder. 70% of the people have no clinical signs or symptoms.
People with HCV are more likely to be carriers. Long-term effects are cirrhosis, liver cancer and
death.

New forms of Hepatitis have been determined and labeled Hepatitis D, Hepatitis E, and Hepatitis
G. These are more fully described in the Infection Control/Bloodborne Pathogen/Exposure
Control Plan in the Policy and Procedure Book.

The Hepatitis B Vaccine is recommended and offered by the Center at no cost to the employee.
All employees are encouraged to have the vaccine. New forms of Hepatitis have been
determined and labeled Hepatitis D, Hepatitis E, and Hepatitis G. These are more fully described
in the Infection Control/Bloodborne Pathogen/Exposure Control Plan in the Policy and
Procedure Book.

66
Employees most at risk and who should ensure that they are vaccinated are employees who care
for patients, handle specimens or clean and repair patient equipment.

HIV is the virus which causes AIDS. HIV attacks and destroys the immune system making the
patient more prone to developing infections. In most instances it is an infection which causes the
death of the AIDS patient. There are many effective drug treatments for HIV, but these drugs
are not a cure. There is no vaccine for prevention of HIV.

*See the Policy and Procedure manual for information regarding additional Hepatitis viruses.

Tuberculosis is a disease which is spread by the airborne route. The organism is inhaled into
the lungs.
Active TB Disease: This is the form that is infectious. The infected person will exhibit a
productive cough, hemopysis, low grade fever, weight loss, loss of appetite, positive chest X-ray
and a positive skin test (PPD)
Latent TB Infection: This is the form where the person is no longer infectious.(cannot pass the
TB organism to another person) but the organism is still carried in their system. The person will
no longer exhibit any clinical symptoms and will have a negative chest x-ray but will still have a
positive skin test (PPD)

Patients with TB or are known to have Active TB should be on Airborne Isolation Precautions in
a negative air pressure room which is exhausted to the outside. These patients are not seen at the
Center because the facility is not built to provide this type of care.

Treatment for TB
There are several medications available to treat TB patients. Most patients will be prescribed
three of these drugs for a period of none to twelve months. It is important to educate the patient
about the necessity for taking their medications as prescribed to prevent possible relapse or
development of a resistant form of TV. Multiple Drug Resistant TB (MDRTB) is the most
difficult form of TB to treat. Many of the common drug therapies do not word with MDRTB.

SARS (Severe Adult Respiratory Syndrome)

67
The infectious disease specialist for the Center is: ________________________________

Address: ___________________________________________________________________

Phone: __________________________________________________________________

The Infection Control Consultant is: _____________________

Address: ____________________________________________

Phone: _________________________________

68
REVIEW AND PROVIDE EACH EMPLOYEE WITH THE INFECTION CONTROL
POLICIES AND PLAN INCLUDING:
BLOODBORNE PATHOGENS/EXPOSURE CONTROL PLAN/SHARPS

69
XNew □Revised
Replaces:
Approval Date:

POLICY: SHARPS INJURY PLAN


Purpose/Objective:
To make every effort to ensure that the staff is aware of how to handle a sharps injury in the
Center.
Procedure:
In the event of a sharps injury in the Center, the following procedure will be followed:

1. Photocopy the patient’s consent. Highlight section indicating authorization for testing

(The surgical consent contains language authorizing blood testing in the event of an
exposure to blood/body fluids. Statement reads:
Should a bloodborne exposure occur during the procedure, I consent to the drawing of
blood for HIV and Hepatitis testing. The results of this test will be placed in my medical
record and protected in accordance with the applicable state laws.)

2. Draw blood (10 cc) for 2 Gold top tubes (these tubes have gel in the bottom)
3. Label blood with patient stickers including date, time and initial.
4. Send blood tubes with completed form signed.
5. Call Lab. Place the 2 source patient tubes in one specimen bag. Place both in an outside
bag.

70
EMMAUS SURGICAL CENTER

Date:

The person listed below requires the following blood tests due to a blood borne pathogen
exposure or similar incident. Please perform the tests as requested and send/fax the
results to the Surgery Center. If you have any questions please notify the
Administrator/Director of Nursing, Kathleen Vaezi at 908-813-9600.

Hepatitis B
Hepatitis C
HIV-1, HIV-2
Other______________________

Name: ____________________
DOB: _____________________
SS#: ______________________
All bills for these blood tests will be paid by the Surgical Center.

Sincerely,

__________________________
Medical Director

71
Manager/Supervisor Actions:
1. Obtain exposure control packet from cabinet in the PACU
2. Fill out paperwork and obtain blood samples from source patient and employee if
indicated.
3. Complete OSHA 300 log and Sharps Injury log
4. Complete Occupational Injury/Illness Report. Ensure that employee section is completed
within 15 days of the incident.
5. Contact Infectious Disease Physician/Infection Control Nurse Consultant, advise him/her
of the injury and get their recommendations for post exposure prophylaxis/treatment.
Arrange for a consultation for the employee.

72
Employee Action:
The exposure kits are located in the PACU, follow the steps below.

Percutaneous (needlestick/sharp object) injury:


• Wash wound for 10 minutes with soap and water
• Remove any foreign materials embedded in the puncture/wound
Non intact skin exposure:
• Wash with soap and water, or antiseptic, if water is not available
• Disinfect
Mucous membrane exposure:
• Irrigate copiously with water, sterile saline or sterile water for 10-15 minutes
• Eyewash stations are located in the soiled utility room and exam room.
• Report the accident/exposure to supervisor/Manager. An incident report will be
completed.
• Sign consent for blood work to be drawn. Two pink tubes will be filled to test for HIV,
Hepatitis B and Hepatitis C.
• Employees may also choose to go to the Emergency Department at the Hospital.
• The supervisor/manager will arrange for relief.
• The supervisor/manager will contact ID Consultants to ensure proper management and
treatment of the exposure. The employee may also request a consultation with the ID
Consultant(s).
Occupational injury and illness report
(Must be completed within 15 days of the incident)
73
TO BE COMPLETED BY MANAGER/SUPERVISOR OF INJURED EMPLOYEE
Post exposure procedure followed:
Consent and blood obtained from employee Yes No
Consent and blood obtained from source patient Yes No
Hepatitis Status of employee Immune No
Infectious Disease contacted Yes No
Recommendation of I.D. consultant Yes No
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___
Assessment of occurrence: _______________________________________________________
Factors contributing to accident: ___________________________________________________
Policy and Procedure: ___________________________________________________________
Engineering controls: ___________________________________________________________
Work practice controls: __________________________________________________________
Hours worked: _________________________________________________________________
Plan of Action to prevent further occurrences of this type: ______________________________
Manager Name: (Print)___________________________________________________________
Manager Signature: _____________________________________________________________
Date: ________________________________________________________________________

CONSENT TO ADMINISTER COMMUNICABLE DISEASE BLOOD TESTS

I, _______________________, am a (patient, employee) of Dr.___________________


(Practitioner), at the Center. The Practitioner has informed me that he recommends that I receive
blood tests for the following communicable diseases in order to facilitate my treatment and
protect Center personnel and other patients: _______________________.

I understand that the blood tests for the virus which is the probable cause of Acquired Immune
Deficiency Syndrome (AIDS) are not 100% accurate, and that these blood tests sometimes
produce false positive or false negative test results. I further understand that the presence of
antibodies means that a person probably has been infected with the AIDS virus, but does not
necessarily mean that a person will develop AIDS.

I have been provided with information about the test for antibodies to the HIV virus, about the
HIV virus, and about AIDS, and I have been given the opportunity to ask questions regarding
this information and have my questions answered. I have been informed by my physician(s) that
the test, in the opinion of the physician(s), is important both to my health care and to ensure that
appropriate evaluation can be undertaken and adequate precautions taken to prevent transmission
of the virus to others.

I understand the Practitioner will notify me of the results of the blood test and that the results
will be explained to me.

I have been informed that the performance and results of the HIV antibody test are considered
confidential. I have been informed by the physician(s) that the test results in my health record
shall not be released without my written permission, except to the individuals and organizations
74
that have been given access by law who also are required to keep my health record information
confidential.

On this basis, I authorize the Center, Practitioner, and anyone authorized by them to perform
the blood tests for the above described communicable diseases.

____________________
_____________________________
_
Date Signature of Patient

____________________
_____________________________
_
Witness Signature of Practitioner

DECLINATION TO ADMINISTER COMMUNICABLE DISEASE TEST(S)

I, ________________________, am a (patient, employee) of Dr.______________________


(Practitioner), at the Center. The Practitioner has informed me that he recommends that I receive
blood tests for the following communicable diseases in order to facilitate my treatment and
protect Center personnel and other patients: _______________________.

I have been informed that by declining permission for this test, decisions concerning infectious
disease precautions will be made on the basis of other medical information concerning me. I
have been informed that if I refuse permission for the HIV antibody test, my health care,
including diagnosis and treatment, may be adversely affected.

75
I agree to assume all risks that may result from my refusal to consent. I also agree not to hold
my practitioner(s) any other personnel or the Center responsible for any adverse results that may
arise from my refusal to consent to the HIV antibody test.

On this basis, I refuse to have Center, Practitioner and anyone authorized by them to perform
the blood tests for the above described communicable diseases.

____________________ ___________________________________
Date Signature of Patient

____________________ ___________________________________
Witness Signature of Practitioner

CONSENT TO RELEASE INFORMATION - THIRD PARTY PAYER

76
(CHECK ONE)

_____ I do not consent to the release of the nature of the test(s) to my insurance company or
medical assistance program.

_____ I authorize the Center to furnish my insurance companies and other third party payers
with any and all information it has or may hereafter have either written or oral, pertaining to or in
any manner connected with the tests authorized herein, that may aid in payment of any account
presented to me or us, jointly or separately, and I further agree that no person, firm, or
corporation shall be held liable in any manner for furnishing or having furnished such
information.

____________________ ___________________________________
Date Signature of Patient

____________________________________________________
Witness

77
Step 6 – Develop an Exposure Control Plan
Attachment 5

CONFIRMATIONOF POST-EXPOSURE EVALUATION


Employee: _________________________________ Date: ________________________
Department: ________________________________ Date of Exposure: ______________

This letter is to inform you of the results of the evaluation that followed your recently
reported exposure to blood or other potentially infectious materials. Current guidelines
recommend that the hepatitis B vaccine be given after an exposure. In your situation:

❒ Hepatitis B vaccination is indicated. We recommend that the vaccine be


given as soon as possible.
❒ You have started the hepatitis B vaccination series and need to complete
the series. Your next dose is due: ________________(insert d ate)

❒ You have previously been vaccinated and have evidence of immunity. No


vaccine is necessary.
❒ You have previously been vaccinated but we have been unable to
document immunity. Hepatitis B vaccination is recommended.
❒ Hepatitis B vaccination is recommended. You declined vaccination or
have not returned to Employee Health Services.

You were tested for : ❒ HIV ❒ hepatitis B immunity ❒ hepatitis C immunity

❒ Follow-up blood testing is due: ___________________________(insert date)

❒ You were given medications for post-exposure prophylaxis (these are not indicated for all
exposures): _______________________________________________________________

This letter also confirms that you have been informed of the results of the evaluation and have
been told about any medical conditions resulting from exposure to blood or OPIM. If you
need additional information regarding your exposure evaluation please contact us at:
__________________________________________________________________________

Attachments: _______________________________________________________________

____________________________________________________________________

_________________________________ _______________________________
Signature of health care professional Title/Department

____________________________________
Please print name
RECORD OF HEPATITIS B VACCINE DECLINATION
I understand that due to my occupational exposure to blood or other potentially infectious
materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the
opportunity to be vaccinated with hepatitis B vaccine, at no charge to me. However, I decline
hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be
at risk of acquiring hepatitis B, a serious disease. If, in the future, I continue to have occupational
exposure to blood or other potentially infectious materials and I want to be vaccinated with
hepatitis B vaccine, I can receive the vaccination series at no charge to me.

_______________________________
Employee Name
_______________________________
Employer Representative
_______________________________ _____________________________
Employee Signature Date
2009 INFECTION CONTROL PLAN
Goal: To prevent post procedure infections.

Objective: Concurrent surveillance of all patients post procedure.


To monitor sterilization parameters.
Indicator 1:
The cleanliness of the environment will be monitored.

Indicator 2:
Infection Complication log will be used to monitor post-op infections and complications

Indicator 3:
Intraoperative QI indicator will monitor sterilization of instruments

Indicator 4:
Refrigerator and Freezer temperatures will be monitored daily.

All of the indicators will be reviewed monthly and reported three times a year at the Medical
Advisory Committee Meeting and Managers’ Meeting
POLICY: PREVENTION OF WORKPLACE VIOLENCE

Although no single set of actions guarantees reduced violence, experts in the workplace violence
have provided some suggestions. The Center has a policy of disciplinary action for any
workplace harassment, threat, or physical action. It is the responsibility of the supervisor and
employees to report any potentially violent signals or incidents.

Recognizing early warning signals can help avoid tragedy. Supervisors are asked to document
any incidents.

Some early warning signals may be:

• Direct or veiled verbal threats of harm.


• Intimidation of others. (This can be physical or verbal intimidation. Harassing phone
calls and stalking are obvious examples.)
• Carrying of a concealed weapon or flashing a weapon to test reactions.
• Paranoid behavior, perceiving that the whole world is against them.
• Mortal righteousness and believing the organization is not following its rules and
procedures.
• Being unable to take criticism of job performance. Holding a grudge, especially against a
supervisor. Verbalizing hope for something to happen to the person against whom the
employee has the grudge.
• Expressions of extreme desperation over recent family, financial or personal problems.
• History of violent behavior.
• Extreme interest in semi-automatic weapons and their destructive power to people.
• Fascination with incidents of workplace violence and showing approval of the use of
violence under similar circumstances.
• Disregard for the safety of co-employees.
• Obsessive involvement with the job, often with uneven job performance and no apparent
outside interests.
• Being a loner who has a romantic obsession with a co-worker who does not share this
• interest.

Keep in mind that employee safety is paramount, we take threatening situations very seriously.
Following are some tips for handling difficult people or situations. Don’t put a difficult person
off. Address their concerns immediately. Use phrases like I’ll do what “I can to help” and
“Let’s get this taken care of”
1. Use your” talking hands” to provide calming, non-threatening hand motions.
2. Be aware of your “personal danger zone” keep the person at least arms length away.
3. Never accuse, shake your finger in the person’s face or say “Calm down”
4. Supervisors should encourage courteous customer service.
5. Management should create a culture of mutual respect to lower stress and reduce the potential
for conflicts.

Procedure:

1. It is the responsibility of every employee to know what Code 5 is, and how to implement this
at the facility.
2. If you encounter a verbally abusive or hostile visitor call a Code 5 X 3 at your location.
If the person is in the waiting room area or around patients or their families ask them (the hostile
visitor) to step into a more private location.
3. Always assume that the person could be dangerous and never allow yourself to be alone and
isolated with such a person. Try to keep the person calm while you wait for the safety team to
respond. Do not tell the person to calm down as this may not produce the desired effect.
Listen to their complaints and remain non-committal while you are waiting.

4. If the person threatens you, one of the physicians, another employee, a patient or their family
member with violence or indicates they are armed or have a weapon with them, the situation
becomes an emergency. You should notify the police immediately.

5. If you receive a phone call threatening any of the above-mentioned people, immediately
notify your supervisor. A police report will be filed for all significant threats to their person and
may file a police report at his discretion.

6. You should avoid leaving or entering the building alone. If you are accosted for drugs,
money, equipment, etc., give them whatever they ask for. Remember there is nothing that can’t
be replaced and nothing that is worth risking your life for. See attached sheet to be used in case
of a robbery to help describe the assailant.
POLICY: DANGEROUS INTRUDER/HOSTILE VISITOR CODE “5

Procedure:

1. It is the responsibility of every employee to know what Code 5 is, and how to implement this
at the facility.

2. If you encounter a verbally abusive or hostile visitor call or dial page and announce CODE 5
times three at your location. If the person is in the waiting room area or around patients or their
families ask the hostile visitor to step into a more private location.

3. Always assume the person could be dangerous and never allow yourself to be alone
and isolated with such a person. Try to keep the person calm while you wait for the Safety Team
to respond. Do not tell the person “Calm down” as this may not produce the desired effect.
Listen to their complaints and remain noncommittal while you are waiting.

4. If the person threatens you, one of the physicians, another employee, a patient or their family
member with violence or indicates they are armed or have a weapon with them, the situation
becomes an emergency. Notify the police immediately.

5. If you receive a phone call threatening any of the above-mentioned people, immediately notify
your supervisor. A police report will be filed for all significant threats. The physician will be
notified of all threats to their person and may file a police report at his discretion.

6. You should avoid leaving or entering the building alone. If you are accosted for drugs,
money, equipment, etc., give them whatever they ask for. Remember there is nothing that can’t
be replaced and nothing that is worth risking your life for. See attached sheet to be used in case
of robbery to help describe the assailant.
CULTURAL DIVERSITY
As the country continues to become more ethnically and racially diverse, healthcare workers
may encounter numerous languages, beliefs, and practices during a normal workday.
It is important to learn about the different cultures and values. It is the difference that can
make or break good patient relations. By understanding these differences, healthcare workers
have the opportunity to meet and exceed patient expectations. If patients feel they are being
misunderstood, ignored, or treated poorly, they may take their business elsewhere.
Cultural Factors to be Aware Of:
1. Country of Origin- most people who live in the United States have roots in other
countries. How long a person has lived here may affect his or her view toward health.
2. Preferred Language- patients who are encouraged to talk or read about care in their
own language may feel more at ease and understand their care better.
3. Views of Health- the patient may see illness as having a supernatural cause, such as
punishment for sins, needing a certain traditional care, such as herbal remedy or
specific diet.
4. Community Style-verbal and non-verbal styles may differ. For example, culture may
affect how, or whether a patient expresses pain.
5. Family and Community Relations- a patient may expect certain people to be involved
in his or her care, or allowed to remain with them.
6. Food Preferences- religious, healing, and other cultural practices all affect what foods
a patient may eat or avoid.
7. Religion- a patient’s religion may affect his or her consent to treatment, schedule of
care (because of certain prayer practices), birth and death practices.
Understanding patterns of cultural behavior and valuing differences are important to
healthcare workers because they provide explanations for behaviors related to life
events. Significant life events are birth, death, puberty, child bearing, child rearing,
and illness. The Center complies with Patient’s Rights, which specifically state that
patients are allowed to exercise cultural and spiritual beliefs that do not interfere with
well-being of others or themselves. Doing a good job as a healthcare worker means
acknowledging, understanding, and supporting the many cultural, social and religious,
etc differences in our patients, their families, and customers with whom the Center
comes into contact.

Communicating with Non-English Speaking Patients:


The Center is sensitive to communicating with non-English proficient patients and
attempts to be proactive in meeting their needs. For the patient, the need to be clearly
understood can’t be understated- especially in a surgical environment where there is
anxiety and fear. Having access to an interpreter can help put the patient at ease, which
facilitates treatment and compliance. Knowing how to overcome a language barrier
and being prepared to do so is imperative in order to handle the situation with ease.
The following are methods the Center has available to meet this challenge:
1. ATT Language Line- dial 1-800-528-5888.
2. List of in-house members and the language in which they are proficient
3. Pain Scales available in over 20 languages

CULTURAL COMPETENCE

Cultural competence refers to the knowledge, attitudes, and skills that enable individuals
and organizations to render services to all cultures in an effective and respectful manner.
There are many determinants of culture. One determinant is ethnicity, which refers to an
individual’s country of origin, race, and religion. However, even in the same ethnic groups,
cultural practices and beliefs can vary greatly. Age, education, length of time in the United
States, and personality differences can cause great variance in how one’s culture is expressed.
Other important factors are gender, socioeconomic status, sexual orientation, physical or mental
status, and geographic differences within the United States.
Language itself is the most obvious barrier to communication, especially when slang,
technical jargon, and abbreviations are used. Non-verbal communication may also present
barriers. Smiles, silence, gestures, nodding, eye contact, and body language can all cause
misunderstandings.
Another barrier is stereotyping, which is judging individuals on their perceived culture.
This is not only unfair, but also often inaccurate. Stereotypes are inflexible assumptions about an
individual based on group membership. Our stereotypes are often formed while we are growing
up through information and misinformation given to us from our families and friends.
In contrast to stereotyping is generalizing, which can be useful. This begins with an initial
assumption, but then leads to getting more complete information to determine if the assumption
actually fits the individual in question.
Here are some ways to improve cross-cultural understanding:
• Begin by being more formal with patients who were born in another culture. The
American custom of using first names is often seen as disrespectful.
• Looking a person in the eye is not done in many cultures. Many Americans
interpret lack of eye contact as dishonesty; to some cultures it is a sign of respect.
• Some cultures will not ask questions if they do not understand. Be sure the
individual understands you by asking open-ended questions, such as “Tell me
how you are going to do this”, or asking for a return demonstration.
• Never laugh at or belittle another person’s cultural beliefs or practices. Besides
being very rude, this will certainly end any open and honest communication.
• Speak slowly, not loudly. Remember the problem is usually comprehension, not
hearing ability. A loud voice implies anger in many cultures.
• Avoid difficult or uncommon words or idioms. An example of an idiom would be
“in the nick of time”. These expressions are often misunderstood.
• Avoid questions that can be answered by a “yes” or “no”. In some cultures, “yes”
can merely mean the patient heard the question. Try to begin questions with
what, where, why, how, and when so you can be sure the question was
understood.
• Face the individual when talking. Use gestures, pictures, or facial expressions. If
the individual’s face indicates a lack of understanding, try restating the
information in a different way.
• Be patient and avoid interruption. It may take longer for a person of another
culture to express his/her thoughts.

Remember, the first Core Standard of the Accreditation Association for Ambulatory
Healthcare is “Rights of Patients”. And item A under this standard states “Patients are
treated with respect, consideration, and dignity”.
Cultural competence is an integral part of this standard.
REVIEW AND REVISE LOOK-ALIKE/SOUND-ALIKE DRUG LIST ANNUALLY
POLICY: LOOK-ALIKE/SOUND-ALIKE DRUGS

OBJECTIVE:
• To make every effort to avoid medication errors.
• To prevent errors involving the interchange of look-alike/sound-alike drugs used.
Procedure:
• The Center will annually review a list of look-alike/sound-alike drugs used in the Center.
• The list will be posted at the medication station to alert the nursing staff and physicians of
medications most likely to be confused.
• All medications that are deemed as medications at risk of being confused will not be
stored in the same bin.
Problematic Drug List
Potential Problematic Drugs Generic Name Trade Name
Sound-alike
Anzemet/Aldomet Dolasetron mesylate Anzemet
Aldomet Methyldopa
Aminophylline/Ampicillin Aminophylline
Ampicillin Alpen, Amcil, Omnipen
Celebrex/Cerebryx Celeoxib Celebrex
Fosphenytoin Sodium Cerebryx
Injection
Diltiazem/Digoxin Diltiazem Hydrochloride Cardizem
Digoxin Lanoxin
Diprivan/Ditropan Propofol Diprivan
Oxybutynin chloride Ditropan
Dobutamine/Dopamine Dobutamine Hydrochloride Dobutrex
Dopamine Intropin
Ephedrine/Epinephrine Ephedrine I-Sedrin Plan
Epinephrine Asmolin, Asthma-meter,
Primatene Mist, Sus-phrine
Toradol/Foradol Toradol Ketoralac Tromethamine
Formoterol fumarate Foradil
Morphine/Hydromorphone Morphine
Hydromorphone Sulfate Dilaudid Sulfate
Hydromorphone Dilaudid Hydrochloride
Hydrochloride
Nitroglycerine/Nitroprusside Nitroglycerine Cardabid, Gly-Trate
Nitro-bid, Nitrol, Nitroprn,
Nitrospam, Nitrotest
Sodium Nitroprusside Nipride
Norepinephrine/Epinephrine Levarterenol Bitartrate Levophed Bitartrate,
Norepinephrine Bitartrate
Epinephrine Asmolin, Asthma-meter,
Primatene Mist, Sus-phrine
Solumedrol/Depomedrol Methylpredinisolone Solumedrol
Sodium Succinate
Methylprednisolone Depo Medrol
Acetate
Diltiazem/Digoxin Diltiazem Hydrochloride Dobutrex

Digoxin Lanoxin

Pain Management- An Overview

Historical Perspective

The French surgeon Daetigus wrote: “Were we to imagine ourselves suspended in timeless
space over an abyss out of which the sounds of revolving earth rose to our ears, we would
hear naught but an elemental roar of pain uttered as with one voice by suffering mankind”
(Bonica, 1990, pg2)
The evolution of pain began with primitive societies in B.C.
By A.D., the Mesopotamians developed the first multidisciplinary approach to pain
management- members may have included a shaman, a priest, a physician, and an exorcist!
The Egyptians introduced a type of electrotherapy application that involved placing an
electric fish from the Nile over the wound- a very early prototype to the TENS
(transcutaneous electric nerve stimulator)!
Ancient China contributed a current modality for pain management during 2800-2600 B.C.
Huang Ti developed acupuncture therapy and practice based on Yin
(negative/feminine/passive) and Yang (positive/masculine/active).
Ancient Greeks such as Aristotle and Hippocrates studied the senses relative to the origin
and nature of sensory data.
The Middle Ages brought religious beliefs rather than reason as the influencing factor for
the practice of medicine.
Then the Renaissance produced a physician during the early to mid-1500s by the name of
Paracelsus. He advocated physical therapies such as massage, exercise, and electrotherapy.
The 16th-19th Centuries showed slow progress relative to pain management. Then in the
mid-19th Century major advances took place in 3 fields:
• Administration of opiates and hypnotics
• Inhalation of analgesic and anesthetic gases
• Administration of local anesthetics by various means
In addition, physical therapies re-emerged in pain management, including such things as
light therapy, hydrotherapy, and thermotherapy.
Key contributors to the surgical approach to pain management during this period include:
• Abbe- introduced posterior rhizotomy
• Spiller and Frazier- performed neurectomy and cordotomy
The 20th Century produced the first studies on chronic pain. Pain centers began to evolve,
as did the organization of pain societies.
By 1992, policies and legislature were enacted to address various types and aspects of pain.
As we entered the 21st Century, pain was recognized by JCAHO as the “Fifth Vital Sign”,
and organizations began focusing on institutional management of pain as well as standard
for pain assessment and management.
Cultural and Communication Considerations

Two factors having a major influence on pain are culture and communication.
Culture as defined by Weber, is the beliefs, values, and practices shared by a group or
community of people. This learned behavior is passed down from one generation to the
next.
Communication as defined by Nance is a transactional process whereby two or more
people engage in the creation of meaning. It involves generating and receiving messages.
In an effort to prevent these two major influences from resulting in ineffective pain
management, the following 8 areas should be considered: *

1. Language can patient communicate with providers effectively?


when using interpreters, consider gender and age of patient
and interpreter.

2. Eye/Physical direct eye/physical contact may be considered


Contact disrespectful in some cultures.

3. Personal Space be aware of personal space issues.


close personal space may be reserved for family
members only.

4. Speech Style tone and pace of speech may be culturally specific.


silence may indicate respect or lack of understanding.

5. Non-verbal watch for non-verbal cues that may indicate lack of


Communication understanding.
also may be important in pain assessment (i.e.
grimacing, immobility)

6. Spiritual/Religious may be important to the healing process.


Beliefs allow time for personal spiritual practices such as
praying or rituals.

7. Health Beliefs are there cultural disparities between practitioners’


and patients’ health beliefs?

8. Familial who are the decision makers and/or caretakers?


Relationships include them in the treatment process.

*Reference: Core Curriculum for Pain Management Nursing, ASPMN, 2002


Legal Considerations
Patients’ Rights- The right to appropriate assessment, treatment, education, and
alternate therapies to treatment are part of the Patient Bill of Rights. A statement
regarding this right has been added to the Center’s Patients’ Rights document, and is
posted throughout the Center for patient reference.
Patient Advocacy- Nursing staff has an obligation to the patient not only to acknowledge
and assess pain, but to offer any measure that may be within their scope of practice to
provide relief. Policies and procedures in the Centers outline this patient advocacy
approach.
Communication- Certain groups of patients may not be able to communicate pain
management needs: (I.e. children, speech or hearing impaired patients,
intubated patients, patients with a language barrier.)
The Center is provided with various tools to enhance communication with these groups
relative to pain assessment/management/education. Multilingual 0-10 pain scales as well as
Wong face scales are available. The AT&T Language Line may be a useful tool in some
situations; the number is posted in the Center for reference. Finally, The Center might
have employees that are bi- or multilingual that may act as interpreters. A list of these
employees and the language they speak are available in the center for reference.

Pain Management Guideline Reference


Listed below are some of the nationally recognized guidelines and their sponsoring
organizations/societies:
• Acute Pain Management Guidelines (1992) – The Agency for Healthcare Policy and
Research (AHCPR); now known as The Agency for Healthcare Research Quality
(AHRQ)
• Cancer Pain Management Guidelines (1994)- same as above
• Acute Pain Management in the Perioperative Setting (1995)- The American Society
of Anesthesiologists (ASA)
• Cancer Pain Management (1996)- same as above
• Chronic Pain Management (1997)- same as above
• Guide for the Management of Acute and Chronic Pain in Sickle-Cell Disease (1999)-
The American Pain Society (APS)
• Standards of Clinical Nursing Practice for Pain Management (1996)- The American
Society of Pain Management Nurses (ASPMN)
• Standards of Clinical Practice for the Specialty of Pain Management Nursing
(1998)- same as above
POLICY: ASSESSMENT AND MANAGEMENT OF ACUTE PAIN
Purpose:
To clarify the assessment and management of acute pain in the Center.
Procedure:
Patients will be asked to scale their pain upon admission preoperatively, postoperatively, and
when warranted by changes in a patient’s condition and self reporting of pain. Results
will be documented in the patient’s chart. Criteria for the assessment of pain will include
but not be limited to:
the pain intensity/severity, character, frequency/pattern or both, location, duration,
precipitating factors, responses to treatment and the personal, cultural, spiritual,
and /or ethnic beliefs that may impact the individuals perception of pain;
a written procedure for the monitoring of a patient’s pain
A written procedure to insure the consistency of pain rating scales
A procedure for educating the patients about pain management
A written procedure for systematically coordinating and updating the pain treatment
plan of a patient in response to documented pain status.
Staff education:
All staff will be educated during initial orientation and annually thereafter regarding the
facility’s policies and procedures on pain assessment and management. This training will
include behaviors potentially indicating pain, personal, cultural, spiritual and or ethnic
beliefs that may impact a patient’s perception of pain, new equipment, new technologies
to assess and monitor a patient’s pain status and patient’s rights. Records of attendance
will be for each program.
Consistency of pain rating scales:
The McGill Pain scale will be used to make every effort to ensure consistency.
The patient will be asked to scale their pain from 1 to 10. 1 being the least amount of pain
and 10 being the most severe pain. The non verbal pain scale will be used to demonstrate
this concept to the patient. The nurse will explain to the patient that 10 would be
intolerable pain to make every effort to ensure that a true indication of the patient’s pain
level is obtained.
The non-verbal pain scale will be utilized to help patients scale his/her pain. The pain scale
is also available in the Center in other languages.
The score will be documented in the chart record.
Educating the patient about pain management:
Each patient will be given a pain pamphlet upon admission. This will explain the procedures
that will be used in the Center to make every effort to keep the patient as comfortable and pain
free as possible during his/her stay.
The nurse will go over the pain management protocol with the patient prior to the procedure
either during the preoperative call or upon admission to the Center.
The nurse will answer any questions regarding pain management procedures prior to the
procedure taking place.
Written Procedure for monitoring the patient’s pain:
Preoperative:
The preoperative nurse will assess the patient’s level of pain on admission and interview the
patient to determine methods that work best for pain relief for the patient. This
assessment will be documented in the chart record.
The O.R. nurse, physician and/or anesthesiologist if applicable, will use the information
provided when determining pain management techniques and medications to be ordered
postoperatively.
Anesthesiologist/Physician:
The anesthesiologist and/or physician will interview the patient preoperatively to assess the
need for pain medication and other methods of pain relief that work best for the patient.
The anesthesiologist and/or physician will write orders for pain medications that may be used
to provide pain relief for the patient in the PACU.
The orders for pain medications to be used in the Center will distinguish in what order the
medications are to be given.
O.R. Nurse:
The O.R. nurse, physician and/or anesthesiologist will document this information clearly in
the chart record and communicate this information to the PACU nursing staff that will be
caring for the patient.

PACU Nurse:
The PACU nurse will manage the patient’s pain postoperatively as ordered by the physician
and/or anesthesiologist. The use of alternative pain management techniques should be
made part of the patient’s pain management plan.
The nurse will evaluate the patient’s pain level postoperatively and prior to discharge. This
will be documented in the chart record. Patients scaling their pain level above tolerable
levels prior to discharge will be reevaluated by the anesthesiologist.
Medication will be prescribed to try to bring the patient’s level of pain to a tolerable level
whenever the physician feels this is appropriate.
The patient will only be discharged when pain is at a tolerable level. If pain is not tolerable
the patient will be admitted to the hospital for appropriate follow up care.
Patients will be instructed during discharge instruction to call the Center if pain is unrelieved
by the medication prescribed by their physician.
When the patient makes a complaint of pain unrelieved by medication prescribed the nurse
taking the call will instruct the patient to call his/her physician. If the patient is unable to
contact his/her physician he/she will be instructed to call the Surgery Center back for
assistance.
All complaints of pain not relieved by medication prescribed will be documented on the
patient complaint log and followed up to ensure that this process is being followed.
Pain management continuous quality improvement
• The facility’s continuous quality improvement program shall include a systematic review
and evaluation of pain assessment, management and documentation practices. The
Center will collect and analyze data in order to evaluate outcomes or performance. Data
analysis shall focus on recommendations for implementing corrective actions and
improving performance.

HAVE BLOOD BANK INSERVICE ANNUALLY


UPDATE SKILLS CHECKLIST ANNUALLY
POLICY: PREVENTION OF PATIENT FALLS
Purpose/Objective:
• To make every effort to prevent patient falls in the Center.
• To make every effort to provide safe patient care.
Procedure:
• The Patient or legal representative will be asked to inform the nurse if he or she is at risk
for falling upon admission.
• A gold star shall be put on the patient’s chart if the patient is thought to be at risk for a
fall.
Information:
Anybody can fall. Although high-risk patients tend to be the elderly, other patient populations
can also experience a fall. For example, a child with a broken leg, multiple sclerosis, or cerebral
palsy may be a fall risk.
Other factors that may lead to a fall in addition to physical limitations include:
• Anxiety
• Unfamiliar location
• Facility-provided slippers, which may not give the same support as patient’s shoes.
Observation:
Observation is the key to helping avoid falls.
Be careful with patients who look or report that they are UNSTEADY ON THEIR FEET. A lot
of elderly patients will tell you if they are unsteady.
Watch for a WOBBLY GAIT or if patients tend to hold onto things as they move.
Assessment:
Ask assessment questions upon patient’s arrival to the facility.
1. Do you have a wobbly gait?
2. Are you unsteady on your feet?
3. Have you fallen before and when?
4. Do you have back problems?
5. Do you need assistance moving around?
6. Do you have difficulty getting up from a sitting position or need to hold onto the furniture
to walk?
7. Have you fallen at home since your last visit?
8. Do you become dizzy or unbalanced when you change your position?
9. Do you have new vision problems?
Information to give to patients:
Ask the patient to help you prevent falls in the surgery center by:
 Wearing glasses and or hearing aids if needed
 Use a walker, cane or wheelchair if needed
 And by letting staff members know if assistance is needed.

To help prevent falls when you are in the Center:

Please:
 Wear your glasses and or your hearing aid
 Use your walker, cane or wheelchair

HELP PREVENT FALLS!

• Do you have a wobbly gait?


• Are you unsteady on your feet?
• Have you fallen before?
• Do you have back problems?
• Do you need assistance moving around?
• Do you have difficulty getting up from a sitting
position or need to hold onto the furniture to walk?
• Do you become dizzy or unbalanced when you
change your position?
• Do you have new vision problems?
 Let us know if you need assistance, we are
never too busy to assist you.

POLICY: CONTINGENCY PLAN

A contingency plan is a routinely updated plan for responding to a system emergency that
includes performing backups, preparing critical facilities that can be used to facilitate continuity
of operations in the event of an emergency, and recovering from a disaster.

A contingency plan should address the potential interruption of claims processing and claims
payment due to problems with transmission using the new HIPAA transaction standards. Just as
each covered entity is different, there is no single contingency approach that would be
appropriate for all situations. Regardless, HIPAA requires that all contingency plans include:
• An application and data-criticality analysis
• Data-backup plan
• Disaster-recovery plan
• Emergency-mode operation plan
• Testing and revisions procedure

Applications and data-criticality analysis:


This is a formal assessment of your sensitivities and vulnerabilities and the security of programs
and information. The analysis should assess how your facility receives, manipulates, stores, and
transmits electronic and hard-copy information.
How to mimic your electronic system on paper.

Procedure:
The receptionist will make copies of all paperwork needed to continue patient care in the Center.
In the event that a disaster occurs and there is no electricity, hard copies will be available to
continue working. No further patient care will be started. The case in progress will be
completed and all patients sent home or to the transfer facility for follow-up care. If the power is
returned to normal the Administrator/Director of Nursing in coordination with the Medical
Director or designee may give the order to continue patient care in the Center. In the event of a
community disaster, fire or evacuation the fire official and police shall be contacted to approve
the order to reenter the building and continue patient care.

Disaster-recovery plan
This is the actual process through which facilities restore lost data in the event of fire, theft,
vandalism, natural disaster, or system failure.

How will systems be brought back online both electronically and physically in the event of a
disaster?
Back up generators are on site to automatically transfer the building to normal power.

Will storage of electronic backup files be at an alternate site?


There are no files in the Center that require back-up off site. The receptionist will make a hard
copy of the following day’s schedule for the Administrator/Director of Nursing or designee.
This will be faxed to the Billing office and secured. If not needed, the schedule will be shredded
the following day by the billing office staff member in charge of the account.

Is there a Data-backup plan?


The data-backup plan deals specifically with electronic PHI.
PHI will be backed up and stored by the Billing Company.
This information is also available in the physicians’ offices in case of loss.

Is there an Emergency-mode plan?

In the case of an emergency, the case in progress will be completed and all patients sent home or
to the transfer hospital.

Is there a testing revision procedure?


Annually a test will be made of the contingency plan and revisions will be made as necessary.
POLICY: SURGICAL SITE
Purpose:
Surgical site verification requires a standard procedure with multiple checks in the system to
minimize the risk of surgery to the incorrect site/side. The policy will be a coordinated effort
between the attending surgeon of record and circulating nurse. All persons involved in the
patients care will confirm the appropriate site and never assume the task has been correctly
performed by another individual. This policy applies to all surgical cases involving laterality,
multiple structures (fingers, toes, lesions) or levels (spine, pain management).
Procedure:
• The surgeon will document the correct side in the medical record and sign the surgical
consent with the appropriate site documented.
• The patient will be asked to identify the correct side/site of surgery unless he/she is
unable to effectively communicate with the staff. If the patient is unable to effectively
communicate with the staff, the surgeon will determine the correct side/ site using
pertinent available information. The consent will be confirmed by the circulating nurse in
the pre-operative holding area. Two patient identifiers will be used to confirm the
side/site. Acceptable identifiers include: DOB, Social Security number, Medical Record
ID number, and Name of patient.
• When the patient is in the pre-operative area, the surgeon will place his initials on the
correct side/site. The appropriate side will be confirmed by the circulating nurse when
the patient is in the operating room.
• A time out will be taken and final confirmation will take place verbally between the
surgeon, circulating nurse, scrub nurse, and anesthesia provider as applicable after the
patient is draped for surgery. The correct patient position will also be verified at the time
out. It is the ultimate responsibility of the surgeon to ensure the time out takes place.
• It will be the responsibility of the circulating nurse to bring the consent form to the time
out. Upon verification he or she will document that the time out has taken place on the
O.R. record.
• Review: Time Out
• Correct patient identity using 2 identifiers
• Correct side and site. The surgeon signs the correct side/site involving the patient if
possible. Identifiers match consent/x-rays. X-rays displayed correctly.
• Agreement on the procedure to be done. Surgical team agrees on the procedure by
checking the consent and asking the patient if possible. Assessment made regarding: the
need for antibiotics following review of medications patient is presently taking and any
allergies he/she may have, the need for implants and/or special equipment that may be
needed ensuring it is available. The risk for a fire is assessed with particular attention to
oxygen sources and electrical equipment being used.
• Correct patient position. Is the patient positioned correctly for the surgery?
Documentation. The circulating nurse documents the time out has occurred

IN THE EVENT OF A DISCREPANCY:


1. STOP (DO NOT PROCEED ANY FURTHER)
2. At least 2 members of the O.R. team will review the chart and check the H&P, admitting
diagnosis and consent. The Administrator/Director of Nursing or designee will be notified
immediately.
3. The surgeon will review the chart and confirm the correct site and procedure.
4. If the discrepancy cannot be resolved the patient and family members will be consulted by the
surgeon and the patient will be cancelled and rescheduled if necessary.

Discovery of wrong side/site surgery:


• The patient’s well-being must remain of utmost importance.
• Appropriate steps will be taken to return the patient to the pre-operative condition.
• The desired procedure at the correct site will be performed unless there are medical
reasons not to proceed.
• The patient, and the patient’s family, if appropriate, should be advised as soon as
reasonably possible, of what occurred and the likely consequences.
• If, after the surgical procedure has been completed, it is determined that the surgery was
performed at the wrong site, the surgeon should: as soon as reasonably possible, discuss
the mistake with the patient and, if appropriate with the patient’s family and recommend
an immediate plan to rectify the mistake unless there is a medical reason not to proceed.
• An incident report will be filed and sent to Risk Management.
Time Out  Correct patient identity using 2 identifiers
 Correct side and site. The surgeon signs the correct side/site involving the patient
if possible. Identifiers match consent/x-rays. X-rays displayed correctly.
 Agreement on the procedure to be done. Surgical team agrees on the procedure
by checking the consent and asking the patient if possible. Assessment made
regarding: the need for antibiotics following review of medications patient is
presently taking and any allergies he/she may have, the need for implants and/or
special equipment that may be needed ensuring it is available. The risk for a fire
is assessed with particular attention to oxygen sources and electrical equipment
being used.
 Correct patient position. Is the patient positioned correctly for the surgery?
Documentation. The circulating nurse documents the time out has occurred
IN THE EVENT OF A DISCREPANCY:
1. STOP (DO NOT PROCEED ANY FURTHER)
2. At least 2 members of the O.R. team will review the chart and check the H&P, admitting
diagnosis and consent. The Administrator/Director of Nursing or designee will be notified
immediately.
3. The surgeon will review the chart and confirm the correct site and procedure.
4. If the discrepancy cannot be resolved, the patient and family members will be consulted by the
surgeon and the case will be cancelled and rescheduled if necessary.
IN-SERVICE: PROPOFOL
Purpose/Objective:
Since there is a potential for rapid profound changes in sedative/anesthetic depth and lack of
antagonist medications for agents such as Propofol, it is not always possible to predict how an
individual patient will respond. Even if moderate sedation is intended, patients receiving
propofol should receive care consistent with that required for deep sedation.
Procedure:
An anesthesiologist should be involved in the care of every patient undergoing anesthesia if
possible. If this is not possible, non-anesthesia personnel who administer propofol should be
qualified to rescue patients whose level of sedation becomes deeper than initially intended and
who enter, if briefly, a state of general anesthesia.
Rescue:
Rescue of a patient from a deeper level of sedation than intended is an intervention by a
practitioner proficient in airway management and advanced life support. The qualified
practitioner corrects adverse physiologic consequences of the deeper than intended level of
sedation and returns the patient to the originally intended level. It is not appropriate to continue
the procedure at an unintended level of sedation.
Physician present:
The physician should be physically present throughout the sedation and remain immediately
available until the patient is medically discharged form the post-procedure recovery area.
Education/training:
The practitioner administering Propofol for sedation/anesthesia should, at a minimum, have the
education and training to identify and manage the airway and cardiovascular changes which
occur in a patient who enters a state of general anesthesia, as well as the ability to assist in the
management of complications.
The practitioner monitoring the patient should be present throughout the procedure and be
completely dedicated to that task.
Monitoring:
During administration, patients should be monitored without interruption to assess level of
consciousness, and to identify early signs of:
o Hypotension
o Bradycardia
o Apnea
o Airway obstruction and/or
o Oxygen desaturation.

 Ventilation
 oxygen saturation
 heart rate and
 blood pressure

should be monitored at regular and frequent intervals.

Monitoring for the presence of exhaled carbon dioxide should be utilized when possible, since
movement of the chest will not dependably identify airway obstruction or apnea.
Age-appropriate equipment:
Age-appropriate equipment must be immediately available for the maintenance of a patent
airway, oxygen enrichment and artificial ventilation in addition to circulatory resuscitation.
The warnings section of the drug’s package insert for Diprivan states that propofol used for
sedation or anesthesia should be administered only by persons trained in the administration of
general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.

AANA-ASA Joint Statement Regarding Propofol Administration:


Whenever Propofol is used for sedation/anesthesia, it should be administered
only by persons trained in the administration of general anesthesia, who are
not simultaneously involved in these surgical or diagnostic procedures. This
restriction is concordant with specific language in the Propofol package insert,
and failure to follow these recommendations could put patients at increased
risk of significant injury or death.
REVIEW AND REVISE IF NEEDED

High Alert Medication List


Published February, 2004
Institute for Safe Medication Practices
http://www.ismp.org

Definition: a drug that has a high risk of causing injury to patients when misused. Errors with the
drugs are not necessarily more common than with other drugs, but their consequences can be
more devastating.
Identification of these drugs and initiating safeguards may reduce the risk of errors. These
safeguards may include such things as limiting access, auxiliary labels, and standardization of
how these drugs are ordered, prepared, and administered.

The updated list includes the following:


Class/category of medications:
• Adrenergic agonists, IV (e.g. Epinephrine)
• Adrenergic antagonists, IV (e.g. Propanolol)
• Anesthetic agents, general/inhaled/IV (e.g. Propofol)
• Cardioplegic solutions
• Chemotherapeutic agents, parenteral and oral
• Dextrose, hypertonic (20% or greater)
• Dialysis solutions, peritoneal and hemodialysis
• Epidural or intrathecal medications
• Glycoprotein IIb/IIIa inhibitors (e.g. Eptifibatide)
• Hypoglycemics, oral
• Inotropic medications, IV (e.g. Digoxin, Milrinone)
• Liposomal forms of medications (e.g. liposomal Amphotericin B)
• Moderate sedation agents (e.g. Midazolam)
• Moderate sedation agents, oral, for children (e.g. Chloral Hydrate)
• Narcotics/opiates, IV and oral (including liquid concentrates, immediate and sustained
release)
• Neuromuscular blocking agents (e.g. Succinylcholine)
• Radiocontrast agents, IV
• Thrombolytics, fibrinolytics, IV (e.g. Tenecteplase)
• Total parenteral nutrition solutions

Specific medications:
• Amiodarone, IV
• Colchicine injection
• Heparin injection (low molecular weight)
• Heparin, IV (unfractionated)
• Insulin, subcutaneous and IV
• Lidocaine, IV
• Magnesium sulfate injection
• Methotrexate, oral, non-oncologic use
• Nesiritide
• Nitroprusside sodium, injection
• Concentrated Potassium chloride injection
• Potassium phosphates injection
• Sodium chloride, hypertonic (greater than 0.9% concentration)
• Warfarin
REVIEW AND REVISE POLICY: ABBREVIATIONS NOT TO USE
REVIEW FORMULARY AND REVISE AS NECESSARY
REVIEW AND REVISE EMERGENCY CART INVENTORY AND HAVE APPROVED BY
THE MEDICAL DIRECTOR
REVIEW AND INSERVICE EVENT RELATED STERILITY POLICY
SIGN OFF POLICY AND PROCEDURE MANUAL ANNUALLY BEFORE IT IS
OUTDATED
Administration - Incident Report
Nosocomial Infections
Infections require:
• A germ
• A carrier
• A way into the body
• A person without resistance who becomes infected

Infection causes tissue injury

A Nosocomial Infection is:


• Not incubating on admission
• Incubating at time of admission that is related to previous admission

Community acquired infection is:


• Present on admission
• Incubating at the time of admission and not related to previous admission

Infections can be:


Endogenous
Examples are:
Inside of the host
o Skin infections- S aureus
o Perineum infections-E coli
or
Exogenous
Outside the host
o People
o Food
o Flowers
o Instruments

5-10% of patients admitted to hospitals have nosocomial infections

Medicine and surgery patients are in the high risk population


Patients over 65 years more susceptible

The patients at lowest risk are:


Pediatric patients

Highest incidence is in large teaching hospitals


Lowest incidence is in non-teaching hospitals

Infection Control is:


Surveillance
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Method of collecting, consolidating and analyzing data concerning the distribution and
determinants of a given disease or event.

How do you find infections:


• Actively you look
• Passive reported to you
• Prospective now, while patient in hospital
• Retrospective later in medical record review

Chart Review:
A. Look for S&S of infection
• Culture Reports
• Colonization vs infection
• X-rays
• Scans
• WBC’s
• ABG’s
• Diagnosis by surgeon

S&S are:
• Pus
• Cough
• Temp Elevation
• Redness
• Swelling
• Pain
B. Review all reports:
o Endoscopy
o Bronchoscopy
o CT Scan
o Ultrasound
o MRI
If it is documented by a physician it is an infection according the CDC.

C. Ask these questions:


• Was it incubating on admission?
• Where was the source?
• Exogenous-Endogenous?
• Was preventable or inevitable?
• Can we identify it after discharge?
D. Set up Report Mechanism
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E. Design an Infection Worksheet that works for your facility

F. Make your ASC aware of your work in preventing nosocomial Infections.

Prevention and Control of Nosocomial Infections

Wash Hands

Professional Standards include:


• Professional Accountability
• Qualifications
• Professional Development
• Leadership
• Ethics

Practice Standards:
• Infection Prevention and Control Practice
• Epidemiology
• Surveillance
• Education Consultation
• Performance Improvement
• Program Management and Evaluation
• Fiscal Responsibility
• Research

Infection Prevention “It’s in your hands”

Nosocomial infections are up to 30 days postoperatively

Note: Pins/Rods: up to a year infection is due to surgical site


Administration - Incident Report
In-service: Patient Safety Act (A review)
The Patient Safety Act focuses on a culture of safety. Patient safety must be the highest priority.
A blame –free environment must be maintained and the focus should be to improve and redesign
systems and processes.
The Center should be focused on:
 Strengthening patient safety

 Promoting a systematic analysis

 Emphasizing confidentiality and

 Setting up a reporting system

A Patient safety Plan and Committee must address the issues.


 Patients must be informed when medical errors occur

 There must be mandatory reporting of serious preventable events and

 There should be anonymous voluntary reporting of less serious events

8:43 E addresses the patient safety and pain regulations.


The regulations state that the facility shall notify the Department immediately (no later than 3
hours) by phone of any event occurring within the facility that jeopardizes the health and safety
of patients or employees.
The administrator must be informed of all findings.
The phone number to report to: 800-792-9770 Hot line to report
You must also confirm in writing within seven days of event
There must be ongoing training for facility personnel annually
The Committee must meet quarterly and meeting must be separately written

What should be reported?


Information concerning injuries to patient/staff, disruption of services, extent of damages and
corrective actions taken.
Resignation or termination of employment of the administrator.
Name and qualifications of administrator’s replacement. (This must be writing to Department
within seven days of resignation/termination.)
All alleged or suspected crimes, which endanger the life or safety of patients or staff and which
have also been reported at the time of occurrence to the local police department.
Loss of significant reduction of water, electrical power, or any other essential utilities necessary
to operate the facility.
All fires, disasters, accidents or other unanticipated events which result in:
 Serious injury or death of patients or staff

 Evacuation of patients from the facility

 Closure of the facility for six or more hours


Administration - Incident Report
 Occurrence of epidemic disease in the facility

Note: The DHSS is required to investigate all complaints


The Patient Safety Committee must be comprised of the:
 Medical Director

 Director of Nursing

 Risk Manager and ad hoc members to contribute to RCA

Note: There are protections for facility deliberations under act


Event/RCA Reporting
 Time frame: 5 business days

 RCA due 45 calendar days after report

Download form HCQ-1 Report of Serious Preventable Adverse Event In a new Jersey Licensed
Health Care Facility
www.NJ.gov/health/ps

Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility:
Submit a Root Cause Analysis (RCA)
Identify the contributing causes of adverse events
Ensure that it is a focused review
Identifying prevention strategies
(What happened? why? and how to prevent it from reoccurring?)
RCA Team should include:
 Staff knowledgeable about processes involved in the event

 Front line staff

 Staff involved in event

Information included should include:


 Pt hx related to event

 Facts of the event in chronological order (specific details)

 Date, time location

 Effect on pt

 Identity of staff (by title not name)

 Similar event in past 3 years?

Triggering Questions should include:


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 Human Factors/Training

 Human Factors Fatigue/Scheduling

 Environment/Equipment

 Rules/Policies/Procedures

 Barriers

5 Rules of Causation:
 Clearly show “cause and effect

 Avoid negative descriptions

 Human error must have a preceding cause

 Violations of procedure must have a preceding cause

 Failure to act only if pre-existing duty

Causality Statement
__________increased the likelihood of _____________happening which led to the adverse
event.
Action Plan
• Address the root causes

• Specific and concrete

• Doable

• Consult process owners

Sample of levels of action plans:


• Weaker action: A memo

• Intermediate action: A checklist

• Stronger action: Visual confirmation

Action plan
1. Create action plan for each causal statement

2. Be specific and concrete

3. Implement the Action Plan


Administration - Incident Report
4. Choose a time frame

5. Review Action Plan

6. Monitor the results

7. Ensure the problem is solved or put another action plan in place.

An example of a Causality Statement is:


The lack of or failure to________related to_________ and may have led to___________

Actions/Prevention strategies
Monitoring
Root Cause Analysis Grid
Causality Statement Action or Prevention Monitoring
Strategy
Cause and Effect Specific, measurable Includes specific time
Relationship actions, implemented frames and
No negative within 45 days of responsible staff
descriptions incident, or are Need to confirm
Human Errors/Policy currently being actions have taken
Violation-must have implemented place
a preceding cause Include time frames,
Procedures responsible staff
deviations
Failure to act only
causal if there is pre-
existing duty to act
Administration - Incident Report
Causality Statement Action or Prevention Monitoring
Strategy

POLICY: MRSA and MDRO


Infection Control Plan for Managing High Risk Infections -
Care of Patients with Resistant Organisms - MRSA and other MDRO in Ambulatory Care
Settings
Purpose:
To provide guidelines for staff in the ambulatory care setting to reduce the risks of cross
contamination with multiple drug resistant bacteria from patients to staff, staff to patients, others,
or the environment of care.

Rationale:
Multidrug-resistant organisms (MDRO), including methicillin-resistant Staphylococcus aureus
(MRSA), vancomycin-resistant enterococci (VRE) and certain gram-negative bacilli (GNB) have
important infection control implications and affect all healthcare settings.
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Patients colonized or infected with these organisms can safely be cared for and managed in the
ambulatory setting by following appropriate infection control practices. CDC does not have
recommendations for pre-admission screening in non-hospital settings. In general, healthy
people are at low risk of getting infected with MRSA or VRE.

Infection Control Practices for Routine Patient Care

Hand Sanitizing: Hand sanitizing and hand washing compliance by staff and each person,
including visitors in the patient care units can NOT be overemphasized since DIRECT
CONTACT is the primary method of cross contamination with MRSA and other MDRO. It is
the single most important Infection Control and Prevention method.

Standard Precautions: These Infection Control Precautions should be used for all patient
care.
Hand hygiene: After touching blood, body fluids, secretions, excretions, contaminated
items; immediately after removing gloves; between patient contacts;
Gloves: For touching blood, body fluids, secretions, excretions, contaminated items; for
touching mucous membranes and non-intact skin;
Gown: During procedures and patient-care activities when contact of clothing/exposed
skin with blood/body fluids, secretions, and excretions is anticipated;
Mask, eye protection (goggles), face shield: During procedures and patient-care
activities likely to generate splashes or sprays of blood, body fluids, secretions, especially
suctioning, endotracheal intubation;

Contact (Isolation) Precautions: These are additional Expanded Infection Control


Precautions which INCLUDE Standard Precautions. The components of Contact Precautions
may be adapted for use in ambulatory facilities, especially if the patient has draining wounds or
difficulty controlling body fluids;
Patient placement: Separate the patient from other patients as soon as possible.
(Common waiting areas)
Place the patient in a private room or area, if possible.
Contact Precautions, cont’d:
When a private room is not available, place the patient in a room with a patient who is
colonized or infected with the same organism, but does not have any other infection (cohorting).
Another option is to place an infected patient with a patient who does not have risk
factors for infection.
At minimum, place patient at a station with as few adjacent stations as possible (e.g. at
the end or corner of the unit) and pull privacy curtains on both sides to create a visual barrier
which will serve as a reminder to staff that extra precautions are required;
Transport: When transport or movement of the patient within the facility is required,
ensure that infected or colonized areas of the patient’s body are contained and covered.
Administration - Incident Report
Gloves: Wear gloves whenever touching the patient’s intact skin or surfaces and articles
in close proximity to the patient (e.g. medical equipment, bed rails). Put on new gloves upon
entry into the room or cubicle.
Gowns: Wear a gown whenever anticipating that clothing will have direct contact with
the patient or potentially contaminated environmental surfaces or equipment in close proximity
to the patient. Put on the gown upon entry into the room or cubicle. Remove gown and wash /
sanitize hands before leaving the patient care environment. After gown removal, ensure that
clothing and skin do not contact potentially contaminated environmental surfaces that could
result in possible transfer of microorganisms to other patients or environmental surfaces.

Notify other healthcare personnel and/or facilities that provide care for the patient that the patient
is colonized/infected with a multidrug-resistant organism.

Environmental Cleaning and Sanitation


Select approved healthcare disinfectants. Follow directions on label for contact time in use.
EPA registered disinfectants or detergents/disinfectants that best meet the overall needs of the
healthcare facility for routine cleaning and disinfection should be selected. In general, use of the
existing facility detergent/disinfectant according to the manufacturer’s recommendations for
amount, dilution and contact time is sufficient to remove pathogens from surfaces of rooms
where colonized or infected individuals were located. This includes those pathogens that are
resistant to multiple classes of antimicrobial agents (MRSA, VRE, etc.).
Key points in addition to routine terminal cleaning of areas. (Concurrent sanitation and
disinfection)
Focus on frequent and between case sanitizing and disinfecting the high touch areas in
close proximity to the patient and the frequently touched surface areas (e.g. bed rails,
bedside tables, commodes, bathroom fixtures, and doorknobs).
Disposable disinfectant equipment and surface wipes are readily available and can be placed in
accessible locations in the patient care areas to allow staff to perform rapid equipment and
surface disinfection during the care hours of operation.

Disposable Items are discarded after single patient use.


Reusable equipment and devices: Place contaminated reusable noncritical patient-care
equipment in a plastic bag for transport to a soiled utility area for reprocessing.
Laundry/linen: Handle in a manner that prevents transfer of microorganisms to others and to
the environment;

Healthcare Workers with MRSA

Occasionally, healthcare workers can become persistently colonized with an MDRO, but these
healthcare workers have a limited role in transmission, unless other factors are present.
Additional risk factors that can facilitate transmission, include chronic sinusitis, upper
respiratory infection and dermatitis.
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Healthcare worker decolonization is indicated only as a prevention and control intervention when
a health care worker is chronically colonized with MRSA and has been epidemiologically
implicated in ongoing transmission of MRSA to patients.

Definitions of Terms relating to Bacteria and Microorganisms

CA-MRSA – Community Acquired - Methicillin/Oxacillin Resistant Staphylococcus aureus.


Presents most commonly as relatively minor skin and soft tissue infections, but severe invasive
disease, including necrotizing pneumonia, necrotizing fasciitis, severe osteomyelitis, and a sepsis
syndrome with increased mortality have also been described in children and adults. Most MRSA
strains isolated from patients with CA-MRSA infections have been microbiologically distinct
from those endemic in healthcare settings.
Colonization – Bacteria or organism is present in or on the body but is not causing illness.
ESBL – extended spectrum beta-lactamases (which are resistant to cephalosporins and
monobactams)
GNB – Gram negative bacilli
Infection – Bacteria or Organism is present and causing illness.
MDRO – Multidrug resistant organisms: bacteria and other microorganisms that have
developed resistance to antimicrobial drugs.
MRSA - Methicillin/Oxacillin resistant Staphylococcus aureus
PRSP – Penicillin resistant Streptococcus pneumoniae
VRE – Vancomycin Resistant Enterococci

References:
Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006
Healthcare Infection Control Practices Advisory Committee, CDC
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare
Settings 2007
Healthcare Infection Control Practices Advisory Committee, CDC
Multidrug-Resistant Organisms in Non-Hospital Healthcare Settings, December 2000; CDC

REVIEW AND REVISE HOUSEKEEPING POLICIES AND INSERVICE EMPLOYEES


ANNUALLY
REVIEW AND REVISE MSDS BOOK

ADD AND REVIEW THE FACILITY EVACUATION PROTOCOL WITH THE


EMPLOYEES
PERFORM A DISASTER PLAN AND CONTACT THE HOSPITAL TO FIND HOW YOU
CAN PARTICIPATE IN DISASTER PLANNING
Administration - Incident Report

POLICY: PREVENTION OF IDENTITY THEFT


Purpose/Objective:
To make every effort to prevent identity theft from occurring in the Center.
The Center conducts an internal risk assessment by:
• Assessing the existing identity theft risk for new and existing accounts by
using a risk assessment to select measures that may be used to detect
attempts to establish fraudulent accounts;

• Training employees regarding procedures to use to prevent the


establishment of false accounts.

• Training employees regarding procedures to implement if existing accounts


are being manipulated.
Administration - Incident Report
• Ensuring that the plan is reviewed, updated and approved by the
Managers/Board annually and more often if needed.

Procedure:
Detection (Red Flags)
The Surgery Center adopts the following red flags to detect potential fraud. These are not
intended to be all-inclusive and other suspicious activity may be investigated as necessary.
• Identification documents appear to be altered

• Photo and physical description do not match appearance of applicant

• Other information provided by applicant is inconsistent with information on


file.

• Personal information provided by applicant does not match other sources of


information

• (e.g. credit reports, SS# not issued or listed as deceased)

• Personal information provided is inconsistent with information requested


beyond what could commonly be found in a purse or wallet.

• Signature on photo ID does not match the signature on the chart record.

Response
Any employee that may suspect fraud or detect a red flag will implement the following response
as applicable. All detections or suspicious red flags shall be reported to the Administrator.
• Ask the patient for additional documentation.

• Notify the Administrator or designee when any staff person becomes aware
of a suspected or actual fraudulent use of a customer identity.

• Notify the Administrator or designee of any attempted or actual identity theft.

• Do not open the account.

• Close the account.

• Do not attempt to collect against the account and notify the Administrator or
designee, who will be responsible to contact the proper authorities.

Security Procedures:
• Paper documents, files and electronic media containing secure information
will be stored in a locked file cabinets.
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• Only specially identified employees with a legitimate need will have access to
the cabinet.

• Files containing personally identifiable information shall be kept in locked file


cabinets except when an employee is working on the file.

• Employees shall not leave sensitive papers out on their desks when they are
away from their workstations.

• Employees shall store files when leaving their work areas

• Employees shall log off their computers when leaving their work areas

• Employees shall lock file cabinets when leaving their work areas

• Employees shall lock the file room doors when leaving their work areas

• Access to offsite storage facilities shall be limited to employees with a


legitimate business need (if archiving is in place)

• Any sensitive information shipped using outside carriers or contractors will be


encrypted.

• Any sensitive information shipped will be shipped using a shipping service


that allows tracking of the delivery of this information.

• Visitors who must enter areas where sensitive files are kept must be escorted
by an employee of the surgery center.

• No visitor will be given any entry codes or allowed unescorted access to the
office.

• Access to sensitive information will be controlled using passwords.


Employees will choose passwords with a mix of letters, numbers and
characters. User names and passwords will be different.

• Passwords should not be shared or posted near workstations.

• Password-activated screen savers will be used to lock employee computers


after a period of inactivity.

• When installing new software, immediately change vendor-supplied default


passwords to more secure password.

• Sensitive consumer data should not be stored on any computer with an


internet connection.
Administration - Incident Report
• Sensitive information that is sent to third parties over public networks will be
encrypted.

• Sensitive information that is stored on computer network or portable storage


devices used by employees will be encrypted.

• Email transmissions within the business will be encrypted if they contain


personally identifying information.

• Anti-virus and anti-spyware programs will be run on individual computers and


on servers daily.

• When sensitive data is received or transmitted, secure connections will be


used.

• Computer passwords will be required

• User names and passwords will be different.

• The use of laptops shall be restricted to those employees who need them to
perform their jobs.

• Laptops are stored in a secure place.

• Laptop users will not store sensitive information on their laptops

• Laptops which contain sensitive data will be encrypted.

• Employees should never leave a laptop visible in a car, at a hotel luggage


stand or packed in a checked luggage.

• If a laptop must be left in a vehicle, it should be locked in a trunk.

• The computer network will have a firewall where the network connects to the
internet.

• Any wireless network in use should be secured.

• Central log files shall be maintained of security-related information to monitor


activity on the network.

• Incoming traffic shall be monitored for signs of a data breach.

• Outgoing traffic shall be monitored for signs of a data breach.


Administration - Incident Report
• References and background checks shall be performed before hiring
employees who will have access to sensitive data.

• New employees will sign an agreement to follow the Company’s


confidentiality and security standards for handling sensitive data.

• Access to customer’s personal identify information shall be limited to


employees with a need to know.

• Every effort will be made to ensure that workers who leave employment no
longer have access to sensitive information.

• Employee training will be performed annually with all other required in-
services.

• Employees will be trained to be alert to attempts at phone phishing.

• Employees are required to notify the Administrator or designee immediately


if there is a potential security breach such as a lost or stolen laptop.

• Employees who violate security policy are subjected to discipline, up to, and
including , dismissal.

• Service providers will be trained to notify the Center of any security incidents
they experience, even if the incidents may not have led to an actual
compromise of data.

• Paper records will be shredded before being placed into the trash.

• Paper shredders will be available as applicable.

• Any data storage media will be disposed of by shredding, punching holes in,
or incineration.

Review and Approval


This plan has been reviewed and adopted by the Surgery Center Governing Board.
Appropriate employees shall be trained on the contents and procedures of this prevention
program.
A report will be prepared annually and submitted to the Governing Board to include matter
related to the program, the effectiveness of the policies and procedures, the oversight and
effectiveness of any third party billing and account establishment entities, a summary of any
identify theft incidents and the response to the incident, and recommendations for substantial
changes to the program if any.

INCIDENT REPORTING
Administration - Incident Report

POLICY:

All occurrences in the Center that are not consistent with the desired operation of the facility or
the care of the patient shall be considered as incidents. All incidents shall be reported,
documented, and reviewed and action taken appropriate to the incident. All incident reports shall
be submitted to the Quality Improvement Committee and Risk Management for review.

RESPONSIBILITY:

The Nursing Director is responsible for administering the incident reporting program. All
employees and staff members are responsible for reporting incidents.

FUNCTION:

Provide a formal means of identification and review of incidents which may constitute a threat to
the health and safety to patients, visitors, staff, and employees as well as a process for
determining appropriate corrective action. As such, the program serves as a basis for Quality
Improvement activities and loss control for risk management.

PROCEDURES:

A. Any employee or staff member who observes or is aware of any occurrence which
is perceived, either prospectively or retrospectively, to constitute a threat to the
health and safety of patients, visitors, staff, and/or employees shall report the
incident to the Nursing Director or designee. The report may be made verbally or
in writing. If in writing, it shall contain the basic information required for the
incident report as described below.

B. The person receiving the report of the incident shall prepare a formal incident
report. NOTE: any occurrence reported as an incident shall be processed as such.
The Incident Report shall be prepared using the appropriate form and containing
the following information.

1. Incident

A brief statement describing the incident, i.e.:

a. Patient slipped on wet floor and fell sustaining


bruises.

b. Patient experienced reaction to post-op


medication.

c. OR improperly set-up for scheduled procedure.

The date the incident occurred.

3. Persons Involved

a. Use patient number and doctor number when


appropriate.
Administration - Incident Report

b. Employee name(s) and position.

c. Visitors.

d. Others.

4. Location

Where the incident specifically occurred.

5. Description

A description of the circumstances related to the incident and


elaboration of what occurred.

6. Recommendations/Action Taken

Recommendations to avoid repetition of the incident may be


provided by the person preparing the report and/or the Nursing
Director. In some instances, appropriate action may be taken to
avoid repetition of the incident by the person preparing the report.
In other instances, the action may require approval or the
assistance of others to implement.

7. Incident Report By and Date

The name of the person and the date the incident was reported
along with the signature of the person.

8. Report Prepared By and Date

The name of the person preparing the report and the date it was
prepared.

9. Incident Investigated By

Some incidents may require investigation by someone in addition


to or other than the person preparing the report.

10. Incident Reviewed By Nursing Director and Date.

All incident reports shall be reviewed by the Nursing Director.

11. Incident Reviewed by Risk Management and the Quality


Improvement Committee – Risk Management and Quality
Improvement Committee will provide Action/Recommendations.

All incidents, unless judged to be inappropriate or invalid by the


Nursing Director shall be reviewed by the Quality Improvement
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Committee. The committee may approve the
recommendations/actions taken or change/add to them.

12. Follow-Up Required

Steps to be taken to assure that the recommendations are properly


implemented.

C. All incidents require at least minimal investigation as soon as possible after they
are reported. The investigation process will assist to determine contributing
factors and ascertain facts versus opinion. The investigation may include, but not
be limited to:

1. Interviewing persons directly/indirectly involved


2. Reviewing the medical record

3. Testing equipment

4. Testing environment

5. Inspecting the physical plant area

6. Reviewing current practices, policies and procedures

7. Recreating the circumstances involved

8. Obtaining photographs

D. All incident reports shall be reviewed by the Nursing Director and Medical
Director/Risk Manager. The Nursing Director may approve or change
recommendations included in the report and take whatever action is deemed
appropriate to avoid repetition of the incident unless such action requires the
approval of some other entity: i.e., Managers.
E. All incidents, unless judged to be inappropriate or invalid by the Nursing
Director, shall be reviewed by the Quality Improvement Committee and
Risk Management Committee of the Center at its next regular meeting.

F. Incident Reports shall be maintained on file in the Nursing Director’s


office along with confirmation of corrective action taken when
appropriate.
POLICY: SENTINEL EVENT:
Purpose/Objective:
To clarify what a sentinel event is and how it should be reported and handled in the
Center.

All Events are to be reported to the Nursing Director who will be responsible for
coordinating the intensive assessment process.

Adverse event is an outcome or circumstance with significant patient injury or


impairment to the patient.
Examples include but are not limited to:
• Significant adverse drug reactions
• Major discrepancy between preoperative diagnosis and postoperative diagnosis
• Significant adverse anesthesia reaction
• Significant deviation from a historical statistical norm.

Sentinel event is an unexpected event occurrence involving death or serious physical or


psychological injury or the risk thereof. It is an adverse event of a severe and urgent
nature. Such events are often red flags for potential litigation, associated with drastic
physical or psychological injury to a patient, and are often indicators of system and/or
personnel problems that pose a threat to future patients.

Examples pertaining to the Center include:


• Death due to medication error
• Major error found at autopsy
• Operation on the wrong site
• Restraint death
• Assault, rape, or homicide
• Infant abduction
• Adverse event associated with public criticism
• Event associated with a lawsuit or the threat thereof
• Event associated with open interpersonal conflict or disruptive behavior affecting
patient care.
Assessment Team:
Consists of The Administrator/Director of Nursing and the Medical Director/Risk
Manager and Chairman of Quality Improvement. Medical and/or management staff with
knowledge related to the event will be added to the team. The Assessment Team will
conduct an analysis of the event. This analysis will include determination of the human
and other factors most directly associated with the sentinel event and the process and
systems related to its occurrence, and the formulation of an action plan.
Inquiry into all areas appropriate to the specific type of event.

Indications for an assessment:


All sentinel events and adverse events will be reviewed by the Administrator/Director of
Nursing, Medical Director, Quality Improvement and Risk Management Committee with
criteria indicating the need for intensive assessment within 24 hours.
Examples include but are not limited to:
• Incident/event reports
• Statistical data from departmental sources
• Risk management communications
• Medical staff case review and screening
• Environmental rounds
• Administration for external sources, I.e., patient complaints or notification from
other facilities and/or agencies.
Staff members who become aware of an event they believe needs intensive assessment,
immediately contact their Manager/Director and complete an Incident report.
The manager, physician, or staff member who becomes aware of an event meeting
indications for intensive assessment will report it immediately to the Nursing Director or
designee.
The Director of Nursing will notify the Administrators and the Medical Director for
immediate judgment, regarding appropriate review assignment, and will take immediate
action to safeguard patient care.
The Assessment Team and additional members, as indicated/appointed, meets within 72
hours of all urgent events, including adverse and sentinel events.
The review team is authorized to review medical records, other records, interview
physicians and personnel and consult other relevant information sources.
The review team assesses, develops and implements a plan of action and reports
conclusions/resolutions/actions to the Quality Improvement Committee and Risk
Management Committee.
Review group is interdisciplinary, including various medical, nursing, other professional
personnel, managers, and others who might contribute to the analysis, depending on the
nature of the event.
Analysis focuses on the causes of the event or circumstance
Actions are taken to avoid recurrence of the event or similar events.
Referral for Confidential Personnel Review
If, in the opinion of the Medical Director, the event is likely due to the performance of a
single identifiable individual, rather than a system problem, the matter is referred directly
for peer review or other appropriate referral such as Administration. Events involving
individual physicians and allied health personnel are the responsibility of the Medical
Director; other staff members are the responsibility of the Administrator/Director of
Nursing.
The review group may decide that the sentinel event is reportable to the State and the
appropriate form will be sent.
Test Questions:

BODY MECHANICS/ERGONOMICS:

If your work in not high enough, you should lean down to it in order to lift it.
True False

Accidents cause most back problems.


True False

Good posture and body mechanics should be used in the presence of acute injuries
only.
True False

Changing positions can add to strain on muscles and joints.


True False

It is important to remember that back problems may also be avoided by finding


alternative ways of accomplishing difficult tasks.
True False
If a task is placing undue strain on your back you should inform the Director of
Nursing.
True False

Workstation ergonomics include such things as chair comfort, arm and keyboard
position, foot position, and lighting.
True False

SAFETY NEEDLE LAW:

The Safety Needle Law will not be passed until 2006? T F

The Safety Needle Law must be complied with at present? T F

All angiocaths must have a safety feature without exception? T F

With the use of needleless products gloves do not have to be worn? T F

You can wait several days before reporting an exposure? T F

If you must recap a needle you should do this only if absolutely necessary,
And then, use a resheathing device or one-handed scoop method? T F

HANDS OFF:

Please circle one:

The most highly recommended technique for preventing sharps injuries in the OR is to
create a neutral or safe zone for no-hands passing of all sharps.
True
False

First the OR team designates the safe zone.


True
False

When deciding alternate methods for the safe zone the key is to focus on communication,
patient safety, and staff safety when deciding what practices you will use.
True
False

When there is a lapse in behavior staff are expected to report it to their manager. The
manager is obligated to report this to the Medical Advisory Committee.
All employees are empowered to speak up and retaliation is an offense.
True
False

RADIATION SAFETY :

1. Only licensed practitioner (chiropractor, dentist, medical doctor, podiatrist or


registered dental hygienist) or a New Jersey licensed radiologic technologist are
permitted to operate x-ray equipment and position a patient for a radiological
procedure.
True False
2. Individuals who are present in the radiographic, fluoroscopic or therapy simulator
room during any exposure shall wear protective aprons of at least 0.25 mm lead
equivalent during every exposure.
True False
3. Protective gloves of at least 0.25 mm lead equivalent shall be worn by the
fluoroscopist and assistant(s) during every examination when it is required that
their hands be placed in the useful beam.
True False
4. Only individuals required for the medical procedure, for training or for equipment
maintenance shall be in the radiographic, fluoroscopic or therapy simulator room
during an exposure.
True False
5. Gonadal shielding of not less than 0.5mm lead equivalent shall be used on a
patient during radiographic and fluoroscopic procedures, except for cases in
which this would interfere with the diagnostic procedure. If the patient is sterile,
the use of gonadal shielding may be omitted.
True False
6. Before an x-ray examination to the torso, operators shall ask female patients of
child bearing age about the possibility of pregnancy: If the patient is unsure, the
procedure should be delayed until the pregnancy status is confirmed.
True False
7. Signs should be placed in the waiting room and x-ray room reminding the patient
to inform the doctor/technologist if they are pregnant.
True False
8. Pregnant radiation workers shall be provided with a personal radiation-monitoring
device to assure the allowable limits to the fetus are not exceeded.
True False
9. The most basic and important way to reduce dose is to reduce time, increase
distance from the source, and use protective shielding.
True False

SEXUAL HARASSMENT:
1.Any employee who feels that he or she has been the subject of sexual
harassment from a coworker, manager, patient,
or any other person in connection with employment at the Center should
immediately report the behavior in question to the Nurse Manager or
designee. The Nursing Manager or designee will obtain from the employee
a signed statement describing the harassment.

True/False
F

2.The Nursing Manager or designee will investigate the report promptly and
as confidentially as possible.

True/False

3.The results of the investigation will be reported to the Administrator.

True/False

4.Appropriate collective action will be taken when a report of sexual


harassment is validated. Such corrective action may
Include a counseling report, observation period, suspension and /or
termination.

True/False
5.In the event that the offending individual is not an employee, the Nursing
Manager in consultation with the Administrator will take action necessary to
prevent a recurrence of the incident in the workplace.

True/False

6.The Center prohibits retaliation against an employee who complains of


sexual harassment.

True/False

7.An employee who knowingly makes a false report of sexual harassment or


who provides false information will be subject to disciplinary action, which
may include termination.

True/False

CORPORATE COMPLIANCE:

1. Only Billing Staff must comply with the Corporate Compliance Program.

True
False

2. All Center staff must comply with the Corporate Compliance Program.

True
False

3. The Compliance Officer in the Center is

The Director of Nursing


The Medical Director
The Risk Manager

4. In order to report a violation you can

Contact the Director of Nursing


Contact the Corporate Compliance officer
Leave an anonymous letter in the Complaint Box
All of the above
6. If you do not report a known violation in the Center you are subject to corrective action
and or dismissal from the Center.

True
False

7. If government investigative agents arrive at the Center you should

Call the Compliance Officer and the Center’s legal council immediately
Answer all questions asked and hand over all information available
Not ask for a copy of the search warrant
Never ask the agent to give you an inventory of items taken and sign for it

8. The Center will not tolerate retaliation against staff that report violations of the
Center’s policies

True
False

9. Gifts to referral sources are prohibited. The Staff will not accept gifts from vendors,
suppliers or other providers in exchange for patient referrals

True
False

10. Incentives to patients that promote preventive care are acceptable

True
False

11. If the reporting person would prefer anonymity they may leave a letter in the
complaint box located in the waiting area.

True
False

13. The Corporate Compliance Program affects only Medicare patients

True
False
CUSTOMER SERVICE:
1. It is important to create a positive first impression.
True False
2. A customer forms impressions about you and your organization within seconds of
contact.
True False
3. Your attitude is the key to customer satisfaction
True False
4. What will please customers most? (Circle all that apply)
• No hassle
• Someone who listens
• Verbal feedback
• Immediate action
• Using his/her name
5. Irritating words to avoid using when speaking with customers include: (Circle all that
apply)
• Can’t
• Can’t help you
• You should have
• All we can do
• It is company policy
• You have to
• What would you like for us to do?
• What will work best for you?
6. Listeners should: (Circle all that apply)
 Judge others before listening
 Pay attention to content and facts
 Listen completely first, this makes people feel valued
 Listen for the main idea
 Try to change the subject
 Avoid eye contact
 Listen carefully, give feedback, ask confirmation
 Make negative statements
 Maintain patience while listening
 Maintain eye contact
7. The Surgical Center employees and personnel should avoid: (Circle all that apply)
o Arguing
o Rationalizing
o Defending
o Complaining
o Reacting
o Emotionalizing
o Promising
8. You should explain to the customer how he or she may make a complaint.
True False

9. When explaining how to complain you should:


Make it difficult to get a phone number
Give a phone number and a name
All of the above

SAFETY AND RISK MANAGEMENT:

Who is responsible for identifying quality and safety concerns at the Center?

The Risk Manager


The Director of Nursing
All employees

What is the reason for reporting unexpected events?

A. To find out who is at fault


B. To blame someone
C. To learn from it and prevent it from happening again

When reporting an unexpected event you should:

A. Determine who is at fault


B. State the facts

Fire Safety:

A. A fire emergency at the Center is a


B. Code Blue
C. Code 5
D. Code Red

The best way to stop fire and smoke from spreading is to:

A. Close all doors


B. Open the windows
C. Evacuate the building

Which type of fire extinguisher is used in the Center?

A. Type A
B. Type B
C. Type C
D. Type ABC

To contact the fire department:

A. Dial 911
B. Dial “0” for the operator

During a fire drill it is important to:

A. Implement evacuation plans and close all doors


B. Evacuate all patients
C. Turn off all oxygen

Electrical Safety:

A. All life-sustaining equipment should be plugged into:


B. Red outlets
C. Black outlets

An electric cord that is frayed should be:

A. Repaired with electrical tape


B. Removed from use immediately

The first step in response to someone who is being electrocuted is to:

A. Pull the person off of the electrical source


B. Turn off the electrical current form the main source
C. Start CPR

A lock on an electrical device signifies it:

A. Is unsafe to use until repaired


B. May be used until the biomedical technician comes in to repair it

Remove defective electrical devices from circulation and report it to:

A. The Nursing Director who will call the Biomedical technician


B. Your friends
C. Public safety

HAZARDOUS MATERIALS:
The most reliable way to find out if a product is hazardous is to:

A. Smell it
B. Look for warnings on the label
C. Ask other employees

The best defense in handling any hazardous material spill is to:


A. Have the housekeeper assist you
B. Call the Police
C. Know the proper clean-up and disposal procedures

First aid and more detailed information about cleaners used in the Center are available in
the:
A. AAAHC Manual
B. State Standards
C. MSDS (Material Safety Data Sheets)

Personal Protective equipment includes:

A. Gloves and goggles


B. bandages
C. Stethoscopes

A master file of all chemicals in the center is located at the:

A. Nurse’s station
B. In the Business Office
C. In the staff lounge
EMERGENCY PREPAREDNESS:
The emergency preparedness plan includes directives for:

A. Internal disasters only


B. External disasters only
C. Both internal and external disasters.

A Code Blue is initiated when a:

A. Patient, visitor or employee stops breathing


B. Someone falls in the Center
C. A person is out of control in the O.R.

A Code 5 is initiated when a:

A. Patient or visitor is violent


B. A customer is complaining
C. A patient is crying

A Code Red is initiated when there is a:

A. Fire
B. Respiratory Arrest
C. Electrical Outage

A Code “B” is used to report:


A. A Blue person who has stopped breathing
B. A Bomb threat
C. A Bad person in the waiting area

A Code “T” is used to report:

A. A Tornado
B. A Hurricane

A Code “H” is used to report

A. A Hurricane
B. A Tornado
C. A state of high humidity in the O.R.

A Code “Disaster Drill is in effect” is used to report:


A. A disaster is in effect and the disaster protocol must be followed
B. Nothing needs to be done at this time
C. Everyone must pack up and go home

BIOTERRORISM:

A respirator mask is necessary to enter a patient’s room that has which of the following:

A. Anthrax
B. Smallpox
C. Botulism

Disposable gown, respirator mask (N95) and gloves are required before entering an
isolation room for:

A. Tuberculosis
B. Smallpox
C. Anthrax

Pneumonic plague requires what type of isolation?

A. Contact
B. Droplet
C. Airborne

If complete decontamination is necessary, it is essential to be trained in the use of the


following equipment:

A. Tyvek suit, boots and gloves


B. PAPR, self-contained breathing equipment
C. All of the above

Smallpox is caused by the:

A. Yersinia pestis virus


B. Bacillus anthracis virus
C. Variola virus
PATIENT’S RIGHTS:
The Patient’s Rights information is posted in the:

A. Patient waiting area


B. Dressing rooms
C. Pre-op or holding room
D. All of the above

According to the Patient’s Rights the patient:


A. Does not have the right to privacy
B. Does not have the right to a copy of the Patient Rights Statement
C. Must follow all orders of the physician without asking questions
D. Has the right to receive a copy of the patient’s right statement prior to admission
E. Has a right to information regarding the credentialing of healthcare professionals

Which of the following is true regarding patient rights:


A. Patient’s do not have a right to personal needs
B. Patient’s do have a right to privacy
C. Patients do have a right to appropriate management of pain

Adherence to the Patient’s Rights is the responsibility of:


A. All employees of the Center
B. The Director of Nursing
C. The Administrator
The Center’s policy is to charge the patient for the cost of an interpreter, if an interpreter
is needed.
A. True
B. False
The Center has a non-discrimination policy.
A. True
B. False
The patient has the right to be:
a. informed, where applicable, physician financial interests or
ownership in the ASC facility in accordance with the intent
of Part 420 of this subchapter. Disclosure of information
must be in writing and furnished to the patient in advance
of the date of the procedure, unless the referral to the
ambulatory surgical center for surgery is made on that
same date; and the referring physician indicates, in writing,
that it is medically necessary for the patient to have the
surgery on the same day, and that surgery in an
ambulatory surgical center setting is suitable for that
patient. In such situations the ambulatory surgical center
must provide the required notice prior to obtaining the
patient’s informed consent.

b. To be provided in advance of the date of the procedure


with information concerning its policies on advance
directives, including a description of applicable State
health and safety laws and if requested, official State
advance directive forms, unless the referral to the
ambulatory surgical center for surgery is made on that
same date; and the referring physician indicates, in writing,
that it is medically necessary for the patient to have the
surgery on the same day, and that surgery in an
ambulatory surgical center setting is suitable for that
patient. In such situations the ambulatory surgical center
must provide the required notice prior to obtaining the
patient’s informed consent.

c. To documentation in a prominent part of the patient’s


current medical record, whether or not the individual has
executed an advance directive, unless the referral to the
ambulatory surgical center for surgery is made on that
same date; and the referring physician indicates, in writing,
that it is medically necessary for the patient to have the
surgery on the same day, and that surgery in an
ambulatory surgical center setting is suitable for that
patient. In such situations the ambulatory surgical center
must provide the required notice prior to obtaining the
patient’s informed consent.
A. None of the above
B. A only
C. All of the above
CONFIDENTIALITY:
Confidential Information includes:
A. Patient information on a computer
B. Information regarding a patient’s treatments
C. All of the above
Patient confidentiality can be protected by:
A. Keeping patient records locked in a cabinet
B. Not faxing information without a cover sheet
C. Not having conversations regarding a patient in the lounge
D. All of the above
Patient information may be given to:
A. Friends of the patient
B. Direct caregivers
C. Any one who requests the information
Proper authorization to release confidential information is obtained by:
A. Asking permission from the patient
B. Calling a physician
C. Asking any relative of the patient
Respecting a patient’s confidentiality is the responsibility of:
A. All employees
B. Only the doctors and nurses
C. Only the patient’s family
HIPAA :
Employee Name:________________________________

HIPAA Policies and procedures are intended to ensure that the practice complies with the
Privacy Standards established by the Health Insurance Portability and Accountability Act
of 1996, as well as other applicable state and federal laws, when maintaining, using and
disclosing protected health information.
True False
Whenever Practice personnel are presented with an issue regarding the release of patient
information which is not addressed by this Manual or further guidance is needed, such
personnel should contact the Privacy Officer. The Privacy Officer in turn should consult
legal counsel where appropriate.
True False
The practice Privacy Officer is the Administrator/Director of Nursing, who will be
responsible for developing, implementing, and supervising the Practice’s privacy policies
and procedures.
True False
Privacy Contact is the Administrator/Director of Nursing.
True False
Any violation of these policies and procedures by any physician, employee, independent
contractor, volunteer, or other member of the Practice’s workforce may result in
disciplinary action, up to and including suspension and/or termination from the Center.
True False

The Center will not intimidate, threaten, coerce, discriminate against, or take other
retaliatory action against any individual for the exercise of any right, participation in any
process, or opposition to any unlawful act or practice, set forth in the Center’s policies
and procedures.
True False
Protected health information (PHI) is any health information transmitted or maintained
in any form that:
A. Is created or received by the Practice
B. Relates to the past, present or future physical or mental health or condition of an
individual, the provision of health care to an individual, or the payment for the provision
of health care to an individual;
C. and identifies the individual or offers a reasonable basis for identification.
D. All of the above
When using or disclosing PHI, or when requesting PHI form another covered entity, the
Center will make reasonable efforts to limit PHI to the minimum necessary to accomplish
the intended purpose of the use, disclosure, or request.
True False
The “Minimum Necessary” Standard will not apply in the following circumstances;
• Disclosures for purposes of treatment
• Disclosures made to the individual
• Disclosures made pursuant to a valid authorization
• Disclosures made to the Secretary of the Department of Health and Human
Services (“HHS”) for purposes of compliance
• Disclosures required by law or
• Disclosures necessary for compliance with the HIPAA Privacy Rules
True False
The Center may use or disclose an individual’s PHI for purposes of treatment, payment,
or health care operations (“TPO”) without the individual’s consent or authorization.
This includes the use of information:
• For the Center’s TPO, as set forth in the Notice of Privacy Practices
• For treatment activities for another health care provider
• For the payment activities of another covered entity, so long as the recipient is
that covered entity; and
• For purposes of health care operations between covered entities participation in a
group health plan or other joint arrangement
Exception to this rule is:
Pursuant to Federal and State law, the Center will not use or disclose, for any purpose,
PHI related genetic testing or received from Federal funded Drug or Alcohol Treatment
Program, without a patient’s authorization. The Practice will not use or disclose PHI
related to HIV/AIDS without a patient’s authorization except for treatment purposes.
Furthermore, the Practice will not release Psychotherapy Notes for purposes of treatment,
payment, or healthcare operations unless permitted under the HIPAA Regulations.
True False
The patient has the right to:
Request limits on uses and disclosures of PHI
Choose How their PHI is sent
See and get copies of their PHI
Get a list of the disclosures that the Center has made
To correct or update their PHI
A copy of the Notice
To get notice via E-Mail
True False
Every patient will be offered a Notice of Privacy Practices for Physician Practices when
they come to the Center for treatment.
True False

Name: _______________________________ Date: _____________


Signature: ___________________________

Privacy Officer: ________________________

ADVANCE DIRECTIVES:

At the Center, signatures on an advance directive may be witnessed by:

A. The patient’s nurse


B. The healthcare proxy
C. Any employee that is not giving direct patient care

A Proxy Directive or “durable power of attorney” identifies the person who will:

A. Inherit your money


B. Make healthcare decisions for you all the time
C. Make healthcare decisions for you when you are unable to make them for yourself

An advance directive can be prepared:

A. Only when hospitalized


B. Only when terminally ill
C. Anytime

An instructional directive or living will are:

A. Verbal instructions given to the nurse


B. Written directions stating what medical care you do or do not want
C. Medical decisions made by your lawyer for you

An advance directive takes effect whenever:

A. You are hospitalized


B. You are no longer able to make healthcare decisions
C. Your family and physician disagree about your treatments

The patient has the right to information regarding advance directives prior to admission
True
False

AGE-SPECIFIC GROWTH AND DEVELOPMENT:

This age group may experience separation anxiety when hospitalized:


A. Infant (birth-1 year)
B. Toddler (1-3 years)
C. Adolescent (12-20 years)

Regarding safety in the pre-school and school-age child, it is important to:

A. Not monitor the care environment for danger or hazards


B. Remove unnecessary equipment or tools from room or treatment area.
C. Remove the parent or significant other during procedures or treatment

When caring for an adolescent (12-18 years) it is important to:

A. Discourage questions regarding their care


B. Communicate directly with the adolescent
C. Be judgmental

When caring for a middle adult (25-65 years) it is necessary to recognize:

That they are at risk for stress related illnesses


That they do not worry about economic responsibilities
That they do not want to be encouraged to ask questions

Older adults (65+) are vulnerable to injury because of :

A. Reduced visual and hearing acuity


B. Uncoordination
C. Basic motor skills

Abuse and Neglect:

A. When working at the Center, suspected child abuse is reported to the


B. A friend
C. The consultant social worker
D. The Director of Nursing or designee
Child abuse and neglect includes:

A. Sexual exploitation
B. Mental retardation
C. Accidental injury

Who is required to report suspected child abuse and neglect in the State of New Jersey?

A. All citizens of NJ
B. Law enforcement officers only
C. Physicians and nurses only

Domestic violence affects:


A. Only married couples
B. Troubled teenagers
C. All racial, ethnic, religious, education, and socioeconomic groups

An elderly person may be afraid to report their abuse because:

A. They believe the authorities will not be able to stop the abuse
B. They are ashamed of having a child who abuses them
C. All of the above
LATEX ALLERGY:

The medical product most often associated with latex allergy is:
A. IV tubing
B. B/P cuffs
C. Latex gloves

Who of the following is at most risk for developing a latex allergy?

A. Children
B. Healthcare workers
C. The elderly

At the Center a patient with a latex allergy is identified by:

A. A notation on the allergy label on the front of the chart


B. A red dot
C. A green dot

Patients who are identified as having a latex-allergy should:

A. Be cared for in a latex-free environment


B. Be given latex gloves to protect their hands
C. Be placed in an isolation room

Which of the following items would need to be removed from the room of a patient with
a latex allergy?

A. Plastic utensils
B. Latex gloves
C. Pillows
CHAIN OF INFECTION/ BLOODBORNE PATHOGENS/TUBERCULOSIS:
The most effective way to prevent the spread of infection is by:
A. Wearing gloves
B. Doing a 15 second hand wash or using waterless soap
C. Enforcing contact isolation

The Center exposure control plans can be found in the:


A. Policy and Procedure Manual
B. The OSHA log book
C. All of the above

PPD skin testing is required on all Center employees and physicians:


A. Initial two step and thereafter annually
B. Every six months

The Hepatitis B and C virus may cause permanent damage to which of these organs?
A. Stomach
B. Heart
C. Liver

Bloodborne pathogens include:


A. HIV and Hepatitis B, C, D and E
B. Varicella
C. MRSA

Examples of airborne transmission would be:


A. Tuberculosis and Smallpox
B. Impetigo

TB isolation rooms require which type of ventilation?


A. Positive pressure
B. Negative pressure
C. Equal pressure

Which of these masks need to be fit tested?


A. Respirator mask (N95)
B. Surgical mask
The infectious disease specialist for the Center is: ______________________
A. True
B. False

Workplace Violence
The code to call for help is:
A. Code Red
B. Code Blue
C. Code 5

The phone number to call for help is:


A. 411
B. 900
C. 911
Cultural Competence- Test Questions

1. Cultural competence is the knowledge, skills, and attitudes that allow


individuals to give effective, respectful care to all cultures.
True False (Circle one)

2. Determinants of culture may include:


a) age
b) education
c) length of time in the U.S.
d) personality differences
e) all the above

3. The most obvious barrier to communication is ___________________.

4. Stereotyping may be defined as judging individuals on their perceived


cultures.
True False (Circle one)

5. Generalizing is a practice that may be helpful in achieving cultural


competence.
True False (Circle one)

6. Using the first name when addressing a patient from another culture may be
interpreted as disrespect.
True False (Circle one)

7. Use of open-ended questions and/or requesting a return demonstration will


ensure the patients’ understanding.
True False (Circle one)

8. Speaking loudly may be interpreted as anger in other cultures.


True False (Circle one)

9. Avoid uncommon words or idioms in order to prevent misunderstanding.


True False (Circle one)

10. “Patients are treated with respect, consideration, and dignity” is a statement
contained in the AAAHC First Core Standard which confirms the
commitment to cultural competence.
True False (Circle one)

Pain Management- Test Questions

Pain management is a branch of medicine developed in the 19th Century.


T F

Pain is recognized as the “5th Vital Sign”.


T F

Culture and communication are two major influences of pain management efficacy.
T F

Language barriers will not impact the treatment of pain.


T F

Non-verbal communication is important to assess understanding as well as to assess


pain.
T F

Cultural differences between the patient and the health provider may lead to
misunderstanding or mistrust.
T F

Patients have a right to expect appropriate assessment, treatment, education, and


alternate therapies to treatment for pain.
T F

While a patient is at the Center, the only obligation the nursing staff has is to provide
medication for pain and document its effectiveness.
T F

Groups of patients that may not be able to communicate their pain management needs
are:
infants/children
speech impaired patients
hearing impaired patients
intubated patients
patients with a language barrier
all of the above

Pain management tools available at the Center may include:


pain scales
AT&T Language Line
employee interpreter
all of the above

The patient will be asked to scale their pain from 1 to 10. 1 being the least amount of
pain and 10 being the most severe pain. The non verbal pain scale will be used to
demonstrate this concept to the patient.
a. True
b. False

The preoperative nurse will assess the patient’s level of pain on admission and
interview the patient to determine methods that work best for pain relief for the
patient. This assessment will be documented in the chart record.
a. True
b. False

The anesthesiologist and/or physician will interview the patient preoperatively to


assess the need for pain medication and other methods of pain relief that work best
for the patient.
a. True
b. False

The nurse will evaluate the patient’s pain level postoperatively and prior to discharge.
This will be documented in the chart record.
a. True
b. False

The patient will only be discharged when pain is at a tolerable level. If pain is not
tolerable the patient will be admitted to the hospital for appropriate follow up care.
a. True
b. False
The Center will collect and analyze data in order to evaluate outcomes or
performance. Data analysis shall focus on recommendations for implementing
corrective actions and improving performance
True
False

Drill: Contingency Plan:

Present:

Objectives:
To test how quickly and effectively how well
The Center staff can retrieve data
The Center staff can react during an emergency
The business office functions without a computer using only paper
The business office functions with no outside power
The shared systems involving vendors and business associates continue to operate

The Manager announced that the contingency plan was in place. All computers were
shut down for 3 hours during patient care hours.

Evaluation:

Administrator’s Signature: ______________________________________Date: ______


Surgical Site Universal Protocol:
All persons involved in the patients care will confirm the appropriate site and never
assume the task has been correctly performed by another individual. This policy applies
to all surgical cases involving laterality, multiple structures (fingers, toes, lesions) or
levels (spine, pain management).
True False
The surgeon will document the correct side in the medical record and sign the surgical
consent with the appropriate site documented.
True False
The patient will be asked to identify the correct side/site of surgery unless he/she is
unable to effectively communicate with the staff. If the patient is unable to effectively
communicate with the staff, the surgeon will determine the correct side/ site using
pertinent available information. The consent will be confirmed by the circulating nurse in
the pre-operative holding area. Two patient identifiers will be used to confirm the
side/site. Acceptable identifiers include: DOB, Social Security number, Medical Record
ID number, and Name of patient.
True False
When the patient is brought to the pre-operative area or directly to the operating room the
surgeon will place his initials on the correct side/site. The appropriate side will be
confirmed by the circulating nurse when the patient is in the operating room.
True False
A time out will be taken and final confirmation will take place verbally between the
surgeon, circulating nurse, scrub nurse, and anesthesia provider as applicable when the
patient is prepped for surgery. The correct patient position will also be verified at the
time out.
True False
It will be the responsibility of the circulating nurse to bring the consent form to the time
out. Upon verification he or she will document that the time out has taken place on the
O.R. record.
True False
Test Questions: High Alert Medications

A drug that has a high risk of causing injury to patients when misused and that has
consequences that can be more devastating is a high alert medication.
True False

Identification of these drugs and initiating safeguards may reduce the risk of errors.
True False

Safeguards may include such things as:


limiting access
auxiliary labels and
standardization of how these drugs are ordered, prepared, and administered
True False
Test Questions: Propofol

An anesthesiologist should be involved in the care of every patient undergoing


anesthesia if possible. If this is not possible, non-anesthesia personnel who administer
Propofol should be qualified to rescue patients whose level of sedation becomes deeper
than initially intended and who enter, if briefly, a state of general anesthesia.
True False

Rescue:
Rescue of a patient from a deeper level of sedation than intended is an intervention by a
practitioner proficient in airway management and advanced life support. It is not
appropriate to continue the procedure at an unintended level of sedation.
True False

Physician present:
The physician should be physically present throughout the sedation and remain
immediately available until the patient is medically discharged form the post-procedure
recovery area.
True False

Education/training:
The practitioner administering propofol for sedation/anesthesia should, at a minimum,
have the education and training to identify and manage the airway and cardiovascular
changes which occur in a patient who enters a state of general anesthesia, as well as the
ability to assist in the management of complications.
The practitioner monitoring the patient should be present throughout the procedure and
be completely dedicated to that task.
True False
Nosocomial Infections: Test Questions:
Please answer either true or false by circling the correct response.
1. In order to have a nosocomial infection you need a germ, a carrier –and a person
without resistance who becomes infected
True False

2. A nosocomial infection is present on admission.


True False

3. A nosocomial infection is not incubating on admission or is incubating at the time


of admission, which is related to a previous admission.
True False

4. A Community acquired infection is present on admission.


True False

5. Surgery patients are at high risk for nosocomial infections.


True False

6. Signs and Symptoms of infection are:


• Pus
• Cough
• Temp elevation
• Redness
• swelling
• pain
True False

7. If a physician documents his/her patient has a surgical site infection you should
not document the patient as having a surgical site infection until you have more data.
True False

8. Nosocomial infections are considered to be up to 30 days postoperatively.


True False
9. Pins/Rods are considered to be a nosocomial infection up to a year following
surgery.
True False

10. A way to prevent nosocomial infections is to wash your hands


True False

The Infectious Disease Specialist For the Center is: Dr.

Address:

Phone #:

The Infection Control Nurse is: _________________________________

Address:

Phone#
_____________________________________________ ____________
Employee signature Date

TEST QUESTIONS: Patient Safety Act (A review)


The Patient Safety Act focuses on a culture of safety. Patient safety must be the highest
priority.
A blame –free environment IS NOT IMPORTANT and the focus should be to improve
and redesign systems and processes.
True False

The Center should be focused on:


 Strengthening patient safety

 Promoting a systematic analysis

 Emphasizing confidentiality and

 Setting up a reporting system

True False

A Patient safety Plan and Committee must address the issues.


 Patients must be informed when medical errors occur

 There must be mandatory reporting of serious preventable events and

 There should be anonymous voluntary reporting of less serious events

True False

8:43 E addresses the patient safety and pain regulations.


The regulations state that the facility shall notify the Department immediately (no later
than 3 hours) by phone of any event occurring within the facility that jeopardizes the
health and safety of patients or employees.
The administrator must be informed of all findings.
The phone number to report to: 800-792-9770 Hot line to report
You must also confirm in writing within seven days of event
There must be ongoing training for facility personnel annually
The Committee must meet quarterly and meeting must be separately written

True False

What should be reported?


1. Information concerning injuries to patient/staff, disruption of services, extent of
damages and corrective actions taken.
2. Resignation or termination of employment of the administrator.
3. Name and qualifications of administrator’s replacement. (This must be writing to
Department within seven days of resignation/termination.)
4. All alleged or suspected crimes, which endanger the life or safety of patients or
staff and which have also been reported at the time of occurrence to the local
police department.
5. Loss of significant reduction of water, electrical power, or any other essential
utilities necessary to operate the facility.
6. All fires, disasters, accidents or other unanticipated events which result in:
 Serious injury or death of patients or staff

 Evacuation of patients from the facility

 Closure of the facility for six or more hours.

 Occurrence of epidemic disease in the facility

True False

The DHSS is required to investigate all complaints


True False

The Patient Safety Committee must be comprised of the:


 Medical Director

 Director of Nursing

 Risk Manager and ad hoc members to contribute to RCA

True False
There are protections for facility deliberations under the Patient Safety
Act.

True False

Event/RCA Reporting
 Time frame is 5 business days

 RCA is due in 45 calendar days after the report is sent in

True False

Download form HCQ-1 Report of Serious Preventable Adverse Event in a New Jersey
Licensed Health Care Facility at:
www.NJ.gov/health/ps

True False
Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care
Facility:
Submit a Root Cause Analysis (RCA)
Identify the contributing causes of adverse events
Ensure that it is a focused review
Identifying prevention strategies
(What happened? why did it happen? and how can the Center prevent it from
reoccurring?)
RCA Team should include:
 Staff knowledgeable about processes involved in the event

 Front line staff

 Staff involved in event

Information included should include:


 Pt hx related to event

 Facts of the event in chronological order (specific details)

 Date, time location

 Effect on pt

 Identity of staff (by title not name)

 Similar event in past 3 years?

Triggering Questions should include:


 Human Factors/Training
 Human Factors Fatigue/Scheduling

 Environment/Equipment

 Rules/Policies/Procedures

 Barriers

True False

The 5 Rules of Causation include:


 Clearly show “cause and effect

 Avoid negative descriptions

 Human error must have a preceding cause

 Violations of procedure must have a preceding cause

 Failure to act only if pre-existing duty

True False

An example of a Causality Statement would be:


__________increased the likelihood of _____________happening which led to the
adverse event.

True False

An Action Plan should


• Address the root causes

• Be specific and concrete

• Be doable

• Consult process owners

True False

Sample of levels of action plans:


• Weaker action: A memo

• Intermediate action: A checklist

• Stronger action: Visual confirmation

True False
When trying to resolve a problem you should:
1. Include an action plan for each causal statement

2. Be specific and concrete

3. Implement the Action Plan

4. Choose a time frame

5. Review Action Plan

6. Monitor the results

7. Ensure the problem is solved or put another action plan in place.

True False

An example of a Causality Statement is:


The lack of or failure to________related to_________ and may have led to___________.

True False
TEST QUESTIONS: Infection Control Plan for Managing High Risk Infections
Care of Patients with Resistant Organisms – MRSA and other MDRO
in Ambulatory Care Settings

Multidrug-resistant organisms (MDRO), including methicillin-resistant Staphylococcus


aureus (MRSA), vancomycin-resistant enterococci (VRE) and certain gram-negative
bacilli (GNB) have important infection control implications and affect all healthcare
settings. Patients colonized or infected with these organisms can safely be cared for and
managed in the ambulatory setting by following appropriate infection control practices.
CDC does not have recommendations for pre-admission screening in non-hospital
settings.
True False

In general, healthy people are at low risk of getting infected with MRSA or VRE.
True False

Hand sanitizing and hand washing compliance by staff and each person, including
visitors in the patient care units can NOT be overemphasized since DIRECT CONTACT
is the primary method of cross contamination with MRSA and other MDRO. It is the
single most important Infection Control and Prevention method.
True False
Standard Precautions should be used for all patient care.
True False
Standard Precautions include:
• Hand hygiene: After touching blood, body fluids, secretions, excretions,
contaminated items; immediately after removing gloves; between patient contacts;
• Gloves: For touching blood, body fluids, secretions, excretions, contaminated
items; for touching mucous membranes and non-intact skin;
• Gown: During procedures and patient-care activities when contact of
clothing/exposed skin with blood/body fluids, secretions, and excretions is
anticipated;
• Mask, eye protection (goggles), face shield: During procedures and patient-care
activities likely to generate splashes or sprays of blood, body fluids, secretions,
especially suctioning, endotracheal intubation;
True False

Contact (Isolation) Precautions include Standard Precautions. The components of


Contact Precautions may be adapted for use in ambulatory facilities, especially if the
patient has draining wounds or difficulty controlling body fluids.
True False
You should separate the patient from other patients as soon as possible. (Common
waiting areas) Place the patient in a private room or area, if possible.
True False

When a private room is not available, place the patient in a room with a patient who is
colonized or infected with the same organism, but does not have any other infection
(cohorting). Another option is to place an infected patient with a patient who does not
have risk factors for infection. At minimum, place patient at a station with as few
adjacent stations as possible (e.g. at the end or corner of the unit) and pull privacy
curtains on both sides to create a visual barrier which will serve as a reminder to staff that
extra precautions are required.
True False

When transport or movement of the patient within the facility is required, ensure that
infected or colonized areas of the patient’s body are contained and covered.
True False

Gloves should be worn whenever touching the patient’s intact skin or surfaces and
articles in close proximity to the patient (e.g. medical equipment, bed rails). You should
put on new gloves upon entry into the room or cubicle.
True False

You should wear a gown whenever anticipating that clothing will have direct contact
with the patient or potentially contaminated environmental surfaces or equipment in close
proximity to the patient. Put on the gown upon entry into the room or cubicle. Remove
gown and wash / sanitize hands before leaving the patient care environment. After gown
removal, ensure that clothing and skin do not contact potentially contaminated
environmental surfaces that could result in possible transfer of microorganisms to other
patients or environmental surfaces.
True False

You should notify other healthcare personnel and/or facilities that provide care for the
patient that the patient is colonized/infected with a multidrug-resistant organism.
True False

EPA registered disinfectants or detergents/disinfectants that best meet the overall needs
of the healthcare facility for routine cleaning and disinfection should be selected. In
general, use of the existing facility detergent/disinfectant according to the manufacturer’s
recommendations for amount, dilution and contact time is sufficient to remove pathogens
from surfaces of rooms where colonized or infected individuals were located. This
includes those pathogens that are resistant to multiple classes of antimicrobial agents
(MRSA, VRE, etc.).
True False
You should focus on frequent and between case sanitizing and disinfecting the high touch
areas in close proximity to the patient and the frequently touched surface areas (e.g. bed
rails, bedside tables, commodes, bathroom fixtures, and doorknobs).
True False
Disposable disinfectant equipment and surface wipes are readily available in accessible
locations in the patient care areas to allow staff to perform rapid equipment and surface
disinfection during the care hours of operation.
True False

Disposable Items are discarded after single patient use.


Reusable equipment and devices and contaminated reusable noncritical patient-care
equipment should be placed in a plastic bag for transport to a soiled utility area for
reprocessing.
Laundry/linen is handled in a manner that prevents transfer of microorganisms to others
and to the environment.
True False

Occasionally, healthcare workers can become persistently colonized with an MDRO, but
these healthcare workers have a limited role in transmission, unless other factors are
present. Additional risk factors that can facilitate transmission, include chronic sinusitis,
upper respiratory infection and dermatitis. Healthcare worker decolonization is indicated
only as a prevention and control intervention when a health care worker is chronically
colonized with MRSA and has been epidemiologically implicated in ongoing
transmission of MRSA to patients.
True False
Drug Competency

1 teaspoon = cc
1 tablespoon = cc
1ml = cc
1ounce = cc
10cc = teaspoons
1kg = lbs

If you were giving a child Versed po syrup (Versed Syrup 2mg/ml), using the maximum
dosage of 0.5mg/kg. What is the maximum allowable dose for a 22lb child?

If you were ordered to give Demerol 50mg IV and Demerol 100mg/ml was the only
dosage available how many ml would you administer?

How is Vancomycin administered IVPB? (Please explain in detail)


What symptoms would you expect to see if you were infusing this too quickly?

How would you prepare Ancef IVPB? Can you give this medication to someone who is
allergic to sulfa?

Penicillin?

Can Gentamycin be pushed IV? Y N

Can Solumedrol be pushed IV? Y N


Can Decadron be pushed IV? Y N
Can Reglan be pushed IV? Y N

What is the maximum dose of Demerol that can be administered to a 70kg man?

What is the maximum dose of Demerol that may be administered to a 30kg child?

What is the maximum dose of Morphine that can be given to a 70kg man?

What is the most frequent complication of narcotic administration?

What is the first action you would take for an episode of narcotic induced respiratory
depression?
What is the protocol for a patient who faints in the Center?

How is Anzemet administered? What is the usual dose?

What is the usual dose of Zofran?

What is the usual dosage of Toradol for an Adult? For a Child?

Can Toradol be given to patients allergic to aspirin?

Can Toradol be given to a patient with a history of Renal Disease, GI problems, Ulcers,
Bleeding, currently taking ASA or non-steroidal anti inflammatory drugs (ASAIDs)?

What is the reversal agent for Narcotic overdoses?


What is the usual dosage of Narcan?

What complication should you continue to look for following Narcan administration?

What is the usual dosage of Versed?

What is the reversal agent for Versed?

Name:_________________________________________ Date: __________________


POLICY: URINE PREGNANCY MONITORING

POLICY: Urine pregnancy can be done in the Center by appropriately trained personnel.

PROCEDURE:

1. Gather supplies:
1. Quick-Vue urine pregnancy kit
2. Procedure Gloves
3. Dropper
4. Specimen Cup

2. Obtain urine sample from patient (First morning specimens generally contain the
highest concentrations of hCG; however, any urine is suitable for testing).

3. Explain procedure to patient. Wash hands and don procedure gloves.

1. Remove Quick-Vue test cassette from foil pouch just before use and place
on dry, level surface.
2. Using one of the disposable pipettes supplied, collect sample and add 3
drops of urine to the Round Sample Well on the test cassette. The test
cassette should not be handled or moved until the test is complete and
ready for reading.
3. Wait three (3) minutes and read.
4. Interpret results
i. Positive: Any pink-to-red test line (T) along with a blue control
line (C)
ii. Negative: A blue control line (C) and no pink test line (T)
iii. Invalid: no blue control line visible at three (3) minutes. If this
happens, retest using a new sample and a new test cassette, or
contact Quidel Technical Support at 800-874-1517.
4. Dispose of kit contents per Center procedure and record results on patient chart
and in POS Test Log.

5. Monthly, results will be reviewed and signed off by the Medical Director.

6. Whenever a new lot number or fresh supplies are obtained, a control must be run
using the hCG Control Set. Documentation of the control is entered on the Log
sheet.
POLICY: CLIA WAIVED TESTING:

Purpose/Objective:

 To make every effort to ensure safe practices are used when performing CLIA
waived testing in the center.
 To make every effort to ensure the staff performing CLIA waived testing are
properly in-serviced annually.
 To make every effort to ensure that the Medical Director oversees the use of
CLIA waived tests.

Procedure:

• The Medical Director shall review the logbook and oversee the use of CLIA
waived tests performed in the Center at least three times a year.
• All Staff members that will be performing CLIA waived tests shall be in-serviced
on CLIA waived tests used in the Center annually.
• An annual in-service will include CLIA waived testing. A list of CLIA waived
employees will be kept in the Control testing book.

CLIA Waived Personnel trained at Linden Surgical Center:

Print Name Title


Date:
Reviewer:

Accu-Vue Urine Pregnancy Competency

The use of the Accu-Vue Urine Pregnancy Kit was explained. Use of the hCG Control
Kit-to be used each time a new lot or shipment of test materials is received- was
explained.
Demonstration of the Test Kit and the Control Kit were also performed.
The Procedure Card was reviewed, including how positive, negative, and invalid test
results are displayed on the cassette.
Discussion re: inability to obtain a urine specimen and appropriate actions was presented.

Objectives:
1. The learner will demonstrate how to use all the components of the urine
pregnancy kit.
2. The learner will demonstrate proper use and documentation of the hCG Control
Kit.
3. The learner will verbalize the rationale for performing a urine pregnancy test per
Center policy.
4. The learner will verbalize appropriate actions to take, per Center policy, in the
event that a patient refuses the test, or inability on the patient’s part to provide a
urine specimen.

Name Return Demonstration Passed Signature of Trainer


Y/N
-------------------------
-
Date:
Reviewer:
Topic: Glucometer
The use of the Glucometer was explained. The reason for controls on each day of use
was explained. A demonstration took place on how to properly run controls on the
glucometer. A demonstration on how to properly obtain a blood glucose took place. A
discussion took place regarding when it is appropriate to obtain a blood glucose on a
patient in the center. There was a discussion on what action to take if a patient has an
abnormal glucose level. It was pointed out that special syringes were purchased for use
with insulin in the Center and that only a U-100 syringe may be used. The storage of
insulin in the medication refrigerator was discussed as well as where to find the proper
syringes. Appropriate IV fluids to run on patients with both a high and low blood sugar
took place.

Objectives:
1. The learner will demonstrate how to turn on the glucometer.
2. The learner will demonstrate how to run controls and document them properly.
3. The learner will explain why it is necessary to take a blood glucose on a patient in the
Center.
4. The learner will explain why only U-100 syringes are used to give insulin to a patient
subcultaneously.
5. The learner will explain why it is necessary to run appropriate fluids on diabetic
patients having surgery.
6. The learner will explain why it is necessary to check the patient’s blood sugar
following surgery if ordered.

Name Return demonstration Passed Signature


of trainer
Y /N
Date:
Reviewer:

Topic: Mock Code:

A cardiopulmonary-respiratory arrest can occur at any time at the Center. In order to


ensure all personnel are prepared for such an occurrence a review of the most common
algorithms is necessary.
A review of the algorithms by the Recovery Room manager took place. A review of
pediatric protocols also took place. The function of the defibrillator was reviewed at this
time also, with a discussion of the proper settings to use.
Objectives:
1. The staff member will explain how to recognize and treat Ventricular
fibrillation.
2. The staff member will explain how to recognize and treat Ventricular
tachycardia.
3. The staff member will explain how to recognize and treat PEA.
4. The staff member will explain how to recognize and treat Bradycardia.
5. The staff member will explain how to recognize and treat Asystole.
6. The staff member will explain the differences in treating pediatric patients
versus adults with these rhythms.
7. The staff member will explain how to use the defibrillator and what setting
would be appropriate for the various rhythms discussed.
8. The staff member will explain how the use of the defibrillator would vary
for a pediatric patient.

Name Return demonstration Passed Signature


of trainer
Code Drills:
Senario:
The patient is in the Recovery Room and his HR is very rapid. 160/min
Evaluate the patient:

Code Drill: Atrial Fibrillation/ Atrial Flutter


Clinically unstable or cardiac impaired?
WPW?
Duration?
Treat unstable patient urgently
Control rate
Convert rhythm
Provide anticoagulation

Narrow Complex:
12 lead EKG
Clinical information
Vagal maneuvers
Adenosine

Wide Complex
12 lead EKG
Clinical information
DC cardioversion
Procainamide
Amiodarone

The patient suddenly goes into V-tach/V-fibrillation: “Someone Call 911”


“When the patient is in V-Fib you have to D-fib”

Patient is on Oxygen, has an IV, is on the cardiac monitor


Place airway device as soon as possible
Confirm airway placement
Confirm effective oxygenation and ventilation
Differential diagnosis: search for causes

CPR UNTIL DEFIBILLATOR IS AVAILAB LE


Shock -360 OR MONOPHASIC EQUIVALENT IF SHOCKABLE RHYTHM
Give Epi-every 3 to 5 minutes or Vasopressin 1 time dose 40Units
Try Amiodarone-Lidocaine-Procainamide

CPR-Drug-Shock-CPR-Drug-Shock-etc
DO 5 CYCLES OF CPR
DO NOT INTERRUPT FOR PULSE CHECKS UNLESS FOR GOOD CAUSE
HAVE SOMEONE SWITCH DOING COMPRESSIONS IF AVAILABLE

Look for causes!

Epi 1mg IV push repeat every 3-5 minutes


Or
Vasopressin 40 U IV single dose only
Attempt to defibrillate 1X 360 or biphasic equivalent
Give either:
Amiodarone
Lidocaine
Magnesium if low magnesium OR TORSADES
Procanimide
Shock
CPR 5 cycles-Drug-Shock etc.
Look for other possible causes:

Patient is in PEA PEA “EPI/ATROPINE”


What are causes of PEA
ITCH-PAD
Infarction/MI
Tension pneumothorax
Cardiac Tamponade/Coronary Thrombosis
Hypoxia
Hypovolemia
Hypokalemia/ Hyperkalemia
Hypothermia
Pulmonary Embolus
Acidosis
Drug overdose

Epi 1mg IV push repeat every 3-5 minutes


Atropine 1mg IV (if PEA is slow) repeat every 3-5 minutes to a total of 0.04mg/kg

Patient is suddenly bradycardic:


Code Drill: Bradycardia BRADYCARDIA Atropine/Dopamine
Patients HR is < 60 bpm
Less than expected/relatively slow

ABCD Survey
Assess ABC’s
Secure airway noninvasively
Ensure monitor/defibrillator is available

Secondary Survey
Assess secondary ABC’s is invasive airway needed?
Oxygen-IV-Monitor-Fluids
VS, pulse oximeter, monitor B/P
12 lead EKG
Problem focused history
Problem focused physical exam
Consider Causes
Type II second-degree AV block? 3rd degree block?
Observe
Serious Signs or Symptoms?
Atropine 0.5 to 1.0mg
Transcutaneous pacing if available
Dopamine 5 to 20ug/kg per minute
Epinephrine 2-10 ug/min
Isoproterenol 2-10ug/min

Patient goes into Asystole:


Code Drill: Asystole Atropine/Epi
ABCD Survey

Epinephrine 1mg IV push repeat every 3-5 minutes


Atropine 1mg IV, repeat every 3-5 minutes up to a total of 0.04mg/kg
Asystole persists withhold or cease resuscitative efforts?
Consider quality of resuscitation?
Atypical clinical features present?
Support for cease-efforts protocols in place?
RISK MANAGEMENT IN-SERVICE: MALIGNANT HYPERTHERMIA
MH is an inherited disorder that affects calcium regulation within the muscle cells.
MH is triggered by the administration of the injectable drug succinylcholine or any of the
volatile inhalation anesthetic agents that could be used during surgery.
Patient Screening:
Pts should be screened for a history of past surgical experiences that may indicate they
may have MH. Ask whether the pt has a relative who suddenly developed severe
complications during or immediately after surgery, and whether or not any of his/her
relatives ever died for no apparent reason either during or immediately after surgery.
MH is characterized by:
• Elevated CO2 production, often two to three times the normal rate
• Unexpected tachycardia, tachypnea, jaw muscle rigidity
• Body rigidity (not always present)
• Both respiratory and metabolic acidosis (therefore, arterial blood gases (ABG are
a useful early test).
• Elevated temperature that can exceed 110 degrees Fahrenheit.
o (Elevated temperature is usually a late sign.)
MH typically occurs intra-operatively, but can occur as late as 4-12 hours
postoperatively.
Have a team leader assign tasks: (follow ABC protocol fro MHAUS Organization)
1. A-Ask for Help/ Ask for MH cart and Dantrolene; Agents/Anesthesia- stop
anesthesia triggering agents and the surgery
2. B- Breathing- hyperventilate with 100% oxygen
3. C- Cooling- IV access with large bore catheter; cold IV fluids 15ml/kg; irrigation
any wounds, as well as stomach (lavage via nasogastric and rectal tubes) and
bladder (Foley); Call MH Hotline at 1-800-644-9737 or 1-315-464-7079 ; PUT
ON SPEAKER PHONE IF AVAILABLE
4. D- DANTROLENE- Give IV at 2.5mg/kg; repeat until signs of MH controlled
5. E- Electrolytes- draw and check, especially for K+ (potassium)
6. Recorder (record each dose of Dantrolene Sodium as it is being administered, as
well as all other treatments)
7. Runner
Response to MH should include:
• Call for help (911) and begin preparing to transfer your pt to a tertiary care
facility as soon as MH is diagnosed.
• Discontinue inhalation anesthetic and any triggering agents being used;
discontinue surgery
• Hyperventilate with 100% oxygen
• Administer Dantrolene Sodium, beginning with 2.5mg/kg of body weight
• Treat respiratory and metabolic acidosis
(Metabolic acidosis (Bicarbonate 1-2 mEq/kg) if blood gas values are not yet
available); then dosage based on guidance by pH , Base deficit
• Institute body cooling measures, attempting to bring the body temperature to 38
degrees Centigrade; use cold intravenous normal saline, ice packs and cold body
lavage (nasogastric/rectal)
• Monitor urine output and attempt to keep the urine output elevated to 2ml/kg/hr
using fluid and diuretics
• Treat hyperkalemia/dysrhythmia (except, REFRAIN FROM USING
CALCIUM CHANNEL BLOCKERS which may cause hyperkalemia or
cardiac arrest in the presence of Dantrolene)

Hospital:
• Obtain A-ABG’s; B- Body temperature (core)- avoid hyper/hypothermia; C-End-
tidal CO2, CK, Coagulation tests, myoglobin levels; D- Diuresis (urine output
and color); E- Electrolytes
• Admit to intensive care unit for at least 24 hours

Review MH Video- video clip available on MHAUS website; full video available with
purchase of MH Kit for Ambulatory Surgery (See MHAUS website for purchase
information)
Practice Mixing:
Dantrolene Sodium is difficult to mix. If your supply expires, use the out-of-date supply
for training. Mix the drug in an assembly-line fashion where several people take the
responsibility for just one small step in the process.
MH cart should include:
Dantrolene Sodium kits, which include 1,000 cc sterile water for injection, a 60cc luer-
lok syringe, a 3-way stopcock and a fluid path
Needles
Syringes
IV catheters
IV tubing
Blood collection tubes and sets including ABG Kit
60 cc Toomey syringe
Nasogastric tube
Esophageal stethoscope
Foley catheter with urimeter
Drugs should include:
Dantrolene Sodium (36 vials) Every ASC should have 36 vials of Dantrolene Sodium
on hand at all times. This enables a 70 kg pt to receive 4 doses of the drug.
Sterile water for injection (preservative free)- advise 100ml vials if available
Calcium chloride (10%)- 10ml vials x2
Insulin- Regular 100units/ml (refrigerated)
Mannitol
50% dextrose- 50mlvials x2
Digoxin
Physostigmine
Furosemide 40mg/amp x 4 ampules
Heparin lock
Dexamethasone
Lidocaine 2%- 100mg/5ml or 100mg/10ml in pre-loaded syringes x3
Sodium bicarbonate 8.4%- 50ml x5
0.9% saline for injection, cold sterile saline for lavage, regular insulin (refrigerate) and
ice.
Make certain your MH ice supply is available at all times.
Keep a conversion chart for pounds to kg available in your MH cart

Reference: Update; FASA; Volume XXV, Number3; pps 24-28


MHAUS Website: accessed 10/23/2008
SAMBA Website: accessed 10/23/2008
MH DRILL

DRILL CALLED BY: ___________________________________________


OR# _______ TIME CALLED: _____________

TEAM RESPONSE: MH HOTLINE CONTACTED/PUT ON SPEAKER PHONE


Y ____ N _____
ROLES CLEARLY DEFINED:
• ANESTHESIA: _________________________________________________
• SCRUB: _______________________________________________________
• CIRCULATOR: ________________________________________________
• RECORDER: ___________________________________________________

RESPONSE OF ADDITIONAL HELP:


• WAS ADDITIONAL HELP AVAILABLE ___________
• RESPONSIBILITIES DELINEATED BY LEADER ______________

ITEM ARRIVAL TIME


MH Cart/Kit
Chilled 1000ml Saline Bags for IV Infusion
Bags of Cold Saline for Wound Irrigation
Foley Catheter/Urimeter
Regular Insulin 100 Units/ml
Dantrolene Mixed/Ready for Administration

TEAM RESPONSE/EFFICIENCY:
EXCELLENT GOOD FAIR POOR

Additional Comments:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
________
___________________________________
______________________________
__________________, RN- Admin/DON Anesthesia Department

Malignant Hyperthermia drill:

Date:

Present:

Instructor:

Case scenario:

A patient is on the O.R. table. Suddenly the patient’s heart rate is 180. The
anesthesiologist shows concern and begins to look for likely causes. Other symptoms
noted are tachypnea, spontaneous ventilation, unstable blood pressure, arrhythmias, dark
blood in the surgical field despite adequate inspired oxygen, cyanotic mottling of the
skin, profuse sweating, fever: rapid rise in temperature (1 degrees Fahrenheit/15min)
sustained rise 108 degrees or more, and fasciculation and/or rigidity (sometimes
involving total body); trismus (lockjaw is an early sign.)

What should be done?

1. Stop anesthesia and surgery immediately. Change all rubber goods on the anesthesia
machine.
Anesthetic agents are absorbed into the rubber, which will exude those agents, providing
a continuous trigger mechanism.
2. Hyperventilate the patient with 100% of oxygen ( 8-10 liters)
3. Administer Dantrium IV as ordered by the anesthesiologist/physician. 36 vials are
obtained with sterile water for injection to reconstitute the vials. One nurse is
assigned this job alone since it is very difficult to mix.
4. RECOMMENED DOSAGE: 1mg-10mg/kg of body weight. For a patient weighing
70kg the initial dose would be 3 ½ vials. If the full dosage should be required
(10mg/kg) ten times the initial dose would be needed or 35 vials.
5. If necessary Pronestyl IV bolus and then continuous drip as ordered by
anesthesiologist/physician.
6. DO NOT USE LIDOCAINE in treating arrhythmia in malignant hyperthermia, as a
local amide anesthetic agent is felt to be a triggering agent.
7. Initiate cooling: Administer IV iced saline solution-100ml/10min for 30min.
8. Do not use lactated ringers solution. IV fluids should be administered through a large
gauge peripheral line. Ideally the patient will require two good peripheral IV sites as
well as a central line. Two liters of iced saline are always available.
9. Surface cooling is done using ice. A nasogastric tube and urinary catheter with 3-way
adapter are placed. The patient may also be lavaged rectally
10. Administer sodium bicarbonate as directed by the anesthesiologist/physician.
11. EKG, temperature, urinary catheter, must all be monitored closely.
12. Administer diuretics as ordered by the Anesthesiologist. Maintain urine output of at
least 2ml/kg/hr.
13. If necessary, administer regular insulin 10/50-50W IV push as ordered by the
Anesthesiologist/physician. To provide energy to the cells.
14. TRANSFER THE PATIENT TO THE HOSPITAL IMMEDIATELY.
15. * FOLLOW THE PROTOCOL AS STATED BY THE MALIGNANT
HYPERTHERMIA ASSOCIATION OF THE UNITED STATES.
Date:
Reviewer:

Topic: Alarm recognition

Objectives:

1. To be able to recognize the different alarm sounds in the surgical center and respond
in an appropriate manner.

Name Return demonstration Passed Signature


of trainer
Y /N
Date:
Reviewer:

Topic: Disaster Drill


Flood
There was a storm that caused a flood on Route ____. There were 10 patients at the
Center.
One surgery was in progress. The surgery was completed and no new surgery cases were
performed. The Generator was functioning. The patients were all recovered and kept in
the Recovery Room.
Family members were called. The town had a disaster in effect. No one was allowed to
leave the building until the police notified the facility that that the roads could be used.
Wrapped sandwiches were purchased from the Deli since none of the patients or staff was
on special diets that would require a different menu. If special food was needed the Deli
would be informed and is able to accommodate such requests. Only single wrapped
servings were used for patients. The disaster ended at 9:00pm. All patients were picked
up by 11:00pm. All staff members were out of the building by 11:30pm. A physician
stayed in the Center until all patients were discharged. All patients were called in the
morning to ensure they had recovered well.
The Center was able to open at 7:00am the next morning since there was no damage to
the building.

Disaster Drill was explained and then performed with the staff members.
The evacuation protocol was explained and simulated with the staff members.
The use of the snow ball list was explained.

Objectives:
1. To ensure all staff members are aware of the procedure to follow in a Disaster and
Evacuation.

2. To demonstrate competence in performing in a disaster situation in the Center.

Name Return demonstration Passed Signature of trainer


Y /N
Date:
Reviewer:

Topic: EVENT RELATED STERILITY


Objectives:
1. To learn the concepts that event related sterility is based upon.

2. To understand the meaning of event related sterility.

3. To understand and demonstrate knowledge of the proper labeling of items sterilized in


the Center using the concept of event related sterility.

4. To demonstrate how items are to be inspected for loss of integrity and the proper
procedures to use when items compromised are found.

5. To demonstrate understanding of proper storage of sterilized items when using this


concept in the Center. First in, First out, Front to Back rotation of items.

The Policy on Event related sterilization was handed out to all staff members involved in
sterilization processes. The Policy was read and a question and answer period took place.
The Policy on Sterilization Procedures/Clean Utility Room Procedure was presented for
review. The Policy was read and a question and answer period took place. The Policy on
Record Keeping of loads was read and reviewed with the staff members. The
documentation of the loads was demonstrated and questions were answered. The Policy
on Single Use Devices was reviewed. This was done to ensure that only proper devices
continue to be sterilized in the Center. The Policy on Recall of In-House Sterilized Items
was reviewed and a demonstration of how this policy works was demonstrated by
pretending that a load was bad. Questions were answered. The monthly Instrument
Packaging Integrity Check was explained and a hands on demonstration took place
implementing the procedure to ensure that the staff understood the procedure.

Name Return demonstration Passed Yes/No Signature of


Trainer
Date:
Reviewer:

Topic: Nurse Call System:

The Nurse Call System is located in the Recovery Room. This serves as the emergency
notification system for the Center. It is always staffed when a patient is in the Center.
This device monitors all necessary areas of the Surgical Center. If a patient or a staff
member is in need of assistance, this system serves to notify another staff member of
their need.

Objectives:
1. The staff member will demonstrate how to answer an incoming call on the system.
2. The staff member will demonstrate how to answer a code situation.
3. The staff member will demonstrate how to answer a bathroom page.
4. The staff member will demonstrate how to speak through the call system.
5. The staff member will explain the importance of staffing this call system at all times
when a patient is present in the Center.

Name Return demonstration Passed Signature


of trainer
Y /N
Date:
Reviewer:

Topic: Fire Drill


Fire in the storage room
There was a fire in the storage room at 9:00am. The circulator found the fire and called
the fire overhead.
Code Red storage room
Code Red storage room
Code Red storage room
The alarm was sounded and the staff closed all windows and doors.
The fire extinguisher was used to put out the fire.
The fire department arrived and no one was evacuated.
An all clear was given by the fire department and the Administrator gave the permission
to proceed with cases.
Rescue-Alarm- Confine-Extinguish
PASS
Pull Pin
Aim
Squeeze
Sweep
Objectives:
1. To ensure all staff members are aware of the procedure to follow in a Disaster and
Evacuation.

2. To demonstrate competence in performing in a disaster situation in the Center.

Name Return demonstration Passed Signature


of trainer Y /N
Date:
Reviewer:

Topic: Welch Allyn

The Welch Allyn monitors were in-serviced including the functions, how to change
parameters, how to hook up the patient properly, how to set alarms, when a patient should
remain on a monitor, how to detach the monitor from the stand to use for patient for
patient transport. A demonstration was given on how to record necessary rhythm strips
and how to properly change the paper in the machine.

Objectives:

1. The learner will demonstrate how to turn on the monitor.


2. The learner will demonstrate how to run a rhythm strip.
3. The learner will explain why it is necessary to occasionally place a patient on a
monitor in second stage recovery room.
4. The learner will demonstrate how to change all intervals and volume controls.
5. The learner will explain how often vital signs are taken in the Center in various
areas according to policy and procedure.

Name Return demonstration Passed Signature of trainer


Y /N
Test Questions: Hand washing
1. Hand washing is generally considered to be the single most important method for
interrupting transmission of microorganisms and preventing infections.
True False

2. Hands must be washed with an approved antiseptic agent before preparing


for the first case of the day.
True False

3. Hands must be washed after direct care of an individual patient, during


Performance of duties (eating, handling dressings, specimens, using
restroom etc.)
True False

4. Artificial fingernails or extenders should not be worn when providing patient care.
True False

5. Nails should be kept less than ¼ inch long.


True False

6. Gloves should be worn when it can be reasonably anticipated that contact with
blood or other potentially infectious materials, mucous membranes, and non-
intact skin will occur. This is required and mandated by Federal and/or state
regulation or standards.
True False

7. If hands are not visibly soiled you may: (Please circle the correct answer.)
A. Use an alcohol-based waterless antiseptic agent for routinely decontaminating
hands.
B. Wait to wash your hands until they become visibly soiled.
8. It is recommended that employees decontaminate hands after contact with a
patient’s intact skin (as in taking a pulse or blood pressure, or lifting a patient.
True False
Competency for PPE
Employee name: ________________________________________________
Observation/Demonstration Competency met Competency not Comments
met
Verbalizes understanding
of Standard Precautions
Wears scrub attire in semi
restricted and restricted
areas.
Wears bouffant cap or hair
covering in designated
areas.
Wears shoe covers if
soiling of shoes is likely.
Wears goggles or face
mask when splashing is
possible.
Wears mask in restricted
areas.
Changes mask after use.
Does not leave mask tied
around neck for reuse.
Wears gown when
applicable
Wears gloves when
touching body fluids/ Uses
standard precautions.
Dons gown appropriately
Dons gloves appropriately
Dons mask appropriately
Removes PPE in correct
order and disposes of
properly.
Washes hands between all
patient encounters.
Washes hands after taking
off gloves.
Washes hands when gloves
are removed following
contact with body fluids.
Supervisor’s signature: ________________________________________

Employee’s signature: _________________________________________ Date: _____

ADD HOUSEKEEPING POLICIES


REVIEW WITH ALL EMPLOYEES
In-service: Medication Tool Kit

AORN provided a Medication Tool Kit which is a summary of the new regulations.
Patient safety issues are on the rise with medication errors comprising a large portion of
medical accidents. Recent studies have received the attention of health care providers,
health care organizations, experts in safety, and federal and state lawmakers.

A study from the institute of Medicine reported that 44,000 to 98,000 people die each
year from medical accidents costing from 17 billion to 29 billion for preventable adverse
medical events.
In 1999 the Institute of Medicine reported that adverse events in surgery account for 20%
of the errors in health care, while medication errors make up about 16% of all medical
adverse events.
According to the U.S. Food and Drug Administration, more than 777,000 patients are
injured by medication errors each year.

The AORN offered a tool kit to help implement safe medication administration practices
in their facility to ensure safe patient outcomes. The tool kit was developed by the
Association of Preoperative Registered Nurses, under an educational grant from Sandel
Medical Industries. This tool provides resources to enhance perioperative medication
competencies and creates awareness of safe medication administration among the
surgical team.

The tool kit includes:


Staff Assessment
PNDS-based perioperative medication competencies
Perioperative Medication Performance Validation Record
Education Modules
Self-directed learning modules
Resources:
Frequently used medication conversions and calculations
Herbal/Dietary Supplement-drug Interaction poster
AORN Guidance Statement on Safe medication Practices in Perioperative Practice
Settings
The Institute of Safe Medication Practices listing of dangerous abbreviations
AORN Recourse List of Related Web Sites and Clinical Medication References
Testing;
Perioperative Medication safety Test
Contact Hours: 4.8 contact hours available
Included in the Modules:
Proper labeling of medications on the sterile field
Proper administration of medications
Medication interactions
The importance of patient knowledge of medication management
The importance of knowledge of pain management

In-service: The Medic Act of 2005:


The institute of Medicine’s report, To err is Human: Building a safer health system,
states that medical errors are the eighth leading cause of death in the United States and
that 44,000 to 98,000 medical error-related deaths occur each year. The medical liability
system attempts to address these occurrences by identifying the causes of medical errors,
remediating those causes to prevent recurrence, and compensating individuals injured by
medical errors. The current liability system, however, can deter health care providers
from reporting medical errors because it subjects them to potential legal liability.

The plan includes identifying and learning from errors by developing a nationwide public
mandatory reporting system and encouraging health care organizations and practitioners
to develop and participate in voluntary reporting systems.
The goal is to provide a system allowing for open disclosure of medical errors while
providing for legal protection for physicians. None of the health technology legislation
introduced to date has addressed issues of medical liability until now.

The National Medical Error Disclosure and Compensation Act of 2005, also known as
the Medic Act is an extension of the recently passed Patient Safety and Quality
Improvement Act of 2005, which was signed into law by president George W. Bush in
June 2005, and is aimed at providing liability protections for physicians who disclose
medical errors to patients and participate in a national error reporting system. According
to the language in the bill, the Medic Act’s purpose is to promote a culture of safety
within hospitals, health system, clinics and other sites of health care, through the
establishment of a national medical program. The Medic Act would establish an Office
of Patient Safety and Health care Quality to implement and oversee a national patient
safety database, as well as the Medic Program.

The Medic Program has four stated goals:


• To improve the quality of health care by encouraging open communication
between patients and health care providers, about medical errors and other patient
safety events
• To reduce rates of preventable medical errors
• To ensure patients have access to fair compensation for medical injury due to
medical error, negligence or malpractice and
• To reduce the cost of medical liability insurance of physician, hospitals, health
systems and other health care providers.
The Medic Act would create a national patient safety database that would serve as a
repository for confidential patient safety data submitted by participants in the Medic
program. Participants must agree to report medical errors and other patient safety events
to the proper authorities so that they can be analyzed by experts from or appointed by the
newly created Office of Patient Safety and Healthcare Quality. These experts will make
recommendations for changes in practice techniques to prevent similar medical errors
from occurring in the future. The database will also serve as a means to establish best
practices, while increasing accountability in the health care system. By reducing
administrative and legal costs for medical malpractice claims, the Medic Act would in
return require that participating medical liability insurance companies and health care
providers apply a percentage of their cost savings toward initiatives to improve patient
safety and reduce medical errors. The bill also requires that to the extent possible, some
of these cost savings be passed along to providers in the form of lower malpractice
insurance premiums.

http://www.aorn.org/EDUCATION/SAFEMEDTOOLKIT.HTM
Patient Safety First:
Improving specimen practices to reduce errors.

In 2005 the AORN approved the AORN guidance statement: Safe specimen
identification, collection and handling in the preoperative practice settings. The
statement provides guidance regarding quality improvement issues of reducing medical
errors specific to preventing misidentification, mislabeling, loss of identifiers, and actual
loss of surgical specimens.
The AORN guidance statement recommends that managers develop separate policies and
procedures that address processes for specimen handling. The policies should include.
• Specimen containment
• Identification, including patient identification that uses at least two identifiers
• Tissue and specimen identification and Source identification
• Transferring specimens from the sterile field
• Transferring specimens to the point of use (e.g. sterile field, person implanting)
• Labeling specimen container(s) on and off the sterile field.
• Documentation:
o On the laboratory requisition(s)
o In the patient’s record
• Chain of custody
• Verbal/written communication;
• Verifying correct information
• E.g., specimen type, patient information)before transferring the specimen
• Storing and maintaining specimens until transfer
• Transferring or facilitating transfer of the specimen for examination and
• Using risk reduction strategies.
Specimen errors are preventable. Each institution is responsible to help evaluate quality
improvement to prevent specimen error that could have a significant effect on a patient,
nursing staff members, medical providers, a facility, and a community.
Errors that have been reported include:
• Lost specimens
• Mislabeling, mix-ups
• Retrieving specimens that have been misplaced in garbage bins, sent to the wrong
laboratory
• Specimens being stored in towels and lost in the laundry
• Multiple specimens being handled simultaneously cause difficulty organizing and
identifying tissues on the field before they are transferred to the circulating nurse
• Loss of lymph node biopsy resulting in patient receiving radiation therapy
Such errors can lead to delayed diagnoses, the necessity of repeating surgical procedures
resulting in decreased patient satisfaction, and potential legal action. Loss of a specimen
tissue could result in the lack of ability to diagnose and treat a critical condition.

Proper Handling of Specimens Evaluation Tool


Question Yes No
Is the policy current and practices consistent with the policy?
Are resource tools available and easy to access?
Are team members able to easily obtain the correct supplies for specimen
handling?
Are supplies stored and handled in a safe manner?
Is the documentation streamlined to improve accuracy or is repetitive
documentation interfering with safe practices?
Are personnel familiar with the tools and processes before they are
assigned to handle specimens? Is there adequate emphasis during
orientation?
Is there adequate emphasis during orientation?
Is there a process for communicating practice changes to all team
members?
Are distractions eliminated during specimen identification, collection, and
handling?
Do all team members perform read backs, including patient identification,
tissue and specimen identification, and source identification at each step of
the process requiring hand off? If not, is there a system of checks and
balances to ensure accuracy?
Are specimens labeled legibly and accurately at each step of the process
from the point of removal until transfer to the final destination (e.g., on the
field, container, laboratory slips, offsite laboratories?
Is there a safe, visible location to place specimens on the field until the
hand off?
Are team members consistently and accurately communicating information
to prepare for specimen handling procedures and ensuring that the
specimen is dispensed correctly?
Are couriers or others who handle specimens aware of the critical
processes required for this practice?
POLICY: GUIDELINES FOR MANAGEMENT OF MODERATE SEDATION
PATIENT WHO SLIPS INTO DEEP SEDATION

Purpose: If a non-anesthesiologist administers moderate sedation and loss of defensive


reflexes occur (deep sedation), reassess the patient including airway, respiratory rate,
oxygen saturation, blood pressure, and cardiac rate/rhythm. Consider using the
following guidelines as appropriate.

1. Increase Stimulation
• Begin procedure if not already in progress
• Jaw thrust (combined noxious stimulus and airway maneuver)
2. Withhold further sedation until protective reflexes return
3. Supplement oxygen if indicated by falling oxygen saturation; airway support if
indicated by falling oxygen saturation or airway obstruction
• Jaw thrust
• Head tilt/Chin lift
• Nasal/Oral airway
• Positive pressure ventilation- call for help
• Suction if indicated
4. Pharmacological reversal
• Narcan (Naloxone)
• Romazicon (Flumazenil)- for Versed (Midazolam)

Documentation must occur on the following forms:

1. An incident report is to be completed on each patient that experiences an


untoward occurrence. Chart Review will then be performed by a physician
reviewer to be included in the quarterly report.
POLICY: PREVENTION OF IDENTITY THEFT

Purpose/Objective:
To make every effort to prevent identity theft from occurring in the Center.

The Center conducts an internal risk assessment by:


• Assessing the existing identity theft risk for new and existing accounts
by using the risk assessment to select measures that may be used to
detect attempts to establish fraudulent accounts;

• Training employees regarding procedures to use to prevent the


establishment of false accounts.

• Training employees regarding procedures to implement if existing


accounts are being manipulated.

• Ensuring that the plan is reviewed, updated and approved by the


Managers/Board annually and more often if needed.

Procedure:
Detection (Red Flags)
The Surgery Center adopts the following red flags to detect potential fraud. These are not
intended to be all-inclusive and other suspicious activity may be investigated as
necessary.
• Identification documents appear to be altered

• Photo and physical description do not match appearance of applicant

• Other information provided by applicant is inconsistent with


information on file.

• Personal information provided by applicant does not match other


sources of information

• (e.g. credit reports, SS# not issued or listed as deceased)


• Personal information provided is inconsistent with information
requested beyond what could commonly be found in a purse or wallet.

• Signature on photo ID does not match the signature on the chart


record.

Response
Any employee that may suspect fraud or detect a red flag will implement the following
response as applicable. All detections or suspicious red flags shall be reported to the
Administrator.
• Ask the patient for additional documentation.

• Notify the Administrator or designee when any staff person becomes


aware of a suspected or actual fraudulent use of a customer identity.

• Notify the Administrator or designee of any attempted or actual


identity theft.

• Do not open the account.

• Close the account.

• Do not attempt to collect against the account and notify the


Administrator or designee, who will be responsible to contact the
proper authorities.

Security Procedures:
• Paper documents, files and electronic media containing secure
information will be stored in locked file cabinets.

• Only specially identified employees with a legitimate need will have


access to the cabinet.

• Files containing personally identifiable information are kept in locked


file cabinets except when an employee is working on the file.

• Employees shall not leave sensitive papers out on their desks when
they are away from their workstations.

• Employees shall store files when leaving their work areas

• Employees shall log off their computers when leaving their work areas

• Employees shall lock file cabinets when leaving their work areas

• Employees shall lock the file room doors when leaving their work areas
• Access to offsite storage facilities is limited to employees with a
legitimate business need (if archiving is in place)

• Any sensitive information shipped using outside carriers or contractors


will be encrypted.

• Any sensitive information shipped will be shipped using a shipping


service that allows tracking of the delivery of this information.

• Visitors who must enter areas where sensitive files are kept must be
escorted by an employee of the surgery center.

• No visitor will be given any entry codes or allowed unescorted access


to the office.

• Access to sensitive information will be controlled using passwords.


Employees will choose passwords with a mix of letters, numbers and
characters. User names and passwords will be different.

• Passwords should not be shared or posted near workstations.

• Password-activated screen savers will be used to lock employee


computers after a period of inactivity.

• When installing new software, immediately change vendor-supplied


default passwords to more secure password.

• Sensitive consumer data should be stored on any computer with an


internet connection.

• Sensitive information that is sent to third parties over public networks


will be encrypted.

• Sensitive information that is stored on computer network or portable


storage devices used by employees will be encrypted.

• Email transmissions within the business will be encrypted if they if they


contain personally identifying information.

• Anti-virus and anti-spyware programs will be run on individual


computers and on servers daily.

• When sensitive data is received or transmitted, secure connections will


be used.

• Computer passwords will be required


• User names and passwords will be different.

• The use of laptops is restricted to those employees who need them to


perform their jobs.

• Laptops are stored in a secure place.

• Laptop users will not store sensitive information on their laptops

• Laptops which contain sensitive data will be encrypted.

• Employees never leave a laptop visible in a car, at a hotel luggage


stand or packed in a checked luggage.

• If a laptop must be left in a vehicle, it is locked in a trunk.

• The computer network will have a firewall where the network connects
to the internet.

• Any wireless network in use is secured.

• Central log files are maintained of security-related information to


monitor activity on the network.

• Incoming traffic is monitored for signs of a data breach.

• Outgoing traffic is monitored for signs of a data breach.

• References and background checks are performed before hiring


employees who will have access to sensitive data.

• New employees will sign an agreement to follow the Company’s


confidentiality and security standards for handling sensitive data.

• Access to customer’s personal identify information is limited to


employees with a need to know.

• Procedures exist for to make every effort to ensure that workers who
leave your employ no longer have access to sensitive information.

• Employee training will be performed annually with all other required in-
services.

• Employees will be trained to be alert to attempts at phone phishing.

• Employees are required to notify the Administrator or designee


immediately if there is a potential security breach such as a lost or
stolen laptop.
• Employees who violate security policy are subjected to discipline, up
to, and including , dismissal.

• Service providers will be trained to notify the Center of any security


incidents they experience, even if the incidents may not have led to an
actual compromise of data.

• Paper records will be shredded before being placed into the trash.

• Paper shredders will be available as applicable.

• Any data storage media will be disposed of by shredding, punching


holes in, or incineration.

Review and Approval


This plan has been reviewed and adopted by the Surgery Center Governing Board of
Directors.
Appropriate employees shall be trained on the contents and procedures of this prevention
program.
A report will be prepared annually and submitted to the governing body to include matter
related to the program, the effectiveness of the policies and procedures, the oversight and
effectiveness of any third party billing and account establishment entities, a summary of
any identify theft incidents and the response to the incident, and recommendations for
substantial changes to the program if any.
Summary from the Risk Advisor:
Protect your organization against data security breaches:
Examples of breaches of data security in the healthcare industry: Analysis of privacy
rights clearing house findings indicates that 11% of all reported incidents of privacy
breach between February 2005 and February 2007 involved healthcare entities.
Examples:
• A hacker breaks into a rehabilitation facility’s computerized record
system exposing patients’ protected medical information.

• A disgruntled employee of a counseling practice copies financial data,


including social security and credit card numbers

• A community health clinic administrator loses a laptop computer


containing identifiable patient billing information

• A vendor engaged to digitize a diagnostic center’s paper files makes


an error, potentially corrupting thousands of individual patient records.

Preventive Strategies:
• Utilize encryption system

• Place controls on data storage and access


• Regulate use of portable devices and storage media

• Carefully dispose of old equipment and outdated records

• Keep a backup set of records off-site

Risk Transfer and Insurance:


Whenever you entrust sensitive or non-public personal information to a third party,
require signed acknowledgement of the following contractual protections:
• An agreement regarding access to and appropriate use of your
information and networks, including compliance with your practice’s
information security standards

• Indemnification/hold harmless agreements for all costs arising from


breaches of the third party or the wrongful use of confidential data by
their employees

Post-breach Response:
If you suspect your information system has been targeted and patient or client
information is exposed, a rapid assessment and mitigation of damage is imperative, as
outlined below:

Evaluate the severity and scope of the incident


Identify the data that may have been exposed and determine whether these materials are
encrypted or protected by password. Consider using forensic experts to define the scope
of the problem. If there is a possibility of identity theft or other criminal action is present
inform appropriate law enforcement agencies of the situation.
Notify potentially affected patients or clients.
Consult with legal counsel.

References: 2009 HPSO Risk advisor Vol. 1

Staff Credentialing: Principles to help reduce risk


Credentialing involves deciding whether the applicant is qualified to provide patient care within
your practice and what specific clinical privileges should be granted.
Establishing Criteria:
• Establish standards reflecting the appropriate competence level for
various procedures in your facility.

• Have a clinical appointment committee in charge of defining qualifying


criteria in such areas as:

o Healthcare provider’s certification/registration

o Board certification
o Education

o Licensing requirements

o Medical professional liability claim history

o Professional experience

o References

o Training

o Approving the credentialing process and oversee its


implementation

Privileging Clinical Procedures


• Determine his or her scope of practice and supervisory requirements.

• If a procedure is identified as high risk it must be scrutinized to


determine whether benefits outweigh hazards.

The following questions are integral to the privileging process:


• What does the peer-reviewed literature say about the procedure or
treatment and the relevant standard of care?

• What complications are most commonly associated with the procedure


or treatment?

• How can your facility best protect patients against these possible
complications?

• Have you, your facility leaders, or administrators documented your


understanding of the risks associated with the procedure or treatment?

• Does the procedure fit within your practice’s current mission and
future plans?

• Clinical privileges must reflect the scope of your facility’s licensure


requirements, as well as its human, technical and financial resources.
A sound privileging process is fundamental to maintaining quality
standards and fostering careful and controlled growth.

The most effective way to reduce your exposure related to negligent credentialing claims is to
implement protocols that clarify administrative responsibilities and ensure conformity with
Federal and State licensure laws, regulations and standards.
Your protocols should reinforce the following fundamental principles:
• Clinical assignments are granted or denied based upon objective
carefully documented institutional criteria.
• Practice rules and regulations and standards are applied equally to all
applicants.

• Quality outcome data and patient information used in the process are
treated with utmost confidentiality.

• All clinical assignment decisions are communicated to the applicant by


letter.

• Credentialing and clinical assignments are carefully delineated.

• Decisions are documented in the applicant’s file, which is maintained


in a secure location.

Note: Healthcare entities must report professional review actions taken against physicians and
dentists and may report such actions against other healthcare practitioners to the NPDB.
References: 2009 HPSO Risk advisor Vol. 1
IN-SERVICE: RED FLAGS
The Federal Trade Commission has enacted a new rule requiring all creditors to
implement written policies aimed at curbing identity theft.
Any Medical practice that extends, renews, or continues credit for a patient-i.e, one that
bills patients for services rendered- is subject to the Red Flags Rule, regardless of
whether the Center first bills an insurance carrier.
A written program has therefore been developed that allows the Center to:
identify relevant red flags
detect flags as they occur and
prevent and mitigate identity theft
A red flag is anything that could alert the Center to suspicious activity that may indicate
identity theft.
The Federal Trade Commission’s guidelines identify four warning-sign categories:
1. Alerts, notifications, or warnings from a consumer reporting agency

2. Suspicious documents

3. Suspicious personal identity information

4. Suspicious activity relating to a covered account or notices from


customers, victims of identity theft, law enforcement authorities, or
other entities about possible identity theft in connection with covered
accounts

Red flags may be detected when you verify a patient’s identity, review medical records,
verify insurance forms, or receive alerts or information of suspicious activity from
outside agencies.

If you note a red flag you must:


 Increase the monitoring of the account
 Contact the payer

 Contact law enforcement agencies

 Change account numbers to prevent misuse

 Or a combination of the above.

This must also be done if there has been a breach or attempted breach of the Center’s data
base.
The Center’s program will be updated when the methods of identity- theft threats change
or new risks and trends develop.

Drlaw.com/publications/Red_Flag_Rules_Template1.pdf.
Reference: Medica Economics April 17, 2009, page 23
INFLUENZA VACCINE DECLINATION FORM
2009

Name(Print): _________________________ Date:


___________

If you work in a patient care area, and did not receive a flu vaccine at the Center, please
complete all applicable sections and return to the Admin/DON by June 1, 2009.
This acknowledges that the following influenza information is understood, as well as the
ability to receive the flu vaccine at the Center with no charge.
• Influenza can be spread for 24-48 hours before symptoms appear
• Yearly vaccination is required, as the flu strains vary year to year
• I cannot get the flu from the flu vaccine
• CDC Recommendations include the receipt of flu vaccine by all
healthcare workers in order to protect patients, visitors, and co-
workers
Vaccinated Elsewhere:
I received vaccine at _______________________________________
(Facility )
I received it on this date: ________________ (INCLUDE MONTH)

Employee Signature/Title: _________________________________________

Contraindications to Vaccine:
Persons with severe egg allergy should not get the vaccine. If you have a history
of Guillain-Barre Syndrome, please consult your physician as to whether or not
the vaccine is appropriate to receive.
I have been advised by my physician not to receive the vaccine.

Employee Signature/Title: _________________________________________

Declination Statement:
Despite review of all the above, and the recommendation by the facility based on
current CDC literature, I choose not to receive the vaccine at this time.

Employee Signature/Title: _________________________________________


H1N1 Novel Influenza Update
June 25, 2009

As of June 24, 92 countries had officially reported 52,160 cases of novel influenza A
(H1N1) infection, including 31 deaths. This includes 21,449 cases in the U.S. with 87
deaths. New Jersey is reporting 609 confirmed cases with another 290 probable.

At the beginning of what is now the influenza pandemic, back in April, the CDC found
that half of flu cases were attributable to regular seasonal flu and the other half to the new
H1N1 novel influenza virus. Today that is no longer the case. Any patients presenting
with flu-like symptoms and testing positive for Influenza A by normal lab/office methods
are considered to have novel H1N1; other (seasonal) flu strains have disappeared by now.

Despite low numbers of confirmed cases, due largely to limited testing, disease is
widespread in our communities. The State Lab is accepting only those specimens from
patients who require hospitalization, or patients involved in institutional outbreaks. There
is no reason to test patients unless doing so will alter treatment, or unless they are a
member of an institutional outbreak.

If a patient presents complaining of fever and cough, reception staff should hand the
patient a mask when they arrive; the patient should be brought back to an exam room as
soon as possible. If the reception staff hears a patient coughing in the Waiting Area, they
should give the patient a mask and ask them to put it on. Check Waiting Areas regularly
to make sure tissues, waste cans, and hand cleaning agents are available.

People with flu-like illness (fever, cough, and/or sore throat) and no other specifically
identified cause ( i.e. Strep throat should stay home for 7 days from work or school). This
applies to employees! If employees come to work sick, the chance of other employees
becoming ill as well is highly likely. Please recognize that dealing with an outbreak next
week, with many people sick, would be far worse than having a few people out now.

Remind parents that Aspirin should not be used for symptom management in
children under 18 due to risk of Reye syndrome, a rare but potentially serious
illness seen in children following viral illnesses and linked to Aspirin use for
symptom management.
H1N1 Novel Influenza Update
June 25, 2009

As of June 24, 92 countries had officially reported 52,160 cases of novel influenza A
(H1N1) infection, including 31 deaths. This includes 21,449 cases in the U.S. with 87
deaths. New Jersey is reporting 609 confirmed cases with another 290 probable.
At the beginning of what is now the influenza pandemic, back in April, the CDC found
that half of flu cases were attributable to regular seasonal flu and the other half to the new
H1N1 novel influenza virus. Today that is no longer the case. Any patients presenting
with flu-like symptoms and testing positive for Influenza A by normal lab/office methods
are considered to have novel H1N1; other (seasonal) flu strains have disappeared by now.

Despite low numbers of confirmed cases, due largely to limited testing, disease is
widespread in our communities. The State Lab is accepting only those specimens from
patients who require hospitalization, or patients involved in institutional outbreaks. There
is no reason to test patients unless doing so will alter treatment, or unless they are a
member of an institutional outbreak.

If a patient presents complaining of fever and cough, reception staff should hand the
patient a mask when they arrive; the patient should be brought back to an exam room as
soon as possible. If reception staff hears a patient coughing in the Waiting Area, they
should give the patient a mask and ask them to put it on. Check Waiting Areas regularly
to make sure tissues, waste cans, and hand cleaning agents are available.

People with flu-like illness (fever, cough, and/or sore throat) and no other specifically
identified cause ( i.e. Strep throat should stay home for 7 days from work or school). This
applies to employees! If employees come to work sick, the chance of other employees
becoming ill as well is highly likely. Please recognize that dealing with an outbreak next
week, with many people sick, would be far worse than having a few people out now.

Remind parents that Aspirin should not be used for symptom management in
children under 18 due to risk of Reye syndrome, a rare but potentially serious
illness seen in children following viral illnesses and linked to Aspirin use for
symptom management.
Disaster Drill: Novel H1N1 Influenza (Swine Flu).
Purpose/Objective:
To make every effort to ensure that the staff is aware of the steps to take if a case of the
Swine Flu is present in the Center.

Present:

Scenario #1:
Patient arrives at the front desk with fever and cold symptoms. The patient is sent into
the exam room and is interviewed by a nurse.

Actions:
Patient is asked to wait in the exam room
Nurse is called to the exam room
Patient is asked to wear a mask
Patient responds that he/she is ill with cold symptoms
The patient is instructed to contact primary care physician and stay home until symptoms
resolve
Wash hands frequently especially after coughing and sneezing
Cough into a tissue (not into bare hands or onto another person
Dispose of tissues in the trash
If the patient experiences a high fever >37.8 degrees C (100 degrees F and cough and/or
sore throat (in the absence of another known cause)
Instruct the patient to go to the hospital.
Scenario #2:
The Center is informed that a patient that was in the Center came down with the Novel
H1N1 Influenza (Swine Flu).
Actions:
Inform the Administrator
Call local health department
Call the infection control nurse for direction
Contact individuals that came in direct contact with the patient
Ask contacts to call the Center if they develop symptoms and are diagnosed with
influenza H1N1.
(Http://nj.gov/health/lh/directory/lhdselectcounty.shtml) If local health department is not
available, please call NJDHSS during normal business hours (M-F 8 a.m. to 5 p.m.) at
609-588-7500 or after hours at 609-392-2020.
All suspect clusters are immediately reportable to the local health department
(Http://j.gov/health/lh/directory/lhdselectcounty.shtml) or when not available
NJDHSS.NJDHSS can be reached during business hours (M-F 8 a.m. to 5 p.m. ) at 609-
588-7500 or after hours at 609-392-2020.
Clusters are defined as:
Two or more individuals with symptom onset within 7 days of each other residing in the
same household or are associated with the same institution/activity/event (i.e., work,
school, travel)
Scenario #3:
Patient is called preoperatively at home and is screened for illnesses, contact with anyone
with a communicable disease or travel outside the US.
The patient responds that he/she is ill with cold symptoms
The patient is instructed to stay home until symptoms resolve
Wash hands frequently especially after coughing and sneezing
Cough into a tissue (not into bare hands or onto another person)
Dispose of tissues in the trash
If the patient has a high fever >37.8 degrees C (100 degrees F and cough and/or sore
throat (in the absence of another known cause)
Instruct the patient to contact his/her primary care physician.
(Http://nj.gov/health/lh/directory/lhdselectcounty.shtml) If local health department is not
available, please call NJDHSS during normal business hours (M-F 8 a.m. to 5 p.m.) at
609-588-7500 or after hours at 609-392-2020.
All suspect clusters are immediately reportable to the local health department
(Http://j.gov/health/lh/directory/lhdselectcounty.shtml) or when not available
NJDHSS.NJDHSS can be reached during business hours (M-F 8 a.m. to 5 p.m.) at 609-
588-7500 or after hours at 609-392-2020.
Clusters are defined as:
Two or more individuals with symptom onset within 7 days of each other residing in the
same household or are associated with the same institution/activity/event (i.e., work,
school, travel)
POLICY: INFLUENZA
Purpose/Objective:
To make every effort to ensure the staff is aware of the procedures to follow if a patient
or visitor is suspected to have influenza like illness.

FOR PATIENTS/VISITORS WITH INFLUENZA LIKE ILLNESS


If the patient has a high fever >37.8 degrees C (100 degrees F and cough and/or sore
throat (in the absence of another known cause)

ENSURE APPROPRIATE INFECTION CONTROL IS ESTABLISHED (Ask individual


to wear a face mask and isolate patient in the exam room.)

IS ADMISSION TO ACUTE CARE FACILITY WARRANTED?

IF YES:
IF YES ADMIT VIA EMERGENCY DEPARTMENT

IF NO:
CALL THE PATIENT’S/VISITOR’S PRIMARY CARE DOCTOR OR URGENT
CARE CENTER AND INQUIRE WHETHER THE PATIENT SHOULD BE
EVALUATED AND/OR SENT FOR A RAPID INFLUENZA TEST.

Preoperative call:
The patient responds that he/she is ill with cold symptoms and fever
The patient is instructed to stay home for 7 days after onset of symptoms or until 24 hours
after symptoms resolve-whichever is longer
Wash hands frequently especially after coughing and sneezing
Cough into a tissue (not into bare hands or onto another person)
Dispose of tissues in the trash
If the patient has a high fever >37.8 degrees C (100 degrees F and cough and/or sore
throat (in the absence of another known cause)
Instruct the patient to contact primary care physician or go to the emergency room if
warranted.
IF PATIENT WAS CANCELLED DUE TO INFLUENZA TYPE ILLNESS, OBTAIN
CLEARANCE FROM PRIMARY MEDICAL DOCTOR PRIOR TO RESCHEDULING
THE PATIENT
INFLUENZA TRIAGE QUESTIONS
2009
1. Recent travel outside the country; visits from anyone residing
outside the country? Y N
Date of onset:

2. Have you received any flu vaccine this season? Y N


Month: ____

3. Have you had 1 or more of the following:


Fever or Chills Y N
Date of onset: ________
Cough Y N
Date of onset: _________Productive ? Y N
Color: ____
Difficulty Breathing Y N
Date of onset: _________
Chest Discomfort Y N
Date of onset: ________
Sore Throat Y N
Date of onset: ________
Headache Y N
Date of onset: ________
Muscle Pain Y N
Date of onset: ________
Watery Diarrhea Y N
Date of onset: ________
Vomiting Y N
Date of onset: _________
Extreme Exhaustion Y N
Date of onset: _________
Stuffy Nose Y N
Date of onset: _________
Sneezing Y N
Date of onset: _________
For children, also assess for:
Ear Ache Y N
Date of onset: ________
Nausea Y N
Date of onset: _________
RN Signature: ______________________________
Date:____________________

If results of triage positive, contact surgeon for cancellation decision


POLICY: PHLEBOTOMY
Purpose/Objective:
To make every effort to ensure that phlebotomy is performed in a safe manner.

Procedure;
Besides the technical concepts and skills required by those performing phlebotomy, the
following areas must also be incorporated to provide a quality experience for patients/
those receiving phlebotomy services:
• Roles and Responsibilities per job description
• Only RN’s that have been trained in phlebotomy will perform
phlebotomy in the Center.
Patient identification

•Use at least 2 patient identifiers, none of which may be a


room/cubicle#
• Regardless of the work setting, proper collection, labeling, and
handling of all specimens are critical to ensure accurate results
and to prevent the need for having to repeat the test
unnecessarily.
• Specimen tubes must be labeled before the RN leaves the
patient’s side, but never before the specimen is drawn.
Communication

o Read back, a current requirement for safe practice, is to be


practiced when communicating/receiving orders for tests
requiring phlebotomy, as well as when receiving the test
results back, when applicable.
o Confidentiality of protected health care information, as
described in HIPAA, is to be followed at all times
o Consent- a full explanation to the patient of the procedure
is required; know when a specific/separate consent may be
required. (i.e. for HIV testing)
o A patient has the right to refuse any procedure, including
obtaining a specimen from them. If this occurs, contact the
physician immediately; if, after speaking with the
physician, a patient still refuses the blood draw, document
in detail the circumstances.
Safety and Infection Prevention

o CDC has established hand hygiene guidelines, since


phlebotomy involves direct access into the vascular
system, performing correct hand hygiene is critical.
o Phlebotomy also exposes the health care professional to
the possibility of bloodborne pathogen exposure- per
OSHA, gloves must be worn to perform phlebotomy, and
changed after each patient.
Basic Concepts:

• Vascular System- knowing the location of blood vessels,


especially the most commonly used arm veins, is essential to
performing venipuncture.

o How to tell the difference between an artery and vein

 Vein will feel bouncy, resilient

 Artery will feel firmer- actually pulsate

o What happens when an artery is accidentally punctured

 Blood will appear bright red instead of dark

 Flow usually more forceful

o Care for accidental arterial puncture:

 Withdraw needle immediately

 Apply firm pressure for at least 5 minutes, then


apply gauze pressure dressing

 Notify physician, complete appropriate QI


documents

o Common Veins Used for Phlebotomy- located in the


antecubital fossa

 Median cubital vein- most commonly used; located in


middle of forearm; largest and least moving vein in
the forearm
 Cephalic vein- “thumb-side” of forearm; well
anchored, but may be difficult to palpate

 Basilic vein- “pinky-side” of forearm; easily


palpated, but tends to roll when touched

• Lies close to the median nerve and the


brachial artery

 Hand veins may also be used if no veins available in


the antecubital fossa

• Roll easily

• May require variation of size/type phlebotomy


needle

o Factors that limit access to veins

 Dermatitis- if both arms affected- put a layer of


gauze between the patient’s arm and the tourniquet

 IV infusion- IV infusion contents will alter the blood


specimen results

 Patients with mastectomy, or those who have had a


stroke- sign should be posted in the room “NO
BLOOD PRESSURES OR VEIN PUNCTURES” in the
affected arm; a color-coded armband may also be
placed if specified per Center policy

• Specimen Collection Equipment- although equipment may vary


for very technical phlebotomy procedures that may be
performed at an ASC, the following items are needed:

o Gloves- non sterile

o Tourniquet- latex free; do not leave on for longer than 1


minute at a time

o Alcohol Prep Pad

o Gauze Pads
o Adhesive Bandage or Tape- patients should be advised to
hold the arm straight, apply pressure for 3-5 minutes, and
remove the bandage in 15-20 minutes.

o Needles must have safety features per Needlestick


Safety and Prevention Act

o Evacuated Tube Holder(specialized plastic adapter that


holds both a needle and a tube for blood collection); come
in both adult and pediatric sizes; or Syringe*- a Butterfly
infusion set may be used for older patients or children that
have small veins

o Sharps Container

o Permanent Marker, Pen, or Computer Labels

o Evacuated Tubes- range in size from 2ml to 15ml

 Come in different colors with different additives in


order to provide different tests based on the
additive. Refer to Lab Manual or Mfg’s Instructions to
determine which color tubes are used at the ASC, as
well as where they are located

• Order or Sequence of Draw

o The order in which blood is collected, when using more


than 1 color evacuated tube, impacts the test results. Use
the following , when drawing multiple tubes having
different colors:

 Sterile Specimens, or Yellow Tubes

 Light Blue*- when using a Butterfly (winged)


collection set, a discard tube is used to eliminate the
dead space, and ensure the proper blood to additive
ratio is maintained in the collection tube

 Gold or Red/Black

 Red Plastic or Glass

 Green
 Light Green or Green/Gray

 Pink or Lavender

 Gray

• Troubleshooting- no more than 2 attempts should be made by


the RN when performing phlebotomy. A
physician/Anesthesiologist should be requested to perform the
procedure. Review of the following may help with
troubleshooting in order to have successful venipuncture:

o Failure to obtain blood- the most common reason is loss of


tube vacuum- always keep spare tube(s) close at hand;
otherwise, reposition needle by pulling back slightly- DO
NOT PROBE; the tourniquet itself may be occluding the
flow of blood- try releasing the tourniquet slightly

o Petechiae- can result if the tourniquet is left on too long;


minimize tourniquet time, and keep pressure on the site as
long as there is bleeding

o Hematoma- may result from: extended tourniquet time;


leaving the tourniquet in place after the needle is
withdrawn; needle that has gone through the vein, or a
needle that is not fully inserted into the vein. If this
occurs, apply firm pressure at the site. Ice may be applied
if the patient complains of discomfort.

o Hemoconcentration- can result from: patient


opening/closing fist too rapidly, tourniquet in place greater
than 1 minute; tourniquet that is too tight (“falling asleep”
sensation can occur during hemoconcentration)

o Alcohol Prep- if alcohol prep is not dry prior to needle


insertion, the patient may experience a burning sensation;
in addition, wet alcohol entering the specimen may cause
it to hemolyze, thus affecting the results.
PHLEBOTOMY CONCEPTS FOR THE RN
Introduction:
During the late 1980’s and early 1990’s, the phlebotomy profession emerged as a result
of technology and expansions of laboratory functions. Initially, only medical
technologists and medical technicians were responsible for collecting blood specimens.
But as technology and the healthcare industry underwent rapid changes in the past few
decades, specimen collection was delegated to other groups of trained professionals,
including Registered Nurses.
The recent growth in Ambulatory Centers has also contributed to the need for additional
members of the healthcare team, besides physicians, to have the knowledge and training
to collect blood specimens. Although larger centers may actually employ phlebotomists
on staff to facilitate preoperative testing procedures, most of the smaller ASCs rely on
contracted laboratories; there are also CLIA-waived, or Point of Service tests, that may
be performed at the Centers without the need for phlebotomy skills.
Regulatory agencies that are involved with phlebotomy include:
CLIA- Clinical Laboratory Improvement Amendment
CLSI- Clinical Laboratory and Standards Institute
OSHA- Occupational Safety and Health Administration
CDC- Centers for Disease Control
CMS- Center for Medicare/Medicaid Services
DHSS- Department of Health and Senior Services
Quality Assurance
Besides the technical concepts and skills required by those performing phlebotomy, the
following areas must also be incorporated to provide a quality experience for patients/
those receiving phlebotomy services:
• Roles and Responsibilities per job description
o The RN requires additional training in order to perform
phlebotomy, despite thorough Anatomy/Physiology courses
as part of the basic nursing curriculum.
• Patient identification
o New safety focused organizations, regulatory agencies,
and internal ASC policies all require the use of at least 2
patient identifiers, none of which may be a
room/cubicle#.
o Obtaining blood from the wrong patient constitutes an act
of negligence, and can result in disciplinary action.
• Specimen collection and handling
o AORN has Recommended Practices on Specimen Handling;
specific protocols are in place from the contracted lab to
which various specimens may be sent; finally, internal ASC
policies may include specimen handling.
o Regardless of the work setting, proper collection, labeling,
and handling of all specimens are critical to ensure
accurate results and to prevent the need for having to
repeat the test unnecessarily.
o Specimen tubes must be labeled before the RN
leaves the patient’s side, but never before the
specimen is drawn.
• Professionalism
o Not only does this include a positive attitude and
appearance, but also keeping up with current information
and products in the field.
• Communication
o Read back, a current requirement for safe practice, is to
occur when communicating/receiving orders for tests
requiring phlebotomy, as well as when receiving the test
results back, when applicable.
o Confidentiality of protected health care information, as
described in HIPAA, is to be followed at all times
o Consent- a full explanation to the patient of the procedure
is required; know when a specific/separate consent
may be required.
o A patient has the right to refuse any procedure, including
obtaining a specimen from them. If this occurs, contact the
physician immediately; if, after speaking with the
physician, a patient still refuses the blood draw, document
in detail the circumstances- remember to follow all
internal policies/procedures, which may vary
according to the circumstances.
• Safety and Infection Prevention
o CDC has established hand hygiene guidelines, the most
recent version in 2002; since phlebotomy involves direct
access into the vascular system, performing correct
hand hygiene is critical.
o Phlebotomy also exposes the health care professional to
the possibility of bloodborne pathogen exposure- per
OSHA, gloves must be worn to perform phlebotomy,
and changed after each patient. In some
circumstances, other PPE may be required- refer to/follow
Center Policy.
Basic Concepts:
• Vascular System- knowing the location of blood vessels,
especially the most commonly used arm veins, is essential to
performing venipuncture.

o How to tell the difference between an artery and vein

 Vein will feel bouncy, resilient

 Artery will feel firmer- actually pulsate

o What happens when an artery is accidentally punctured

 Blood will appear bright red instead of dark

 Flow usually more forceful

o Care for accidental arterial puncture:

 Withdraw needle immediately


 Apply firm pressure for at least 5 minutes, then
apply gauze pressure dressing

 Notify physician, complete appropriate QI


documents

o Common Veins Used for Phlebotomy- located in the


antecubital fossa

 Median cubital vein- most commonly used; located in


middle of forearm; largest and least moving vein in
the forearm

 Cephalic vein- “thumb-side” of forearm; well


anchored, but may be difficult to palpate

 Basilic vein- “pinky-side” of forearm; easily


palpated, but tends to roll when touched

• Lies close to the median nerve and the


brachial artery

 Hand veins may also be used if no veins available in


the antecubital fossa

• Roll easily

• May require variation of size/type phlebotomy


needle

o Factors that limit access to veins

 Dermatitis- if both arms affected- put a layer of


gauze between the patient’s arm and the tourniquet

 IV infusion- IV infusion contents will alter the blood


specimen results

 Patients with mastectomy, or those who have had a


stroke- sign should be posted in the room “NO
BLOOD PRESSURES OR VEIN PUNCTURES” in the
affected arm; a color-coded armband may also be
placed if specified per Center policy
• Specimen Collection Equipment- although equipment may vary
for very technical phlebotomy procedures that may be
performed at an ASC, the following items are needed:

o Gloves- non sterile

o Tourniquet- latex free; do not leave on for longer than


1 minute at a time

o Alcohol Prep Pad

o Gauze Pads

o Adhesive Bandage or Tape- patients should be advised to


hold the arm straight, apply pressure for 3-5 minutes, and
remove the bandage in 15-20 minutes.

o Needles- should have safety features per Needlestick


Safety and Prevention Act

o Evacuated Tube Holder( specialized plastic adapter that


holds both a needle and a tube for blood collection);
comes in both adult and pediatric sizes; or Syringe*- a
Butterfly infusion set may be used for older patients or
children that have small veins

o Sharps Container

o Permanent Marker, Pen, or Computer Labels

o Evacuated Tubes- range in size from 2ml to 15ml

 Come in different colors with different additives in


order to provide different tests based on the
additive. Refer to Lab Manual or Mfg’s
Instructions to determine which color tubes
are used at the ASC, as well as where they are
located

• Order or Sequence of Draw

o The order in which blood is collected, when using more


than 1 color evacuated tube, impacts the test results. Use
the following , when drawing multiple tubes having
different colors:

 Sterile Specimens, or Yellow Tubes

 Light Blue*- when using a Butterfly (winged)


collection set, a discard tube is used to eliminate the
dead space, and ensure the proper blood to additive
ratio is maintained in the collection tube

 Gold or Red/Black

 Red Plastic or Glass

 Green

 Light Green or Green/Gray

 Pink or Lavender

 Gray

• Troubleshooting- no more than 2 attempts should be made by


the RN when performing phlebotomy. A
physician/Anesthesiologist should be requested to perform the
procedure should this occur. Review of the following may help
with troubleshooting in order to have successful venipuncture:

o Failure to obtain blood- the most common reason is loss of


tube vacuum- always keep spare tube(s) close at hand;
otherwise, reposition needle by pulling back slightly- DO
NOT PROBE; the tourniquet itself may be occluding the
flow of blood- try releasing the tourniquet slightly

o Petechiae- can result if the tourniquet is left on too long;


minimize tourniquet time, and keep pressure on the site as
long as there is bleeding

o Hematoma- may result from: extended tourniquet time;


leaving the tourniquet in place after the needle is
withdrawn; needle that has gone through the vein, or a
needle that is not fully inserted into the vein.If this
occurs, apply firm pressure at the site. Ice may be
applied if the patient complains of discomfort.
o Hemoconcentration- can result from: patient
opening/closing fist too rapidly, tourniquet in place greater
than 1 minute; tourniquet that is too tight (“falling asleep”
sensation can occur during hemoconcentration)

o Alcohol Prep- if alcohol prep is not dry prior to needle


insertion, the patient may experience a burning sensation;
in addition, wet alcohol entering the specimen may cause
it to hemolyze, thus affecting the results.

• Risk Management

CLSI has specific standards that apply to all persons who


perform venipuncture. The focus is accurate and safe
performance of phlebotomy procedures. Most injuries resulting
from phlebotomy procedures fall under malpractice (incorrect
treatment of a patient by a healthcare worker) or negligence
(failure to perform reasonably expected duties for patients)

Attempting to perform procedures that you are not fully trained


to perform can lead to poor quality as well as perceived risk to
the Center. Never perform any procedures that you are not
fully trained to perform.

The following are common causes for liability in the area of


phlebotomy:

• Misidentification of the patient

• Breach of confidentiality

• Acting outside the scope of practice

• Improperly labeled specimens

• Mishandling of a specimen, resulting in erroneous results

• Injury to blood vessels or nerves

• Poor sterile technique, resulting in patient infection

• Permanent scarring or disfigurement

References:
Booth,Wallace, Fitzgerald; Phlebotomy for Healthcare Personnel,
2nd Edition, 2009

AORN, Perioperative Standards and Recommended Practices,


2009 Edition

TEST QUESTIONS- PHLEBOTOMY CONCEPTS FOR THE RN

1. Regulatory agencies involved with phlebotomy include CLIA, CLSI, OSHA,


CDC, CMS, and DHSS

True False
2. RNs automatically may perform phlebotomy base on their core nursing education

True False
3. Specimen tubes must be labeled before the RN leaves the patient; never before the
specimen is drawn

True False
4. Performing correct hand hygiene is critical to prevention of infection during
phlebotomy

True False
5. Name the 3 most common veins, located in the antecubital fossa, that are used for
phlebotomy:

a. ____________________________________________________

b. ____________________________________________________

c. ____________________________________________________

6. An important thing to remember if using the basilic vein for phlebotomy is a)it
lies close to the median nerve and b) it lies close to the brachial artery.

True False
7. Factors that may limit access to veins include dermatitis, existing IV infusions,
patient history of mastectomy or stroke

True False
8. Choosing an evacuated tube color is based on: lab manual from contracted
institution, manufacturer’s instructions for technical products

True False
9. If multiple tubes of different colors are required, it doesn’t matter which tube is
used first.
True False
10. If the RN has difficulty locating a vein and/or performing the venipuncture,
attempts should be limited to 2; at this point a physician/Anesthesiologist should
be called to perform.

True False
11. Hematoma formation may result from leaving the tourniquet in place after the
needle is withdrawn

True False
12. Care for an accidental arterial puncture should include: immediate withdrawal of
the needle; application of firm pressure for at least 5 minutes followed by
application of a gauze pressure dressing; notification of the physician; notification
of DON and completion of appropriate QI documents

True False
13. Common causes for liability in the area of phlebotomy include: misidentification
of the patient, breach of confidentiality, acting outside the scope of practice,
improperly labeled/mishandling of specimens, injury to blood vessels or nerves,
poor sterile technique resulting in infection, permanent scarring or disfigurement

True False

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