January 22, 2018 NOTICE

Transcription

1 January 22, 2018 NOTICE The Board of Directors of the Kaweah Delta Health Care District will meet in an open Board of Directors meeting at 5:30PM on Monday January 22, 2018 in the Sequoia Regional Cancer Center Maynard Faught Conference Room {4945 W. Cypress Avenue, Visalia}. The Board of Directors of the Kaweah Delta Health Care District will meet in a closed Board of Directors meeting at 5:31PM on Monday January 22, 2018 in the Sequoia Regional Cancer Center Maynard Faught Conference Room {4945 W. Cypress Avenue, Visalia} pursuant to Health and Safety Code 32155, Government Code Section (d)(1), Government Code Section (d)(2), and Health & Safety Code The Board of Directors of the Kaweah Delta Health Care District will meet in an open Board of Directors meeting at 6:00PM on Monday January 22, 2018 in the Sequoia Regional Cancer Center Maynard Faught Conference Room {4945 W. Cypress Avenue, Visalia}. The Board of Directors of the Kaweah Delta Health Care District will meet in a closed Board of Directors meeting immediately following the 6:00PM open Board meeting on Monday January 22, 2018 in the Sequoia Regional Cancer Center Maynard Faught Conference Room {4945 W. Cypress Avenue, Visalia} Government Code 54957(b)(1). All Kaweah Delta Health Care District regular board meeting and committee meeting notices and agendas are posted 72 hours prior to meetings (special meetings are posted 24 hour prior to meetings) in the Kaweah Delta Medical Center, Mineral King Wing entry corridor between the Mineral King lobby and the Emergency Department waiting room. The disclosable public records related to agendas are available for public inspection at the Kaweah Delta Medical Center Acequia Wing, Executive Offices (Administration Department) {1st floor}, 400 West Mineral King Avenue, Visalia, CA and on the Kaweah Delta Health Care District web page KAWEAH DELTA HEALTH CARE DISTRICT Nevin House, Secretary/Treasurer Cindy Moccio - Board Clerk / Executive Assistant to CEO DISTRIBUTION: Governing Board Legal Counsel Executive Team Chief of Staff West Mineral King Avenue Visalia, CA (559)

2 KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS Sequoia Regional Cancer Center Maynard Faught Conference Room 4945 W. Cypress Avenue, Visalia Call to order Approve agenda Monday January 22, 2018 OPEN MEETING AGENDA {5:30PM} Public / Medical Staff participation Members of the public or the medical staff may comment on agenda items before action is taken and after the item has been discussed by the Board. Each speaker will be allowed five minutes. Members of the public wishing to address the Board concerning items not on the agenda and within the subject matter jurisdictions of the Board are requested to identify themselves at this time. 1. Approval of Closed Agenda as follows: Closed Meeting Agenda 5:31PM 1.1. Credentialing - Medical Executive Committee (January 2018) requests that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval pursuant to Health and Safety Code 1461 and Harry Lively, MD, Chief of Staff 1.2. Conference with Legal Counsel Existing Litigation Pursuant to Government Code (d)(1) Dennis Lynch, Legal Counsel & Evelyn McEntire, Risk Manager 1. Linda Rivas #VCU Conference with Legal Counsel Anticipated Litigation Significant exposure to litigation pursuant to Government Code (d)(2) 12 Cases - Dennis Lynch, Legal Counsel & Evelyn McEntire, Risk Manager 1.4. Credentialing - Health and Safety Code 1461 & Dennis Lynch, Legal Counsel 1.5. Approval of closed meeting minutes {12/20/17} Adjourn CLOSED MEETING AGENDA {5:31PM} Call to order 1. Credentialing - Medical Executive Committee (January 2018) requests that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval pursuant to Health and Safety Code 1461 and Harry Lively, MD, Chief of Staff 2. Conference with Legal Counsel Existing Litigation Pursuant to Government Code (d)(1) Dennis Lynch, Legal Counsel & Evelyn McEntire, Risk Manager 2.1. Linda Rivas #VCU Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III Carl Anderson Zone IV Nevin House Zone V Board Member President Board Member Board Member Secretary/Treasurer

3 3. Conference with Legal Counsel Anticipated Litigation Significant exposure to litigation pursuant to Government Code (d)(2) 12 Cases - Dennis Lynch, Legal Counsel & Evelyn McEntire, Risk Manager 4. Credentialing - Health and Safety Code 1461 & Dennis Lynch, Legal Counsel 5. Approval of closed meeting minutes {12/20/17} Action Requested: Approval of the 12/20/17 closed meeting minutes. Adjourn OPEN MEETING AGENDA {6:00PM} Call to order Approve agenda Public / Medical Staff participation Members of the public or the medical staff may comment on agenda items before action is taken and after the item has been discussed by the Board. Each speaker will be allowed five minutes. Members of the public wishing to address the Board concerning items not on the agenda and within the subject matter jurisdictions of the Board are requested to identify themselves at this time. Closed Session Action Taken Report on actions taken in closed session. 1. Recognitions Director Carl Anderson 1.1. Presentation of Resolution 1981 to Kevin Rodriguez, PT III, O/P Rehab-CCPTS, for the Service Excellence Award January Consent Calendar (All matters under the Consent Calendar will be approved by one motion, unless a Board member request separate action on a specific item). Recommended Action: Approve the January 22, 2018 Consent Calendar. 3. Quality Report 3.1. Fall Prevention - A review of current performance in fall prevention measures and associated actions RoseNewsom, RN, MSN NE-BE, Director of Nursing Practice 4. Strategic Plan Element Report 4.1. Facilities and Technology Management Develop Future Facilities and Technology to Support Key Service Lines Thomas Rayner, Vice President and Chief Operating Officer and Julieta Mondada, Director of Facilities Planning 5. Kaweah Delta Medical Foundation Status report on the progress of the Kaweah Delta Medical Foundation Rick Strid, Kaweah Delta Medial Foundation Chief Executive Officer & Visalia Medical Clinic Executive Director 6. Recognition Recognition of Carl Anderson in appreciation of his service to the Kaweah Delta Health Care District Board, and Gary Herbst, Chief Executive Officer 7. Kaweah Delta Board of Directors Zone IV Discussion of appointment process for filling the Zone IV Kaweah Delta Health Care District Board seat Dennis Lynch, Legal Counsel & Gary Herbst, Chief Executive Officer Monday January 22, 2018 Page 2 of 3 Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III Carl Anderson Zone IV Nevin House Zone V Board Member President Board Member Board Member Secretary/Treasurer

4 8. Credentialing Medical Executive Committee request that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval Harry Lively, MD, Chief of Staff Recommended Action: Whereas a thorough review of all required information and supporting documentation necessary for the consideration of initial applications, reappointments, request for additional privileges, advance from provision al status and release from proctoring and resignations (pursuant to the Medical Staff bylaws) has been completed by the Directors of the clinical services, the Credentials Committee, and the Executive Committee of the Medical Staff, for all of the medical staff scheduled for reappointment, Whereas the basis for the recommendations now before the Board of Trustees regarding initial applications, reappointments, request for additional privileges, advance from provision al status and release from proctoring and resignations has been predicated upon the required reviews, including all supporting documentation, Be it therefore resolved that the following medical staff be approved or reappointed (as applicable), as attached, to the organized medical staff of Kaweah Delta Health Care District for a two year period unless otherwise specified, with physician-specific privileges granted as recommended by the Chief of Service, the Credentials Committee, and the Executive Committee of the Medical Staff and as will be documented on each medical staff member s letter of initial application approval and reappointment from the Board of Trustees and within their individual credentials files. 9. Chief of Staff Report Update from the Chief of Staff relative to Medical Staff issues - Harry Lively, MD, Chief of Staff 10. Chief Executive Officer Report Report relative to current events and issues - Gary Herbst, Chief Executive Officer Cardiac Month Show Us Your Heart Art contest Feb. 2, 2018 Acequia Wing Lobby Patient Safety Symposium Monday February 5, 2018 Visalia Convention Center Joint Commission Primary Stroke Center Survey February 9, Nursing Recruitment California Department of Public Health (CDPH) licensing status 11. Board President Report Report from the Board President relative to current events and issues Lynn Havard Mirviss, Board President 12. Approval of Closed Agenda as follows: Closed Meeting Agenda Kaweah Delta Medical Center Blue Room Immediately following the 6:00PM open meeting 1. Personnel Discuss the appointment of the Chief Financial Officer - Pursuant to Government Code 54957(b)(1) Gary Herbst, Chief Executive Officer Adjourn Call to order CLOSED MEETING AGENDA {following the 6:00PM open meeting} 1. Personnel Discuss the appointment of the Chief Financial Officer - Pursuant to Government Code 54957(b)(1) Gary Herbst, Chief Executive Officer Adjourn In compliance with the Americans with Disabilities Act, if you need special assistance to participate at this meeting, please contact the Board Clerk (559) Notification 48 hours prior to the meeting will enable the District to make reasonable arrangements to ensure accessibility to the Kaweah Delta Health Care District Board of Directors meeting. Monday, January 22, 2018 Page 3 of 3 Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III Carl Anderson Zone IV Nevin House Zone V Board Member President Board Member Board Member Secretary/Treasurer

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17 Service Excellence January 2018 Kevin Rodriguez, PT III, O/P Rehab-CCPTS (19 Years) Nominated By: Cynthia Lee Behavioral Standards of Performance - Compassionate Service- Cares for you as an individual and cares tremendously about his profession. Respect- Always! Communication- Searches articles regarding your injuries and shares what he has discovered with you in order for your treatment to be the best it can be. Personal Ownership - You know right away that Kevin loves his job and is willing to do all he can to see that your health is top quality and your goals are reached. Professional Image- Kevin always looks professional. Comments: Kevin is truly an asset to this organization and hands down deserves the honor of being named Employee of the Month. His caring attitude and going above and beyond is sharing his knowledge and expertise are qualities that shine and Kevin certainly sets this example. He is always willing to go the extra mile involving your care. DIRECTORS: Jonah Miller, Jag Batth BOARD MEMBER: Carl Anderson

18 KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS - CONSENT CALENDAR Sequoia Regional Cancer Center Maynard Faught Conference Room 4945 W. Cypress Avenue, Visalia Monday January 22, :00PM NOTE: All items listed on the Consent Calendar are considered to be routine by the District Board of Directors, and will be enacted by one motion. There will be no separate discussion of these items unless a Board Member so requests, in which event, the item will be removed from the Consent Calendar and considered in its normal sequence on the regular agenda Reports A. Medical Staff Recruitment B. Risk Management C. Medical Imaging D. Quality and Patient Safety Dashboard E. Finance 2.2. Policies: A. ADMINISTRATIVE 1. Receiving Personal Items at KDHCD AP.113 Reviewed 2. Cash Receipts AP.121 Deleted B. HOME HEALTH 1. Therapeutic Wound Packing HH-PC New 2. Wound Care HH-PC Revised C. IMAGING & SRCC RADIATION ONCOLOGY 1. MRI Coronary Artery Stent Screening IS New 2. Radiation Protection Program IS 5.6a Revised 3. Emergency Care in Imaging Services IS 9.1 Revised 4. Routine Views IS 17.6 Revised 5. Radiology Barium Swallow/Esophogram Physician Preference IS Revised 6. Radiology Upper G.I. Physician Preference IS Revised 7. Radiology Small Bowel Follow Through (SBFT) IS Revised 8. Radiology Modified Barium Swallow with Speech Therapy Physician Preference IS Revised 9. Contrast/Medication Procurement, Storage, Control, Distribution, Administration and Monitoring of Radiographic Contrast Media IS 18.2 Revised Consent Calendar January 22, 2018 Page 1 of 3

19 10. Nuc Med Lasix Renogram IS Revised 11. Discharge Criteria for Post Myelogram Patients IS 2.06 Reviewed 12. CT Scheduling Priority for Patient Services IS 2.10 Reviewed 13. Patient Holding (Observation) IS Reviewed 14. Ordering Radiology Services IS 2.12 Reviewed 15. Conflicting Examinations IS 2.3 Reviewed 16. Patient Priority IS 2.6 Reviewed 17. Explaining Procedures to Patients IS 2.80 Reviewed 18. Procedures requiring Informed Consent IS 2.9 Reviewed 19. Appropriateness of Service IS 3.02 Reviewed 20. Notifying Radiologists of Emergency Procedures IS 3.1 Reviewed 21. Emergency Department Patients IS 3.12 Reviewed 22. Equipment Performance IS 4.1 Reviewed 23. Equipment Calibration IS 4.20 Reviewed 24. Nuclear Medicine Quality Control Tests IS 4.40 Reviewed 25. Fluoroscopy Guidelines IS 5.20 Reviewed 26. Radiation Safety: Portable Mobile Unit IS 5.3 Reviewed 27. Hazards of Portable Radiology IS 5.4 Reviewed 28. Personnel Dosimetry IS 5.5 Reviewed 29. Privacy of Employee Telephone Numbers IS 6.0 Reviewed 30. Recording Completed Exams IS 7.1 Reviewed 31. Emergency Call Back Protocol IS 9.5 Reviewed 32. Contrast/Medication Emergency Process & Supplies IS Reviewed 33. Patient Preparations IS 17.2 Reviewed 34. Radiology Radiographic Pellet (ring) Study Physician Preference IS Reviewed 35. Pediatric Contrast Dose IS 19.6 Reviewed D. MENTAL HEALTH 1. Therapeutic Hold (Restraint) of Patients in Behavioral Crisis MH1.91 Revised E. RENAL SERVICES 1. Accessing Dialysis Indwelling Catheter for Blood Draws/IV Antibiotics RS-L.01 Revised 2. Biohazard Waste/Sharps Waste RS-H.01 Revised 3. Exterior Cleaning of Hemodialysis Equipment RS-N.16 Revised 4. Rinseback Technique: Emergent RS-L.03 Revised 5. Water Analysis RS-N.12 Revised 6. Water Cultures RS-N.11 Revised 7. Medical Records: Physician Discharge Summary at Chronic Dialysis RS-F.03 Delete 8. Dialysis Adequacy/Run Time for Hemodialysis RS-L.46 Delete 9. IV Iron Administration RS-J.04 Delete Consent Calendar January 22, 2018 Page 2 of 3

20 10. New Employee Orientation/Training RS-G.01 Delete 11. Acute Aquaboss R.O. Operation RS-N.29 Delete 12. Acute Reverse Osmosis (RO) Disinfection Aquaboss RS-N.30 Delete F. SURGICAL SERVICES 1. Point of Use: Instrument Cleaning & Transport SPD 1001 New 2. Traffic Control: Visitors/Observers in Surgical Services SS 4009 Revised 2.3. Resolution 1983 to Chris Robertson, Clinical Informatics Supervisor, retiring from duty from Kaweah Delta after thirty-six (36) years of service Approval of the Board of Directors meeting open minutes: 12/20/ Recommendations from the Medical Executive Committee January 16, a. Carts & Kits 1. Crash Cart Supplies b. Order Sets 1. AMB OB Antepartum (New - KD Hub) 2. ANES Labor Patient Controlled Epidural Analgesia (PCEA) (New - KD Hub) 3. ANES POST-Op Epidural (or INTRAthecal) Anesthesia (New - KD Hub) 4. CVS Cardiac Surgery POST-Op (New - KD Hub) 5. CVS Cardiothoracic Surgery Addendum Orders for Transfer (New - KD Hub) 6. CVS Cardiothoracic Surgery PRE-Op (New - KD Hub) 7. CVS General Thoracic Surgery POST Op Admission (New - KD Hub) 8. CVS Impella Ventricular Assist Device (New - KD Hub) 9. MED Wound Care Full Thickness (New - KD Hub) 10. MED Wound Care Moisture Associated Skin Damage (New - KD Hub) 11. MED Wound Care Partial Thickness (New - KD Hub) 12. MED Wound Care Pressure Injury (New - KD Hub) 13. MED Wound Care Skin Tear (New - KD Hub) 14. MED Wound Care Wound VAC Therapy (New - KD Hub) 15. OB Hypertension Acute (New - KD Hub) 16. OB POST Partum Magnesium (New - KD Hub) 17. ORTHO Admission (New - KD Hub) 18. ORTHO Admission Pain Management (New - KD Hub) 19. ORTHO Hip Fracture Admission (New - KD Hub) 20. ORTHO POST-Op Pain Management (New - KD Hub) 21. TR Med Surge Trauma Admission (New - KD Hub) c. Resolution regarding professional liability insurance requirements for all members of the medical staff and advanced practice provider staff. Consent Calendar January 22, 2018 Page 3 of 3

21 Kaweah Delta Physician Recruitment Open Position Snapshop - January 2018 Prepared by: Brittany Taylor, Physician/Leadership Recruiter btaylor@kdhcd.org - (559) Date prepared: 1/10/2018 Kaweah Delta Medical Foundation Horizon Critical Care Adult Primary Care 1 Intensivists 2 Dermatology 1 Gastroenterology 3 IQ Surgical Associates Orthopedic Surgery - Adult Reconstruction 1 General Surgery (Colorectal or other subspecialty) 1 Pediatrics 1 Psychiatry 2 Sequoia Radiation Oncology Medical Associates Radiation Oncologist 1 Kaweah Exeter Medical Group Adult Primary Care 1 Valley Children's Health Care OB/Gyn 1 Maternal Fetal Medicine 2 Pediatrics 1 Pediatric Hospitalist 3 CEP - Family Medicine Clinic Valley Hospitalist Medical Group Family Medicine Core Faculty 1 Hospitalist 2 Golden State Cardiac & Thoracic Surgery Other Recruitment Cardiac & Thoracic Surgery 1 Palliative Medicine 2

22 Specialty Group Last Name First Name Availability Board Certification Miscellaneous Current Status Adult Primary Care - Family Medicine Kaweah Delta Medical Foundation Candidate Activity Okoro, M.D. Ebimoboere 07/18 American Board of Family Medicine, Eligible CA Licensed; Completing resident in Fresno, grew up in Bakersfield. Site Visit: 11/6/17; 2nd Visit: 12/1/17. Offer extended. Adult Primary Care - Family Medicine Cardiology, Invasive/Non- Interventional CT Surgery Dermatology Endocrinology Gastroenterology Gastroenterology Gastroenterology Kaweah Delta Medical Foundation Kaweah Delta Medical Foundation Golden State Cardiac & Thoracic Surgery Kaweah Delta Medical Foundation Kaweah Delta Medical Foundation Kaweah Delta Medical Foundation Kaweah Delta Medical Foundation Kaweah Delta Medical Foundation Chan, M.D. Roy 02/18 Said, M.D. Sarmad 08/18 Thomas, M.D. Donald TBD Carcamo, M.D. Alex 01/18 Saif, M.D. Noman 02/18 Cheung, M.D. Onpan 04/18 Theethira, M.D. Thimmaiah G. 08/17 Hsueh, M.D. William 08/19 1 American Board of Family Medicine, Certified American Board of Internal Medicine, Certified; American Board of Internal Medicine - Cardiovascular Disease, Eligible American Board of Surgery, Certified; American Board of Thoracic Surgery, Certified American Board of Dermatology, Diplomate American Board of Internal Medicine, Certified; American Board of Internal Medicine - Endocrinology, Certified American Board of Internal Medicine, Diplomate; American Board of Internal Medicine Gastroenterology, Diplomate American Board of Internal Medicine, Certified American Board of Internal Medicine, Certified CA Licensed; Candidate reached out directly on 5/25/17. CA Licensed; Presented on 7/13/17 by Physician Empire. CA licensed; Presented on 12/1/17 by Pacific Companies. CA Licensed; Presented on 12/4/17 by Physician Empire. CA licensed; Currently practicing in Longview, TX; Brother is moving to Fresno. Presented by Cejka on 2/1/17. CA Licensed; Currently practice in Minnetonka, MN; Presented by Pacific Companies on 12/1/17. Site visit: 8/9/17; Offer accepted; Anticipated start date: 2/1/2018 Site visit: 9/22/17; Offer accepted. Pending phone interview Currently under review Site Visit: 3/9/17; Offer accepted, Start Date TBD. Site visit: 2/5/18 CA Licensed; Completing fellowship at UCSF, Site visit: 9/18/17; Offer Fresno; Met at extended, considering CareerMD Career Fair on options will reply in 1/18 7/20/17, CV received 8/7/17. No CA license; Presented by Fidelis Partners on 7/25/17. Site visit: 11/10/17; Offer accepted.

23 Specialty Group Last Name First Name Availability Board Certification Miscellaneous Current Status American Board of Internal Medicine, Gastroenterology Diplomate; American CA licensed; presented Kaweah Delta Medical Pua, M.D. Shirley 02/18 Board of Internal by Integro Healthcare on Foundation Medicine 4/19/17. Gastroenterology, Certified General Surgery IQ Surgical Associates Kirkpatrick, M.D. Vincent 07/18 GME Family Medicine Faculty (full-time) GME Family Medicine Faculty (full-time) Hospitalist Hospitalist CEP Scott, M.D. Ariel Joy TBD CEP Parungao, M.D. Jodi 09/18 Valley Hospitalist Group Valley Hospitalist Group Ferrer, M.D. Linda 08/18 Legesse, M.D. Ashenafi 01/18 American Board of Surgery - General Surgery, In progress American Board of Family Medicine, Certified American Board of Family Medicine, Eligible American Board of Internal Medicine, Eligible American Board of Internal Medicine, Eligible CA Licensed; Presented by Fidelis Partners on 11/6/17. Completed residency in NM; Direct candidate presented by CEP 1/4/18. No CA license; Candidate information rec'd on 9/11/17. No CA license; Candidate presented by Physician Empire on 9/14/17. CA Licensed; Candidate is currently practicing in Fresno; Candidate reached out directly on 9/18/17. Currently under review. Met at conference 5/8/17. Site visit: 7/11/17. Offer accepted. Star date: 2/19/2018 Site Visit: 12/15/17; Offer accepted Site visit: 2/5-2/7/18 Site visit: 9/19/17; Offer accepted; tentative start date: 8/2018 Site Visit: 1/3/18 Site Visit: 11/13/17; 2nd Visit: 12/13/17. Out of country, will reconnect in 2/18. Hospitalist Valley Hospitalist Group Kanji, M.D. Rehan Amin 01/18 American Board of Family Medicine, Eligible CA Licensed; Spouse is employed by KDHCD. Candidate reached out directly on 9/13/17. Site Visit: 10/31/17; Offer accepted. Hospitalist Valley Hospitalist Group Boparai, M.D. Namrita 09/17 American Board of Internal Medicine, Eligible CV rec'd directly through CareerMD posting on 4/26/17. Candidate reached back out 11/2018. Considering joining as part-time nocturnist. Offer accepted (Part-Time Nocturnist); Start Date: 1/9/18 Hospitalist Valley Hospitalist Group Chen, M.D. David Peng 07/18 American Board of Internal Medicine, Eligible Completing residency in Peoria, IL; Wife accepted an NP position in Site visit: 12/12/17; offer Porterville. Candidate accepted reached out directly on 10/9/17. 2

24 Specialty Group Last Name First Name Availability Board Certification Miscellaneous Current Status Hospitalist Valley Hospitalist Group. Howard, M.D. Ryan 07/18 American Board of Family Medicine, Eligible No CA License; Completing residency in AZ; also considering Hospitalist position; Candidate reached out directly on 7/10/17. Site visit: 11/3/17; Offer accepted with Valley Hospitalist Medical Group. Hospitalist Valley Hospitalist Group Gumaste, M.D. Purva 08/18 American Board of Internal Medicine, Eligible No CA license; Husband is joining local Nephrology group; Candidate reached out directly on 7/6/17. Site visit: 9/11/17; Offer accepted. Anticipated start date: 8/29/18 Intensivist Horizon Critical Care Yeattes, M.D. Dale 01/18 Orthopedic Surgery - Adult Reconstruction Pediatrics Pediatric Hospitalist Orthopaedic Associates Kaweah Delta Medical Foundation Valley Children's Hospital Kim, D.O. Jun 08/19 Krogstad, M.D. Judi Ann TBD Eldadah, M.D. Maher TBD American Board of Internal Medicine - Critical Care Medicine, Certified; American Board of Emergency Medicine, Certified American Board of Orthopedic Surgery, Eligible American Board of Pediatrics, Certified American Board of Pediatrics, Certified; American Board of Pediatrics - Critical Care, Certified CA Licensed; Presented by Puzzle Piece Solutions on 10/5/17. Site visit: 10/19/17; Offer accepted. Start Date: 12/20/17 No CA license; Direct candidate referred by Site visit dates pending Dr. Bruce Le on 12/11/17. CA Licensed; Currently practicing in Fresno; Initial Site visit: 1/15/2018 Candidate referred by Dr. Darrin Smith at VMC. CA Licensed; Presented by VCH on 10/26/17. Site visit: 10/30/17; Offer accepted. Start Date: 2/26/18 (pending credentialing) Psychiatry Kaweah Delta Medical Foundation Elledge, M.D. Brian ASAP American Board of Psychiatry and Neurology, eligible CA Licensed; Direct candidate. Offer pending Psychiatry Kaweah Delta Medical Foundation Serna, M.D. Michael 07/18 American Board of Psychiatry and Neurology, eligible CA Licensed; Current Kaweah Delta Resident; Direct candidate. Offer pending 3

25 Specialty Group Last Name First Name Availability Board Certification Miscellaneous Current Status Radiation Oncology Sequoia Radiation Oncology Medical Associates Hauck, M.D. Carlin 07/18 American Board of Radiology-Radiation Oncology, Eligible No CA License; Candidate applied directly on 12/12/17. Site visit dates pending Radiation Oncology Sequoia Radiation Oncology Medical Associates Hess, M.D. Clayton 07/18 American Board of Radiology-Radiation Oncology, Certified CA Licensed; Candidate applied directly on 12/11/17. Initial Site Visit: 1/5/18 Radiation Oncology Sequoia Radiation Oncology Medical Associates Mann, M.D. Justin 07/18 American Board of Radiology-Radiation Oncology, Eligible No CA License; Candidate applied directly on 12/18/17. Site visit dates pending Radiation Oncology Sequoia Radiation Oncology Medical Associates Sood, M.D. Sumit 07/18 American Board of Radiology-Radiation Oncology, Eligible No CA License; Candidate applied directly on 12/4/17. Site visit dates pending Urology Kaweah Delta Medical Foundation Ford, M.D. Joseph 07/18 No CA License; Completing Oncology fellowship ; Presented by Fidelis Partners on 6/14/17. Site Visit: 7/7/17; Offer accepted 4

26 Risk Management Report Open 4 th Quarter 2017 January 22, 2018 Evelyn McEntire Director of Risk Management

27 Risk Management Goals 1. Reduce frequency and severity of harm (patient and non-patient). Zero incidents of never events 2. Reduce frequency and severity of claims. 3. Promote a safety culture as a proactive risk reduction strategy.

28 Total of 812 Risk Events for 4 th Qtr 2017

29 Improvements Achieved Reduced occurrences: Physician Issues, Clinical Practice Incorrect dose, overdose Patient falls Improved process for patients who elect to not receive blood transfusions utilizing No Blood armbands Improved process for the administration of IV infusions in the Cardiovascular Operating Room

30 Claims Frequency CY Average of Claims/Year = 15

31 Total of 125 Complaints & Grievances for 4 th Qtr Trends: Lost belongings Visitor falls Physician care / Visitor injury Q Q Q Q Q Q Q Q Q Q Q Q 2017

32 Kaweah Delta Health Care District Annual Report to the Board of Directors Medical Imaging Services Gordon Ah Tye, Director, (559) ; Renee Lauck, Director (559) December 22, 2017 Summary Issue/Service Considered Deferred or Completed Projects for regarding Foundation Funding & Budget Freeze: 1. KDMC: Plan to retrofit x-ray units to meet Consolidated Appropriations Act of DR technology Upgrades: Phases 1,2,&3 pending current capital budget fund availability 2. KDMC: Three new Port C-Arms to meet added surgery suites- 1 of 3 Foundation Funded 12/ KDIC- Replacement of CT Scanner - Foundation funded FY '16-17-Projected Installation 2/ KDIC- Replaced MRI Breast Coil- Foundation funded FY ' Completed 10/2018 Project Plans for DR technology Upgrade projects to meet CMS requirements by 12/31/2018, to avoid 7% reimbursement penalties. 2. Replace Rad-Fluoro X-ray unit at KDIC (CMS requirements) 3. Replace 2 X-ray units at CHC South Campus (CMS requirements) 4. Replace 2 Rad-Fluoro units at KDMC (CMS requirements) Project Plans for KDMC- Purchase and install of 3 rd CT scanner 2. SRCC- RO- Rapid Arc Linac Upgrades Quality/Performance Improvement Data 1. Employee Safety/Satisfaction Surveys: Continue to exceed District avg. across the board. Action items: Market review of Imaging & Radiation Oncology tech positions; Staffing- Recruitment 2. Monthly Performance Improvement monitors: Procedure Complication rates, Emergency Department (ED) Imaging Discrepancies, Repeat Rates, Critical Value Compliance, Extravasation rates, Turn-around Time Reports, Stroke Alert Compliance rates. 3. Patient and Employee Safety focus: Falls; Staff injury monitoring & compliance; CT & X-ray Radiation Reduction Initiatives; CT & MRI annual staff safety testing; Comprehensive Unit-based Safety Program (CUSP) Team, Radiation Safety Committee, Unit Based Council; Cerner RadNet to utilize ACR Appropriateness Criteria software to decrease CT, MRI, & Nuclear Med imaging over utilization. Policy, Strategic or Tactical Issues 1. Upgrades or replacement of Diagnostic X-ray equipment to meet CMS regulations for DR Technology. 2. Increase CT staffing to meet increased volume demands from ED 3. American College of Radiology (ACR) Accreditation for KD imaging modalities at 90% completion 4. Software screening processes to improve Imaging Services over utilization - ACR Select National Decision Support System.: Pending Cerner/RadNet transition 5/1/18 Go Live 5. Meet need for expanding surgery demands Pending purchase of 2 C-arms and increased staff 6. Continue to improve assessment process for coding and billing charges for all imaging services Recommendations/Next Steps Continue replacement of equipment beyond useful life, and adding of equipment as needed for expanded services and increasing volumes in all service lines

33 Retrofit or replace Computerized Radiolography (CR) systems with Digital Radiolography (DR) to meet Consolidated Appropriation Act of 2016 requirements to avoid 7% reimbursement penalties. Add 3 rd CT Scanner to meet ED and IP demand: CT guided procedures and volumes Add new C-Arms and staff to meet expanding imaging needs for Neurosurgical services Approvals/Conclusions - Reductions in reimbursement for imaging services will continue to impact profitability - Overutilization of all imaging services require changes in clinician assessment processes, which will be addressed with new ACR Select, National Decision Support System. - Continue to assess opportunities to improve turnaround times to support ED and IP Length of stay Important Notes in Review of Financial and Statistical Information 2015 vs. 2016: - 5.2% increase in total volumes- We had an 8,062 increase in total volume of procedures across the board. (146,720 to 154,782) Attributed to 3D Mammo volume increases (3,980) & expanded staff scheduling; Emergency CT, MRI, & US increases notable % increase in net revenue- Our increase in total procedure volumes were favorable in terms of reimbursement. Thus our overall net revenue increased by $769, % decrease in Direct Costs- Although we continued to experience increased volumes in all service lines, we were able to manage our efficiencies in staff to help reduce our direct costs. We also had numerous pieces of equipment in our Breast Center and Ultrasound departments that were under warranty reducing service contract expenses, which are typically expensive. - 18% increase in Net Income- Improvement in our Net Income due to increased volumes in all but one Imaging Service line. Primary contributor is our Breast Center services due to 3D Tomosynthesis.

34 Kaweah Delta Health Care District Annual Report to the Board of Directors Financial & Statistical Information Medical Imaging Services Gordon Ah Tye, Director ( ) January 2017 Service Line Report Data: Fiscal Year 2017 Patient Net Direct Contribution Indirect Net Service Procedures Revenue Costs Margin Costs Income Diagnostic Imaging 39,337 $272,830 $283,391 ($10,561) $96,905 ($107,466) Radiology - CHC 20, , , , , ,693 Radiology - KDIC 11,762 1,053, , , , ,650 Breast Center 30,232 2,476,511 1,152,641 1,323, , ,637 CT Scan 18, ,950 73, ,447 35, ,253 CT Scan - KDIC 4,091 1,630, ,169 1,175, , ,248 MRI 1, ,688 67,706 64,982 30,809 34,173 MRI - KDIC 3,809 2,576, ,378 1,977, ,450 1,727,024 Ultrasound 11, ,570 58,035 55,535 31,084 24,451 Ultrasound - KDIC 8,256 1,037, , , , ,828 Nuclear Medicine 5, , , , , ,166 PET Scan 821 1,626, , ,303 59, ,327 Grand Total 154,782 $12,704,747 $5,256,970 $7,447,777 $1,727,793 $5,719,984 Service Line Report Data: Fiscal Year 2016 Patient Net Direct Contribution Indirect Net Service Procedures Revenue Costs Margin Costs Income Diagnostic Imaging 39,293 $344,952 $444,907 ($99,955) $154,207 ($254,162) Radiology - CHC 19, , , , , ,728 Radiology - KDIC 11, , , , ,920 21,447 Breast Center 26,252 1,996,301 1,077, , , ,657 CT Scan 16, ,668 93, ,269 40, ,263 CT Scan - KDIC 4,008 1,705, ,336 1,226, , ,472 MRI 1,536 73,668 32,511 41,157 14,689 26,468 MRI - KDIC 3,744 2,659, ,877 2,061, ,216 1,772,231 Ultrasound 10, ,817 74,888 94,929 40,995 53,934

35 Ultrasound - KDIC 7, , , , , ,027 Nuclear Medicine 4, , ,178 91,078 90, PET Scan 805 1,512, , ,929 65, ,232 Grand Total 146,720 $11,934,919 $5,415,914 $6,519,005 $1,831,195 $4,687,810 Increase (Decrease) 8,062 $769,828 ($158,944) $928,772 ($103,402) $1,032,174

36 Last Year This Year Net Revenue Per Case $81 $82 Direct Cost Per Case $37 $34 Contribution Margin Per Case $44 $48

37 Board of Directors Quality and Patient Safety Dashboard 4th Quarter 2017 ED Patient Throughput (Quarterly Report) 1st qtr th qtr 2017 (Tom Siminski) 1) Median ED Arrival time to ED Departure Time for In-patients {minutes} - (down Trend Positive) Benchmark (Hospital Compare Average) Trends (Red Line = Benchmark) 423 Minutes Emergency Department (Core Measure) Last Data Point (green = benchmark achieved) 474 Oct 2017 Compl Due Date Nov 2017 Comments / Actions Jan 5, 2018:The ED LOS for door to admission (departure time) based on 100% sampling is reflecting performance times higher than the benchmark of 423 minutes. This data shows times of 491 minutes for November and 602 minutes for December. There were 1789 admissions in November with 7885 registered for treatment, and there were 1905 admissions in December with 8008 registered for treatment. There were 1944 ambulance runs received in November and 2120 in December. This is about more than an average month prior. The hospital has been at 100% capacity most days creating a need to hold as many as admissions in the ED at most times of the day. Because the hospital has been at capacity, the ED admissions have had extended wait times before beds are open and then assigned. The ED plans to continue to work on performing efficient workups and timely dispositions. They will work with Case Management to accurately request the appropriate beds for patients. Nursing staff will continue to push for efficient and timely report and transport of ED patients to the floors after beds are assigned. The ED Director and Medical Director will push for early discharges on the floors and the use of the discharge lounge to open beds up sooner in the day. Most of the discharges are occurring after 2p on the inpatient units which has added to the total LOS for admitted patients in the ED. 1

38 Value Based Purchasing (VBP) Measures Measure CMS Benchmark / *TJC National Rate Trends (Red Line = Benchmark) Last Data Point (green = benchmark achieved) Compl Due Date Comments / Actions PCM-01 Early Elective Deliveries - down trend positive (Clinical Staff Sponsor - Tracie Plunkett) *2.42% 0% Oct 2017 Oct 2017 No Fallouts - Benchmark Maintained Patient Satisfaction A) Inpatient (Ed Largoza): Benchmark (Internal) Trends (Red Line = Benchmark) Last Data Point (green = benchmark achieved) Compl Due Date Comments / Actions 1) Inpatient Satisfaction - HCAHPS Performance data (up trend positive) 74.5% 76.9% Sep 2017 Jun 2017 Benchmark Maintained B) ED (Tom Siminski / Ed Largoza): Benchmark (Internal) Trends (Red Line = Benchmark) Last Data Point (green = benchmark achieved) Compl Due Date Comments / Actions 1) ED Patient Satisfaction - not included in HCAHPS (mean score - up trend positive) 50th Percentile 1st percentile Nov 2017 Dec 2017 January 5, 2018: Implement leader rounding to include nursing and physician rounds on the ED patients to improve the patient and family experience and for real-time service recovery. Rounds to include ED Largoza and Miriam Bermudez our Patient Experience specialists. Work on increasing staff purposeful rounds and emphasizing the use of AIDET when caring for our patients. Continue to work on improving the flow in triage and the intake areas to decrease the overall length of stay of our patients especially our lower acuity patients in those areas. Implement a second charge nurse in the ED to help manage the operations, flow, and treatment/disposition of patients in the triage, phlebotomy, and intake areas. 2

39 Physician/Staff Satisfaction Benchmark (Internal) Trends (Red Line = Benchmark) Last Data Point (green = benchmark achieved) Compl Due Date Comments / Actions C) Physician Satisfaction (every 2 years, due 2011; up trend positive) 46 percentile 75th Percentile 2009; 37 in 2007 n/a Pending data update D) Employee Satisfaction (Dianne Cox) (every 2 years - due 2019; up tend positive) N/A vs. Nat'l Hlthcare Avg (63rd Percentile) 2017 n/a 2017 results under review A) Employee Turnover 4th qtr rd qtr 2017 (Dianne Cox) (reported quarterly): 1) All Employees Turnover (down trend positive) 2) RN Turnover (down trend positive) Benchmark (CHA - changes quarterly) Trends (Red Line = Benchmark) 2.9% 2.8% Human Resources Last Data Point (green = benchmark achieved) 3.3% 3rd qtr % 3rd qtr 2017 Compl Due Date 4th qtr th qtr 2017 Comments / Actions With our upcoming RN Interview Day on January 11, 2018, we look forward to filling several of our open RN positions with new graduates and experienced nurses in attendance. In addition, KD has designed a Critical Care Nursing Internship program (CCNI) exclusively for experienced Kaweah Delta RNs. This will provide a supportive transition for current nurses into the critical care environment, as developing our own staff is one of the most effective tools we have in filling our critical positions. B) Contracted / Traveler Staff - December 2017: 37 out of 4617 total staff (down trend positive) 0.32% (internal benchmark) 0.80% Dec 2017 Jan travelers used in December 2017; goal is to reduce the number of travelers to 15. 3

40 Finance A) Capital Structure (Malinda Tupper) (up trend positive): Benchmark (Budget FY 2018) Trends (Red Line = Benchmark) Last Data Point (green = benchmark achieved) Compl Due Date Comments / Actions 1) Maximum Annual Debt Service Coverage: net income available to cover debt payments Nov 2017 Jun 2017 Benchmark maintained B) Liquidity: 1) Days Cash on Hand: number of days operating expenses covered by cash (up trend positive) Nov 2017 Jun 2017 Benchmark maintained 2) Net Days in Accounts Receivable: average number of days to collect a patient account (down trend positive) Nov 2017 Dec 2017 Dec 2017 Benchmark was not met due to the following reasons: 1) High census resulting in an increase to 0-30 day AR balance (approx. 2 days). Census is expected to drop in March/April 2) Delayed claim submissions as a result of staffing shortages (approx. 3 days). This issue should be resolved by mid Feb18 3) Change in Medi-cal s Rural Health Claims acceptance methodology removing the flat reimbursed amount (approx. 2 days). This is a permanent change. 4) Incorrectly denied Rural Health Medi-cal claims. KDH is resubmitting the claim and resolve by Mar18. C) Profitability (up trend positive): 1) Operating Margin: profit from corebusiness revenue and expenses 2.6% 4.9% Nov 2017 Feb 2017 Benchmark maintained 2) Operating Cash Flow Margin: cash flow available to pay debt & purchase capital assets 8.1% 9.1% Nov 2017 Jun 2017 Benchmark maintained Abbreviations CMS = Centers for Medicare & Medicaid Services CHA = California Hospital Association PSAT = Patient Satisfaction Action Tool TJC = The Joint Commission Color Code Benchmark Achieved Within 10% of Benchmark >10% From Benchmark 4

41 Policy Submission Summary Manual Name: Administrative Date: January 2018 Support Staff Name: Cindy Moccio Policy/Procedure Title # Status New, Revised, Reviewed, or Deleted * Name and phone extension of person who wrote or revised policy - * for New and Revised policies only Receiving Personal Items at Kaweah Delta Health Care AP.113 Reviewed Edward Hirsch, MD District Cash Receipts AP.121 Deleted Malinda Tupper

42 Policy Submission Summary Manual Name: Home Health Date: 01/05/18 Support Staff Name: Bertha Hernandez Status List policies * Name and phone Policy/Procedure Title # in this order and extension of person who identify if: New *, wrote or revised policy - * Revised *, Reviewed, or Deleted for New and Revised policies only Therapeutic Wound Packing HH-PC New Sheryl Engstrom, ext Wound Care HH-PC Revised Sheryl Engstrom, ext. 6415

43 Home Health Policy Number: HH-PC Date Created: 01/04/2018 Document Owner: Bertha Hernandez Date Approved: Not Approved Yet (Administrative Assistant) Approvers: Board of Directors (Administration), Board of Directors (Home Health), Bertha Hernandez (Administrative Assistant), Cindy Moccio (Board Clerk/Exec Assist-CEO), Jag Batth (Dir of Orthopedic Service Line), Sheryl Engstrom (RN-QA/PI/Education) Therapeutic Wound Packing Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: Every patient that receives a therapeutic wound packing, including negative pressure wound therapy sponges, will have a green wound packing or other identifiable sticker placed on their wound dressing to serve as a visual cue to other care providers. The presence of therapeutic wound packing, including the type and quantity, will be documented in the medical record. A final disposition for the wound packing will be addressed by the discharging licensed care provider in the patient s discharge instructions and will be communicated to the patient s physician and the patient/caregiver by the licensed care provider DEFINITIONS: Licensed Care Provider (LCP): Includes Registered Nurse (RN) and Licensed Vocational Nurse (LVN). A new Licensed Care Provider shall not perform wound packing on their own until they have completed their wound packing competency and have been signed off by their mentor. Procedure: After the placement of therapeutic wound packing, it will be documented in the medical record. Documentation will include: 1. Type of packing 2. Quantity and/or length, if applicable 3. Anatomical location DOCUMENTATION: 1. The skilled nursing note and/or care plan shall address the packing until it has been removed. 2. The skilled nursing note and/or care plan will include documentation of the presence and removal of the packing with communication to the patient and/or family of the same.

44 Therapeutic Wound Packing 2 3. If the patient is discharged with packing in place, the disposition will be addressed in the discharge instructions. When the therapeutic wound packing is changed, the licensed care provider will: 1. Apply and secure an updated green wound packing sticker or other identifiable sticker to the patient s dressing with the date, number of pieces of packing and the licensed care provider s initials. 2. Documentation in the medical record, including the type of packing, quantity and/or length, if applicable and the anatomical location. If the patient has therapeutic wound packing removed and not replaced, the following will be documented in the medical record: 1. Removal time 2. Location 3. Type and quantity and/or length of packing removed 4. The licensed care provider 5. Communication of the removal of the packing to the patient The removal of the therapeutic wound packing will be communicated to the patient s physician and the wound clinic, if applicable. If the patient is to be discharged from Home Health services with therapeutic wound packing in place: 1. The discharging licensed care provider will address the disposition of the packing in the patient s discharge instructions. 2. Patient/caregiver education, specifically addressing the wound packing and aftercare instructions, will be provided and documented by the licensed care provider. 3. The patient s physician will be notified. References: KCHDC Patient Care Policy PC.171-Therapeutic Wound Packing "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

45 Therapeutic Wound Packing 3

46 Home Health Policy Number: HH-PC Date Created: 04/01/1999 Document Owner: Bertha Hernandez Date Approved: Not Approved Yet (Administrative Assistant) Approvers: Board of Directors (Administration), Board of Directors (Home Health), Jag Batth (Dir of Orthopedic Service Line) Wound Care Printed copies are for reference only. Please refer to the electronic copy for the latest version. PURPOSE To provide guidelines for the consistent assessment and treatment of wounds in the home. POLICY Every patient will have a thorough skin assessment done at Start of Care, Resumption of Care, Recertification and Discharge by an RN or Therapist, if nursing Is not ordered for the patient, looking at all skin surfaces including areas at high risk for pressure ulcer development and the feet of diabetic patients. If a non-healing open wound is found by a Therapist, a Skilled Nursing referral will be requested. The Therapist will obtain the physician order for Skilled Nursing service. A physician order is required for wound care procedures. The physician ordered wound care will be included in the patient s plan of care. PROCEDURE I. Wound Assessment A. Outcome and Assessment Information Set (OASIS) wound questions will be answered according to current CMS and Wound, Ostomy, Continence Nurses Society (WOCN) guidelines. B. Nutritional risk will be assessed and documented. (See HH-PC-2-011, Nutritional Assessment) C. The wound assessment will be done according to current (WOCN) guidelines.

47 Wound Care 2 D Pressure ulcers, stasis ulcers, diabetic ulcers, arterial ulcers and open or deteriorating surgical wounds will be measured on admission or discovery of the wound, then weekly in centimeters in the following manner: 1. Length measure using the 12-6 o clock orientation 2. Width measure using the 3-6 o clock orientation 3. Depth deepest area of wound using a cotton tip applicator 4. Undermining, tunneling or sinus tract depth, use clock method for location Closed surgical wounds will be measured on admission only unless complications occur which result in an open wound. E. Documentation of wounds will include: 1. Type of wound 2. Wound bed (according to color and percentage. Ex: 75% red, 25% yellow slough). 3. Wound edges 4. Periwound skin 5. Signs and symptoms of infection 6. Exudate type and amount 7. Wound measurements (length, width, depth) 8. Undermining or tunneling, if present F. Pressure ulcers, stasis ulcers, diabetic ulcers, arterial ulcers and open or deteriorating surgical wounds will be photographed by the clinician using an agency approved digital camera 1. on admission or discovery 2. monthly thereafter, 3. if a change in wound status is noted, 4. upon discharge. 5. Photographs will be identified with patient s name, medical record number and date taken and location of wound. 6. Photographs will be saved to the patient s progress note in the computerized clinical documentation system. II. Wound Care Techniques A. Refer to Perry and Potter 78 th Ed. Clinical Nursing Skills and Techniques for wound care procedures. B. Wound care will be done using clean technique unless sterile technique is specifically ordered by the physician. C. Soiled dressings will be placed into a plastic bag which will be tied and disposed of in the wastebasket in the patient s home.

48 Wound Care 3 III. Suture and Staple removal A. Refer to Performing Suture and Staple Removal in Perry and Potter, 68 th Edition; Clinical Nursing Skills and Techniques. B. Physical Therapists may perform suture and staple removal in the home. IV. Application of Wound Vac/Wound Packing A. Refer to KDHCD Patient Care Policy CP-92 Wound Therapy: Negative Pressure Wound Therapy (NPWT) Device and Therapeutic Wound Packing Policy HH-PC for policy and procedure. Pressure Wound Therapy (NPWT) Device for policy and procedure. V. Education and Documentation A. The patient s family/caregiver will be instructed in wound care as appropriate. B. A return demonstration of wound care techniques will be done before the family/caregiver are considered independent in wound care. C. Documentation of this instruction and the response to teaching will be included in the patient s medical record. D. Instruction in wound care will be included in the patient s plan of care. Wound Irrigation I. Refer to Perry and Potter, 78th Edition, Performing Wound Irrigation. II. III. IV. VI. Normal saline containers used for wound irrigation shall be dated when opened, stored in a clean area and discarded after 30 days. Normal saline will be warmed to room temperature before wound is irrigated. Blunt 19 ga needles may be used for irrigation. Use clean cotton tip applicators to apply ointments or gels to wounds and to measure and pack wounds. Cleaning and storage of equipment: A. Irrigation syringes/blunt needles for clean, no-touch technique change weekly and store in clean Ziploc bag between uses; if the needle/syringe touches the wound it must be discarded after use and a new needle/syringe used on the next wound irrigation. B. Wound scissors for clean, no-touch technique clean with alcohol swab after use and store in clean Ziploc bag between uses. If contaminated discard and use new set. C. Specimen containers with clean, no-touch technique, replace weekly;

49 Wound Care 4 After use, discard any leftover solution and store cup between uses; if contaminated by syringe or needle that has touched the wound, discard cup. References: Rhinehart, Emily and Mary M. Friedman, Infection Control in Home Care, An Official APIC Publication, Jones and Bartlett Publishers, Inc., Bryant, Ruth A and Denise P Nix, Acute and Chronic Wounds, Current Management Concepts, Third Edition, Mosby, Elsevier, 2007.

50 Manual Name: Imaging & SRCC Radiation Oncology Services Support Staff Name: Carla Hernandez Board of Directors Policy/Procedure Title # Status (New, Revised, Reviewed, Deleted) January 10, 2018 Name and Phone # of person who wrote the new policy or revised an existing policy MRI Coronary Artery Stent Screening IS New Tim Pedersen, ext Radiation Protection Program IS 5.6a Revised Jose Thekkumthala, ext Emergency Care in Imaging Services IS 9.1 Revised Renee Lauck, ext Routine Views IS 17.6 Revised WindyDay Vaughn, ext Radiology Barium Swallow/Esophogram Physician IS Revised WindyDay Vaughn, ext Preference Radiology Upper G.I. Physician Preference IS Revised WindyDay Vaughn, ext Radiology Small Bowel Follow Through (SBFT) IS Revised WindyDay Vaughn, ext Radiology Modified Barium Swallow with Speech IS Revised WindyDay Vaughn, ext Therapy Physician Preference Contrast/Medication Procurement, Storage, IS 18.2 Revised Renee Lauck, ext Control, Distribution, Administration and Monitoring of Radiographic Contrast Media Nuc Med Lasix Renogram IS Revised Ashley Vander Poel, ext Discharge Criteria for Post Myelogram Patients IS 2.06 Reviewed CT Scheduling Priority for Patient Services IS 2.10 Reviewed Patient Holding (Observation) IS Reviewed Ordering Radiology Services IS 2.12 Reviewed Conflicting Examinations IS 2.3 Reviewed Patient Priority IS 2.6 Reviewed Explaining Procedures to Patients IS 2.80 Reviewed Procedures requiring Informed Consent IS 2.9 Reviewed Appropriateness of Service IS 3.02 Reviewed Notifying Radiologists of Emergency Procedures IS 3.1 Reviewed Emergency Department Patients IS 3.12 Reviewed Equipment Performance IS 4.1 Reviewed Equipment Calibration IS 4.20 Reviewed Nuclear Medicine Quality Control Tests IS 4.40 Reviewed Fluoroscopy Guidelines IS 5.20 Reviewed Radiation Safety: Portable Mobile Unit IS 5.3 Reviewed Hazards of Portable Radiology IS 5.4 Reviewed Personnel Dosimetry IS 5.5 Reviewed Privacy of Employee Telephone Numbers IS 6.0 Reviewed Recording Completed Exams IS 7.1 Reviewed

51 Manual Name: Imaging & SRCC Radiation Oncology Services Support Staff Name: Carla Hernandez Board of Directors Policy/Procedure Title # Status (New, Revised, Reviewed, Deleted) Emergency Call Back Protocol IS 9.5 Reviewed Contrast/Medication Emergency Process & IS Reviewed Supplies Patient Preparations IS 17.2 Reviewed Radiology Radiographic Pellet (ring) Study IS Reviewed Physician Preference Pediatric Contrast Dose IS 19.6 Reviewed January 10, 2018 Name and Phone # of person who wrote the new policy or revised an existing policy

52 Policy Number: IS Date Created: 07/10/2017 Document Owner: Carla Hernandez (Administrative Date Approved: Not Approved Yet Assistant) Imaging Services MRI Approvers: Board of Directors (Administration), Carla Hernandez (Administrative Assistant), Cindy Moccio (Board Clerk/Exec Assist-CEO), Daniel Hightower (Radiology), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Renee Lauck (Dir OP Rad Onc & Imaging Svcs) MRI Coronary Artery Stent Screening Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: It is acceptable and safe to perform MRI examinations in all patients with coronary artery stents by following specific guidelines developed by taking into account possible safety concerns (i.e., those related to magnetic field interactions and MRI-related heating) for these particular implants. Procedure: 1. Patients with all commercially available coronary artery stents (including both drug-eluting and non-drug eluting or bare metal versions) can be scanned (including two or more overlapped stents). 2. Patients with all commercially available stents can undergo MRI immediately after placement. 3. The MRI examination must be performed using the following parameters: Whole body averaged specific absorption rate (SAR) of 2-W/kg, operating in the Normal Operation Mode for the MR System The scan time for an individual series is to not exceed 15 minutes. 4. Note: Any deviation from the above MRI conditions requires prior approval by the Radiologist. Important Note: This policy does not apply to other stents such as peripheral vascular stents, abdominal aortic aneurysm (AAA) stent grafts, biliary stents, ureteral stents, or stents used for other applications (e.g., tracheobronchial stents, esophageal stents, etc.). These types of implants are to be researched prior to scanning the patient. Related Documents: None References: Shellock FG. Reference Manual for Magnetic Resonance Safety, Implants, and Devices: 2016 Edition. Biomedical Research Publishing Group, Los Angeles, CA, "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

53 MRI Coronary Artery Stent Screening 2

54 Imaging Services, SRCC Policy Number: IS 5.6A Date Created: 07/12/2012 Document Owner: Carla Hernandez Date Approved: Not Approved Yet (Administrative Assistant) Approvers: Board of Directors (Administration), Carla Hernandez (Administrative Assistant), Daniel Hightower (Radiology), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Jose Thekkumthala (Clinical Radiation Physicist), Renee Lauck (Dir OP Rad Onc & Imaging Svcs) Radiation Protection Program Printed copies are for reference only. Please refer to the electronic copy for the latest version. References: Radiation Protection, Policy IS 5.6 RADIATION PROTECTION PROGRAM AT KAWEAH DELTA HEALTH CARE DISTRICT RADIATION PROTECTION PROGRAM AT KAWEAH DELTA HEALTH CARE DISTRICT Formatted: Centered, Indent: Left: 0", Pattern: Clear (Gray-12.5%) Formatted: Centered Formatted: Font: 18 pt Formatted: Centered Kaweah Delta Health Care District 400 W. Mineral King Ave Visalia, CA 93291

55 Radiation Protection Program 2 TABLE OF CONTENTS 1. Organization and Administration 2. ALARA Program 3. Dosimetry Program a. Family, guests or children b. Occupational Workers c. Pregnant Workers d. Dose to Fetus 4. Pregnant Patients 5. Area Monitoring and Control a. Area Radiation Monitoring b. Instrument Calibration and Maintenance c. Room Requirements d. Lead Shielding Devices e. Image Recording Devices f. Fluoroscopy 6. Radiological Controls a. Entry and Exit Controls b. Posting c. Disposal of Equipment 7. Emergency Exposure Situations and Radiation Accident DosimetryMisadministration 8. Record Keeping and Reporting 9. Reports to Individuals 10. Radiation Safety Training a. Operating and Safety Procedures b. Occupational Workers b. Non-Occupational Workers 11. Quality Assurance Program a. Radiation Oncology 12. Internal Audit Procedures Formatted: Right: 0.81" Formatted: Right: 0.44" Formatted: Indent: Left: 1", Hanging: 0.19", Numbered + Level: 1 + Numbering Style: a, b, c, + Start at: 3 + Alignment: Left + Aligned at: 0.97" + Indent at: 1.22" Formatted: Right: 2.63" Formatted: Right: 1.5" Formatted: Indent: Hanging: 0.08", Numbered + Level: 1 + Numbering Style: a, b, c, + Start at: 2 + Alignment: Left + Aligned at: 0.83" + Indent at: 1.08" Formatted: Left, Indent: Left: 0.58", Hanging: 0.14", Right: 2.94", Tab stops: 0.94", Left + 1", Left ", Left ", Left + Not at 0.97" Formatted: Tab stops: 0.88", Left Formatted: Indent: Left: 1", First line: 0", Numbered + Level: 1 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.83" + Indent at: 1.08", Tab stops: 1.19", Left Formatted: Indent: Left: 1", Tab stops: 1.19", Left Formatted: Indent: Left: 0.56", Tab stops: 0.88", Left

56 Radiation Protection Program 3 1. Organization and Administration ORGANIZATION CHART FOR RADIATION PROTECTION PROGRAM RADIATION SAFETY COMMITTEE Chairman Radiologist RSO Physicist 2. ALARA Program Imaging Radiology Surgery Endoscopy Nuc Med Onc. Svcs. 3S Med./Surg. SRCC Formatted: CCL Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial The objective of this program is to maintain radiation exposure, both internal and external, at a level as low as reasonably achievable. The principle is to minimize the contamination of unrestricted areas at a level as low as reasonably achievable below established limits. ALARA requires careful design and choice of equipment as well as good radiation protection practices including good planning and the proper use of appropriate equipment by qualified, welltrained personnel. The primary mechanism for minimizing radiation exposure is an alert and knowledgeable worker. Adequate protection shall be available to provide a safe working environment for a radiation worker and general public. Such protections may include the use of shielding, exhaust hoods, glove boxes, spill pans, remote manipulators, protective apparels such as gloves, aprons etc. Secondary protective measures such as procedural controls and monitoring systems may be employed. Time, distance and shielding are three cardinal factors controlling the ALARA (As Low As Reasonably Achievable) concept:

57 Radiation Protection Program 4 Minimize time of contact with radiation, increase distance to radiation source and have shielding available in radiation environments. The RSO will make sure that procedures in a radiation environment are conducted as stipulated in RML. Along with physicist, RSO will investigate overexposure, accidents, spills, losses and thefts. Incidents, such as misadministration, must have to be investigated and policies be put in place to eliminate such incidents. ALARA investigational levels are as follows: SITE Whole Body (DDE; tissue depth 1cm) Eye Lens (LDE; depth = 0.3 cm) Skin (SDE; depth = cm averaged over area 1 cm2) ALARA1 Quarterly Limit (mrem) ALARA2 Quarterly Limit (mrem) Maximum Annual Permissible Dose MPD(mRem) Formatted: Font: (Default) Arial Formatted Table Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial, 12 pt 3. Dosimetry Program The KDHCD shall control the occupational dose to individual adults for the following dose limits. Proper use and storage of dosimetry devices will be defined by the facility Radiation Safety Committee. The total effective dose equivalent being equal to 5 rems (0.05 Sv). The annual limits to the lens of the eye, to the skin of the whole body, and to the skin of the extremities, are: A lens dose equivalent of 15 rems (0.15 Sv), and A shallow-dose equivalent of 50 rem (0.5 Sv) to the skin of the whole body or to the skin of any extremity. A. Family, guests or children a. Family or guests of patients, will not be permitted in any xray room unless absolutely necessary to help hold patient. In these cases, the person will wear a lead apron, thyroid shield and gloves. A.b. For safety reasons and to assure staff are able to focus on the radiation safety of each patient, children (not receiving exam) will not be allowed in the x-ray room or surrounding areas, at any time. Formatted: Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent at: 0.25" Comment [JK1]: Suggestion: Radiation safety committee should have final approval for type of device for monitoring as well. Formatted B. Occupational Workers

58 Radiation Protection Program 5 All individuals who, on a regular basis, handle radioactive material that emits ionizing radiation will be issued a film and TLD finger monitor that will be processed by a contracted service (Landauer) on a monthly basis. These individuals are likely to receive radiation exposure in excess of 10% of the maximum permissible dose. All personnel who work with radioactive materials will be issued a whole-body badge as well as ring badge. Exposure readings on these badges will be reviewed quarterly by the RSC using ALARA levels. All individuals who are exposed to radiation on an occasional basis, such as Surgery Physicians and Personnel, will be issued a whole body monitor to be worn anytime radiation is used in the operating room. Other individuals who are exposed to radiation on an occasional basis, such as delivery personnel and nurses who have received diagnostic dosages will not normally be issued exposure monitors. Formatted: Tab stops: 0", Left + Not at 2.2" The ALARA program requires that each individual have their own exposure badge before working in an area of radiation exposure or be assigned a visitor badge until their regular badge has been delivered. All badges are to be ordered by the Department manager or his assistant as soon as new personnel have been hired. In addition, a control badge accompanies the monthly group of badges and should not be placed inside a badge holder. This control badge is kept in a secure place together with any other badges that are no longer active. Proper wearing of the personnel radiation badge indicates it should be worn closest to the source of radiation. Film badges will be interpreted monthly by the contracted service, and a report returned to the Department manager. This report is then posted in the Department readily accessible to all employees. If there is a case of overexposure the personnel involved is notified immediately along with the RSO and the Physicist. The RSO will investigate all unusually high exposures as well as maintain a permanent employeeexposure record, as required by ALARA program. Protective lead aprons must be worn by all personnel within an x-ray room during fluoroscopy and radiography. In addition, personnel required to place their hands within the direct radiation beam will wear protective lead gloves. The use of radiation safety thyroid shields will be at the discretion of each individual. Personnel not regularly exposed to radiation, for example, portable exams on units, Emergency Department, or use in surgery who do not have a film badge lead apron should be asked to leave the area during radiographic or fluoroscopic procedures. The Technologist will announce when an exposure is to be made. A distance of 15 to 20 feet will ordinarily result in minimal exposure. If one of the above personnel are required to stay in the vicinity of a radiation producing unit always wear a lead apron. If the Technologists do not have enough lead aprons with them, they are to be asked to retrieve one for each person involved. C. Pregnant Workers Declaration of pregnancy is governed by specific policy. Pregnant personnel are advised to notify their supervisors as soon as possible of their condition. Upon declaration of pregnancy, the radiation worker is issued a fetal badge that is worn at Formatted: Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent at: 0.25", Tab stops: 0.25", Left + Not at 2.13"

59 Radiation Protection Program 6 the waist level. The waist badge is to be worn at all times while on the job. Every effort will be made to keep radiation exposure level to the fetus below 500 mr during the entire gestation period or 50 mr in any given month during gestation period. Where possible, the pregnant radiation worker will be re-assigned responsibilities away from sources of radiation if RSO deems it necessary to keep fetal dose at ALARA level. Radiation safety counselcouncil may be sought with the RSO if pregnant radiation worker so desires. PREGNANCY DECLARATION FORM This form letter is provided for your convenience. To make your written declaration of pregnancy, you may fill in the blanks in this form letter, you may use a form letter the licensee has provided to you, or you may write your own letter Formatted: Normal, Indent: Left: 0", Border: Bottom: (Single solid line, Auto, 0.75 pt Line width) To: Formatted: Normal, Indent: Left: 0" In accordance with the NRC s regulations at 10 CFR , Dose to an Embryo/Fetus, I am voluntarily declaring that I am pregnant. I believe I became pregnant in (only the month and year need be provided). I understand the radiation dose to my embryo/fetus during my entire pregnancy will not be allowed to exceed 0.5 rem (5 millisievertt) (unless that dose has already been exceeded between the time of conception and submitting this letter). I also understand that meeting the lower dose limit may require a change in job or job responsibilities during my pregnancy. (Your signature) (Your name printed Formatted: Normal, Indent: Left: 0" (Date Section II. Rescinding Pregnancy Declaration The pregnant worker may withdraw the above declaration in writing at any time without explanation and the dose monitoring will be discontinued and the applicable radiation worker occupational dose limits will apply. Formatted: Normal, Indent: Left: 0" I,, declare I no longer wish to be considered a declared pregnant woman.

60 Radiation Protection Program 7 Kaweah Delta Health Care District PREGNANCY DECLARATION FORM Name of Employee: Date supervisor Notified: Birthdate: SSN: Work Phone: Work Location: Name of Supervisor/Principal Investigator: Approximate Date of Conception: Due Date: Radionuclides: Forms: Amounts: Radiation Emitting Devices: Type of Dosimetry Worn: ο Whole Body Badge ο Collar ο Ring ο Wrist ο Other Location of Dosimetry Worn: ο Waist ο Collar ο Under Apron ο Other Brief Description of Occupational Exposure: Employee Signature: Date: Supervisor Signature: Date: Signature and date Employee/Student ID Formatted: Font: 10 pt

61 Radiation Protection Program 8 Kaweah Delta Health Care District PREGNANCY DECLARATION FORM Name of Employee: Date supervisor Notified: Birthdate: SSN: Work Phone: Work Location: Name of Supervisor/Principal Investigator: Approximate Date of Conception: Due Date: Radionuclides: Forms: Amounts: Radiation Emitting Devices: Type of Dosimetry Worn: ο Whole Body Badge ο Collar ο Ring ο Wrist ο Other Location of Dosimetry Worn: ο Waist ο Collar ο Under Apron ο Other Brief Description of Occupational Exposure: Employee Signature: Date: Supervisor Signature: Date: B.D. Dose to Fetus Dose to the fetus is documented in the badge report. The report for this badge will be received and posted with the regular monthly reports. Formatted: Font: (Default) Arial Formatted: Indent: Left: 0" Formatted: Font: (Default) Arial

62 Radiation Protection Program 9 4. Pregnant Patients A pregnant patient can receive radiotherapy depending upon the following factors: 1. The stage and aggressiveness of the tumor; 2. The location of the tumor; 3. Potential hormonal effects of pregnancy of the tumor; 4. Various therapies and their length, efficacy, and complications; 5. Impact of delaying therapy; 6. Expected effects of maternal ill-health on the fetus; 7. The stage of pregnancy; 8. Fetal assessment and monitoring; 9. How and when the baby could be safely delivered; 10. Whether the pregnancy should be terminated; 11. Legal, ethical, and moral issues. The fetal dose may be reduced if the following factors are kept in mind: The first consideration is if the treatment can be postponed until the fetus is at a later gestation age. If the decision is made that radiotherapy is necessary, it is important to calculate the dose to the fetus before the treatment is given. When external radiotherapy is used for treatment of tumors at some distance from the fetus, a very important factor in fetal dose is the distance from the edge of the radiation field. The American Association of Physicists in Medicine (AAPM) recommends that the following points be considered: 1. Complete all planning as though the patient were not pregnant. If the fetus is near the treatment beam, do not take portal localization films with open collimation and blocks removed. 2. Consider modifications to the treatment plan that would reduce the radiation dose to the fetus (e.g. changing field size, radiation energy). If possible use photon energies of less than 25 MV. 3. Estimate dose to the fetus using phantom measurements, a shield may be constructed with 4-5 half-value layers of lead. 4. Document the treatment plan and discuss it with the staff involved in patient set-up. Document the shielding (perhaps with a photograph). 5. Monitor the fetal size and growth throughout the course of treatment and reassess fetal dose if necessary. 6. On completion of treatment, document the total dose including the range of dose to the fetus during therapy. 7. Consider referring the patient to another institution if equipment and personnel are not available for reducing and estimating the fetal dose. 5. Area Monitoring and Control / Instrument Calibration and Maintenance A. Area Radiation Monitoring Radiation area monitoring is important to make sure exposure levels are within acceptable limit. It is also important that the radiation measuring instruments are Formatted: Indent: Left: 0" Formatted: Indent: Left: 0.19" Formatted: Indent: Left: 0" Formatted: Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.25" + Indent at: 0.5" Formatted: Indent: Left: 0.25", First line: 0", Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.25" + Indent at: 0.5" Formatted: Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.25" + Indent at: 0.5" Formatted: Indent: Left: 0" Formatted: Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent at: 0.25", Widow/Orphan control, Adjust space between Latin and Asian text, Adjust space between Asian text and numbers, Tab stops: Not at 0.58" Formatted: Font color: Auto, Character scale: 100%

63 Radiation Protection Program 10 calibrated at periodic intervals and maintained properly. All electrometers and ionization chambers used in radiation output calibration are calibrated once every two years at Accredited Dose Calibration Laboratories (ADCL). They are K&S Associates, Inc. in Nashville, Tennessee. All survey meters are calibrated once annually by Sutter Health Medical Physics Center, Sacramento, CA Sealed sources possessed under the License shall be tested for leakage and/or contamination every six months, as required by Title 17, California Code of Regulations. The sources are Sr90 Pterygium and Co-57. The source Ir-192 is replaced in MHDR unit by Licensed Nucletron engineer and this happens five times per year. The source is leak-tested every time replacement takes place. B. Instrument Calibration and Maintenance The following calibration instruments and survey meters are used to perform QA measurements and surveysthe following calibration instruments and survey meters are used to perform QA measurements and surveys:: 1. Survey Meters a. Manufacturer s name: Ludlum, Manufacturer s model number: Model 3 (with model probe), Type of detector: Energy Compensated Thin Wall G-M Low Energy Scintillator, Number of instruments available:1, Minimum range: 0 mr/hr to 0.2 mr/hr, Maximum range: 0mr/hr to 200 mr/hr Formatted: Font color: Auto, Character scale: 100% Formatted: Font: (Default) Arial, 12 pt, Character scale: 100% Formatted: Font color: Auto, Character scale: 100% Formatted: Font: (Default) Arial, 12 pt, Font color: Auto, Character scale: 100% Formatted: Font: (Default) Arial, 12 pt, Character scale: 100% Formatted: Font: (Default) Arial, 12 pt, Character scale: 100% b. Manufacturer s name: Victoreen, Manufacturer s model number: 450, Type of detector: Ionization Chamber, Number of instruments available:2, Minimum range: 0 mr/hr to 0.l mr/hr, Maximum range: 0mr/hr to 5000 mr/hr c. Manufacturer s name: Ludlum, Manufacturer s model number: 14C (with model 44.9 probe), Type of detector: Pancake G-M, Number of instruments available:2, Minimum range: 0 mr/hr to 0.2 mr/hr, Maximum range: 0mr/hr to 2000 mr/hr 2. Dose Calibrator Manufacturer s name: Capintec Corp., Manufacturer s model number: CRC30BC, Number of instruments available: 1 3. Diagnostic Instruments Manufacturer s name: Siemens/Toshiba, Manufacturer s model number: E.Cam, Type of detector: Dual-Head Gamma Camera, Number of instruments available: 2 Formatted: Indent: Left: 0.5" 4. Ratemeter/Well Chamber Manufacturer s name: Ludlum, Manufacturer s model number: Scaler/Ratemeter 2200/203, Type of detector: Shielded Well Scintillator, Number of instruments available: 1 5. Room Monitor

64 Radiation Protection Program 11 Manufacturer s name: Ludlum, Manufacturer s model number: 177, Type of detector: End window G-M, Minimum range: 0 cpm to 500 cpm, Maximum range: 0cpm to 50,000 cpm, Number of instruments available: 1 All new sealed sources are ordered, received and delivered by RSO. The RSO will conduct a physical inventory every six months to account for all the sealed sources. Records of the inventories will be maintained for inspection. Any radioactive material with a physical half lifehalf-life of less than 65 days will be kept for decay in storage before disposal in ordinary trash provided (1) the radioactive waste to be disposed of in this manner shall be held in storage for at least half-lives livesand (2). bbefore disposal, radioactive waste will be surveyed to determine that the exposure shall not exceed the background level. C. Room Requirements All internal walls of rooms containing stationary radiation producing devices, such as stationary x-ray equipment will contain sufficient lead or lead composite material to prevent scattered radiation from leaving the area and thereby exposing other people in adjacent areas. All fixed radiation devices will have short exposure cables and switches preventing the operator from leaving the shielded area. A protective barrier is utilized to shield the control area for all fixed units. Operators must stand behind the protective barrier. Any x-ray unit malfunction (collimator malfunction, door interlock not working properly, etc.) should be reported immediately to the Administrative Director of Radiology or Supervisor. If the malfunction involves accidental/unwarranted exposure to a worker or patient the Radiation Safety Officer or Physicist will immediately be notified. After hours you will notify the Administrative Director or the Supervisor who will report the incident to the Radiation Safety Officer. There will be uniform and accepted radiation warning signs conforming to the prescribed format, posted throughout exposure areas. All doors of rooms containing radiation devices will be closed during radiological examinations. A viewing window should be used to observe the patient at all times. R Radiation devices will be equipped with collimation accessories which restrict the x-ray beam only to the part examined. Field size indicators should be referenced to determine collimation settings at various SID's. Calibration of diagnostic radiology equipment will be performed semi-annually by either the Biomedical Engineering department or a contracted service and confirmed at least annually by the Physicist according to state and/or federal regulations. A written calibration record will be kept. A radiation protection survey including calibration is also performed when radiologic equipment is initially installed, altered significantly, or relocated. Any x-ray unit malfunction (collimator malfunction, door interlock not working properly, etc.) should be reported immediately to the Administrative Director of Formatted: Bulleted + Level: 1 + Aligned at: 0.25" + Indent at: 0.5", Tab stops: 0.5", Left + Not at 2.13" Formatted: Bulleted + Level: 1 + Aligned at: 0.25" + Indent at: 0.5", Tab stops: 0.5", Left + 2.2", Left Formatted: Bulleted + Level: 1 + Aligned at: 0.25" + Indent at: 0.5", Tab stops: 0", Left + 0.5", Left + Not at 2.13" Formatted: Tab stops: 0.5", Left + 2.2", Left + Not at 2.13" Formatted: Tab stops: 0.5", Left + Not at 2.13" Formatted: Bulleted + Level: 1 + Aligned at: 0.25" + Indent at: 0.5", Tab stops: 0.5", Left + Not at 2.13" Formatted: Tab stops: 0.5", Left + Not at 2.13" Formatted: Tab stops: 0.5", Left + 2.2", Left

65 Radiation Protection Program 12 Radiology or Supervisor. If the malfunction involves accidental/unwarranted exposure to a worker or patient the Radiation Safety Officer or Physicist will immediately be notified. After hours you will notify the Administrative Director or the Supervisor who will report the incident to the Radiation Safety Officer. Formatted: No bullets or numbering D. Lead Shielding Devices All leaded gloves, aprons and other shielding devices used will be checked at least annually for signs of cracks, tears, or other damage which might result in radiation leakage. Such inspections will be documented by a Physicist report. The apron should first be visually examined for any obvious defects such as torn straps, ripped covering, and tears or holes in the lead equivalent material. If there are any such defects, the aprons are to be removed from service and repaired or replaced as necessary. Aprons that are visually satisfactory should be examined under fluoroscopy to determine existence of any defects that would unknowingly increase exposure to ionizing radiation. Such inspections will be documented by a Physicist report Any aprons that are determined to be unsatisfactory shall be removed from service. Radiographic film, intensifying screens, and other image recording devices should be as sensitive as is consistent with the requirement of the film manufacturer, the equipment manufacturer and the examination. Film processing materials and techniques should be those recommended or determined acceptable by the film manufacturer to insure maximum information content of the developed radiographs and, where practical, quality control methods should be employed to insure optimum results according to manufacturer s recommendations. E. Image Recording Devices F. Fluoroscopy Proper use and storage of dosimetry devices will be defined by the facility Radiation Safety Committee. Fluoroscopy will not be used as a substitute for radiography, but will be reserved for the study of dynamics or spatial relationships or for guidance in spot-film recording of critical details or for interventional radiology procedures. Guidelines for the fluoroscopist: The exposure rate in fluoroscopy should be as low as is consistent with the fluoroscopic requirements and shall not exceed 10 R/min measured at the position where the beam enters the patient. The smallest practical field sizes and shortest exposure times should be employed. The possibilities of reducing dose by techniques utilizing high tube potential and low current should be considered. Fluoroscopy should be performed only by or under the immediate supervision of physicians properly trained in fluoroscopic procedures. Extraneous light which interferes with the fluoroscopic examination should be eliminated. Special precautions, consistent with clinical needs, should be taken to minimize exposure of the gonads of potentially procreative patients and exposure of the embryo or fetus in patients known or suspected to be pregnant. Protective lead aprons of at least 2.5 mm lead equivalent should be worn by Formatted: Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 5 + Alignment: Left + Aligned at: 0" + Indent at: 0.25", Tab stops: 0.25", Left + Not at 2.13" Formatted: Bulleted + Level: 1 + Aligned at: 0.25" + Indent at: 0.5", Tab stops: 0.5", Left + Not at 2.13" Formatted: Bulleted + Level: 1 + Aligned at: 0.25" + Indent at: 0.5", Tab stops: 0.5", Left + Not at 2.13"

66 Radiation Protection Program 13 each person (except the patient). The hand of the fluoroscopist should not be placed in the useful beam unless the beam is attenuated by the patient and a protective glove of at least 2.5 mm lead equivalent is worn. Only persons whose presence is needed should be in the fluoroscopy room during the procedure. Patients: All radiographic examinations will be performed only when they conform to accepted clinical indications, or in cases requiring clarification the Radiologist and/or the ordering Physician will be questioned. Diagnostic examinations will be performed with such technical factors as to minimize exposure to diagnostic radiation and still satisfy the need for the desired information. All female patients of child bearing age will be questioned regarding the possibility of pregnancy prior to any exam. Gonad shields are to be provided for all children, young adults and females of child bearing age within the limitations of the examination desired. These general Radiation Safety Guidelines will be applicable throughout the medical facility. Any modifications requested must be referred to the Radiation Safety Officer, the Medical Director of Radiology or the Administrative Director of Radiology. Be sure you understand the studies requested. This will avoid retakes and unnecessary exposure to you and your patient. Advise unit personnel and requesting physicians when an x-ray request is a suspected duplicate to avoid necessary exposure. Advise the Director, Supervisor or the Radiologist of any requests that may seem excessive. Formatted: Indent: Left: 0.5", Tab stops: 0.5", Left + Not at 2.13" Formatted: Indent: Left: 0.25", Tab stops: 0.5", Left + Not at 2.13" Formatted: Bulleted + Level: 1 + Aligned at: 0.25" + Indent at: 0.5", Tab stops: 0.5", Left + Not at 2.13" Formatted: Indent: Left: 0.5", Tab stops: 0.5", Left + Not at 2.13" Formatted: Indent: Left: 0.25", Tab stops: 0.5", Left + Not at 2.13" 6. Radiological Controls A. Entry and Exit Controls Entry to controlled areas is managed by designated employees involved in radiation treatment or diagnostic procedures. Radiation warning signs also control the flow of radiation workers, public or patients. The emergency exit routes take personnel or other people through a path not going through controlled areas. B. Posting Signage will conform to NRC regulations. The Caution-Radiation Area sign bearing the radiation symbol will be posted just outside the room that either produces radiation or houses radioactive material. The Department manager is responsible to make sure that the appropriate radiation warning sign is posted. Formatted: Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent at: 0.25" Formatted: Indent: Hanging: 0.02", Tab stops: 0.56", Left Formatted: Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent at: 0.25", Tab stops: 0.56", Left Formatted: Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent at: 0.25" The two primary reasons for radiological posting are

67 Radiation Protection Program 14 to inform workers of the area s radiological conditions, and to inform workers of the entry requirements for the area. In order to maintain exposure to radiation ALARA, access to areas or devices in which one can receive more than 100 mrem per year is restricted. Areas controlled for radiological purposes must be posted with a black or magenta standard three-bladed radiological warning symbol. Postings and barriers must be clearly visible from all accessible directions. Postings on doors should remain visible when doors are open or closed. Postings should state the radiation dose rate and the entry requirements. If more than one radiological hazard exists in an area, the posting should identify each hazard. Postings that indicate an intermittent radiological condition should include a statement specifying when the condition exists such as; for example, when a red light is on. The same posting requirements apply for x-ray or gamma radiation as for any other type of radiation. The following documents are required to be posted: 1. A current copy of the 17 CCR, incorporated sections of 10 CFR 20, and a copy of operating and emergency procedures applicable to work with sources of radiation (If posting of documents specified above is not practicable, the registrant may post a notice which describes the document and states where it may be examined.) 2. A current copy NOTICE TO EMPLOYEES in a sufficient number of places to permit individuals working in or frequenting any portion of a restricted area to observe a copy on the way to or from such area. The following is copy of Notice to Employees : 3. Any notice of violation involving radiological working conditions or any order issued pursuant to the Radiation Control Law and any required response from the registrant. The following is copy of Notice to Employees : CALIFORNIA DEPARTMENT OF PUBLIC HEALTH NOTICE TO EMPLOYEES Formatted: Font: (Default) Arial, 12 pt Formatted: Normal, Pattern: Clear Formatted: Font: (Default) Arial, 20 pt, Bold

68 Radiation Protection Program 15 STANDARDS FOR PROTECTION AGAINST RADIATIONCALIFORNIA RADIATION CONTROL REGULATIONS (CALIFORNIA CODE OF REGULATIONS, TITLE 17, SECTION 30255) The California Radiation Control Regulations include standards for protection against radiation hazards. The State Department of Public Health has primary responsibility for administering these standards which apply to both employers and employees. Enforcement is carried out by the Department of Public Health or its authorized inspection agencies. EMPLOYEES RESPONSIBILITIES You should know and understand those California radiation protection standards and your employer s operating and emergency procedures which apply to your work. You should comply with these requirements for your own safety and the safety of others. Report promptly to your employer any condition which may lead to or cause a violation of these standards or employer s operating and emergency procedures. SCOPE OF THE STANDARDS The Standards for Protection Against Radiation define: 1. Limits on exposure to radiation and radioactive materials; Formatted: Normal, Line spacing: single, Pattern: Clear Formatted: Font: (Default) Arial, Bold Formatted: Font: (Default) Arial, 10 pt, Bold Formatted: Font: Arial, Bold Formatted: Font: (Default) Arial, 10 pt, Bold Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt, Bold Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt, Bold Formatted: Font: (Default) Arial, 12 pt Formatted: Normal, Pattern: Clear 2. Actions to be taken after accidental exposure; 3. Working conditions requiring personnel monitoring, safety surveys, engineered controls, and safety equipment; 4. Proper use of caution signs, labels, and safety interlock devices; 5. Requirements for keeping worker exposure records and reporting of such exposures; 6. The requirement for specific operating and emergency procedures for radiation work; and 7. The rights of workers regarding safety inspections. EMPLOYERS RESPONSIBILITIES Your employer is required to: 1. Comply with the requirements of the California Radiation Control Regulations, departmental orders, and license conditions; Formatted: Normal, Left, Line spacing: single, Pattern: Clear Formatted: Font: (Default) Arial, 12 pt, Bold Formatted: Font: (Default) Arial, 12 pt Formatted: Normal, Pattern: Clear 2. Post or make available to you copies of the Radiation Control Regulations, any license issued there under, and your operating and emergency procedures; 3. Post any notice of violation of radiological working conditions; and 4. Provide you with information on your exposure to radiation. Formatted: Normal, Left, Line spacing: single, Pattern: Clear

69 Radiation Protection Program 16 REPORTS ON YOUR RADIATION EXPOSURE HISTORY 1. California Radiation Control Regulations require your employer to give you a written report if you receive an exposure greater than the limits set in the radiation safety standards. Basic limits for occupational radiation exposure can be found in Section referencing title 10, Code of Federal Regulations, part 20. Limits on exposure to radiation and exposure to concentrations of radioactive material in air are specified in title 10, Code of Federal Regulations, part 20, subpart C. 2. If the radiation protection standard, under 10 CFR 20 (subpart F) requires that your radiation exposure be monitored, your employer must, upon your request, (a) give you a written report of your exposures upon termination of your employment, and (b) advise you of your exposures annually. INSPECTIONS The Department or one of its contractors will inspect your workplace from time to time to ensure that health and safety requirements are being followed and that these requirements are effective in protecting you. Inspectors may confer privately with you at the time of inspection. At that time you may direct the inspector s attention to any condition you believe is or was a violation of the safety requirements. In addition, if you believe at any time that any health and safety requirements are being violated, you or your workers representative may request that an inspection be made by sending a complaint to the Department of Public Health or other official agency. Your complaint must describe the specific circumstances of the apparent violation and must be signed by you or your workers representative. The Department is required to give your employer a copy of any such complaint. Names may be withheld at your request. You should understand, however, that the law protects you from being discharged or discriminated against in any way for filing a complaint or otherwise exercising your rights under the California Radiation Control Regulations. POSTING REQUIREMENTS Copies of this notice must be posted in a sufficient number of places in every establishment where employees are employed in activities regulated by the California Radiation Control Regulations, to permit employees working in or frequenting any portion of a restricted area to observe a copy on the way to or from their place of employment. FOR RADIOLOGICAL EMERGENCY ASSISTANCE (24/7), PHONE To contact the Radiologic Health Branch, phone (916) or go to: C. Disposal of Equipment KDHCD shall report in writing to the Department the sale, transfer, or discontinuance of use of any reportable source of radiation. We are governed by the following rules in this regard: Formatted: Font: (Default) Arial, 12 pt, Bold Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt, Bold Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt, Bold Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt, Bold Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt, Font color: Auto Formatted: Font: 12 pt Formatted: Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent at: 0.25" We shall report the final disposition of the X-ray machine on the Radiation Machine Registration form (RH2261). Documentation on service reports evidencing

70 Radiation Protection Program 17 disassembly or disabling of the machine, photos, sales contract, etc. will be furnished. We shall clearly demonstrate the disposition of the X-ray machine. Continued registration is required for X-ray machines that are not used but are physically present in a facility or are in storage. This guidance does not apply to particle accelerators. Although there is no residual radiation, there may be environmental restrictions on what components may go into a land-fill after disassembly, such as chemical contaminants in cooling oil. Any hazardous materials should be disposed of by appropriately licensed companies or authorities. We shall follow the disposal instructions provided by the manufacturer in the product manual, and/or contact the manufacturer for information and guidance. Formatted: No bullets or numbering When manufacturer guidance is not available: The X-ray machine components may be returned to a commercial X-Ray machine assembler or vendor; or The X-ray machine may be totally disabled and the components sold as scrap metal or disposed of according to our county s environmental requirements; or The X-ray machine may be rendered non-functional by disassembly and/or component removal such that repair and use may not be readily affected. Other Controls We shall evaluate the need for other controls in addition to those mentioned above. The following items will be considered: 1. Types of controls used to reduce or control exposure to radiation, such as positioning aids, gonad shielding, protective aprons, protective gloves, mobile shields, etc. 2. Procedures for routine inspection/maintenance of such controls. 7. Emergency Exposure Situations and Radiation Accident Dosimetryand Misadministration Events Formatted: Indent: Left: 0.25", Bulleted + Level: 1 + Aligned at: 0.5" + Indent at: 0.75", Tab stops: 0.5", Left + Not at 0.81" Formatted: Indent: Hanging: 0.5", Bulleted + Level: 1 + Aligned at: 0.5" + Indent at: 0.75" Formatted: Indent: Left: 0.06", Hanging: 0.31" Emergency exposure situations include radiation diagnostic machines such as X- ray machines, CT, fluoroscopy, mammography, linear accelerators, HDR unit and treatments/diagnostic procedures involving radioactive materials. Radiation accident is defined as incident where a radiation dose different from prescribed dose is delivered to patient. An incident report is generated citing causes that resulted in the overexposure. These incident reports function as valuable guide in preventing future occurrences. Misadministration means the administration of radiation therapy to wrong patient, an external treatment dose when the treatment consists of three or fewer fractions and the administered dose differs from the prescribed dose by more than 10%, or when the weekly doses differ by 30%, or total doses differ by 20%. In case of misadministration, the licensee must notify CDPH Radiation branch by telephone no later than the next calendar day. The licensee must submit a written

71 Radiation Protection Program 18 report within 15 days of the misadministration. The referring physician and the patient are notified within 24 hours, unless the physician takes the responsibility Of informing the patient. A written report should be sent to the patient within 15 days. 8. Record Keeping and Reporting We commit to comply with regulations governing record keeping and reporting. We shall maintain all records of the Radiation Protection Program, including annual program audits and program content review. The person responsible for maintaining all required records is the respective Department manager, who maintains it in paper form or computer file. The format is governed by the KDHCD on-line documentation. Mobile providers keep their own records that we have access to. 9. Reports to Individuals The KDHCD shall provide reports of individual exposure when requested in accordance with 17 CCR Monthly radiation badge report resides with each individual department after RSO completes the review. This report shall be posted in all applicable departments. Any employee getting exposure above the ALARA limits will be notified of the exposure, giving chance for the manager to reallocate the work site for that particular employee Radiation Safety Training A. Operating and Safety Procedures All machines have operating and safety procedure manual that resides with the machine. These safety procedures will be posted on the machine or where the operator can observe them while using the machine. All safety standards and procedures will be observed and practiced by employees as required by the California State department of Health, Title 17, for their own safety and that of the general public and patients. When new equipment is acquired, staff responsible for treatment use will be trained with either manufacturer on site or off-site or by radiation therapist or radiographer who has undergone training. Annual safety training is provided at the HDR machine. Any training including continuing education received by the staff will be documented. B. Occupational Workers KDHCD shall: 1. Inform all individuals working in or frequenting any portion of a controlled Formatted: Indent: Hanging: 0.19", Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent at: 0.25", Tab stops: 0.38", Left + Not at 0.57" Formatted: Indent: Left: 0.33", Right: 0.12", Space Before: 0 pt, Line spacing: single Formatted: Not Expanded by / Condensed by Formatted: Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent at: 0.25", Tab stops: 0.31", Left Formatted: Indent: Left: 0"

72 Radiation Protection Program area of the use of radiation in such portions of the controlled area; 2. Instruct such individuals in the health protection problems associated with exposure to radiation, in precautions or procedures to minimize exposure, instruct such individuals in, and instruct them to observe, to the extent within their control, the applicable provisions of Department regulations for the protection of personnel from exposures to radiation occurring in such areas; 3. Instruct such individuals of their responsibility to report promptly to the manager any condition which may lead to or cause a violation of department regulations or unnecessary exposure to radiation, and of the inspection provisions of 17 CCR 30254; 4. Instruct such individuals in the appropriate response to warnings made in the event of any unusual occurrence or malfunction that may involve exposure to radiation and advise such individuals as to the radiation exposure reports which they may request pursuant to 17 CCR Quality Assurance Programs Quality Assurance checks at the treatment machines include daily checks, monthly checks and annual checks. Radiation checks and mechanical checks are performed. The checks are reviewed by the Physicist and appropriate action taken. These actions could be either in-house or in consultation with the machine vendor. A. Radiation Therapy We Kaweah Delta Health Care District commits to the policies practices as narrated below, in order to reduce unwanted exposures to patients and prevent any misadministration: 1. We do daily checksrequired QA I performed on each unit to insure their radiation output is within specified range. 2. We do more ddetailed monthly physics checks are performed monitoring beam output, symmetry and energy on radiation therapy units. 3. We do mmonthly mechanical checks oon the radiation therapy machines units are completed to assure various parameters appearing in the patient treatment are within acceptable tolerance. 4. We do a very Perform thorough annual calibration of our radiation machines, confirming data residing in our treatment planning system. 5. We do TLD checks on the radiation therapy machineunitss, which are independently verified by a RPC, Formatted: Indent: Hanging: 0.33" Formatted: Indent: Left: 0" Formatted: Indent: Left: 0" Formatted: Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent at: 0.25" Formatted: Indent: Left: -0.02"

73 Radiation Protection Program a federally funded agency 6. CconfirmConfirm the accuracy of our treatment planning systems by comparing their numbers with an independent manual calculation for each and every patient 7. Confirm the accuracy of dose delivery by a device called diode placed on patient s treatment site during treatment. 8. Perform kv images and portal images (MV) during treatment, confirming the location of treatment, as part of our Image Guided Radiation Therapy (IGRT). 9. Respiratory gating, part of IGRT, which enables beam cut off in the event treatment target wanders off the designated location. 10. Monitor and review of treatment errors and discuss them in our technical meeting as part of continuing education of our staff. Formatted: Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.29" + Tab after: 0.54" + Indent at: 0.54" 12. Internal Audit Procedures We commit to audit the Radiation Protection Program on an annual basis. Documentation of the annual audits may be requested during inspection. KDHCD has right and obligation to contact the Radiologic Health Branch of the Department of Public Health of California for clarification on radiation protection issues. The address is as follows: Department of Public Health Radiologic Health Branch P.O. Box , MS-7610 Sacramento, CA Formatted: Right: 2.44"

74 Imaging Services Policy Number: IS 9.1 Date Created: 11/01/2004 Document Owner: Carla Hernandez (Administrative Date Approved: Not Approved Yet Assistant) Approvers: Board of Directors (Administration), Carla Hernandez (Administrative Assistant), Daniel Hightower (Radiology), Deana Hale (Imaging Services Manager), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Renee Lauck (Dir OP Rad Onc & Imaging Svcs) Emergency Care in Imaging Services Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: Technologist or RNs will initiate emergency protocol as necessitated by patient condition. Emergency drug chestsmedication kits are available in areas where a patient may have an invasive procedure or a procedure that involves a contrast agent. These chests kits are checked by pharmacy, monthly. Procedure: I. In the case of an unexpected systemic reaction or sudden deterioration in a patient's condition, the technologist will: A. Notify the radiologist at once. B. CPR will be initiated if there is a sudden cessation in breathing or pulse, and a "Code Blue" will be called according to District guidelines for the main campus or KDH site. All outside areas will call 9,911, according to district policy for those that work in other facilities away from the main campus. C. In the case of cardiac arrest, one person will be delegated to keep a concurrent written record of events, with times recorded of each event or treatment, type and amount of any drugs given. This record will be placed in the patient chart or given to those taking over the care of the patient if off campus. D. Patient's attending physician will be informed of the event at the first possible practical moment following alleviation of the emergency. Related Documents: NONE References: NONE

75 Emergency Care in Imaging Services 2 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

76 Imaging Services Policy Number: IS Date Created: 10/01/2007 Document Owner: Carla Hernandez (Administrative Date Approved: Not Approved Yet Assistant) Approvers: Board of Directors (Administration), Carla Hernandez (Administrative Assistant), Daniel Hightower (Radiology), Deana Hale (Imaging Services Manager), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Renee Lauck (Dir OP Rad Onc & Imaging Svcs) Routine Views Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: Staff will refer to the following guide for routine views of diagnostic exams. Refer to plate size for studies when working in a room requiring CR plates. In a Digital Radiography room, utilize appropriate collimation. Procedure: Body Part Views Plate Size Hand PA 1 10 x 12 Oblique 1 8 x 10 Lateral (Fingers Separate Fingers PA of Hand 1 10 x 12 Oblique & Lateral Affected Finger Wrist PA 2 8 x 10 Oblique Lateral Navicular View Elbow PA 2 10 x 12 Both Obliques Lateral Forearm AP 2 14 x 17 Lateral Inc. Both Joints Humerus AP 2 14 x 17 Lateral Transthoracic (if fractured) Shoulder INT & EXT Rotation 2 10 x 12 Axially View for Dislocation 1 8 x 10 Y view if unable to get axillary 1 10 X12

77 Routine Views 2 Clavicle AP 2 10 x 12 AP Cephalad Angle 20 degrees Body Part Views Plate Size Scapula AP (Arm over head) 2 10 x 12 Y view AC Joints AP with/without weights 1 14 x 17 Sternoclavicular Joints PA PA both Obliques (cone) 3 8 x 10 Foot AP 2 10 x 12 Mediolateral Oblique Lateral Ankle AP 2 10 x 12 Both Obliques Lateral Knee AP 4 8 x 10 Both Obliques Lateral Sunrise (if requested) 1 8 x 10 Hip AP Pelvis 1 14 x 17 Frog Lateral of Hip(s) 1 10 x 12 Cross Table Lateral (if trauma, post-op) Femur AP 2 14 x 17 (proximal) Lateral (include both joints) 2 10 x 12 (distal) TIB/FIB AP 2 14 x 17 Lateral (include both joints) 2 10 x 12 Soft Tissue Neck Lateral Neck (chin up) 1 10x12 4 years old and younger do AP also 1 8x10 Cervical Spine Trauma in Collar (If cleared to remove collar do routine cervical spine views and repeat any views with collar artifact) AP w/collar Odontoid w/collar Lateral w/collar Swimmers (if necessary for C7) x10 8x10 10x12 10x12 Cervical Spine AP 1 8 x 10 Both Obliques 3 10 x 12 Odontoid

78 Routine Views 3 Lateral Swimmers (if necessary for C7) Thoracic Spine AP 2 14 x 17 Lateral 1 8 x 10 Swimmers Body Part Views Plate Size Lumbar Spine AP to include Kidneys 1 14 x 17 Lateral 1 14 x 17 Both Obliques 2 14 x 14 Spot for L5-S1 1 8 x 10 Sacrum/Coccyx AP (15 degree up sacrum) 2 10 x 12 (10 degree down coccyx) Lateral 1 8x10 Sacroiliac Joints PAAP 3 8 x 10 LAOLPO RAORPO Pelvis AP to include Hips 1 14 x 17 (Toes turned in) Skull AP 5 10 x 12 Both Laterals Townes View Facial Bones PA Caldwell 5 8 x 10 Waters Lateral Zygomatic Arch Views Mastoids Schuller Laws 8 8 x 10 (Bilateral) Stenvers Owens/Mayers Towne Paranasal Sinus PA Caldwell 3 8 x 10 All Films Waters (Open Mouth) Upright Lateral (Affected Side) Collimate- Use Cone Mandible AP 5 8 x 10 Both Obliques Towne Lateral of Affected Side Nasal Bones Waters 3 8 x 10 Both Lateral (Soft Tissue)

79 Routine Views 4 Body Part Views Plate Size Orbits Caldwell 6 8 x 10 Waters 30 degrees Modified Waters 15 degrees Lateral Both Obliques (each oblique to include both orbits) Optic Foramen PA 4 8 x 10 Rhese Caldwell (Do both orbits) Chest PA 2 14 x 17 (All Upright) Left Lateral Chest Lateral Decub Rt Decub 2 14x17 (always both sides) Lt Decub 14x17 Sternum RAO 2 10 x 12 Lateral Ribs PA or AP Chest 4 14 x 17 Both Obliques (affected side) 1 11 x 14 Lower Ribs as needed AP Ribs Bone Age PA (both hands)left Hand 2 1 PA (both wrists) Do on one film 10 x 12 Pelvimetry AP Pelvis 2 14 x 17 Only on Radiologists Lateral approval (Colcher Sussman) Abdomen Series AP 2 14 x 17 AP Upright or LT LAT Decub Include Diaphragm Bone Survey Chest 4 14 x 17 (Metastases) Pelvis 3 10 x 12 AP & Lateral Skull 1 14 x 17 AP & Lateral C, T, L-Spines AP & Lateral Humeri & Femora Bone Survey AP & Lat Skull As appropriate (confer with AP Chest radiologist for AP Abdomen arthritis) AP Long Bones AP Pelvis

80 Routine Views 5 Related Documents: NONE References: NONE "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

81 Imaging Services, Radiology Policy Number: IS Date Created: 10/01/2004 Document Owner: Carla Hernandez (Administrative Date Approved: Not Approved Yet Assistant) Approvers: Board of Directors (Administration), Carla Hernandez (Administrative Assistant), Daniel Hightower (Radiology), Deana Hale (Imaging Services Manager), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Renee Lauck (Dir OP Rad Onc & Imaging Svcs) Radiology Barium Swallow/Esophogram - Physician Preference Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: When performing a Barium Swallow, the following will procedure will be followed. Procedure: I. Supplies A. EZ paque Thin Liquid Barium B. Baricon ThickEZ HD 340g Barium mix according to directions C. EZ gas Crystals D. Small amount of Water II. III. IV. 14 X 17 Scout of Chest/Esophagus Have a 14 x 14 in the fluoro tower if not in a room with digital spot film capability. Show film to radiologists V. Have 10 x 12 and 14 x 14 films available when doing exam in a room without digital spot film capability. VI. Patient in upright position. Related Documents: NONE References: NONE "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

82 R Imaging Services, Radiology Policy Number: IS Date Created: 10/01/2004 Document Owner: Carla Hernandez (Administrative Date Approved: Not Approved Yet Assistant) Approvers: Board of Directors (Administration), Carla Hernandez (Administrative Assistant), Daniel Hightower (Radiology), Deana Hale (Imaging Services Manager), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Renee Lauck (Dir OP Rad Onc & Imaging Svcs) Radiology Upper G.I. - Physician Preference Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: When performing an UGI procedure, the staff will adhere to the following procedure. Procedure: I. Supplies A. Baricon EZ HD 340g Thick Barium mix according to directions B. EZ paque Thin Liquid Barium C. EZ Gas 11 D. 2 medicine cups II. III. IV. Scout A. 14 x 17 Flat Plate Abdomen to include Stomach Show to Radiologist. Overheads ***NOTE- At Kaweah Delta Imaging Center, overheads are taken only by specific request of Radiologist. Spot Films are routinely taken by the Radiologist which eliminates the need of overhead imaging. *** A. AP 14 x 17 B. Right lateral 10 x 12 C. RAO 10 x 12 Related Documents: NONE References: NONE "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

83 Imaging Services, Radiology Policy Number: IS Date Created: 10/01/2004 Document Owner: Carla Hernandez (Administrative Date Approved: Not Approved Yet Assistant) Approvers: Board of Directors (Administration), Carla Hernandez (Administrative Assistant), Daniel Hightower (Radiology), Deana Hale (Imaging Services Manager), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Renee Lauck (Dir OP Rad Onc & Imaging Svcs) Radiology Small Bowel Follow Through (SBFT) Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: When performing a Small Bowel Follow Through, the following will procedure will be followed. Procedure: I. Supplies A. 2 Containers of EZ paque Thin Liquid Barium OR B. 3 Bottles of Gastroview II. III. 14 X 17 Abdomen Scout Show film to radiologists IV. Take films as requested by Radiologist. If at SICKDIC, take KUB at 1520, minutes and 1 hour. Show to Radiologist and set up fluoro.have 10 X12 films available for taking spot films Related Documents: NONE References: NONE "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

84 Imaging Services, Radiology Policy Number: IS Date Created: 10/01/2004 Document Owner: Carla Hernandez (Administrative Date Approved: Not Approved Yet Assistant) Approvers: Board of Directors (Administration), Carla Hernandez (Administrative Assistant), Daniel Hightower (Radiology), Deana Hale (Imaging Services Manager), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Renee Lauck (Dir OP Rad Onc & Imaging Svcs) Radiology Modified Barium Swallow with Speech Therapy - Physician Preference Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: When performing a Modified Barium Swallow/ Video Swallow, the following will procedure will be followed. Procedure: I. Notify Speech Pathologist when patient has arrived. Supplies will be obtained and prepared by Speech Pathologist II. III. IV. Position patient sitting upright in pink gurneyspeech Eval chair with back extension removed. Stand up fluoro table, place patient in chair laterally against table. Right side of patient should be against the table. Ensure Video Recorder is on and tape is available.set up Fluoro to record/ Save Images Cine Mode (Usually handled by Speech Pathologist) V. Notify radiologist after patient is in the proper position and the Speech Pathologist has contrast/supplies ready. Related Documents: NONE References: NONE "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

85 Contrast/Medication, Imaging Services Policy Number: IS 18.2 Date Created: 03/01/2007 Document Owner: Carla Hernandez (Administrative Date Approved: Not Approved Yet Assistant) Approvers: Board of Directors (Administration), Medical Executive Committee, Pharmacy and Therapeutics, Carla Hernandez (Administrative Assistant), Daniel Hightower (Radiology), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Renee Lauck (Dir OP Rad Onc & Imaging Svcs) Contrast/Medication - Procurement, Storage, Control, Distribution, Administration and Monitoring of Radiographic Contrast Media Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: Procedure: I. Formulary Management A. The formulary system described in Pharmacy Manual Policy Formulary System: Drug Product Selection will be followed. II. III. Radiographic contrast is procured by filling out an appropriate supply requisition and sending it to the pharmacy department. A pharmacy department buyer places the order. Contrast Media Storage A. The contrast media are stored in the Imaging areas in which it is used: Diagnostic Radiology, C.T., MRI, Kaweah Delta Imaging Center, and Interventional Radiology. B. Contrast media will be stored: 1. In a segregated manner in accordance with the intended route of administration. 2. In a secure area. 3. Under necessary conditions to ensure stability. C. Use of contrast warmers 1. Clinical experience indicates that it is desirable for iodinated or non-ionic contrast media to be at body temperature (98.6F or 37C) prior to intravascular injection, and contrast warmers are

86 Contrast/Medication - Procurement, Storage, Control, Distribution, Administration and Monitoring of Radiographic Contrast Media 2 often used for this purpose. 2. The contrast warmer temperature should not exceed 98.6F (37C). Contrast media should be stored as specified on the package insert, and should not be kept in the warmer for any period of time longer than that reasonably needed to reach body temperature or to assure that a supply of properly warmed media is readily available for use in ongoing radiological procedures. 3. The First In, First Out method of inventory control will assure that the time each container remains in the warmer is relatively uniform. 4. Manufacturer states there is data to support allowing Isovue to remain in the contrast warmer not exceeding 98.6 F (37C) for less than one month when the product has at least 6 months remaining on labeled expiration date, and otherwise appears suitable for use. Bottles or vials of Isovue should be maintained in an upright position while in warmer Contrast bottles will be placed in the warmer at the beginning of the day for that days use and will be used on a first in first out basis. Bottles will not be stored in warmer for more than 24 hours. Warmer will be emptied at the end of each day to assure bottles are not left overnight. Any unused vials will be disposed of. IV. The technologists in the aforementioned Imaging areas monitor usage and place orders appropriately. V. Once an order is placed, contrast media are distributed to the appropriate Imaging area. VI. Contrast Media Ordering A. The order basics described in Patient Care Manual Policy CP 19 Medication: Administration are followed. B. Contrast media are administered to patients by order of the Radiologist performing the exam or the prescriber ordering the exam. VII. Contrast Media Administration A. The administration basics described in Patient Care Manual Policy CP 19 Medication: Administration are followed. 1. Exception: IV contrast media orders do not require a review by the pharmacist. The licensed independent practitioner (LIP) is in control of the ordering, preparation, and administration of

87 Contrast/Medication - Procurement, Storage, Control, Distribution, Administration and Monitoring of Radiographic Contrast Media 3 contrast media. a) In the radiology setting, LIP control of these processes does not require he/she be at the bedside or personally administering the contrast media. b) In the radiology setting, LIP control does require the LIP to be within the department in close proximity and readily available in the event of an adverse reaction during IV contrast administration. 2. Exception: Oral and rectal contrast media orders do not require a review by the pharmacist. Prior to administration, orders for oral and rectal contrast media are reviewed for appropriateness by the radiologist. A. Prior to radiographic contrast media administration, the patient is screened by the radiology technologist for any allergies or drug interactions, which would preclude product use. Pertinent information will be brought to the attention of the radiologist who will determine how to proceed. B. A RN or a Radiographer may inject contrast media. Those Radiographers who possess an IV certification may start IV if needed. C. Each patient, who receives iodinated or non-ionic contrast media, has the amount, type and any reactions recorded on the Radiology Procedure Record. Related Documents: NONE References: NONE "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

88 Imaging Services, Nuclear Medicine Policy Number: IS Date Created: 06/02/2014 Document Owner: Carla Hernandez (Administrative Date Approved: Not Approved Yet Assistant) Approvers: Board of Directors (Administration), Carla Hernandez (Administrative Assistant), Daniel Hightower (Radiology), Deana Hale (Imaging Services Manager), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Renee Lauck (Dir OP Rad Onc & Imaging Svcs) Nuc Med - Lasix Renogram Printed copies are for reference only. Please refer to the electronic copy for the latest version. Procedure: I. INDICATIONS - Differential diagnosis of obstructive vs. non-obstructive hydronephrosis - Evaluation of renal perfusion and function - Evaluation of differential renal function - Evaluation and follow-up of renal trauma - Evaluation and follow-up of renal transplants - Screening for renal vascular disease II. PRINCIPLE MAG3 is cleared rapidly from the blood stream primarily by tubular secretion with some glomerular filtration. Dynamic images are acquired posteriorly and a timeactivity curve is generated to indicate the function of each kidney expressed as uptake and clearance of the tracer. In the case of hydronephrosis, MAG3 will accumulate in upper urinary tracts. Following the administration of Lasix to cause diuresis, a washout of activity will be seen in the case of non-obstruction. In the case of obstructive hydronephrosis, however, washout does not occur. III. SCHEDULING Exam Duration: IV injection with immediate dynamic imaging (40 min) Followed with a pre and post void static image (5 min) Collimators: LEHR IV. PATIENT PREP No Lasix diuretics for 6 hrs prior to imaging. Pt needs to drink at 1-2 glasses of water no more than 30 min prior to imaging. Check for allergies to Lasix. Have pt empty bladder just prior to imaging. V. RADIOPHARMACEUTICAL

89 Nuc Med - Lasix Renogram 2 Isotope: 99mTc MAG3 Dose: 10 mci Diuretic Dose: 40 mg Lasix Administration: Intravenous Time from Injection to Imaging: Immediate (acquire flow study) VI. ACQUISITION PROTOCOL Have pt drink 1-2 glasses of water and start an IV (preferably large AC vein). Instruct pt to empty their bladder just prior to imaging. Images are acquired in the supine position. For native kidneys, posterior imaging is acquired. But for transplant kidneys, anterior pelvic imaging is best. Pt to be positioned in the camera FOV with xiphoid at the top of the FOV, hips at the bottom of the FOV to try and include bladder, if possible. It is important not to image too low and miss the top of the kidneys, except for when imaging transplant kidneys (which are usually located in the pelvic region). Flow study is acquired for the first 60 seconds post injection, followed by dynamic imaging for 40 minutes (40 frames, 1 min/ frame). When the technologist starts to see collecting system (renal pelvis and ureters), the RN is instructed to administer the Lasix and the computer time (see the P-scope display) needs to be recorded for processing purposes. It is important that Lasix never be injected later than 20 minutes remaining. If pt can tolerate holding their bladder, a 1-3 minute static with bladder and kidneys in the FOV is acquired pre-void. Have pt empty their bladder and repeat static image for the same length of time for a post-void image. At any time during the test, if the pt can no longer tolerate holding their bladder, exam is terminated. References: O Connor, M.K.: The Mayo Clinic Manual of Nuclear Medicine ( ), "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

90 Policy Submission Summary Date: 1/8/2018 Manual Title: Mental Health Support Staff Name: Kathryn Tunstall Policy / Procedure Title # Therapeutic Hold (Restraint) of Patients in Behavioral Crisis (To be renamed, Manual Hold (Restraint) of Patients in Behavioral Crisis ) Status (New, Revised, Reviewed or Deleted) Name and Phone # of person who wrote new policy or revised an existing policy MH 1.91 Revised Mary Laufer (559)

91 Mental Health Policy Number: MH 1.91MH Date Created: 01/09/2012 Document Owner: Kathryn Tunstall (Administrative Date Approved: Not Approved Yet Assistant) Approvers: Board of Directors (Administration), Board of Directors (Mental Health), Kathryn Tunstall (Administrative Assistant), Mary Laufer (Director of Mental Health Svcs) Therapeutic Hold (Restraint) of Patients in Behavioral Crisis Printed copies are for reference only. Please refer to the electronic copy for the latest version. Comment [LM1]: Change Therapeutic Hold to Manual Hold (align with verbiage updates throughout policy) Purpose: Policy: To provide guidelines to ensure that the use of therapeutic holding (restraint) of patients is restricted to clinically appropriate and adequately justified situations in which less restrictive alternative methods have proven to be ineffective. Ongoing performance improvement monitoring will be used to ensure appropriate use of therapeutic holds Kaweah Delta Mental Health Hospital recognizes that the use of any type of restraint poses a significant inherent risk to an individual s to the physical safety and psychological well-being of the patient. The mental health hospital upholds each individual s the right of patients to be free from restraint, in any form, that is not medically necessary to protect patients fromprevent self-harm or harm of others. Direct care providers demonstrate competency in identifying indications for and use of manual restraint. All patient care staff will demonstrate competency in the indication and use of the restraint process (CP.24, Restraint/Seclusion of Patients). I. Definitions: Therapeutic HoldA manual hold is the use of the hands to limit the movement of patient a person s head, limbs or body when an emergency situation presents that places the patientan individual or others in immediate danger. For definitions of other types of restraint, please refer to CP.24PC.24, Restraints/Seclusion of Patients. II. General Provisions A. Indications: 1. A Therapeutic manual holds may be used when less restrictive means would not be effective to protect the physical safety of patients an individual or others. 1. Formatted: Indent: Left: 2", No bullets or numbering

92 Therapeutic Hold (Restraint) of Patients in Behavioral Crisis 2 2. Generally, therapeutic holds of patientsmanual holds are used only in emergency situations and for short periods of time (generally 15 minutes or less) to assist the patientan individual to regain self- control. of behavior which may or may not include the administration of emergency psychiatric medications (which are standard treatments for the patient new or emerging condition) but do not include the use of any mechanical device, material, or equipment for restraint. B. Initiation, Assessment and Monitoring: See Violent/Self Destructive Restraint/Seclusion, CPPC.24 Restraint/Seclusion of Patients C. PRN Orders: PRN orders for therapeutic manual hold shall are not be usedvalid.. D. Duration of Orders: Orders for therapeutic holds shall generally be for brief periods of time (15 minutes or less). See Attachment A,, Therapeutic Hold (Restraint) Protocol. However, if patient is unable to regain behavorial self control to decrease immediate risk of harm to self or others within a brief period of time, restraint or seclusion (with mechanical devices, materials or equipment) may be indicated (Violent/Self Destructive Restraint/Seclusion, CP.24, Restraint/Seclusion of Patients). Formatted: Indent: Left: 0.5", Numbered + Level: 1 + Numbering Style: I, II, III, + Start at: Alignment: Left + Aligned at: 1" + Tab after: 1.5" + Indent at: 1.5" E. Assessment and Monitoring: See Violent/Self Destructive Restraint/Seclusion, CP.24 Restraint/Seclusion of Patients `III. F. Training 1. Certification in Crisis Prevention Institute, Nonviolent Crisis Intervention or Pro-ACT Crisis Intervention 2. Training requirements as identified in CP.24 Restraint/Seclusion of Patients C. References "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document." Formatted: Normal, Indent: Left: 1", Hanging: 0.5", Tab stops: -1", Left Formatted: Level 1, Numbered + Level: 1 + Numbering Style: I, II, III, + Start at: Alignment: Left + Aligned at: 1" + Tab after: 1.5" + Indent at: 1.5", Tab stops: -1", Left + 1", Left

93 Policy Submission Summary Manual Name: Renal Services Date: 1/9/18 Support Staff Name: Nicole Rhodes Routed To: Approved By: (Name/Committee Date) Department Director Medical Director (if applicable) Medical Staff Department (if applicable) Patient Care Policy (If applicable) Pharmacy & Therapeutics (if applicable) Interdisciplinary Practice (if applicable) Executive Team (if applicable) Medical Executive Committee (if applicable) Board of Directors Policy/Procedure Title # Status (New, Revised, Reviewed, Deleted) Jon Knudsen Roger Haley Name and phone number of person who wrote the new policy or revised an existing policy Accessing Dialysis Indwelling Catheter for Blood Draws/IV Antibiotics RS-L.01 Revised Darrell Chudej Cathy Gage-Ivers Biohazard Waste/Sharps Waste RS-H.01 Revised Darrell Chudej Cathy Gage-Ivers Exterior Cleaning of Hemodialysis Equipment RS-N.16 Revised Darrell Chudej Cathy Gage-Ivers Rinseback Technique: Emergent RS-L.03 Revised Darrell Chudej Cathy Gage-Ivers Water Analysis RS-N.12 Revised Darrell Chudej Cathy Gage-Ivers Water Cultures RS-N.11 Revised Darrell Chudej Cathy Gage-Ivers Medical Records:Physician Discharge Summary at Chronic Dialysis RS-F.03 Delete Darrell Chudej Cathy Gage-Ivers Dialysis Adequacy/Run Time for Hemodialysis RS-L.46 Delete Darrell Chudej Cathy Gage-Ivers IV Iron Administration RS-J.04 Delete Darrell Chudej Cathy Gage-Ivers New Employee Orientation/Training RS-G.01 Delete Darrell Chudej Cathy Gage-Ivers Acute Aquaboss R.O. Operation RS-N.29 Delete Darrell Chudej Cathy Gage-Ivers Acute Reverse Osmosis (RO) Disinfection Aquaboss RS-N.30 Delete Darrell Chudej Cathy Gage-Ivers

94 Acute Dialysis, Chronic Dialysis Policy Number: RS-L.01 Date Created: 08/29/2001 Document Owner: Nicole Rhodes (Database Date Approved: Not Approved Yet Reporting Analyst) Approvers: Board of Directors (Administration), Jon Knudsen (Dir of Renal & Oncology Svcs), Nicole Rhodes (Database Reporting Analyst), Roger Haley (Nephrology) Accessing Dialysis Indwelling Catheter for Blood Draws/IV Antibiotics Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: With a current physician s order Registered Nurse s can access the indwelling vascular catheter for obtaining laboratory samples or to administer IV -intravenous antibiotics/solutions. Equipment: Face mask, non-sterile gloves, absorbent padappropriate Personal Protection Equipment Absorbent pad Antimicrobial wipes 1 package sterile 4 x 4 10ml syringe to aspirate blood from access port Lab tubes if ordered, and prepared antibiotic if intravenous orderedantibiotic pre-mixed in IV bag, or IV solution- IV pump with tubing- I0 ml syringes with normal saline, (2) 21 g needles- Vacutainer with adapter needles for catheters 3 ml- s-syringe with prescribed anticoagulant if prescribedconcentration and amount of anticoagulant for catheter flush.- Two (2-) s-sterile port caps and 1 micropore tape for bridge tape - Procedure: Formatted: Indent: Left: 0.5", Bulleted + Level: 1 + Aligned at: 0" + Tab after: 0.25" + Indent at: 0.25", Tab stops: 0", Left ", List tab + Not at -1" " I. Draw up 2 syringes of normal saline, 10 ml each and syringe with prescribed anticoagulant-. II. Explain procedure to patient III. Apply face mask on patient and self, wash hands, put on gloves IV. Place absorbent pad under ports of catheterand, sterile 4x4 beneath ports of catheter. V. Clean outside of port cap with antibicrobial antimicrobial-l wipe for designated time..

95 Accessing Dialysis Indwelling Catheter for Blood Draws/IV Antibiotics 2 VI. Remove port cap from venous port and cleanse port with antibicrobial antimicrobiall wipe for designated time. If TEGO present it is not necessary to remove. VII. Connect 10ml syringe, unclamp -open catheter clamp, and aspirate 5ml s of blood to clear port and line of anticoagulant, and close clamp.. VIII. If drawing blood with vacutainer: A. Connect vacutainer to port B. Insert lab tube, unclamp -open clamp C. Fill lab tube, close clamp after- D. Insert another tube, open clamp, and repeat the process until all lab tubes are filled. Close clamp. IX. If drawing blood with syringe: A. Attach appropriate sized syringe to end of port B. Draw enough blood to place in all tubes C. Attach 21 g- needle to end of syringe and insert into middle of lab tube. The vacuum of the lab tube will pull the blood into the tube; be sure to aim the stream of blood to run down the side of the tube., this This will prevent hemolysis of the blood specimen. X. If only drawing blood, remove the vacutainer or syringe after collecting the samples: A. Attach the syringe and flush with 20 ml of normal saline B. Flush line with 10ml of normal saline- C. Attach 3ml syringe- the syringe and flush port and line with the prescribed amount of anticoagulant if prescribed. D. Apply sterile port cap. and bridge tape.- XI. To infuse IV antibiotics/solution: A. Connect IV tubing to port, begin infusion. Clamp catheter line, disconnect IV tubing- B. When infusion is complete, close clamp, disconnect IV tubing B.C. Clean outside of port or TEGO cap with antimicrobial wipe. AAttach 10 ml syringe with normal saline and flush line

96 Accessing Dialysis Indwelling Catheter for Blood Draws/IV Antibiotics 3 C.D. Attach 3- ml - syringe and flush port and line with the anticoagulant if prescribed. prescribed amount of anticoagulant- D.E. AttachApply sterile port cap if needed., bridge tape,- and anticoagulant label.- "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

97 Acute Dialysis, Chronic Dialysis Policy Number: RS-H.01 Date Created: 08/29/2001 Document Owner: Nicole Rhodes (Database Date Approved: Not Approved Yet Reporting Analyst) Approvers: Board of Directors (Administration), Jon Knudsen (Dir of Renal & Oncology Svcs), Nicole Rhodes (Database Reporting Analyst), Roger Haley (Nephrology) Biohazard Waste / Sharps Waste Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: - To ensure the safe disposal of all biohazard waste (blood and all other potentially infectious material) and all sharps waste (devices having acute rigid corners, edges or protuberances capable of cutting or piercing). Procedure: I. Containment and Segregation of Biohazard Waste A. Biohazard Waste 1. Biohazard waste, i.e., blood tubing, dialyzers and bloody dressings are collected and disposed of in red biohazard bagsas needed, or -after each patient treatment. Disposal will be covered under in-house transport. - B. Sharps Waste 1. Sharps waste, i.e., fistula needles, hypodermic needles and syringes are contained for disposal in a puncture resistant rigid plastic red container. with the words "BIOHAZARDOUS WASTE" or with the international biohazard symbol and the word "BIOHAZARD" The hard plastic red -container comes equipped with a lid that isthat can closed and permanently locked when the containerit is three-quarters full and discarded.. 3. The red containers are discarded as needed. Disposal will be covered under in-house transport.- II. Method of In-house Transport A. Biohazard Waste

98 Biohazard Waste / Sharps Waste 2 1. Persons handling the biohazard waste will wear the appropriate PPE (personal protective equipment) at all times. 2. Moveable containers are used to collect waste from each station. 3. The moveable containers are labeled with the words "BIOHAZARDOUS WASTE" or with the international biohazard symbol and the word "BIOHAZARD" The moveable containers are lined and completely protected from contamination by disposable plastic bags. All bags used are red in color. and labeled with the words "BIOHAZARDOUS WASTE" or with the international biohazard symbol and the word "BIOHAZARD".. 5. Nurses, technicians or housekeeping clean the area after each patient treatment, and are responsible for disposing of waste to the moveable container. 6. When the red bag, in the moveable- container, - is half full, full,it isthe bag is tied to prevent leakage. or expulsion of contents.- 7. The bagged waste is then transported within the moveable container to the secured storage area. B. Sharps Waste 1. The sharps containers are used until they are ¾three quarters full. 2. The red plastic rigid- sharps containers are closed permanently shut with the lid provided to preclude prevent loss of contents. 3. Chronic Dialysis [ Hemo and PD ]- a) The waste sharps container is taken to the Biohazard room. 4. Acute Dialysis a) The entire red container is placed in the moveable container lined with a red plastic certified bag, labeled with the words BIOHAZARDOUS WASTE or with the international biohazard symbol and the word BIOHAZARD. b) When the red bag in the moveable container is half full, it is tied to prevent leakage or expulsion of contents.- Formatted: Indent: Left: 1", Hanging: 0.5", Tab stops: 1.5", List tab

99 Biohazard Waste / Sharps Waste 3 III. Storage A. Biohazard waste is segregated from other wastes.- Formatted: No bullets or numbering IV. Containers and Safety A. Sharps containers are not reusable. B. All persons handling biohazard waste are required to wear the appropriate PPE (personal protective equipment) at all times. PPE is provided for all employees.

100 Biohazard Waste / Sharps Waste 4 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

101 Acute Dialysis, Chronic Dialysis Policy Number: RS-N.16 Date Created: 08/26/2001 Document Owner: Nicole Rhodes (Database Date Approved: Not Approved Yet Reporting Analyst) Approvers: Board of Directors (Administration), Jon Knudsen (Dir of Renal & Oncology Svcs), Nicole Rhodes (Database Reporting Analyst), Roger Haley (Nephrology) Exterior Cleaning of Hemodialysis Equipment Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: The exterior of the dialysis machine, patient chair, monitors (ie. Crit Line), will be cleaned and disinfected after each dialysis treatment. Computer on wheels (COW) will be cleaned after being in the patient treatment area. and frequently touched surfaces in the patient zone will be cleaned and disinfected after each dialysis treatment. Application of new tubing is not to be done while the patient from the same treatment is in the chair. Appropriate PPE is to be worn with application of tubing, machine and chair cleaning. Equipment: Cleaning cloth(s) soaked in dilute bleach solution 1:100, prepared at least daily or other hhospital approved germicidal wipes. Procedure: I. Before beginning routine disinfection of the dialysis station, ensure that the patient has left the dialysis station.perform hand hygiene before and after cleaning the patient station II. Perform hand hygiene before and after cleaning the patient station Formatted: Indent: Left: 0", Hanging: 0.5", Line spacing: single Formatted: Highlight III. IVII. IV. - VI. Don - PPE per policy RS-L.42, gloves, gown, and mask with eye protection or full face shield. Obtain cleaning cloth(s)wipes with solution just prior to cleaning. Two SsSeparate clothswipes should be used when cleaning different equipment the chair and the machine.per manufacturer s recommendation. Allow time to dry. when moving to a different object in the patient zone. Clean all frequently touched surfaces in the patient zone-area: chair, armrests, chair side table, bedside table (if applicable), exterior of the dialysis machine (including knobs, back of machine and IV pole and Critline monitor if present), counters (if applicable), computer keyboard and trash cans (inside and outside) outside of sharps containers, if applicable.

102 Exterior Cleaning of Hemodialysis Equipment 2 VII. VIII. Computer on wheels will be cleaned once daily at the end of day by closing staff. a. If COW is taken into the patient treatment area, it must be cleaned, top to bottom, immediately coming out of patient treatment area. Clean the top of an object first and work down to avoid soiling surfaces just cleaned. Formatted: Numbered + Level: 1 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Indent at: 0.75" IXVII. Using friction,- eensure the entire surface is wet per manufacturer recommendation and allow to air dry. XVIII. If object to be cleaned has movable parts (i.e. arms of chair and footrest) these should be opened for cleaning. If arms of chairs do not open, special attention should be paid to cleaning down the insides of the arms of chair. IXI Blue clamps should be cleaned after every use. a. a. In the chronic unit the clamps will be openedy will be and soaked in a dilute bleach solution 1:100 for 10 minutes contact time, rinsed and allowed to air dry in clean area. b. In acutes dialysis they will be thoroughly cleaned with hospital approved wipes per manufacturer recommendations, hung up in open position, and allowed to air dry on clean IV pole. Formatted: Numbered + Level: 1 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Indent at: 0.75" Formatted: Indent: First line: 0" XII. XIII. Avoid getting too much solution on the computer and Crit line screens. When screen dries, use a dry paper towel or cloth to wipe any residue off. a. Avoid getting cleaning solution inside the clip of the Crit line. If cleaning needed, use cotton tip applicator and window type cleaner. IV poles with pumps attached and oxygen concentrators must be cleaned between patient use and before storage. Formatted: Numbered + Level: 1 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Indent at: 0.75" Formatted: Indent: Left: 0.75", First line: 0" XIVII. Dispose of used clothswipes in trash can located in the respective patient zone. appropriate receptacle.. Note: See policy RS-N.01 Dialysis Machine Cleaning and Disinfection for internal disinfection of dialysis machines.

103 Exterior Cleaning of Hemodialysis Equipment 3

104 Exterior Cleaning of Hemodialysis Equipment 4 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

105 Acute Dialysis, Chronic Dialysis Policy Number: RS-L.03 Date Created: 06/02/1997 Document Owner: Nicole Rhodes (Database Date Approved: Not Approved Yet Reporting Analyst) Approvers: Board of Directors (Administration), Jon Knudsen (Dir of Renal & Oncology Svcs), Nicole Rhodes (Database Reporting Analyst), Roger Haley (Nephrology) Rinseback Technique: Emergent Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: Dialysis staff will use this rinseback technique when the patient is assessed to be in an emergent or unstable condition requiring immediate termination of dialysis treatment and return of their blood. Procedure: I. To be used on AVF/AVG or Central Venous Access Devices. - II. Make -En sure there is at least 500ml normal saline in the bag. III. IV. Touch thepress TX Treatment Clock and press confirm to stop treatment. Turn blood flow pump off. V. Place plastic line forceps on the left side of the Normal Saline inlet port, and turn the blood flow pump on at ml/min. This will return the blood through the dialyzer via the venous bloodline. VI. VII. Clamp the venous access line and the venous bloodline. If time permits and arterial bloodline is not clotted, place plastic line forceps on the right side of the Normal Saline inlet port. Care must be taken to assure no clots are present. VIII. Compress the Normal Saline Bag until the line is cleared of blood. IX. Clamp the arterial access line and the arterial blood line. X. Remove the patient from dialysis or keep bloodline secured for further fluid administration.

106 Rinseback Technique: Emergent 2

107 Rinseback Technique: Emergent 3 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

108 Acute Dialysis, Chronic Dialysis Policy Number: RS-N.12 Date Created: 04/29/2004 Document Owner: Nicole Rhodes (Database Date Approved: Not Approved Yet Reporting Analyst) Approvers: Board of Directors (Administration), Jon Knudsen (Dir of Renal & Oncology Svcs), Nicole Rhodes (Database Reporting Analyst), Roger Haley (Nephrology) Water Analysis Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: To assure that the R.O. (Reverse Osmosis) water produced by the water treatment systems meets AAMI (Association for the Advancement of Medical Instrumentation) standards for dialysis. Procedure: 1. Wash hands Complete lab requisition form - as instructed online as instructed. Print label 3. 3.Write the source of the water sample and the date of collection on the bottle label. This bottle and requisition form- will be supplied by the lab that performs the test. Formatted: No bullets or numbering Formatted: Indent: Left: 1", No bullets or numbering Formatted: Indent: Left: 0.13", No bullets or numbering 4.1. Use a sterile technique when obtaining samples. Just prior to obtaining the water sample, wash hands and wear gloves. and wear gloves Rinse the bottle with the water that is to be tested, then fill the bottle with the test sample. Secure cap Place label on the bottle and pack the bottle in the Styrofoam - shipping container and close the container. Wrap requisitions around the container and secure with a rubber ban-d Place container in cardboard mailer and ship to (lab name)-the lab that performs the test within 24 hours All results are to be logged at each facility.

109 Water Analysis 2 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

110 Acute Dialysis, Chronic Dialysis Policy Number: RS-N.11 Date Created: 08/30/2001 Document Owner: Nicole Rhodes (Database Date Approved: Not Approved Yet Reporting Analyst) Approvers: Board of Directors (Administration), Jon Knudsen (Dir of Renal & Oncology Svcs), Nicole Rhodes (Database Reporting Analyst), Roger Haley (Nephrology) Water Cultures Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: - To assure that R.O. (Reverse Osmosis) water and - dialysate -meets AAMI ( Association for Advancement of Medical Instrumentation)standards by monitoring levels of bacteria and endotoxin. R.O. water samples will be collected and tested for bacteria and endotoxin from the first and last outlets of the water distribution loop. and where water enters equipment used to prepare concentrate.- Dialysate samples will be collected and tested for bacteria and endotoxin from at least two machines per month and from enough machines so that each machine is tested at least once per year. Procedure: I. Wash hands.- II. 1 Acquire sterile, endotoxin-free containers with tight fitting lids, as designated by the laboratory performing the test. III.II. Sample collection: A. Use a sterile technique when obtaining samples. Just prior to obtaining the water sample wash hands and wear gloves. B. The R.O. water samples will be collected from the outlet sample valves within the water distribution system on a monthly basis. The water outlet valve where the sample is to be collected should be opened and the water allowed to run for at least 60 seconds before the sample is collected in a sterile container. C. The dialysate samples will be collected in a sterile container from a dialysate port of the dialyzer with the machine in dialysis mode.- IV.III. The samples will be labeled as specified by the laboratory. Information should include time, date, initial, and location of sample. Formatted: No bullets or numbering

111 Water Cultures 2 V.IV. The samples are then sent to the laboratory. If sample can not be sent directly to the laboratory, it must be immediately refrigerated and tested within 24 hours of collection. R.O. water AAMI Standard Action Level Bacteria culture count < 100 CFU/ml 50 CFU/ml Endotoxin (LAL) concentration <.25EU/ml.125 EU/ml Dialysate- AAMI Standard Action Level Bacteria culture count- < 100CFU/ml- 50 CFU/ml- Endotoxin (LAL) concentration- <.5 EU/ml-.25 EU/ml- VI.V. Elevated bacteria cultures or endotoxin concentrations will be reported immediately to the Lead Equipment Technician (or his/her delegate), the Medical Director and the Nurse Manager. VII.VI. Elevated bacteria cultures or endotoxin concentrations will initiate the action plan. VIII.VII. All elevated bacteria cultures or endotoxin concentrations will be discussed at the patient care conferences with the Medical Director. IX.VIII. All results are logged at each facility.

112 Water Cultures 3

113 QAPI Action Plan If any culture or Water LAL Cultures is above AAMI standards or above the action level, the action plan will be set 4 into motion. This is to be completed, and placed into the water culture records. The Medical Director is to be notified and sent a copy of the action plan Water cultures or LALs that are above AAMI standards or the action level will be re-tested immediately to verify the results. Water cultures or LALs that are above AAMI standards or the action level for two consecutive tests, the system will be disinfected and re-tested to assure adequate disinfection of the system. A copy of the re-test will be sent to the Medical Director. Product water used to prepare dialysate Total viable microbial count Endotoxin concentration AAMI Standard Action Level < 100 CFU/ml 50 CFU/ml <.25 EU/ml.125 EU/ml Dialysate Total viable microbial count Endotoxin concentration AAMI Standard Action Level < 100 CFU/ml 50 CFU/ml <.5 EU/ml.25 EU/ml Unit location: Acute Dialysis Kaweah Dialysis Porterville Dialysis Machine Control Number: Type: Dialysis Machine Portable RO Main RO (Visalia or Porterville) Bicarbonate Delivery System Test: RO water culture Results: Date: Dialysate culture RO water LAL Dialysate LAL Action taken: Re-test elevated sample Results: Date: Re-test after system disinfection Results: Date: Comments: System disinfected Chief Machine Technician notified Dr. notified: Date: Time: Initials: Reported at QAPI meeting: Date: Time: Initials: Chief Technician: Date:

114 Water Cultures 5 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

115 Policy Manuals AP38 Appendix D Policy Submission Summary Manual Name: Surgical Services Date: 12/06/17 Support Staff Name: Tina Lockwood Policy/Procedure Title # Point of Use: Instrument Cleaning & Transport SPD 1001 Status (New, Revised, Reviewed, Deleted) New Name and Phone # of person who wrote the new policy or revised an existing policy Brian Piearcy x-5032 and Melissa Janes x-2174 Traffic Control: Visitors/Observers in Surgical Services SS 4009 Revised Benton Duckett X-2409

116 Subcategories of Department Manuals not selected. Policy Number: SPD 1001 Date Created: July 28, 2016 Document Owner: Tina Lockwood (Administrative Date Approved: Not Set Assistant) Approvers: Board of Directors (Administration), Dept of Surgery, Benton Duckett (Director of Surgical Services), Cindy Moccio (Board Clerk/Exec Assist-CEO), Rose Marie Gonzalez (Executive Assistant) Point of Use: Instrument Cleaning and Transport Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To ensure proper cleaning and transport of surgical instruments used for a procedure returning tto the Sterile Processing Department (SPD), while decreasing the possibility of mitigating further contamination during transport and and preventionng of the formation n formulation of biofilm on the instruments. Policy: All instruments used in a procedure will be cleaned of gross soil, sprayed with instrument spray enzymatic instrument spray post procedure op and returned to the SPD in a red punctureleak proof, locking container labeled as Bio Hazardous.. Procedure: 1. Procedure complete. Obtain instruments to be cleaned Formatted: Font: (Default) Arial, 12 pt Room away from patient care. 2. Wear appropriate PPE, per task. 3. Pre-cleaning gross soil ASAP ((to prevent the formulation of biofilm) ASAP at point of use (i.e., procedure room after patient leaves, OR, soiled utility room, etc.) per product recommendations and manufacturer s instructions for use (IFU). 4. Per AAMI Guidelines, a disposable sponge or brush soaked in water could be used to wipe gross soil. 5. All items will be placed in SPD provided leak proof red container labeled as biohazardous., without water added. 6. Prior to transport spray item with SPD provided enzymatic instrument spray. a. Assure fully covered, especially around the hinges b. Hinged instruments to remain open Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: Italic Formatted: Font: Not Italic Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt

117 Point of Use: Instrument Cleaning and Transport 3 7. Arrange for transport to SPD a. Department with dirty instrumentation will transport instrumentation by SPD/courier to SPD in red biohazardous container for reprocessing. b. Each department will be given an appropriate quantity of red biohazardous containers 8. When instruments have been reprocessed they will be picked up by SPD/courier to be returned to the appropriate department. Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt 1. Wear appropriate PPE, per task. 2. Upon completion of a pprocedure, dirty instrumentation will be pre-cleaned at the point of use prior to transport to the SPD. 3. Point of care Use cleaning should be performed away from patient care areas. 4. Point of Usecare cleaning, depending on the department of origin, may be performed byfollowed by spraying dirty i instrumentation (after cleaning) with SPD approved instrument spray or using a one-time use commercially available enzymatic sponge. 5. Pre-cleaning should be performed as soon as possible after use to ASAP (to prevent formation of formulation of biofilm on the dirty instrument(s). Protocols: 1. Manufacturer s instruction for use will be utilized for pre-cleaning instrumentation. per product recommendations and manufactures instructions for use (IFU) 2. Per AAMI Guidelines, a disposable sponge soaked in water could be used to wipe gross soil 3. Instrumentation All items will be placed in a red puncture proof, locking container that will be provided by the SPD. The container will be labeled as Bio Hazardous.SPD provided leak proof red container labeled as biohazard

118 Point of Use: Instrument Cleaning and Transport 4 4. Prior to transport, the point of use user should verify the following: spray item with SPD provided instrument spray a. Assure the instrumentation is fully covered, especiallycovered, with emphasis around the hinghinge of the instrument(s). es b. Hinged instruments are to remain in the open position 5. Arrange for transport to SPD a. Department with dirty instrumentation will transport instrumentation for reprocessing using a case cart or by courier to SPD in red biohazard containers provided by the SPD for reprocessing b. Each department will be given an appropriate quantity of red biohazard containers 6. AfterWhen instruments have been reprocessed they will be either stored in the SPD (for example trays needed for surgical procedure in house) or picked up by a courier and to be returned to the appropriate department or facility. References: AAMI Standards High Level Disinfection, The Joint Commission Booster Pack (Sterilization, P.3) CMS Standard, Reprocessing of Semi-Critical Equipment (2014, 3.A.4, p.20) Formatted: Font: (Default) Arial "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

119 Surgical Services Policy Number: SS 4009 Date Created: Not Set Document Owner: Tina Lockwood (Administrative Date Approved: Not Set Assistant) Approvers: Board of Directors (Administration), Dept of Surgery, Benton Duckett (Director of Surgical Services) Traffic Control: Visitors/Observers in Surgical Services Subject: Visitors/Observers/Non-Students in the Surgical and other Clinical Settings Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: Policy: To ensure that all patients will have the benefit of complete confidentiality and strict adherence to infection control practices. All staff will be responsible for managing visitors in the Surgical Services or other clinical settings. Only personnel and visitors in proper surgical attire will be allowed into semi-restricted and restricted areas of Surgical Services. Procedure: I. All Vvisitors/Observers/Non-Students: A. Must be attired according to Surgical Apparel policy #4000. B. Must have on proper identification. C. Must be cleared to enter the procedural areas by the Surgical Services Director, Assistant Director, Nurse Manager or designee to other clinical areas. ED. Patient consent for observer presence is contained in paragraph 3 of the Consent to Surgery. II. III. Privileges to observe may be revoked at any time that the proceduralist and/or anesthesiologist feel that it is not in the patient s best interest to have the observer present. The following defined categories of individuals will be allowed to visit/observe in Surgical Services:

120 Traffic Control: Visitors/Observers in Surgical Services 2 A. Physicians Observers: 1. Courtesy observation may be extended to physicians at the request of a member of the KDHCD medical staff and is processed through the Medical Staff Office. 2. A physician observer may not assist or in any way participate in the care of the patient in the operating room. Formatted: Indent: Left: 1", Hanging: 0.25", Tab stops: 1.25", Left Formatted: Indent: Left: 1", Hanging: 0.5" Formatted: Indent: Left: 1", Hanging: 0.25" 3. If assistance with a procedure is anticipated, the physician must be cleared for temporary privileges through the Medical Staff Office.. The patient must give consent for the physician to assist during the procedure. B. Allied Health Providers 1. Private scrub personnel/first assistants employed by physicians on staff and contracted care providers will be cleared through Human Resources where all current documentation will be collected and maintained. C. Employees 1. KDHCD employees in orientation (sterile processing, central supply, x-ray, etc.), or working in areas that provide care for surgical patients may be allowed to observe in the OR at the approval and coordination of the Director, Assistant Director, Nurse Manager, or Clinical Educator, or designee. Formatted: Indent: Hanging: 0.25", Outline numbered + Level: 2 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Indent at: 1", Tab stops: 1.25", Left Formatted: Indent: Left: 1", Hanging: 0.25", Tab stops: 1.25", Left + 1.5", Left D. Students Although KDHCD is a participant in the clinical education of many students, Kaweah Delta does not participate or permit any observerships * for student or visiting learners All students and visiting learners at Kaweah Delta must be cleared by the Office odf Graduate Medical Education Once cleared by the office of the GME, all students and visiting learners must be under the direct supervision of a medical staff member/kdhcd staff member and must have a minimal orientation to dress, confidentiality, and infection control standards Must be currently enrolled in a medical school that is approved by the State of California. Formatted: Outline numbered + Level: 3 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 1" + Tab after: 1.5" + Indent at: 1.5" Formatted: Outline numbered + Level: 3 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 1" + Tab after: 1.5" + Indent at: 1.5" Formatted: Outline numbered + Level: 3 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 1" + Tab after: 1.5" + Indent at: 1.5" Formatted: Outline numbered + Level: 3 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 1" + Tab after: 1.5" + Indent at: 1.5"

121 Traffic Control: Visitors/Observers in Surgical Services Students should be introduced to the patients. *Observerships are periods of time of one or more days in which an individual attends patient care team rounds or observes communication with patients, physical examinations, and/or procedures in the clinical setting. Formatted: Outline numbered + Level: 3 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 1" + Tab after: 1.5" + Indent at: 1.5" Formatted: Indent: Left: 0.5" 1. KDHCD is a participant in the clinical education of many students, this includes Medical Students. If the observing student attends a program with which the District is affiliated, consent is obtained from the patient in the Conditions of Admission. Affiliated students may participate in the patient s care as is defined by the relationship between the school and KDHCD. 2. All students must be under the direct supervision of a staff member and must have a minimal orientation to dress, confidentiality, and infection control standards. Nursing, CNA s, and all other Non-Medical Students: The scheduling of students and orientation of the students will be coordinated by the Surgical Services Clinical Educator. 3. Medical Students: The on-boarding process of the medical students will be organized by the ACGME staff. The HR department will be involved in this process The scheduling of the medical student in surgery will also be handled by the ACGME staff. Once the medical student arrives in the surgery arena, they will be given an orientation coordinated by the Surgical Services Clinical Educator. Formatted: Font: Bold, Strikethrough Formatted: Strikethrough Formatted: Font: Bold, Strikethrough 46. Both Medical and non-medical Students should be introduced to the patient as needed. E. Medical Sales Representatives The physician/office scheduler must notify the Scheduling Clerk, Clinical Materials Manager, Charge Nurse, Director or Nurse Manager of the date, time, and procedure for which the representative is requested. 1. All medical sales representatives will check in and out with the reception desk in Human Resources Department, where appropriate paperwork will be completed and an authorized visitor badge will be provided.

122 Traffic Control: Visitors/Observers in Surgical Services 4 2. Once cleared from Human Resources the Representative will report to, Charge Nurse or designee who will escort the representative to the appropriate operating room. 3. The medical sales representative (Rep) may act only as a resource for the specific product being presented and may not scrub or in any way participate in the care of the patient including opening supplies/implants to the sterile field. 4. Rep must obtain visitors identification pass from the Human Resources and check in with the Charge Nurse or designee prior to entering the operating room. 5. Reps may review the surgical schedule only with the direct assistance of the Charge Nurse or designee to determine need for additional product. When reviewing schedule, the Charge Nurse or designee must ensure compliance of patient confidentiality. 6. Reps may not have access to any supply areas except those containing their own consigned inventory. The Charge Nurse, designee or Service Team Specialist will assist in the review of all consigned inventory. Formatted: Indent: Left: 0.56", Hanging: 0.44", Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 6 + Alignment: Left + Aligned at: 0.5" + Indent at: 0.75"

123 Traffic Control: Visitors/Observers in Surgical Services 5 E.F. Family members Hospital and/or Medical Staff Family members, or friends of patients will not be allowed to observe in the operating room, with the following exceptions: 1. The father/support person for mothers scheduled for cesarean section 2. Specific cases involving children or mentally handicapped patients at the discretion of the anesthesiologist or proceduralist. a. Verbal consent for the parent to accompany the child into the procedure room will be obtained from the proceduralist and/or the anesthesiologist. The circulating nurse will be notified of this visit as soon as possible. b. The parent will be properly attired in a disposable jump suit, hat, shoe covers and mask. c. The parent and child will be escorted to the procedure room by the surgical personnel or Special Services personnel and the circulating nurse. d. Following the initial anesthetic induction of the patient, the parent will be escorted out of the procedure room by Special Services personnel or by the surgical personnel. e. The parent may be asked to leave the procedure room at any time the anesthesiologist or proceduralist feels the patient's safety may be compromised.

124 Traffic Control: Visitors/Observers in Surgical Services 6 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

125 RESOLUTION 1983 WHEREAS, Chris Robertson, Clinical Informatics Supervisor, is retiring from duty at Kaweah Delta Health Care District after 36 years of service; and, WHEREAS, the Board of Directors of the Kaweah Delta Health Care District is aware of her loyal service and devotion to duty; NOW, THEREFORE, BE IT RESOLVED that the Board of Directors of the Kaweah Delta Health Care District, on behalf of themselves, the Hospital Staff and the community they represent, hereby extend their appreciation to Chris Robertson for 36 years of faithful service and, in recognition thereof, have caused this resolution to be spread upon the minutes of this meeting. PASSED AND APPROVED this 22 day of January 2018 by a unanimous vote of those present. ATTEST: President, Kaweah Delta Health Care District Secretary/Treasurer, Kaweah Delta Health Care District and of the Board of Directors, thereof

126 MINUTES OF THE OPEN MEETING OF THE KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS HELD WEDNESDAY, DECEMBER 20, :45PM, IN THE ACEQUIA WING CONFERENCE ROOM AT THE KAWEAH DELTA MEDICAL CENTER, CARL ANDERSON PRESIDING PRESENT: Directors Anderson, Havard Mirviss, Hipskind, Hawkins & House; G. Herbst, Chief Executive Officer; T. Rayner, SPV & COO; M. Tupper, Interim VP & CFO; H. Lively, MD, Chief of Staff; E. Hirsch, VP & CMO/CQO; D. Cox, VP of Human Resources; D. Cochran, VP of Development; D. Leeper, VP & CIO; D. Lynch, Legal Counsel; C. Moccio, Board Clerk The meeting was called to order at 5:45PM by Director Anderson. Director Anderson asked for approval of the agenda. MMSC (House/Havard Mirviss) to approve the agenda. This was supported unanimously by those present. Vote: Yes Anderson, Havard Mirviss, Hawkins, House & Hipskind Public participation none Director Anderson called for the approval of the closed agenda. 1. Approval of Closed Agenda as follows: Closed Meeting Agenda Kaweah Delta Medical Center Blue Room 5:46PM 1.1. Credentialing - Medical Executive Committee (December 2017) requests that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval pursuant to Health and Safety Code 1461 and Harry Lively, MD, Chief of Staff 1.2. Conference with Legal Counsel Anticipated Litigation Significant exposure to litigation pursuant to Government Code (d)(2) 1 Case - Dennis Lynch, Legal Counsel 1.3. Approval of closed meeting minutes {11/29/17} MMSC (Havard Mirviss/House) to approve the closed agenda. This was supported unanimously by those present. Vote: Yes Anderson, Havard Mirviss, Hawkins, House & Hipskind Adjourn - Meeting was adjourned at 5:46PM Carl Anderson, President Kaweah Delta Health Care District and the Board of Directors Thereof ATTEST: Lynn Havard Mirviss, Secretary/Treasurer Kaweah Delta Health Care District Board of Directors

127 MINUTES OF THE OPEN MEETING OF THE KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS HELD WEDNESDAY, DECEMBER 20, :00PM, IN THE ACEQUIA WING CONFERENCE ROOM AT THE KAWEAH DELTA MEDICAL CENTER, CARL ANDERSON PRESIDING PRESENT: Directors Anderson, Havard Mirviss, Hipskind, Hawkins & House; G. Herbst, Chief Executive Officer; T. Rayner, SPV & COO; M. Tupper, Interim VP & CFO; H. Lively, MD, Chief of Staff; D. Cox, VP of Human Resources; D. Cochran, VP of Development; D. Leeper, VP & CIO; D. Lynch, Legal Counsel; C. Moccio, Board Clerk The meeting was called to order at 6:00pm by Director Anderson. Director Anderson asked for approval of the agenda. MMSC (House/Havard Mirviss) to approve the agenda. This was supported unanimously by those present. Vote: Yes Anderson, Havard Mirviss, Hawkins, House & Hipskind Public/Medical Staff participation No comments. Closed Session Action Taken: Approval of the closed meeting minutes 11/29/17. Recognitions Director John Hipskind, M.D. Presentation of Resolution 1978 to Monica Contreras, LVN, Sub Acute, for the Service Excellence Award November Presentation of Resolution 1974 to Yvette San Souci, RN, CVICU, for the Service Excellence Award December Presentation of Resolution 1975 to Liz Pannell, Executive Assistant, retiring from duty from Kaweah Delta after twenty-five (25) years of service. Consent Calendar Director Anderson requested the approval of the consent calendar (copy attached to the original of these minutes and considered a part thereof). MMSC (Havard Mirviss/House) to approve the consent calendar as presented. This was supported unanimously by those present. Vote: Yes Anderson, Havard Mirviss, Hawkins, House & Hipskind. Quality Report - Diabetes Quality Focus Team; Review of Key Quality of Care Indicators and Actions for the Diabetes Population (copy attached to the original of these minutes and considered a part thereof) Rose Newsom, RN, Director of Nursing Practice, Ryan Gates, Director of Population Health Management Quality Report - Patient Experience; Review of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Performance and Actions (copy attached to the original of these minutes and considered a part thereof) - Edward Largoza, Director of Patient Experience Strategic Plan Element Report - Excellent Service Thomas Rayner, SVP & Chief Operating Officer, Regina Sawyer, RN, Vice President & Chief Nursing Officer, and Ed Largoza, Director of Patient Experience

128 Strategic Plan Element Reports Mr. Herbst noted that the Strategic Plan is a living breathing document and at every Board meeting there will be a verbal report on the status of an initiative of the Strategic Plan. Strategic Plan Element Report -Outstanding Health Outcomes - Edward Hirsch, M.D., Vice President & Chief Medical/Quality Officer Improve Clinical Quality and Patient Safety, Public Reports Reflect Continual Improvement, and Develop a Collaborative Culture Committed to Rapid Cycle Improvement o The reorganization of ProStaff and Quality Council seems to be working well focusing each group to specific but different tasks relating to quality. o There are 22 CUSP teams that identify issues and fix them, grassroots organization run by front line staff. o Peer review process is improving and getting better. The Cleveland Clinic affiliation relative to CABG is doing well, however, there are other areas that still need improvement and we are working on these areas. o The treatment of Diabetes is a challenge due to the population that we are serving. o Stroke has improved and we are going to be submitting our Joint Commission certification application - we will do this after the Cerner launch and will likely be stroke certified. o The Chronic Disease Center is doing well and stop the line is working well - we are creating a good culture. o Palliative care is an opportunity and a challenge; we need two full time palliative care physicians to care for our population. o Computerized Order Entry is working we are very near 100% participation - relative to public reporting we do well. o Development of collaborative culture quality risk committees, there is a group from risk and quality that review cases and determine how they should be handled. We have only had one RCA this year, focused reviews are being done when appropriate and RCA s are being done when appropriate. Quality and Safety with Risk are working well together and we have had a lot of improvement. Review of KD*Hub projects and capital spending Review of capital spending relative to the KD*Hub project (copy attached to the original of these minutes and considered a part thereof) Gary Herbst, Chief Executive Officer & Douglas Leeper, Vice President & Chief Information Officer MMSC (Hipskind/House) Approve proposed increase to KD*Hub project budget to reflect expanded scope and revised go-live date of May 1, 2018 as well as proposed plan of funding to use unspent capital funds from prior years, additional proceeds of the 2015B Board of Directors Meeting - Open 12/20/17 Page 2 of 5

129 Revenue Bond and cash reserves. This was supported unanimously by those present. Vote: Yes Anderson, Havard Mirviss, Hawkins, House & Hipskind. Credentialing Harry Lively, MD Chief of Staff - Medical Executive Committee request that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval. Director Anderson requested a motion for the approval of the credentials report excluding the Emergency Medicine providers a highlighted on Exhibit A {copy attached to the original of these minutes and considered a part thereof}. MMSC (Hipskind/House) Whereas a thorough review of all required information and supporting documentation necessary for the consideration of initial applications, reappointments, request for additional privileges, advance from provisional status and release from proctoring and resignations (pursuant to the Medical Staff bylaws) has been completed by the Directors of the clinical services, the Credentials Committee, and the Executive Committee of the Medical Staff, for all of the medical staff scheduled for reappointment, Whereas the basis for the recommendations now before the Board of Trustees regarding initial applications, reappointments, request for additional privileges, advance from provision al status and release from proctoring and resignations has been predicated upon the required reviews, including all supporting documentation, Be it therefore resolved that the following medical staff, excluding Emergency Medicine Providers as highlighted on Exhibit A (copy attached to the original of these minutes and considered a part thereof), be approved or reappointed (as applicable), to the organized medical staff of Kaweah Delta Health Care District for a two year period unless otherwise specified, with physician-specific privileges granted as recommended by the Chief of Service, the Credentials Committee, and the Executive Committee of the Medical Staff and as will be documented on each medical staff member s letter of initial application approval and reappointment from the Board of Trustees and within their individual credentials files. Vote: Director Anderson, Havard Mirviss, House, Hawkins & Hipskind Yes. Director John Hipskind, MD left the room for the vote on the credentials, for the Emergency Medicine providers as highlighted on Exhibit A {copy attached to the original of these minutes and considered a part thereof}. MMSC (Havard Mirviss/House) Whereas a thorough review of all required information and supporting documentation necessary for the consideration of initial applications, reappointments, request for additional privileges, advance from provisional status and release from proctoring and resignations (pursuant to the Medical Staff bylaws) has been completed by the Directors of the clinical services, the Credentials Committee, and the Executive Committee of the Medical Staff, for all of the Emergency Medicine providers scheduled for reappointment. Whereas the basis for the recommendations now before the Board of Trustees regarding initial applications, reappointments, request for additional privileges, advance from provision al status and release from Board of Directors Meeting - Open 12/20/17 Page 3 of 5

130 proctoring and resignations has been predicated upon the required reviews, including all supporting documentation, Be it therefore resolved that the following medical staff Emergency Medicine providers be approved or reappointed (as applicable), to the organized medical staff of Kaweah Delta Health Care District for a two year period unless otherwise specified, with physician-specific privileges granted as recommended by the Chief of Service, the Credentials Committee, and the Executive Committee of the Medical Staff and as will be documented on each medical staff member s letter of initial application approval and reappointment from the Board of Trustees and within their individual credentials files. Vote: Director Anderson, Havard Mirviss, House & Hawkins Yes. Director Hipskind Absent Election of Officers - Kaweah Delta Health Care District The offices of President, and Secretary/Treasurer shall be selected at the first regular meeting in December of a nonelection year of the District. To hold the office of President, a Board member must have at least one year of service on the Board of Directors. These officers shall hold office for a period of two (2) years or until the successors have been duly elected (or in the case of an unfulfilled term, appointed) and qualified. The officer positions shall be by election of the Board itself Dennis Lynch, Legal Counsel Mr. Lynch described the process of the biannual election of officers. Mr. Lynch opened the floor for nominations for the office of President of the Board. o Director Anderson nominated Lynn Havard Mirviss as President o Director Hipskind nominated Nevin House as Secretary/Treasurer Following an affirmative vote on the nominations with no other nominations made Mr. Lynch confirmed that Lynn Havard Mirviss is the new President and Nevin House is the new Secretary/Treasurer. CHIEF OF STAFF REPORT Report from Harry Lively, MD, Chief of Staff: No Report. CHIEF EXECUTIVE OFFICER REPORT Report from Gary Herbst, Chief Executive Officer: Community Advisory Committees first meeting o The orientation process has been completed and the first meeting for each group has been held. Census saturation o Discussion relative the very high census we are experiencing, we are using travelers for staffing where necessary and are using the Blue Room for patient care. Open Houses; o Kaweah Delta Ambulatory Surgery Center {Thursday January 11th 5:00pm} o Neurosurgery Center {moved to March 5 th } Board of Directors Meeting - Open 12/20/17 Page 4 of 5

131 Kaweah Delta: Today and Tomorrow CEO staff presentation and Q&A for the staff will begin in early February. Sequoia Prompt Care relocating to Visalia Medical Clinic QuickCare Kaweah Delta and the Visalia Medical Clinic (Kaweah Delta Medical Foundation) have several joint efforts. We both operate walk-in urgent care centers in a very near vicinity to each other. In order to avoid duplication of services we have agreed to consolidate them and rebrand this service as Sequoia Quick Care and we will lease the current space of the Sequoia Prompt Care in the Sequoia Medical Center (SMC) to the vascular surgeons who currently lease space in the SMC. BOARD PRESIDENT REPORT Report from Mr. Carl Anderson, Board President Director Anderson reminded the Board members that the AB1234 Ethic Training needs to be completed by the end of the year. Director Anderson noted that he will be leaving the Board before the end of his term, however he has not determined yet when this will happen. Adjourn - Meeting was adjourned at 7:57PM Carl Anderson, Board President Kaweah Delta Health Care District and the Board of Directors Thereof ATTEST: Lynn Havard Mirviss, Secretary/Treasurer Kaweah Delta Health Care District Board of Directors Board of Directors Meeting - Open 12/20/17 Page 5 of 5

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133 Unique Plan Description: AMB OB Antepartum Management Plan Selection Display: AMB OB Antepartum Management PlanType: Medical Version: 1 Begin Effective Date: 12/9/ :33 End Effective Date: Current Available at all facilities OB Management Ambulatory - Initial Visit Laboratory Urinalysis Dipstick POC PPD Administration (TB Screen) POC HBSAG Blood, Routine, T;N Alpha-feto Protein Blood, Routine, T;N Hgb and Hct. Blood, Routine, T;N Chlamydia/Gonorrhea DNA Probe -Tulare Co HD Urine, Routine, T;N Cystic Fibrosis (CFTR) 32 Mutations-ARUP Blood, Routine, T;N Glucose Tolerance Test (Ambulatory) Blood, Routine, T;N Miscellaneous Lab Order Routine collect, T;N Blood Bank Type and Screen Only Routine, T;N ABO/Rh Blood, Routine Antibody Screen Blood, Routine Chemistry Thyroid Stimulating Hormone Blood, Routine Hematology CBC with Differential Blood, Routine Microbiology Urine Culture Urine, Clean Catch GC Culture Swab, Vagina, Routine collect, RT - Routine, Nurse collect Saline Wet Mount Swab, Vagina Screening Tests RPR Blood, Routine, T;N VDRL with Reflex to Titer CSF-ARUP Cerebrospinal Fluid, Routine, T;N OB Quad Screening Test Antepartum(SUB)* Serology

134 Rapid Plasma Reagin Blood, Routine Hepatitis B Surface Antigen Blood, Routine HIV Ag/Ab Combo 1/2 Screen-Routine Blood, Routine Urine Studies HCG Qualitative Urine Urine, Routine Collect HCG Qualitative POC Diagnostic Tests US OB Less Thn 14 wks w/tvs if indicated Routine, Reason: Anomalies (DEF)* Routine, Reason: Bleeding Routine, Reason: Cervical Length Routine, Reason: Dating Routine, Reason: Multiple Gestation Routine, Reason: Nuchal Translucency, Pregnant Routine, Reason: Rule Out Ectopic pregnancy Routine, Reason: Viability US OB Greater Than 14 Weeks Routine, Reason: Amniotic Fluid Index (DEF)* Routine, Reason: Anatomy Routine, Reason: Anomalies Routine, Reason: Bleeding Routine, Reason: Cervical Length Routine, Reason: Dating Routine, Reason: Growth Routine, Reason: Multiple Gestation Routine, Reason: Placental Location Routine, Reason: Viability US OB Transvaginal Routine, Reason: Adnexal Masses (DEF)* Routine, Reason: Cervical Length Routine, Reason: Dating Routine, Reason: Rule Out Ectopic pregnancy Routine, Reason: Placental Location Routine, Reason: Viability US OB Limited Routine, Reason: Bleeding (DEF)* Routine, Reason: Cervical Length Routine, Reason: Fetal Position Routine, Reason: Placental Location Routine, Reason: Qualitative Amniotic Fluid Routine, Reason: Viability Chest X-ray should be taken if previous positive PPD skin test(note)* XR Chest 2 Views Amniocentesis for genetic analysis is normally performed between weeks of gestation(note)* Chorionic Villus Sample is normally performed between weeks of gestation(note)* Non Categorized OB Antepartum Initial Pregnancy OB Management Ambulatory - Up to 24 wks Laboratory

135 Urinalysis Dipstick POC Hgb and Hct. Blood Bank Antibody Screen Blood, Routine Hematology CBC with Differential Blood, Routine Screening Tests Collect Quad Screen between weeks of gestation(note)* OB Quad Screening Test Antepartum(SUB)* Diagnostic Tests US OB Less Thn 14 wks w/tvs if indicated Routine, Reason: Anatomy (DEF)* Routine, Reason: Anomalies Routine, Reason: Bleeding Routine, Reason: Cervical length Routine, Reason: Dating Routine, Reason: Growth Routine, Reason: Multiple gestation Routine, Reason: Nuchal translucency Routine, Reason: Placental location Routine, Reason: Rule Out Ectopic pregnancy Routine, Reason: Viability US OB Greater Than 14 Weeks Routine, Reason: Amniotic Fluid Index (DEF)* Routine, Reason: Anatomy Routine, Reason: Anomalies Routine, Reason: Bleeding Routine, Reason: Cervical length Routine, Reason: Dating Routine, Reason: Growth Routine, Reason: Multiple gestation Routine, Reason: Placental location Routine, Reason: Viability US OB Transvaginal Routine, Reason: Adnexal mass (DEF)* Routine, Reason: Cervical length Routine, Reason: Dating Routine, Reason: Placental location Routine, Reason: Rule Out Ectopic pregnancy Routine, Reason: Viability US OB Limited Routine, Reason: Bleeding (DEF)* Routine, Reason: Cervical length Routine, Reason: Fetal position Routine, Reason: Placental location Routine, Reason: Qualitative amniotic fluid Routine, Reason: Viability US OB Follow Up Routine Amniocentesis for genetic analysis is normally performed between weeks of gestation(note)* CVS is normally performed between weeks of gestation(note)* Fetal echo is generally performed between weeks of gestation(note)* Non Categorized OB Antepartum Up to 24 Weeks

136 Pregnancy OB Management Ambulatory wks Medications If father of baby is known to be Rh D Negative, antenatal prophylaxis is unnecessary. Prophylaxis should be administered if there is any doubt about the baby's paternity or blood type of the father.(note)* RhoGAM 300 mcg IM inj 300 mcg, IM, Injection, Once Comments: Administer at 28 weeks if patient RHo (D) negative Laboratory Fetal Fibronectin Vaginal, Routine Collect Urinalysis Dipstick POC Rapid Plasma Reagin Blood, Routine, T;N Hgb and Hct. Blood, Routine, T;N Glucose Tolerance Test (Ambulatory) Blood, Routine, T;N Blood Bank ABO/Rh Blood, Routine Antibody Screen Blood, Routine Hematology CBC with Differential Blood, Routine Serology HIV Ag/Ab Combo 1/2 Screen-Routine Blood, Routine Diagnostic Tests US OB Follow Up Routine US OB Limited Routine, Reason: Bleeding (DEF)* Routine, Reason: Cervical length Routine, Reason: Fetal position Routine, Reason: Placental location Routine, Reason: Qualitative amniotic fluid Routine, Reason: Viability US OB Greater Than 14 Weeks Routine, Reason: Amniotic Fluid Index Non Categorized OB Antepartum Weeks Pregnancy OB Management Ambulatory wks Medications Boostrix (Tdap) 0.5 ml, IM, Susp-Inj, As Directed for 1 doses Laboratory Fetal Fibronectin Vaginal, Routine Collect Fetal Lung Maturity Tests Urinalysis Dipstick POC Hgb and Hct.

137 Hematology CBC with Differential Blood, Routine Microbiology Collect Group B strep swabs at weeks gestation(note)* GBS GC Culture Swab Serology HIV Ag/Ab Combo 1/2 Screen-Routine Blood, Routine Diagnostic Tests US OB Follow Up Routine US OB Limited Routine, Reason: Bleeding (DEF)* Routine, Reason: Cervical length Routine, Reason: Fetal position Routine, Reason: Placental location Routine, Reason: Qualitative amniotic fluid Routine, Reason: Viability US OB Greater Than 14 Weeks Routine, Reason: Amniotic Fluid Index Non Categorized OB Antepartum Weeks Pregnancy Initial Approval Date Annual Review Date OB Management Ambulatory wks Laboratory Fetal Lung Maturity Tests Urinalysis Dipstick POC Diagnostic Tests US OB Greater Than 14 Weeks Routine, Reason: Amniotic Fluid Index, Pregnant Non Categorized OB Antepartum 37 Weeks - Post Dates Pregnancy *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

138 Unique Plan Description: ANES OB Patient Controlled Epidural Analgesia (PCEA) Plan Selection Display: ANES OB Patient Controlled Epidural Analgesia (PCEA) PlanType: Medical Version: 1 Begin Effective Date: 7/10/ :11 End Effective Date: Current Available at all facilities ANES OB Patient Controlled Epidural Analgesia (PCEA) Patient Care Criteria: Patients and patient representatives (i.e. family, friends, etc) must be mentally alert and capable of understanding and complying with PCEA instructions(note)* Nursing Communication Order The PCEA orders supersede all other orders for vital signs, activity, and treatment for respiratory depression, pain, nausea, and pruritis until they expire, which will be upon delivery of the infant unless otherwise indicated by the Anesthesia Provider Monitoring Nursing Communication Order Obtain and document baseline blood pressure, heart rate, pain level, oxygen saturation, and respiratory rate/quality prior to epidural initiation. Nursing Communication Order After epidural initiation, rate change, or bolus dose: Assess/document blood pressure, heart rate, pain level, oxygen saturation, and respiratory rate/quality every 5 minutes x4, every 1 hr x12, every 2 hrs x6, then every 4 hrs until epidural discontinued RASS Obtain and document RASS prior to epidural initiation. Following epidural initiation: Assess and document RASS every 1 hour x12, every 2 hours x6, then every 4 hours until epidural discontinued. Assess Dermatome Level Every 1 hour and notify Anesthesia Practitioner if sensory level higher than T6 Epidural Catheter Management Epidural Catheter Management Label epidural specific pump and special epidural tubing: "FOR EPIDURAL USE ONLY" Epidural Catheter Discontinue RN with epidural removal competencies to stop epidural infusion and remove catheter after delivery Continuous Infusions Lactated Ringers Bolus 500 ml, IV Bolus, Soln-IV, Once Comments: Infuse immediately prior to and during epidural placement Medications Epidural Medications fentanyl/ropivicaine 2 mcg/ml 0.125% - PCEA EPIDURAL Bolus/PCEA Dose (ml): 5, Lockout Interval (min): 15, 1-hour Dose Limit (ml): 30, Continuous Dose (ml/hr): 10, Total Volume (ml): 50, Epidural Comments: This order supersedes all other physician orders for pain fentanyl/ropivicaine 2 mcg/ml 0.125% - INTRATHECAL 50 ml, Intrathecal, 2 ml/hr Comments: Hourly Limit (Continuous) 4 ml/hrthis order supersedes all other physician orders for pain Prior to selecting Ropivicaine WITHOUT Fentanyl epidural, contact the Pharmacist to inform them of the clinical need. This custom order requires preparation and dispensing from the main Pharmacy.(NOTE)* ropivacaine 0.2% PCEA 60 ml syringe (IVS)* Syringe - PCEA* Bolus/PCEA Dose (ml): 5, Lockout Interval (min): 15, 1-hour Dose Limit (ml): 30, Continuous Dose (ml/hr): 10, Total Volume (ml): 60, Epidural Comments: This order supersedes all other physician orders for pain ropivacaine 0.2% additive

139 120 mg, EB HYPOtension ephedrine 50 mg/ml injectable 10 mg, IV Push, Injection, every 5 min for 3 doses, PRN other (see comment) Comments: For Systolic Blood Pressure LESS than 100 mmhg or 20% LESS than baseline administer UNTIL Systolic Blood Pressure GREATER than 100 mmhg and call Anesthesia practitioner if used. Lactated Ringers Bolus 250 ml, IV Bolus, Soln-IV, As Directed for 2 doses, PRN other (see comment) Comments: For Systolic Blood Pressure LESS than 100 mmhg or 20% LESS than baseline administer 250 ml bolus. Administer second bolus if ineffective. Miscellaneous Nubain 5 mg, IV Push, Injection, every 4 hours., PRN itching Comments: Automatic substitution with Diphenhydramine (Benadryl) 25 mg IV every 4 hrs PRN itching will take place if Nalbuphine is unavailable) Zofran 4 mg, IV Push, Injection, every 4 hours., PRN nausea/vomiting Narcan 0.2 mg, IV Push, Injection, every 2 min, PRN other (see comment) Comments: Administer if respirator rate is LESS than or EQUAL to 8 breathes per minute, Oxygen saturation LESS 90% and/or RASS -3 or LESS. Stop epidural infusion, call RRT, and notify Anesthesia practitioner. Respiratory Oximetry - Continuous Oxygen Therapy SpO2 goal Other (please specify), Nasal Cannula, Administer supplemental oxygen as needed to maintain oxygen saturation GREATER than 97% Laboring patients are considered to be at high risk for opioid induced over sedation and respiratory depression if they have any of the following comorbidities and should be initiated on End Tidal CO2 monitoring: Sleep Apnea, BMI GREATER than or EQUAL to 40, Asthma, COPD, Diabetes, or Opioid Dependency(NOTE)* End Tidal CO2 Monitoring Notify Anesthesia Practitioner if end tidal CO2 is GREATER than 50mmHg Communication Orders Notify Practitioner If respiratory rate LESS than or EQUAL to 8 per minute or patient complains of shortness of breath STOP the continuous epidural and notify the Anesthesia Provider Notify Practitioner Report the following to the Anesthesia Provider: Patient discomfort, pain level GREATER than 4/10, substantial changes in the level of the block, sensory level HIGHER than T6, RASS -3 or LESS, or respiratory rate LESS than or EQUAL to 8 per minute Notify Practitioner Report the following to the Anesthesia Provider: SpO2 LESS than 90%, cardiac arrhythmia, convulsions, or EtCO2 GREATER than 50mmHg Notify Practitioner Notify Anesthesia Practitioner of delivery time *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note

140 Unique Plan Description: ANES POST-Op Epidural (or INTRAthecal) Anesthesia Plan Selection Display: ANES POST-Op Epidural (or INTRAthecal) Anesthesia PlanType: Medical Version: 1 Begin Effective Date: 7/14/ :30 End Effective Date: Current Available at all facilities ANES POST-Op Epidural (or INTRAthecal) Anesthesia Patient Care Nursing Communication Order These orders supersede all other Practitioner orders for vital signs, activity, IV fluids, and treatment for respiratory depression, pain, nausea, and pruritis until these orders expire Nursing Communication Order Label bed: EPIDURAL ANALGESIC (DEF)* Label bed: INTRATHECAL ANALGESIC Vital Signs Respiratory rate every 30 minutes for 4 hours, then every 1 hour for 20 hours. Blood pressure and pulse every 1 hour x 4, then every 4 hours x 5. Equipment/Supplies To Have At Bedside Keep airway management equipment immediately available for 24 hours (oral-pharyngeal airway, resuscitation bag/mask, O2 set-up, O2 mask) Respiratory Assessment Monitor patient until respirations GREATER than 12 per minute for at least 1 hour using pulse oximeter and apnea monitor Nursing Communication Order Do not give hypnotics, sedatives or narcotics unless ordered by the anesthesiologist Activity HOB Head of Bed Level: 30 degrees or GREATER (DEF)* Head of Bed Level: 30 degrees or GREATER, Elevate head of bed after 3 hours Continuous Infusions IV Continuous Drips Lactated Ringers 1,000 ml, IV, 125 ml/hr, Order Duration: 24 hr (DEF)* 1,000 ml, IV, 125 ml/hr, Order Duration: 12 hr Epidural Cont Infusion fentanyl 2 mcg/ml-ropivacaine 0.125% NS 250 ml epidural 250 ml, Epidural, ml/hr Medications Pain Management Toradol 30 mg, IV Push, Injection, every 6 hours. for 4 doses (DEF)* 15 mg, IV Push, Injection, every 6 hours. for 4 doses morphine 2 mg, IV Push, Injection, every 2 hours. for 24 hr, PRN pain (DEF)* Comments: PRN Pain GREATER than 4 out of 10 (Moderate/Severe) 4 mg, IV Push, Injection, every 2 hours. for 24 hr, PRN pain Comments: PRN Pain GREATER than 4 out of 10 (Moderate/Severe) 6 mg, IV Push, Injection, every 2 hours. for 24 hr, PRN pain Comments: PRN Pain GREATER than 4 out of 10 (Moderate/Severe) Dilaudid 0.5 mg, IV Push, Injection, every 2 hours. for 24 hr, PRN pain, breakthrough (DEF)* 1 mg, IV Push, Injection, every 2 hours. for 24 hr, PRN pain, breakthrough Opioid Reversal

141 Treatment for respiratory depression or difficulty to arouse(note)* Narcan 0.08 mg, IV Push, Injection, every 1 min, PRN respiratory distress Comments: Treatment for respiratory depression or difficulty to arouse. Repeat until Respiratory Rate GREATER than 10 breaths per min. <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>narcan rate: mg/hour</u></font></body></html>(note)* naloxone (Narcan) 1.2 mg/sodium Chloride 0.9% 250 ml* (IVS)* Sodium Chloride 0.9%* 250 ml, IV, Goal: NA naloxone additive* 1.2 mg, mg/hr Nausea/Vomiting Zofran ODT 4 mg, Oral, Tab-Dis, every 8 hours., PRN nausea/vomiting Comments: First Line. May give IV if unable to take oral. Zofran 4 mg, IV Push, Injection, every 8 hours., PRN nausea/vomiting Comments: First Line Narcan 0.08 mg, IV Push, Injection, every 15 min for 5 doses, PRN nausea/vomiting Comments: Second line, give if ondansetron(zofran) fails. Pruritis Benadryl 25 mg, IV Push, Injection, every 4 hours., PRN itching Comments: First line Narcan 0.08 mg, IV Push, Injection, every 15 min for 4 doses, PRN itching Comments: Second line if diphenhydramine (Benadryl) fails Communication Orders Notify Practitioner Contact anesthesiologist on call if respiratory rate LESS than 8 per minute, itching, nausea, uncontrolled pain, or difficulty arousing patient Notify Practitioner Notify anesthesiologist for respiratory depression (respirations LESS than 8 per minute) or if patient is difficult to arouse Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

142 Unique Plan Description: CVS Cardiac Surgery POST-Op Plan Selection Display: CVS Cardiac Surgery POST-Op PlanType: Medical Version: 1 Begin Effective Date: 6/27/ :45 End Effective Date: Current Available at all facilities CVS Cardiac Surgery POST-Op Admit/Transfer/Discharge/Status Admission Status(SUB)* Keep As Same Admission Status Level of Care Transfer Transfer to CVICU Patient Care Hemodynamic Monitoring Per unit standard of care. Do not wedge Pulmonary Artery Catheter. Vital Signs Per unit standard of care I&O Per unit standard of care Weight in Kilograms Daily, By 0600 Turn Cough Deep Breathe every 2 hr, when patient is stable Pacemaker Settings Temporary Transvenous Epicardial Mode: Fully automatic (DDD), Rate: 90, Atrial Output: 10-20, Ventricular Output: 10-25, Isolate pacer wires if not in use Ace Wrap Application for 12 hr, Apply to harvested leg(s) Anti-Embolism Stocking AK SCDs Nursing Communication Order Pacing wires, chest tube site(s), and liquid suture sites to be cleaned with wound cleanser daily. Change chest dressing if saturated. Lines/Tubes/Drains Orogastric/Nasogastric Tube Care Tube to Low Intermittent Suction Pulmonary Arterial Catheter Discontinue When patient is hemodynamically stable Arterial Line Care Change dressing per standardized procedure Arterial Line Discontinue Post extubation when patient is hemodynamically stable Chest Tube Care -20 cm water suction, Drainage system to continuous suction. Milk/strip tubes to maintain patency Urinary Catheter Discontinue Discontinue on postoperative day (POD) 2 Intra-Aortic Balloon Pump Settings 1:1 Activity Head of Bed Head of Bed Level: degrees

143 Dangle at Bedside Post Extubation +1 Days Up to Chair POST-Op Day #1 +1 Days Ambulate POST-Op Day #1 Diet/Nutrition NPO After patient is extubated, start full liquid diet if no nausea/vomiting. Advance to cardiac diabetic diet as tolerated if patient has no nausea/vomiting. 1800mLper 24 hour PO fluid restriction. Aspiration Precautions Continuous Infusions IV Maintenance Sodium Chloride 0.9% 1,000 ml, IV, 75 ml/hr Medications Vasoactive Agents <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>nitroprusside to start at 0.1 mcg/kg/min</font></u></body></html>(note)* nitroprusside (Nipride) 50 mg/dextrose 5% Water 250 ml* (IVS)* Dextrose 5% Water* 250 ml, IV, Titration instructions: 0.5 mcg/kg/min every 5 min, Max Dose: 5 mcg/kg/min, Goal: Keep Systolic Blood Pressure LESS than 140 mmhg and Cardiac Index GREATER than 2.2 Comments: Titration may vary based on patient response or urgency of situation nitroprusside additive* 50 mg <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>nitroglycerin to run at 5 mcg/min</font></u></body></html>(note)* nitroglycerin (mcg/min) 25 mg/dextrose 5% Water 250 ml Premix* (IVS)* Premix Dextrose 5% Water* 250 ml, IV, Goal: n/a nitroglycerin additive* 25 mg, EB, 5 mcg/min nitroglycerin 0.4 mg/hr Patch 1 patches, Transdermal, Film-ER, Daily, First Dose: T+1:N Comments: Initiate 1 hour before Nitroglycerin Drip is discontinued <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>milrinone to start at mcg/kg/min</font></u></body></html>(note)* milrinone (Primacor) 20 mg/dextrose 5% Water 100 ml Premix* (IVS)* Premix Dextrose 5% Water* 100 ml, IV, Titration instructions: mcg/kg/min every 1-15 min., Max Dose: mcg/kg/min, Goal: Keep Cardiac Index GREATER than 2.2 Comments: Titration may vary based on patient response or urgency of situation milrinone additive* 20 mg, EB, mcg/kg/min <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META

144 content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>dobutamine to start at 2.5 mcg/kg/min</font></u></body></html>(note)* DOBUTamine 250 mg/dextrose 5% Water 250 ml Premix* (IVS)* Premix Dextrose 5% Water* 250 ml, IV, Titration instructions: 2 mcg/kg/min every 1-15min, Max Dose: 10 mcg/kg/min, Goal: Systolic Blood Pressure GREATER than 100 mmhg and Cardiac Index GREATER than 2.2 Comments: Titration may vary based on patient response or urgency of situation DOBUTamine additive* 250 mg, EB, 2.5 mcg/kg/min <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>epinephrine to start at 0.01 mcg/kg/min</font></u></body></html>(note)* EPINEPHrine (mcg/kg/min) 4 mg/dextrose 5% Water 250 ml* (IVS)* Dextrose 5% Water* 250 ml, IV, Titration instructions: 0.02 mcg/kg/min every 1-10min, Max Dose: 2 mcg/kg/min, Goal: Keep Systolic Blood Pressure GREATER than 100 mmhg and Cardiac Index GREATER than 2.2 Comments: Titration may vary based on patient response or urgency of situation EPINEPHrine additive* 4 mg <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>dopamine to start at 2 mcg/kg/min</font></u> </BODY></HTML>(NOTE)* DOPAmine 400 mg/dextrose 5% Water 250 ml Premix* (IVS)* Premix Dextrose 5% Water* 250 ml, IV, Titration instructions: 2 mcg/kg/min every 1-10min, Max Dose: 10 mcg/kg/min, Goal: Keep Systolic Blood Pressure GREATER than 100 mmhg and Cardiac Index GREATER than 2.2 Comments: Titration may vary based on patient response or urgency of situation DOPamine additive* 400 mg <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>norepinephrine to start at 0.01 mcg/kg/min</u></font></body></html>(note)* norepinephrine (mcg/kg/min) 4 mg/dextrose 5% Water 250 ml (Levophed)* (IVS)* Dextrose 5% Water* 250 ml, IV, Titration instructions: 0.02 mcg/kg/min every 1-2 min, Max Dose: 2 mcg/kg/min, Goal: Systolic Blood Pressure GREATER than 100 mmhg Comments: Titration may vary based on patient response or urgency of situation norepinephrine additive* 4 mg, EB, 0.01 mcg/kg/min labetalol 10 mg, IV Push, Injection, every 1 hr, PRN other (see comment) Comments: May give 5-10mg for Systolic Blood Pressure GREATER than 140 mmhg with Heart Rate GREATER than 80 beats per minute, and active drip orders ineffective. Do not exceed 300 mg of labetalol within 24 hrs hydralazine 10 mg, IV Push, Injection, every 1 hr, PRN hypertension Comments: May give 5-10mg for Systolic Blood Pressure GREATER than 140 mmhg and

145 active drip orders ineffective Antiarrhythmics <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>amiodarone to start at 1 mg/min</u></font> </BODY></HTML>(NOTE)* AMIODArone (Cordarone) 900 mg/dextrose 5% Water 500 ml* (IVS)* Dextrose 5% Water* 500 ml, IV, Titration instructions: Initial Rate: 1 mg/min (33.3 ml/hr) x6 hrs. Maint. Rate: 0.5 mg/min (16.7 ml/hr) x 48 hrs. Patient must be monitored., Goal: n/a, Order Duration: 48 hr AMIODArone additive* 900 mg, 1 mg/min <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>lidocaine to start at 2 mg/min</u></font></body></html>(note)* lidocaine (mg/min) 2 g/dextrose 5% Water 500 ml Premix* (IVS)* Premix Dextrose 5% Water* 500 ml, IV, Titration instructions: WEAN to OFF overnight if no arrhythmias, Goal: n/a lidocaine 2% additive* 2,000 mg, EB, 2 mg/min Antihypertensives Coreg mg, Oral, Tab, BID (DEF)* Comments: Begin POD #1 Hold for Heart Rate less than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg 6.25 mg, Oral, Tab, BID Comments: Begin POD #1 Hold for Heart Rate less than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg 12.5 mg, Oral, Tab, BID Comments: Begin POD #1 Hold for Heart Rate less than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg Lopressor (tartrate) 12.5 mg, Oral, Tab, BID (DEF)* Comments: Begin POD #1 Hold for Heart Rate LESS than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg 25 mg, Oral, Tab, BID Comments: Begin POD #1 Hold for Heart Rate LESS than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg Glycemic Control GM IV Insulin Infusion (CVS)(SUB)* Antibiotics Antibiotic POST-Op CABG, Other Cardiac(SUB)* Sedation CC Analgesia and Sedation Management(SUB)* Pain Management +1 Days Norco 5 mg-325 mg oral tablet 1 tab, Oral, Tab, every 3 hr, PRN pain, mild (scale 1-3) Comments: Begin POST Extubation +1 Days Norco 5 mg-325 mg oral tablet 2 tab, Oral, Tab, every 3 hr, PRN pain, moderate (scale 4-6) Comments: Begin POST Extubation Respiratory Medications Proventil 2.5 mg/3 ml (0.083%) inhalation solution 2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 6 hours Comments: GIVE IN LINE WHILE ON VENT. Discontinue when extubated.

146 Proventil 2.5 mg/3 ml (0.083%) inhalation solution 2.5 mg, NEB, Device: MetaNeb, Soln-Inhalation, Resp every 4 hours while awake Comments: Begin POST Extubation Proventil 2.5 mg/3 ml (0.083%) inhalation solution 2.5 mg, NEB, Device: MetaNeb, Soln-Inhalation, Resp every 2 hours, PRN other (see comment) Comments: For dyspnea or bronchospasm. Begin POST Extubation Atrovent 0.02% 500 mcg/2.5 ml solution for nebulization 0.5 mg, NEB, Device: MetaNeb, Soln-Inhalation, Resp every 4 hours while awake Comments: Begin POST Extubation Atrovent 0.02% 500 mcg/2.5 ml solution for nebulization 0.5 mg, NEB, Device: MetaNeb, Soln-Inhalation, Resp every 2 hours, PRN other (see comment) Comments: For dyspnea or bronchospasm. Begin POST Extubation Anticoagulation / Antiplatelet Agents +1 Days Ecotrin 81 mg, Oral, Tab-DR, every evening (DEF)* Comments: Begin Post Op Day #1 325 mg, Oral, Tab-DR, every evening Comments: Begin Post Op Day #1 +1 Days Lovenox 40 mg, Subcut, Injection, Daily (DEF)* Comments: Begin Post Op Day #1. Give at 10:00 30 mg, Subcut, Injection, Daily Comments: Begin Post Op Day #1. Give at 10:00 +1 Days heparin 5,000 units/ml injectable 5,000 units, Subcut, Injection, every 12 hours. (DEF)* Comments: Begin Post Op Day #1. Give at 10:00 and 22:00 5,000 units, Subcut, Injection, every 8 hours. Comments: Begin Post Op Day #1 Gastrointestinal Agents Mylanta 200/200/20 oral suspension 30 ml, Oral, Susp, Daily, PRN indigestion Comments: Begin Post Op Day #1 Pepcid 20 mg, IV Push, Injection, BID Constipation Colace 100 mg, Oral, Cap, BID Comments: Begin Post Op Day #1 +2 Days Milk of Magnesia 8% 400 mg/5 ml susp 30 ml, Oral, Susp, Daily, PRN other (see comment) Comments: Begin Post Op Day #2 if constipation unrelieved by docusate (Colace) +2 Days Dulcolax Laxative 10 mg, PR, Supp, Daily, PRN other (see comment) Comments: Begin Post Op Day #2 if magnesium hydroxide (milk of magnesia) ineffective after 12 hours after administration. +2 Days Fleet Enema (Adult) rectal enema 133 ml, PR, Enema, Daily for 1 doses, PRN other (see comment) Comments: Begin Post Op Day #2 if bisacodyl (Dulcolax) ineffective 12 hours after administration. Nausea/Vomiting Zofran ODT 4 mg, Oral, Tab-Dis, every 4 hours., PRN nausea/vomiting Statins +1 Days Lipitor 40 mg, Oral, Tab, every evening

147 Comments: Begin Post Op Day #1 +1 Days Crestor 5 mg, Oral, Tab, every evening Comments: Begin Post Op Day #1 Miscellaneous Tylenol 650 mg, PR, Supp, every 4 hours., PRN fever Comments: Temperature GREATER than 38.6 DegC (101.5 DegF) Laboratory PT with INR Blood, Stat, T;N, Nurse collect Comments: Open Heart Surgery Patient PTT Blood, Stat, T;N, Nurse collect Comments: Open Heart Surgery Patient Fibrinogen Lvl Blood, Stat, T;N, Nurse collect Comments: Open Heart Surgery Patient Rapid Rteg and Rtegh Blood, Stat, T;N, Nurse collect AM Labs CBC with Differential Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 7 days, Nurse collect Renal Panel 1 Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 7 days, Nurse collect PT with INR Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 7 days, Nurse collect Diagnostic Tests XR Chest 1 View Portable Stat, Reason: Line placement Congestion XR Chest 1 View Portable T+1;0600, In AM, Reason: Congestion XR Chest 1 View Portable T+2;0600, In AM, Reason: Congestion XR Chest 1 View Portable T+3;0600, In AM, Reason: Congestion XR Chest 1 View Portable T+4;0600, In AM, Reason: Congestion Card/Vasc/Neuro EKG 12 lead Stat ECG 12 Lead In AM Respiratory Oxygen Therapy SpO2 goal 92% or GREATER, Simple Mask, Post extubation Incentive Spirometry Respiratory Resp every 1 hour, 10 times every hour while awake BiPAP Protocol Post-Extubation Therapies Physical Therapy Evaluation and Treatment Acute POST Extubation

148 Occupational Therapy Evaluation and Treatment Acute POST Extubation Consults/Referrals Consult to Pharmacy - Anemia Management Reason for Consult: Other, please specify, POST Cardiac Surgery Special PROTOCOL ICU/ICCU: STAT Lab and X-Ray for Unstable Patients Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

149 Unique Plan Description: CVS Cardiothoracic Surgery Addendum Orders for Transfer Plan Selection Display: CVS Cardiothoracic Surgery Addendum Orders for Transfer PlanType: Medical Version: 1 Begin Effective Date: 12/27/ :41 End Effective Date: Current Available at all facilities Plan Comment: meds added from Cardiothoracic Surgery Addendum Orders for Transfer 2/21/17 dsm CVS Cardiothoracic Surgery Addendum Orders for Transfer Admit/Transfer/Discharge/Status Level of Care Transfer Transfer to MedSurg, Telemetry Needed Comments: Patient to go to 4T Patient Care Telemetry General POST-Op Cardiac Surgery Vital Signs Per unit standard of care Intake and Output Per unit standard of care Weight in Kilograms Daily Peripheral IV Lock Insert Ensure that saline lock is in place prior to removal of central line Post-Surgical Education/Instruction Dressing Removal As Directed, Discontinue antimicrobial dressing on discharge or by POD 7. Once antimicrobial dressing is removed, clean wounds with wound cleanser BID and keep chest wound open to air. Turn Cough Deep Breathe every 2 hr TED Hose Thigh (Anti-embolitic Stockings) Remove for 1hr q 8 hrs., every 8 hr Lines/Tubes/Drains Orogastric/Nasogastric Tube Care Tube to Low Intermittent Suction Central Line Care Per policy Chest Tube Care T;N, -20 cm water suction, Place to Water Seal with activity, Daily chest tube site dressing change, apply Neosporin ointment; place steristrips at discharge and a new dressing Activity Ambulate TID Diet/Nutrition Cardiac Diet 24 Hour Fluid Permitted 1800 ml, Fluid restriction is for 2 days Cardiac Diet Diabetic, 24 Hour Fluid Permitted 1800 ml, Fluid restriction is for 2 days Medications Diuretics Lasix 40 mg, Oral, Tab, Daily (DEF)* 40 mg, Oral, Tab, BID

150 K-Dur 20 meq, Oral, Tab-ER, BID (DEF)* 20 meq, Oral, Tab-ER, TID K-Dur 20 meq, Oral, Tab-DR, Daily, PRN other (see comment) Comments: For Potassium = mmol/l. Give in addition to any scheduled Potassium Chloride orders. K-Dur 40 meq, Oral, Tab-DR, Daily, PRN other (see comment) Comments: For Potassium LESS than or EQUAL to 3 mmol/l. Give in addition to any scheduled Potassium Chloride orders. Antihypertensives Coreg mg, Oral, Tab, Daily Comments: Hold for Heart Rate LESS than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg Lopressor (tartrate) 12.5 mg, Oral, Tab, BID (DEF)* Comments: Hold for Heart Rate LESS than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg 25 mg, Oral, Tab, BID Comments: Hold for Heart Rate LESS than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg Zestril 2.5 mg, Oral, Tab, Daily Comments: Hold for Systolic Blood Pressure LESS than 100 mmhg Diovan 80 mg, Oral, Tab, Daily Comments: Hold for Systolic Blood Pressure LESS than 100 mmhg Norvasc 5 mg, Oral, Tab, Daily Comments: Hold for Systolic Blood Pressure LESS than 100 mmhg Procardia XL 30 mg, Oral, Tab-ER, Daily Comments: Hold for Systolic Blood Pressure LESS than 100 mmhg Nitro-Dur 0.4 mg/hr Patch 1 patches, Transdermal, Film-ER, Daily Comments: Daily at 0600 Imdur 30 mg, Oral, Tab-ER, Daily (DEF)* Comments: Hold for Systolic Blood Pressure LESS than 100 mmhg 60 mg, Oral, Tab-ER, Daily Comments: Hold for Systolic Blood Pressure LESS than 100 mmhg Antiarrhythmics Cordarone 200 mg, Oral, Tab, BID Statins Lipitor 40 mg, Oral, Tab, QHS Crestor 5 mg, Oral, Tab, QHS Anticoagulants aspirin enteric coated 81 mg, Oral, Tab-DR, QHS (DEF)* 162 mg, Oral, Tab-DR, QHS

151 325 mg, Oral, Tab-DR, QHS Lovenox 40 mg, Subcut, Injection, Daily (DEF)* Comments: Daily at mg, Subcut, Injection, Daily Comments: Daily at 1000 heparin 5,000 units/ml injectable 5,000 units, Subcut, Injection, every 12 hours. (DEF)* Comments: Every 12 hours at 1000 and ,000 units, Subcut, Injection, every 8 hours. Plavix 75 mg, Oral, Tab, every evening Consult to Pharmacy - Warfarin Dose Per Pharmacy Coumadin 0.5 mg, Oral, Tab, every evening for 7 days (DEF)* 1 mg, Oral, Tab, every evening for 7 days 2 mg, Oral, Tab, every evening for 7 days 2.5 mg, Oral, Tab, every evening for 7 days 3 mg, Oral, Tab, every evening for 7 days 4 mg, Oral, Tab, every evening for 7 days 5 mg, Oral, Tab, every evening for 7 days 6 mg, Oral, Tab, every evening for 7 days 7.5 mg, Oral, Tab, every evening for 7 days 10 mg, Oral, Tab, every evening for 7 days GI Prophylaxis Mylanta 200/200/20 oral suspension 30 ml, Oral, Susp, every 6 hours., PRN indigestion Protonix 40 mg, Oral, Tab-DR, Daily Comments: Do not crush or chew Pepcid 20 mg, Oral, Tab, BID Miscellaneous Tylenol 650 mg, Oral, Tab, every 4 hours., PRN other (see comment) Comments: For Headache or Temperature GREATER than 38.6 DegC (101.5 DegF) Zofran ODT 4 mg, Oral, Tab-Dis, every 6 hours., PRN nausea/vomiting Pain Management Motrin 400 mg, Oral, Tab, TID w/ Meals Norco 5 mg-325 mg oral tablet 1 tab, Oral, Tab, every 3 hr, PRN pain, mild (scale 1-3) Norco 10 mg-325 mg oral tablet 2 tab, Oral, Tab, every 3 hr, PRN pain, moderate (scale 4-6) morphine 2 mg, IV Push, Injection, every 4 hours., PRN other (see comment) Comments: For pain, moderate (scale 4-6) and/or chest tube removal morphine 4 mg, IV Push, Injection, every 4 hours., PRN other (see comment) Comments: For pain, severe (scale 7-10) and/or chest tube removal Wound Care Neosporin topical ointment 1 app, Topical, Ointment, Daily

152 Comments: Apply to chest tube dressing Respiratory Medications Proventil 2.5 mg/3 ml (0.083%) inhalation solution 2.5 mg, NEB, Device: MetaNeb, Soln-Inhalation, Resp every 4 hrs while awake Proventil 2.5 mg/3 ml (0.083%) inhalation solution 2.5 mg, NEB, Device: MetaNeb, Soln-Inhalation, Resp every 2 hours, PRN other (see comment) Comments: For dyspnea or bronchospasm Atrovent 0.02% 500 mcg/2.5 ml solution for nebulization 0.5 mg, NEB, Device: MetaNeb, Soln-Inhalation, Resp every 4 hrs while awake Atrovent 0.02% 500 mcg/2.5 ml solution for nebulization 0.5 mg, NEB, Device: MetaNeb, Soln-Inhalation, Resp every 2 hours, PRN other (see comment) Comments: For dyspnea or bronchospasm Glycemic Control GM Subcut Eating (basal/bolus + correction)(sub)* GM Subcut NPO/Continuous Enteral Feeding (basal + correction)(sub)* Constipation Colace 100 mg, Oral, Cap, BID Comments: Hold for Diarrhea Milk of Magnesia 8% 400 mg/5 ml susp 30 ml, Oral, Susp, Daily, PRN other (see comment) Comments: For constipation unrelieved by docusate (Colace) by post op day 2 Dulcolax Laxative 10 mg, PR, Supp, Daily, other (see comment) Comments: For constipation not relieved 12 hours after magnesium hydroxide (Milk of Magnesia) administration on post op day 2 Fleet Enema (Adult) rectal enema 133 ml, PR, Enema, Daily, PRN other (see comment) Comments: For constipation not relieved within 2 hours after Bisacodyl (Dulcolax) administration Laboratory CBC with Differential Blood, Mon/Wed/Fri, for 1 weeks Renal Panel 1 Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 7 days Protime with INR Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 7 days Diagnostic Tests XR Chest 2 Views T+1;0600, In AM, Reason: Congestion Comments: Patient may go to radiology without registered nurse XR Chest 2 Views T+2;0600, In AM, Reason: Congestion Comments: Patient may go to radiology without registered nurse XR Chest 2 Views T+3;0600, In AM, Reason: Congestion Comments: Patient may go to radiology without registered nurse XR Chest 2 Views T+4;0600, In AM, Reason: Congestion Respiratory O2 Therapy Routine, SpO2 goal 92% or GREATER, Nasal Cannula, for 14 days, Titrate O2 down and off Incentive Spirometry Respiratory Resp every 1 hour, 10 times every hour while awake

153 Therapies Physical Therapy Evaluation and Treatment Acute Occupational Therapy Evaluation and Treatment Acute Consults/Referrals Consult to Registered Dietitian Consult to Pharmacy - Anemia Management Reason for Consult: Other, please specify, POST Cardiac Surgery Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

154 Unique Plan Description: CVS Cardiothoracic Surgery PRE-Op Plan Selection Display: CVS Cardiothoracic Surgery PRE-Op PlanType: Medical Version: 1 Begin Effective Date: 6/20/ :46 End Effective Date: Current Available at all facilities Admission Admit/Transfer/Discharge/Status Admission or Observation Status Admit to Inpatient Length of Stay: 8-10 Patient Care Verify Surgical Consent Nursing Communication Order Surgeon: Dr. L. Araim (DEF)* Surgeon: Dr. Caminha Vital Signs Per unit standard of care I&O Per unit standard of care Weight in Kilograms Daily, By 0600 Preprocedure Education Post-Surgical Education/Instruction Respiratory Education/Instruction PRE-Op: Give respiratory instruction on POST-Op BIPAP use and cough and deep breathing, Routine No Blood Pressure (BP) or Veno-Arterial Punctures T;N, Right Upper extremity restriction (DEF)* T;N, Left Upper extremity restriction Intra-Aortic Balloon Pump Settings 1:1, Keep at 1:1 ratio Activity Bedrest (strict) Bathroom Privileges Up ad Lib Activity as Tolerated Diet/Nutrition Cardiac Diet Cardiac, Na: 2 g sodium (DEF)* Cardiac Renal, Na: 2 g sodium Diabetic Regular Diet Medications Antihypertensives Coreg mg, Oral, Tab, BID Comments: Hold for Heart Rate LESS than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg Lopressor (tartrate) 25 mg, Oral, Tab, BID Comments: Hold for Heart Rate LESS than 60 beats per minute or Systolic Blood Pressure

155 LESS than 100 mmhg Zestril 5 mg, Oral, Tab, Daily Comments: Hold for Systolic Blood Pressure LESS than 100 mmhg Lotensin 5 mg, Oral, Tab, Daily Comments: Hold for Systolic Blood Pressure LESS than 100 mmhg Diovan 80 mg, Oral, Tab, Daily Comments: Hold for Systolic Blood Pressure LESS than 100 mmhg Norvasc 5 mg, Oral, Tab, Daily Comments: Hold for Systolic Blood Pressure LESS than 100 mmhg Statins Lipitor 40 mg, Oral, Tab, every evening Crestor 5 mg, Oral, Tab, every evening Antiplatelet Agents Ecotrin 81 mg, Oral, Tab-DR, every evening (DEF)* 325 mg, Oral, Tab-DR, every evening Anticoagulants To address VTE prophylaxis, order chemical and/or mechanical VTE prophylaxis via the subphase(s) below. To document a risk score and/or contraindication to prophylaxis, select the VTE Advisor order below(note)* heparin 5,000 units/ml injectable 5,000 units, Subcut, Injection, BID (DEF)* Comments: Give at 1000 and ,000 units, Subcut, Injection, every 8 hours. Lovenox 40 mg, Subcut, Injection, Daily (DEF)* Comments: Give at Discontinue after AM dose on day prior to cardiac surgery 30 mg, Subcut, Injection, Daily Comments: Give at Discontinue after AM dose on day prior to cardiac surgery 1 mg/kg, Subcut, Injection, every 12 hours. Comments: Discontinue after AM dose on day prior to cardiac surgery MED Heparin Infusion for Acute Coronary Syndrome (ACS)(SUB)* VTE Advisor Constipation Colace 100 mg, Oral, Cap, BID Comments: Hold for Diarrhea Milk of Magnesia 8% 400 mg/5 ml susp 30 ml, Oral, Susp, Daily, PRN other (see comment) Comments: For constipation unrelieved by docusate (Colace) on hospital day #2 Dulcolax Laxative 10 mg, PR, Supp, Daily, other (see comment) Comments: For constipation not relieved 12 hours after magnesium hydroxide (Milk of Magnesia) administration on hospital day #2 Gastrointestinal Agents Protonix 40 mg, Oral, Tab-DR, Daily Mylanta 200/200/20 oral suspension 30 ml, Oral, Susp, Daily, PRN indigestion

156 Miscellaneous Nitrostat 0.4 mg, SL, Tab, every 5 min for 3 doses, PRN chest pain Comments: Call practitioner if no relief after 3 doses Zofran ODT 4 mg, Oral, Tab-Dis, every 6 hours., PRN nausea/vomiting Tylenol 650 mg, Oral, Tab, every 6 hours., PRN other (see comment) Comments: For headache or temperature GREATER than 38.6 DegC (101.5 DegF) Bactroban 2% topical ointment 1 app, Nares - Both, Ointment, BID for 5 days, Indication: Ear, Eye, Nose or Throat infection Comments: Apply 1/4 inch Glycemic Control GM Subcut Eating (basal/bolus + correction)(sub)* GM Subcut NPO/Continuous Enteral Feeding (basal + correction)(sub)* GM IV Insulin Infusion(SUB)* Laboratory CBC with Differential Blood, Routine, T;N Renal Panel 1 Blood, Routine, T;N CMP Blood, Routine, T;N PT with INR Blood, Routine, T;N PTT Blood, Routine, T;N Teg Platelet Mapping Blood, Routine, T;N Thyroid Panel (T4,Free T4 Index, T3 Uptake) Blood, Routine, T;N UA with Microscopic Routine Collect, T;N, Nurse collect (DEF)* Urine, Clean Catch, Routine Collect, T;N Nasal MRSA Screen Nasal, Routine collect, RT - Routine, T;N Urine Culture Urine, Clean Catch, Routine collect, RT - Routine, T;N Troponin-I (cardiac marker) Blood, Routine, T;N Troponin-I (cardiac marker) Blood, Timed Study, every 8 hr, for 3 times ABG Blood, Routine, T;N Lipid Panel (Chol, Trig, HDL, LDL, VLDL) Blood, Routine, T;N Hemoglobin A1c (Glycosylated) Blood, Routine, T;N BNP Blood, Routine, T;N Blood Bank Type and Screen Only

157 Blood Bank Order Routine Diagnostic Tests XR Chest 2 Views Routine, Reason: Other (please specify), Reason: Pre-Open Heart Surgery, PA and Lateral US Saphenous Vein Mapping Routine, Reason: Other (please specify), Reason: Pre-Open Heart Surgery Card/Vasc/Neuro EKG 12 lead Routine, Pre-Op [High Risk Operation], Once CV Echocardiogram w/doppler Routine CV Carotid Ultrasound - Duplex Scan Routine Respiratory Incentive Spirometry Respiratory Routine, Resp every 1 hour, Thoracic Surgery, Perform 10 times every hour while awake Pulmonary Function Test Complete Routine, Reason: Other (please specify), Cardiac Surgery Therapies Physical Therapy Evaluation and Treatment Acute Routine, Once Occupational Therapy Evaluation and Treatment Acute Routine Communication Orders Nursing Communication Order Place Pre-OHS Checklist on front of chart: allergies, height & weight, B/P R&L arms and, if no palpable pedal pulses R&L angles, if pt. is an autologous blood donor or Jehovah's Witness. Pt to sign blood transfusion refusal if applicable & core measures Nursing Communication Order Please make sure H&P is on record. Activate Evening Before Surgery Patient Care Preoperative Surgical Prep Instruction Clip body hair from neck to toes (including bilateral arms), bed-line to bed-line, with circumferential clip of legs. Include clipping of bilateral groin area. Nursing Communication Order Make patient NPO at midnight the night before surgery Continuous Infusions Sodium Chloride 0.9% 1,000 ml, IV, 75 ml/hr Comments: Start evening PRIOR to surgery Medications Miscellaneous Peridex 0.12% mucous membrane liquid 15 ml, Mucous Membrane, Soln, BID for 2 times Comments: Start evening PRIOR to surgery and again morning of surgery. Swish in mouth for 15 seconds and spit Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order

158 Unique Plan Description: CVS General Thoracic Surgery POST-Op Admission Plan Selection Display: CVS General Thoracic Surgery POST-Op Admission PlanType: Medical Version: 1 Begin Effective Date: 5/12/ :12 End Effective Date: Current Available at all facilities CVS General Thoracic Surgery POST-Op Admission Admit/Transfer/Discharge/Status Keep As Same Admission Status Level of Care Transfer Transfer to CVICU Patient Care Hemodynamic Monitoring Per unit standard of care Vital Signs Per unit standard of care Intake and Output Per unit standard of care Weight in Kilograms Daily, By 0600 Turn Cough Deep Breathe every 2 hr, when patient is stable Pacemaker Settings Temporary Transvenous Epicardial Mode: Fully automatic (DDD), Rate: 90, Atrial Output: 10-20, Ventricular Output: 10-25, Isolate pacer wires if not in use SCDs To lower extremities TED Hose Nursing Communication Order Chest tube site and liquid suture sites cleaned with wound cleanser daily. Change chest dressing if saturated. Lines/Tubes/Drains Orogastric/Nasogastric Tube Care Tube to Low Intermittent Suction Urinary Catheter Maintain Chest Tube Care -20 cm water suction, Milk/strip tubes to maintain patency. Notify practitioner if chest tube output is LESS than 200 ml/hr Central Line Care Per policy Arterial Line Care Per policy Activity HOB Head of Bed Level: degrees Dangle at Bedside POST extubation OOB To chair, after dangling at bedside Ambulate To ambulate POD 1 (After getting OOB to chair)

159 Diet/Nutrition NPO Post-extubation, advance to full liquid, cardiac, diabetic diet. PO fluid limit 1800mL for 2 days Aspiration Precautions Continuous Infusions IV Maintenance Sodium Chloride 0.9% 1,000 ml, IV, 75 ml/hr sodium chloride 0.9% flush 10 ml, IV Push, Injection, As Directed, PRN other (see comment) Comments: To maintain patency of Arterial, Pulmonary, and Central Lines Medications Vasoactive Agents <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>nitroprusside to start at 0.1 mcg/kg/min</font></u></body></html>(note)* nitroprusside (Nipride) 50 mg/dextrose 5% Water 250 ml* (IVS)* Dextrose 5% Water* 250 ml, IV, Titration instructions: 0.5 mcg/kg/min every 5 min, Max Dose: 5 mcg/kg/min, Goal: Keep Systolic Blood Pressure LESS than 140 mmhg and Cardiac Index GREATER than 2.2 Comments: Titration may vary based on patient response or urgency of situation nitroprusside additive* 50 mg <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>nitroglycerin to run at 5 mcg/min</font></u></body></html>(note)* nitroglycerin (mcg/min) 25 mg/dextrose 5% Water 250 ml Premix* (IVS)* Premix Dextrose 5% Water* 250 ml, IV, Goal: n/a nitroglycerin additive* 25 mg, EB, 5 mcg/min nitroglycerin 0.4 mg/hr Patch 1 patches, Transdermal, Film-ER, Daily, First Dose: T+1:N Comments: Initiate 1 hour before Nitroglycerin Drip is discontinued <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>dobutamine to start at 2 mcg/kg/min</font></u></body></html>(note)* DOBUTamine 250 mg/dextrose 5% Water 250 ml Premix* (IVS)* Premix Dextrose 5% Water* 250 ml, IV, Titration instructions: 2 mcg/kg/min every 1-15min, Max Dose: 10 mcg/kg/min, Goal: Systolic Blood Pressure GREATER than 100 mmhg and Cardiac Index GREATER than 2.2 Comments: Titration may vary based on patient response or urgency of situation DOBUTamine additive* 250 mg, EB, 2.5 mcg/kg/min <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>epinephrine to start at 0.01

160 mcg/kg/min</font></u></body></html>(note)* EPINEPHrine (mcg/kg/min) 4 mg/dextrose 5% Water 250 ml* (IVS)* Dextrose 5% Water* 250 ml, IV, Titration instructions: 0.02 mcg/kg/min every 1-10min, Max Dose: 2 mcg/kg/min, Goal: Keep Systolic Blood Pressure GREATER than 100 mmhg and Cardiac Index GREATER than 2.2 Comments: Titration may vary based on patient response or urgency of situation EPINEPHrine additive* 4 mg <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>dopamine to start at 2 mcg/kg/min</font></u> </BODY></HTML>(NOTE)* DOPAmine 400 mg/sodium Chloride 0.9% 250 ml* (IVS)* Sodium Chloride 0.9%* 250 ml, IV, Titration instructions: 2 mcg/kg/min every 1-10 mins, Max Dose: 10 mcg/kg/min, Goal: Keep Systolic Blood Pressure GREATER than 100 mmhg and Cardiac Index GREATER than 2.2 DOPamine additive* 400 mg, 2 mcg/kg/min <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>norepinephrine to start at 0.01 mcg/kg/min</u></font></body></html>(note)* norepinephrine (mcg/kg/min) 4 mg/dextrose 5% Water 250 ml (Levophed)* (IVS)* Dextrose 5% Water* 250 ml, IV, Titration instructions: 0.02 mcg/kg/min every 1-2 min, Max Dose: 2 mcg/kg/min, Goal: Systolic Blood Pressure GREATER than 100 mmhg Comments: Titration may vary based on patient response or urgency of situation norepinephrine additive* 4 mg, EB, 0.01 mcg/kg/min labetalol 10 mg, IV Push, Injection, every 1 hr, PRN other (see comment) Comments: May give 5-10mg for Systolic Blood Pressure GREATER than 140 mmhg with Heart Rate GREATER than 80 bpm, and all Vasoactive Infusions have reached their max drip rate. Do not exceed 300 mg of labetalol within 24 hrs. hydralazine 10 mg, IV Push, Injection, every 1 hr, PRN hypertension Comments: May give 5-10mg for Systolic Blood Pressure GREATER than 140 mmhg and Drips ineffective and all Vasoactive Infusions have reached their max drip rate Electrolyte Management potassium CHLORide for central IV 20 meq, IV Piggyback, Soln-IV, Daily, PRN other (see comment) Comments: For Potassium LESS than 4.5 mmol/l Antiarrhythmics <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>amiodarone to start at 1 mg/min</u></font> </BODY></HTML>(NOTE)* AMIODArone (Cordarone) 900 mg/dextrose 5% Water 500 ml* (IVS)* Dextrose 5% Water* 500 ml, IV, Titration instructions: Initial Rate: 1 mg/min (33.3 ml/hr) x6 hrs. Maint. Rate: 0.5 mg/min (16.7 ml/hr) x 48 hours, Goal: n/a, Order Duration: 48 hr AMIODArone additive* 900 mg, 1 mg/min

161 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>lidocaine to start at 2 mg/min</u></font></body></html>(note)* lidocaine (mg/min) 2 g/dextrose 5% Water 500 ml Premix* (IVS)* Premix Dextrose 5% Water* 500 ml, IV, Titration instructions: WEAN to OFF overnight if no arrhythmias, Goal: n/a lidocaine 2% additive* 2,000 mg, EB, 2 mg/min Antihypertensives Coreg mg, Oral, Tab, BID Comments: Hold for Heart Rate LESS than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg Lopressor (tartrate) 12.5 mg, Oral, Tab, BID (DEF)* Comments: Hold for Heart Rate LESS than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg 25 mg, Oral, Tab, BID Comments: Hold for Heart Rate LESS than 60 beats per minute or Systolic Blood Pressure LESS than 100 mmhg Glycemic Control GM IV Insulin Infusion (CVS)(SUB)* GM Subcut Eating (basal/bolus + correction)(sub)* GM Subcut NPO/Continuous Enteral Feeding (basal + correction)(sub)* Antibiotics Antibiotic POST-Op CABG, Other Cardiac(SUB)* Sedation CC Analgesia and Sedation Management(SUB)* Pain Management Norco 5 mg-325 mg oral tablet 1 tab, Oral, Tab, every 3 hr, PRN pain, mild (scale 1-3) Comments: Begin POST Extubation Norco 5 mg-325 mg oral tablet 2 tab, Oral, Tab, every 3 hr, PRN pain, moderate (scale 4-6) Comments: Begin POST Extubation Respiratory Medications Proventil 2.5 mg/3 ml (0.083%) inhalation solution 2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 6 hours Comments: Give in line while on ventilator. Discontinue when extubated. Proventil 2.5 mg/3 ml (0.083%) inhalation solution 2.5 mg, NEB, Device: EzPAP, Soln-Inhalation, Resp every 4 hours Comments: Begin POST Extubation Atrovent 0.02% 500 mcg/2.5 ml solution for nebulization 0.5 mg, NEB, Device: EzPAP, Soln-Inhalation, Resp every 4 hours Comments: Begin POST Extubation Proventil 2.5 mg/3 ml (0.083%) inhalation solution 2.5 mg, NEB, Device: EzPAP, Soln-Inhalation, Resp every 2 hours, PRN shortness of breath or wheezing Comments: Begin POST Extubation Atrovent 0.02% 500 mcg/2.5 ml solution for nebulization 0.5 mg, NEB, Device: EzPAP, Soln-Inhalation, Resp every 2 hours, PRN shortness of breath or wheezing Comments: Begin POST Extubation Anticoagulation / Antiplatelet Agents

162 +1 Days aspirin enteric coated 81 mg, Oral, Tab-DR, every evening (DEF)* Comments: Begin POST OP Day #1 162 mg, Oral, Tab-DR, every evening Comments: Begin POST OP Day #1 325 mg, Oral, Tab-DR, every evening Comments: Begin POST OP Day #1 +1 Days Lovenox 40 mg, Subcut, Injection, Daily (DEF)* Comments: Begin POST OP Day #1. Daily at mg, Subcut, Injection, Daily Comments: Begin POST OP Day #1. Daily at Days heparin 5,000 units/ml injectable 5,000 units, Subcut, Injection, BID (DEF)* Comments: Begin POST OP Day #1 BID at 1000 and ,000 units, Subcut, Injection, every 8 hours. Comments: Begin POST OP Day #1 VTE Advisor Gastrointestinal Agents Pepcid 20 mg, IV Push, Injection, BID Constipation Colace 100 mg, Oral, Cap, BID Comments: Begin POST Op Day #1 +1 Days Milk of Magnesia 8% 400 mg/5 ml susp 30 ml, Oral, Susp, QHS, PRN other (see comment) Comments: Begin POST Op Day #2 if constipation unrelieved by docusate (Colace) +2 Days Dulcolax Laxative 10 mg, PR, Supp, QHS, PRN other (see comment) Comments: Begin POST Op Day #2 if magnesium hydroxide (milk of magnesia) ineffective after 12 hours after administration +2 Days Fleet Enema (Adult) rectal enema 133 ml, PR, Enema, Daily for 1 doses, PRN other (see comment) Comments: Begin POST Op Day #2 if bisacodyl (Dulcolax) ineffective 12 hours after administration Nausea/Vomiting Zofran ODT 4 mg, Oral, Tab-Dis, every 4 hours., PRN nausea/vomiting Statins +1 Days Lipitor 40 mg, Oral, Tab, QHS Comments: Begin POST OP Day #1 +1 Days Crestor 5 mg, Oral, Tab, QHS Comments: Begin POST OP Day #1 Miscellaneous Tylenol 650 mg, PR, Supp, every 4 hours., PRN fever Comments: Temperature GREATER than 38.6 DegC (101.5 DegF) Laboratory AM Labs CBC with Differential Blood, AM Draw (Inpatient Only), T+1;0330, every morning, for 7 days Renal Panel 1

163 Blood, AM Draw (Inpatient Only), T+1;0330, every morning, for 7 days Arterial Blood Gas (ABG) POINT OF CARE In AM, Daily for 7 days Diagnostic Tests XR Chest 1 View Portable Stat, Reason: Line placement Congestion XR Chest 1 View Portable T+1;0600, In AM, Reason: Congestion XR Chest 1 View Portable T+2;0600, In AM, Reason: Congestion XR Chest 1 View Portable T+3;0600, In AM, Reason: Congestion XR Chest 1 View Portable T+4;0600, In AM, Reason: Congestion Respiratory Incentive Spirometry Respiratory every 2 hr while awake Oxygen Therapy SpO2 goal 92% or GREATER, Simple Mask BiPAP Protocol Post-Extubation Therapies Physical Therapy Evaluation and Treatment Acute Occupational Therapy Evaluation and Treatment Acute Consults/Referrals Consult to Pharmacy - Anemia Management Reason for Consult: Other, please specify, POST Thoracic Surgery Communication Orders Notify Practitioner Maintain temperature LESS than degf (38.6 degc), HR GREATER than 60 bpm and LESS than 120 bpm, Systolic BP 90 to 140 mmhg, and CVP 5 to 15 mmhg. Notify Practitioner if these parameters are not maintained Notify Practitioner Maintain Serum Potassium 4.5 to 5.0 mmol per liter, Urine Output 50 ml/hr or GREATER. Call Practitioner if these parameters not maintained Special PROTOCOL ICU/ICCU: STAT Lab and X-Ray for Unstable Patients Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

164 Unique Plan Description: CVS Impella Ventricular Assist Device Plan Selection Display: CVS Impella Ventricular Assist Device PlanType: Medical Version: 1 Begin Effective Date: 1/13/ :56 End Effective Date: Current Available at all facilities CVS Impella Ventricular Assist Device Admit/Transfer/Discharge/Status Admit to Inpatient Level of Care: CVICU Patient Care Vital Signs Every 15 minutes x4, then every 30 minutes x2, then every hour for the duration of Impella support Hemodynamic Monitoring Constant order, Every 15 minutes x4, then every 30 minutes x2, then every hour for the duration of Impella support Knee Immobilizer Application PRN, Leg with Impella site to be kept straight. Apply knee immobilizer, if needed Neurovascular Assessment every 1 hr, On the extremity of the Impella insertion. Notify Practitioner for any changes with pulses of affected extremity Impella Catheter Size Right side (DEF)* CP Impella (Ventricular Assist Device) Pump Orders Note: Do NOT decrease performance level below P2 as long as the pump is in the ventricle. Retrograde flow will occur across the Aortic Valve if the pump is set at P0. The console will only run at P9 for 5 minutes and then default to P8. Impella (Ventricular Assist Device) Instructions Chest compressions and defibrillators can be administered during Impella support. During chest compressions, decrease the performance level (P) to P2. The Impella does not have to be stopped or unplugged to defibrillate Impella (Ventricular Assist Device) Instructions Maintain RED pressure sidearm on the Impella like an arterial line. Connect 500 ml of normal saline to red pressure side arm with portless tubing and a pressure bag at 300 mmhg Impella (Ventricular Assist Device) Instructions Perform device assessment and assess impella access site and distal pulses every 15 minutes x4, then every 30 minutes x2, then every hour for the duration of Impella support Impella (Ventricular Assist Device) Instructions Monitor Impella pump placement using the placement screen with motor current and placement signal. In the event the distal tip (pigtail) of the Impella becomes displaced from the left ventricle, call Practitioner ASAP and notify Abiomed Clinical Support Impella (Ventricular Assist Device) Instructions Connect the purge solution to infuse via the yellow sidearm of the Impella device. The purge solution should always be infused by the Automated Impella Controller Console, and never placed under pressure Impella (Ventricular Assist Device) Instructions every 2 days, The purge cassette to be changed every 48 hours Activity Bedrest (strict) Impella Ventricular Assist Device in place HOB Head of Bed Level: Up to 30 degrees, Patient may be turned side to side

165 Continuous Infusions Purge Solutions <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>heparin Purge Solution For Impella Device</U></FONT></BODY></HTML>(NOTE)* heparin (unit/hr) 25,000 Units/Dextrose 5% Water 500 ml (IMPELLA PURGE)* (IVS)* Premix Dextrose 5% Water* 500 ml, IV, Titration instructions: Titrated by impella device, Goal: ACT seconds, Per Impella Pump Comments: Impella STANDARD Purge SolutionIf ACT GREATER than 180 seconds, stop STANDARD heparin purge solution & start the HALF concentration heparin 12,500 Dextrose 5% 500 ml purge solution. heparin additive 25,000 units, EB heparin 12,500 Units/Dextrose 5% Water 500 ml (IMPELLA PURGE)* (IVS)* Dextrose 5% Water* 500 ml, IV, Titration instructions: Titrate per impella device, Goal: ACT seconds, Per impella device Comments: Impella HALF CONCENTRATION Purge SolutionPRN heparin purge solution. Start if ACT GREATER than 180 seconds, and stop STANDARD heparin purge solution heparin additive 12,500 units Heparin Infusion <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>heparin to start at </U><U>200 units/hr</u></font> </BODY></HTML>(NOTE)* heparin (unit/hr) 25,000 Units/Dextrose 5% Water 500 ml* (IVS)* Premix Dextrose 5% Water* 500 ml, IV, Titration instructions: Per Impella Heparin Nomogram (see Reference Text), Goal: ACT seconds Comments: Impella Heparin Infusion heparin additive 25,000 units, 200 units/hr Medications Glycemic Control GM IV Insulin Infusion (CVS)(SUB)* Laboratory CBC with Diff Blood, Stat, T;N Renal Panel 3(CMP+Mg,Phos,Uric) Blood, Stat, T;N ACT Monitoring POC ACT checks for purge solution every 1 hour x4, then every 4 hours while on Impella AM Labs CBC with Diff Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 1 days Renal Panel 3(CMP+Mg,Phos,Uric) Blood, AM Draw (Inpatient Only), T+1;0330 B-Type Natriuretic Peptide (BNP) Blood, AM Draw (Inpatient Only), T+1;0330 Diagnostic Tests XR Chest 1 View Portable Stat

166 XR Chest 1 View Portable T+1;0600, In AM Card/Vasc/Neuro CV Echocardiogram w/doppler Stat, Indication: Other (see special instructions), Confirm placement of Impella EKG 12 lead Stat Communication Orders Notify Practitioner Notify Cardiologist on call of Impella supported patient. Notify Practitioner In the event the distal tip (pigtail) of the Impella becomes displaced from the left ventricle, Call practitioner ASAP and notify Abiomed Clinical Support. Notify Practitioner For Impella problems, notify Practitioner, and call Abiomed Clinical Support (24/7) for troubleshooting help at Notify Practitioner Notify Practitioner and Abiomed Clinical Support for any ongoing purge pressure alarms. Notify Practitioner Notify Practitioner and Abiomed Clinical Support for purge infusion rate of LESS than 4mL/hour or GREATER than 25mL/hour Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

167 Unique Plan Description: MED Wound Care Full Thickness Plan Selection Display: MED Wound Care Full Thickness PlanType: Medical Version: 1 Begin Effective Date: 6/16/ :28 End Effective Date: Current Available at: KD Medical Center Plan Comment: OEF and ord sent updated 7/6/17 dsm; MED Wound Care Full Thickness Patient Care Wound Care Instructions Full Thickness: Skin damage extends beyond the dermis (i.e. visible adipose, fascia, muscle, tendon, ligament, carilage or bone)(note)* <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY background-color: rgb(255,255,128);margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2 face=tahoma>select <STRONG>ONE</STRONG> wound care orderable per wound</font> </BODY></HTML>(NOTE)* Wound Care Full thickness Wound Care Full thickness Wound Care Full thickness Wound Care Full thickness Wound Care Full thickness Wound Care Full thickness Wound Care Medications Santyl 250 units/g topical ointment 1 app, Topical, Ointment, Daily zinc oxide 20% topical ointment 1 app, Topical, Ointment Betadine 10% topical solution 1 app, Topical, Soln-Top Dakins Half Strength 0.25% topical solution 1 app, Topical, Soln-IRR Dakins Quarter Strength 0.125% topical solution 1 app, Topical, Soln-Top Pressure Redistribution Surfaces Waffle Boots Pressure Reducing Cushion Waffle Seat Cushion Specialty Bed Consults/Referrals Consult to Wound Care Specialist Wound Ongoing Evaluation every week Consult to Registered Dietitian Physical Therapy Evaluation and Treatment Acute Once

168 Unique Plan Description: MED Wound Care Moisture Associated Skin Damage Plan Selection Display: MED Wound Care Moisture Associated Skin Damage PlanType: Medical Version: 1 Begin Effective Date: 7/5/ :24 End Effective Date: Current Available at: KD Medical Center Plan Comment: OEFs/meds updated 7/6 MED Wound Care Moisture Associated Skin Damage Patient Care Wound Care Instructions <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY background-color: rgb(255,255,128);margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2 face=tahoma>select <STRONG>ONE</STRONG> wound care orderable per wound</font> </BODY></HTML>(NOTE)* Wound Care Moisture associated skin damage Wound Care Medications zinc oxide 20% topical ointment 1 app, Topical, Ointment, As Directed, PRN other (see comment) Comments: Reapply PRN after each incontinent episode Boudreaux Butt Paste 16% topical ointment 1 app, Topical, Ointment, As Directed, PRN other (see comment) Comments: Reapply PRN after each incontinent episode Baza Antifungal 2% topical cream 1 app, Topical, Cream, BID Comments: (for moisture associated skin damage) Baza Antifungal 2% topical cream 1 app, Topical, Cream, As Directed, PRN other (see comment) Comments: PRN for excessive moisture (for moisture associated skin damage) Mycostatin 100,000 units/g topical powder 1 app, Topical, Powder, BID, Indication: Other (Please specify in comments) Comments: (for moisture associated skin damage) Mycostatin 100,000 units/g topical powder 1 app, Topical, Powder, PRN, Indication: Other (Please specify in comments), PRN other (see comment) Comments: PRN for excessive moisture (for moisture associated skin damage) Consults/Referrals Wound Ongoing Evaluation every week *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

169 Unique Plan Description: MED Wound Care Partial Thickness Plan Selection Display: MED Wound Care Partial Thickness PlanType: Medical Version: 1 Begin Effective Date: 7/5/ :27 End Effective Date: Current Available at: KD Medical Center MED Wound Care Partial Thickness Patient Care Wound Care Instructions <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY background-color: rgb(255,255,128);margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2 face=tahoma>select <STRONG>ONE</STRONG> wound care orderable per wound</font> </BODY></HTML>(NOTE)* Wound Care Partial thickness Wound Care Partial thickness Wound Care Partial thickness Wound Care Partial thickness Wound Care Partial thickness Wound Care Partial thickness Wound Care Medications Santyl 250 units/g topical ointment 1 app, Topical, Ointment, Daily zinc oxide 20% topical ointment 1 app, Topical, Ointment Betadine 10% topical solution 1 app, Topical, Soln-Top Dakins Half Strength 0.25% topical solution 1 app, Topical, Soln-Top Dakins Quarter Strength 0.125% topical solution 1 app, Topical, Soln-Top Pressure Redistribution Surfaces Waffle Boots Pressure Reducing Cushion Waffle Seat Cushion Specialty Bed Consults/Referrals Consult to Wound Care Specialist Wound Ongoing Evaluation every week Consult to Registered Dietitian *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator

170 Unique Plan Description: MED Wound Care Pressure Injury Plan Selection Display: MED Wound Care Pressure Injury PlanType: Medical Version: 1 Begin Effective Date: 7/5/ :28 End Effective Date: Current Available at: KD Medical Center Plan Comment: OEFS/meds added 7/6 dsm; MED Wound Care Pressure Injury Patient Care Wound Care Instructions <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY background-color: rgb(255,255,255);margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2 face=tahoma>select <STRONG>ONE</STRONG> wound care orderable per wound</font> </BODY></HTML>(NOTE)* Wound Care Wound Care Wound Care Wound Care Wound Care Wound Care Wound Care Medications Santyl 250 units/g topical ointment 1 app, Topical, Ointment, Daily zinc oxide 20% topical ointment 1 app, Topical, Ointment Betadine 10% topical solution 1 app, Topical, Soln-Top Dakins Half Strength 0.25% topical solution 1 app, Topical, Soln-Top Dakins Quarter Strength 0.125% topical solution 1 app, Topical, Soln-Top Pressure Redistribution Surfaces Waffle Boots Pressure Reducing Cushion Waffle Seat Cushion Specialty Bed Consults/Referrals Consult to Wound Care Specialist Wound Ongoing Evaluation every week Consult to Registered Dietitian *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

171 Unique Plan Description: MED Wound Care Skin Tear Plan Selection Display: MED Wound Care Skin Tear PlanType: Medical Version: 1 Begin Effective Date: 7/5/ :29 End Effective Date: Current Available at all facilities MED Wound Care Skin Tear Patient Care Treatment A: Skin Flap(NOTE)* Wound Care Cleanse with Wound Cleanser, Protect peri wound with Other (See Comment), Cover with Other (See Comment), Change dressing Daily, Skin tear. Protect peri wound with: Skin prep, Cover with: Silicone dressing, Secure dressing with: Adhesive Foam Comments: If skin flap remains, gently use a sterile tongue depressor or cotton swab to approximate edges. Allow steri-strips to fall off Treatment B: Light to moderate drainage with or without skin flap(note)* Wound Care Cleanse with Wound Cleanser, Protect peri wound with Skin prep, Cover with Silicone dressing, Change dressing Daily, Skin tear Comments: If skin flap remains, gently use a sterile tongue depressor or cotton swab to approximate edges. *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

172 Unique Plan Description: MED Wound Care Wound VAC Therapy Plan Selection Display: MED Wound Care Wound VAC Therapy PlanType: Medical Version: 1 Begin Effective Date: 4/18/ :55 End Effective Date: Current Available at: KD Medical Center MED Wound Care Wound VAC Therapy Patient Care Negative Pressure Wound Therapy Change solution bag every 24 hrs and PRN to help maintain irrigation cycle. Change irrigation cassette with every dressing change Comments: If irrigation ordered: Instillation fluid amount to be determined with each dressing change using the "Fill Assist" on the machine. May adjust volume of fluid instilled into wound PRN to maintain seal. Transparent dressings PRN to seal leaks or for reinforcement Wound Care-Negative Pressure Wound Therapy Mon/Wed/Fri, Cleanse with dermal wound spray, dry well, protect peri-wound area with barrier spray and strips of adhesive drape. (DEF)* Comments: Change dressing PRN if leaks, blockage, soiled underneath drape or comes off. Tue/Th/Sa, Cleanse with dermal wound spray, dry well, protect peri-wound area with barrier spray and strips of adhesive drape. Comments: Change dressing PRN if leaks, blockage, soiled underneath drape or comes off. every 48 hr, Cleanse with dermal wound spray, dry well, protect peri-wound area with barrier spray and strips of adhesive drape. Comments: Change dressing PRN if leaks, blockage, soiled underneath drape or comes off. every 72 hr, Cleanse with dermal wound spray, dry well, protect peri-wound area with barrier spray and strips of adhesive drape. Comments: Change dressing PRN if leaks, blockage, soiled underneath drape or comes off. Nursing Communication-Negative Pressure Wound Therapy Adjust NPWT Continuous pressure to lower setting according to patient's pain tolerance PRN, going no lower than 75mmHg Nursing Communication-Negative Pressure Wound Therapy Bridge Trac pad to flat surface and/or away from pressure area Nursing Communication-Negative Pressure Wound Therapy Bridge wounds together if same etiology Nursing Communication-Negative Pressure Wound Therapy "Y" connector to connect more than one wound to one machine Wound Drain Management Empty and Record Output every 4 hr, NPWT Wound Care Medications Santyl 250 units/g topical ointment 1 app, Topical, Ointment, Mon/Wed/Fri (DEF)* Comments: Per Negative Pressure Wound Therapy Order Instructions. 1 app, Topical, Ointment, Tue/Th/Sa Comments: Per Negative Pressure Wound Therapy Order Instructions. 1 app, Topical, Ointment, every 48 hr Comments: Per Negative Pressure Wound Therapy Order Instructions. 1 app, Topical, Ointment, every 72 hr Comments: Per Negative Pressure Wound Therapy Order Instructions. Santyl 250 units/g topical ointment 1 app, Topical, Ointment, PRN other (see comment) Comments: Per Negative Pressure Wound Therapy Order Instructions. Dakins Quarter Strength 0.125% topical solution 1 app, Topical, Soln-Top Comments: Per Negative Pressure Wound Therapy Order Instructions. In BBraun Bottle with

173 adapter, sent from pharmacy. Change every 24 hrs and PRN to help maintain irrigation cycle. Dakins Quarter Strength 0.125% topical solution 1 app, Topical, Soln-Top, PRN other (see comment) Comments: Per Negative Pressure Wound Therapy Order Instructions. In BBraun Bottle with adapter, sent from pharmacy. Change every 24 hrs and PRN to help maintain irrigation cycle. Supplies Wound Vac (Equipment Order - VAC ULTA) Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

174 Unique Plan Description: OB Hypertension Acute Plan Selection Display: OB Hypertension Acute Plan Synonyms: Administration of Labetalol for Severe Hypertension in Pregnancy PlanType: Medical Version: 1 Begin Effective Date: 12/8/ :06 End Effective Date: Current Available at all facilities Plan Comment: ADDED hydralazine 5mg IVP over 2 minutes x1 stat, hydralazine 10mg IVP over 2 minutes x1 stat, Repeat hydralazine 10mg in 20 minutes IVP over 2 minutes if BP still elevated >160/110, Call MD for further orders if BP continues to be greater than or equal to 160/110 after repeat dose. 2/13/17 dsm (from info ed); OB Hypertension Acute Admit/Transfer/Discharge/Status Admit to Inpatient Place in Observation Patient Care Weight in Kilograms Daily Fetal Heart Monitor External Continuous Intake and Output Strict Foley Catheter Reason: Other (required documented rationale), Hourly output Communication Order Obtain blood pressure, pulse, oxygen saturation and respiratory rate every 5 minutes during bolus administration and until stable. Activity Bedrest (strict) In lateral position Medications labetalol 20 mg, IV Push, Injection, Once Comments: IVPush over 2-3 min. *MAX 300 mg/24 Hrs* labetalol 20 mg, IV Push, Injection, every 10 min, PRN other (see comment) Comments: PRN until Diastolic Blood Pressure mmhg. IV Push over 2-3 min, MAX 300mg/24Hrs Trandate 100 mg, Oral, Tab, Once, PRN other (see comment) Comments: Discontinue IV dose & give PO x1 if patient not in labor & responds to labetalol LESS than 40 mg IV. Trandate 100 mg, Oral, Tab, every 12 hours., PRN other (see comment) Comments: Discontinue IV dose & give PO Q12H if patient not in labor & responds to labetalol LESS than 40 mg IV. Notify Practitioner Bradycardia, Hypotension, Dizziness, Drowsiness, Bronchospasms, Irregular Heart Rate hydralazine 5 mg, IV Push, Injection, Once (DEF)* Comments: Give over 2 minutes 10 mg, IV Push, Injection, Once Comments: Give over 2 minutes

175 hydralazine 10 mg, IV Push, Injection, As Directed for 1 doses, PRN other (see comment) Comments: Give if Blood Pressure is still elevated GREATER than Systolic Blood Pressure 160 mmhg OR Diastolic Blood Pressure 110 mmhg 20 minutes after STAT hydralazine dose. Give over 2 minutes Notify Practitioner For further orders if BP continues to be GREATER than or equal to 160/110 mmhg after repeat hydralazine dose Laboratory PTT Blood, Stat, T;N, Nurse collect Protime with INR Blood, Stat, T;N, Nurse collect Fibrinogen Lvl Blood, Stat, T;N, Nurse collect DDimer, Quantitative Blood, Stat, T;N, Nurse collect Liver Panel Blood, Stat, T;N, Nurse collect Uric Acid Blood, Stat, T;N, Nurse collect Renal Panel 1 Blood, Stat, T;N, Nurse collect Renal Panel 2 (BMP +MG,Phos,Uric) Blood, Stat, T;N, Nurse collect Card/Vasc/Neuro EKG 12 lead Communication Orders Notify Practitioner Target diastolic blood pressure (DBP) is mmhg. Once target DBP is achieved, if any subsequent DBP exceeds target, contact Practitioner for further orders. Notify Practitioner For bradycardia, hypotension, dizziness, drowsiness, bronchospasms, or irregular heart rate. Non Categorized Initial Approval Date 4/18/17 Annual Review Date 11/1/17 *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

176 Unique Plan Description: OB Postpartum Magnesium Plan Selection Display: OB Postpartum Magnesium PlanType: Medical Version: 1 Begin Effective Date: 11/22/ :26 End Effective Date: Current Available at all facilities OB Postpartum Magnesium Patient Care Vital Signs Except temperature. Every 30 minutes for the first 2 hours and then every 1 hour unless the patient's condition warrants more frequent assessment. Pulse Oximetry - Spot Check Every 30 minutes for the first 2 hours and then every 1 hour unless the patient's condition warrants more frequent assessment. Neurological Assessment every 1 hr, Assess more frequently if patient's condition warrants. Specifically assess level of consciousness, visual changes, presence of headache, deep tendon reflexes, and clonus. Integumentary Assessment every 1 hr, Assess more frequently if patient's condition warrants. Specifically assess nondependent edema. Pain Assessment Adult every 1 hr, Assess more frequently if patient's condition warrants. Specifically assess epigastric pain. Respiratory Assessment every 1 hr, Assess more frequently if patient's condition warrants Intake and Output every 1 hr, Assess more frequently if patient's condition warrants Continuous Infusions Magnesium Sulfate (2 g/hr) <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>starting Rate = <STRONG><FONT color=#ff0000>2 g/hr</font></strong> (No Bolus)</U></FONT></BODY></HTML>(NOTE)* magnesium sulfate 20 g/lactated Ringers 500 ml Premix* (IVS)* Premix Lactated Ringers* 500 ml, IV, Goal: n/a, Order Duration: 24 hr Comments: Monitor for signs of toxicity such as severe respiratory depression or arrest, decreased level of consciousness, cardiac arrest and discontinue magnesium sulfate, notify practitioner, draw a serum magnesium level magnesium sulfate additive* 20 g, EB, 2 g/hr <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>starting Rate = <FONT color=#ff0000><strong>2 g/hr</strong></font> (4 g Bolus)</FONT></U> </BODY></HTML>(NOTE)* magnesium sulfate 20 g/lactated Ringers 500 ml Premix* (IVS)* Premix Lactated Ringers* 500 ml, IV, Bolus Instructions: Give initial bolus of 4 g over 30 minutes, Goal: n/a, Order Duration: 24 hr Comments: Monitor for signs of toxicity such as severe respiratory depression or arrest, decreased level of consciousness, cardiac arrest and discontinue magnesium

177 sulfate, notify practitioner, draw a serum magnesium level magnesium sulfate additive* 20 g, EB, 2 g/hr <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><U><FONT size=2>starting Rate = <STRONG><FONT color=#ff0000>2 g/hr</font></strong> (6 g Bolus)</FONT></U></BODY></HTML>(NOTE)* magnesium sulfate 20 g/lactated Ringers 500 ml Premix* (IVS)* Premix Lactated Ringers* 500 ml, IV, Bolus Instructions: Give initial bolus of 6 g over 30 minutes, Goal: n/a, Order Duration: 24 hr Comments: Monitor for signs of toxicity such as severe respiratory depression or arrest, decreased level of consciousness, cardiac arrest and discontinue magnesium sulfate, notify practitioner, draw a serum magnesium level magnesium sulfate additive* 20 g, EB, 2 g/hr Magnesium Sulfate (1 g/hr) <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>starting Rate =<FONT color=#ff0000> <STRONG>1 g/hr</strong></font> (No Bolus)</U></FONT></BODY></HTML>(NOTE)* magnesium sulfate 20 g/lactated Ringers 500 ml Premix* (IVS)* Premix Lactated Ringers* 500 ml, IV, Goal: n/a, Order Duration: 24 hr Comments: Monitor for signs of toxicity such as severe respiratory depression or arrest, decreased level of consciousness, cardiac arrest and discontinue magnesium sulfate, notify practitioner, draw a serum magnesium level magnesium sulfate additive* 20 g, EB, 1 g/hr <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>starting Rate = <STRONG><FONT color=#ff0000>1 g/hr</font></strong> (4 g Bolus)</U></FONT></BODY></HTML>(NOTE)* magnesium sulfate 20 g/lactated Ringers 500 ml Premix* (IVS)* Premix Lactated Ringers* 500 ml, IV, Bolus Instructions: Give initial bolus of 4 g over 30 minutes, Goal: n/a, Order Duration: 24 hr Comments: Monitor for signs of toxicity such as severe respiratory depression or arrest, decreased level of consciousness, cardiac arrest and discontinue magnesium sulfate, notify practitioner, draw a serum magnesium level magnesium sulfate additive* 20 g, EB, 1 g/hr <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=content-type><style> BODY margin:0; P margin:0 </STYLE><META name=generator content="mshtml "></HEAD><BODY><FONT size=2><u>starting Rate = <STRONG><FONT color=#ff0000>1 g/hr</font></strong> (6 g Bolus)</U></FONT></BODY></HTML>(NOTE)* magnesium sulfate 20 g/lactated Ringers 500 ml Premix* (IVS)* Premix Lactated Ringers* 500 ml, IV, Bolus Instructions: Give initial bolus of 6 g over 30 minutes, Goal: n/a, Order Duration: 24 hr Comments: Monitor for signs of toxicity such as severe respiratory depression or arrest, decreased level of consciousness, cardiac arrest and discontinue magnesium sulfate, notify practitioner, draw a serum magnesium level

178 magnesium sulfate additive* 20 g, EB, 1 g/hr Medications calcium GLUConate 1 g, Slow IV Push, Injection, As Directed, PRN other (see comment) Comments: For magnesium toxicity. Give IV slow push over 10 minutes Laboratory Magnesium Level Blood, Routine, T;N, every 6 hr, for 4 times SGOT (AST) Blood, Routine, T;N, Once SGPT (ALT) Blood, Routine, T;N, Once CBC with Diff Blood, Routine, T;N, Once Communication Orders Notify Practitioner T;N, For magnesium level GREATER than 7 mg/dl, absent deep tendon reflexes, urine output LESS than 30mL/hr, respirations LESS than 12 breaths per minute, or oxygen saturation LESS than 90% Non Categorized Initial Approval Date 4/18/17 Annual Review Date 11/1/17 *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

179 Unique Plan Description: ORTHO Admission Plan Selection Display: ORTHO Admission PlanType: Medical Version: 1 Begin Effective Date: 2/24/ :09 End Effective Date: Current Available at: KD Medical Center Plan Comment: ORTHO Admission Admit/Transfer/Discharge/Status Admission Status(SUB)* Patient Care General Telemetry(SUB)* Resuscitation Status Full Code (Full Treatment) Vital Signs T;N, Every 2 hours x 2, then every 4 hours x 2. If vital signs within normal limits then every 6 hours (DEF)* T;N, every 12 hr Neurovascular Assessment every 4 hr, fractured limb Ice Therapy BID, Ice to affected joint 2 times per day X 30 minutes and PRN pain Cooling Device T;N, Patient supplied Intake and Output T;N, every 12 hr Turn Patient Turn and reposition every 2 hours. Dressing Change T;N, Change dressing: Daily, starting 24 hours post op Lines/Tubes/Drains Insert Indwelling Urinary Catheter Reason: Neurogenic Bladder Comments: if not placed in ER Urinary Catheter Discontinue Discontinue on postoperative day (POD) 1, T+720 Straight Catheter PRN, if unable to void within 6 hours post op straight cath q4-6 hrs, prn inability to void Discontinue Drain(s) T;N, 24 hours post-op or when drainage is less than 30 ml in 8 hours. Activity Bedrest (strict) Bathroom Privileges Overbed Frame / Trapeze Overhead frame and trapeze if patient not confused Weight Bearing Status T;N, non weight-bearing, Right Upper, OOB with assistance (DEF)* T;N, non weight-bearing, Right Lower, OOB with assistance T;N, non weight-bearing, Left Upper, OOB with assistance T;N, non weight-bearing, Left Lower, OOB with assistance Weight Bearing Status T;N, toe touch weight-bearing, Right Upper, OOB with assistance (DEF)*

180 T;N, toe touch weight-bearing, Right Lower, OOB with assistance Weight Bearing Status T;N, partial weight-bearing, Right Upper, OOB with assistance (DEF)* T;N, partial weight-bearing, Right Lower, OOB with assistance T;N, partial weight-bearing, Left Upper, OOB with assistance T;N, partial weight-bearing, Left Lower, OOB with assistance Weight Bearing Status T;N, weight bearing as tolerated, Right Upper, OOB with assistance (DEF)* T;N, weight bearing as tolerated, Right Lower, OOB with assistance T;N, weight bearing as tolerated, Left Upper, OOB with assistance T;N, weight bearing as tolerated, Left Lower, OOB with assistance Diet/Nutrition NPO NPO at Midnight Regular Diet Diabetic Diet Cardiac Diet Continuous Infusions Lactated Ringers 1,000 ml, IV, 80 ml/hr (DEF)* 1,000 ml, IV, 100 ml/hr 1,000 ml, IV, 125 ml/hr 1,000 ml, IV, 150 ml/hr D5-0.45NaCl w/k10 1,000 ml, IV, 60 ml/hr (DEF)* 1,000 ml, IV, 80 ml/hr 1,000 ml, IV, 120 ml/hr Medications Consult to Pharmacy - Pain Management Pain Management ORTHO Admission Pain Management(SUB)* Reversal Agents Narcan 0.4 mg, IV Push, Injection, every 2 min for 3 doses, PRN other (see comment) Comments: Respiratory Rate LESS THAN OR EQUAL to 8/min (very shallow and ineffective) OR if RASS LESS THAN -3. Notify practitioner if administered. VTE Prophylaxis To address VTE prophylaxis, order chemical and/or mechanical VTE prophylaxis via the subphase(s) below. To document a risk score and/or contraindication to prophylaxis, select the VTE Prophylaxis Guidelines order below(note)* VTE Medical Patients(SUB)* VTE Prophylaxis Guidelines Glycemic Control GM Subcut Eating (basal/bolus + correction)(sub)* GM Subcut NPO/Continuous Enteral Feeding (basal + correction)(sub)* Constipation Colace 100 mg, Oral, Cap, BID (DEF)* Comments: Hold for Diarrhea. 250 mg, Oral, Cap, BID Comments: Hold for Diarrhea. Senokot 17.2 mg, Oral, Tab, QHS, PRN constipation Milk of Magnesia 8% 400 mg/5 ml susp

181 30 ml, Oral, Susp, QHS, PRN other (see comment) Comments: Constipation unrelieved by either docusate (Colace) or senna (Senokot) Dulcolax Laxative 10 mg, PR, Supp, QHS, PRN other (see comment) Comments: Constipation not relieved by magnesium hydroxide (Milk of Magnesia) Fleet Enema (Adult) rectal enema 133 ml, PR, Enema, Daily, PRN other (see comment) Comments: Constipation if not relieved with bisacodyl (Dulcolax) Nausea/Vomiting Zofran ODT 4 mg, Oral, Tab-Dis, every 6 hours., PRN nausea/vomiting Phenergan 25 mg, IV, Injection, every 6 hours., PRN nausea/vomiting Comments: May give 12.5 to 25 mg as needed if nausea/vomiting not relieved by ondansetron (Zofran) Laboratory CBC with Differential Blood, Stat, T;N Basic Metabolic Panel Blood, Stat, T;N Type and Screen Only Blood, Stat, T;N, Once, for 1, times HCG Qualitative Urine Urine, Stat Collect, T;N UA with Microscopic Stat Collect, T;N Nursing Communication Order TEG with platelet mapping if patient taking (or took within last 5 days) Clopidogel (Plavix) or Ticlopidine Morning Labs CBC with Differential Blood, AM Draw (Inpatient Only), T+1;0330 (DEF)* Comments: Notify practitioner if Hemoglobin LESS than 9 or Hematocrit LESS than 27 Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 3 days Comments: Notify practitioner if Hemoglobin LESS than 9 or Hematocrit LESS than 27 Basic Metabolic Panel Blood, AM Draw (Inpatient Only), T+1;0330 (DEF)* Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 3 days PT with INR Blood, AM Draw (Inpatient Only), T+1;0330, for 3 days Comments: call Practitioner with PT/INR results Diagnostic Tests XR Chest 1 View Portable T;N, Reason: Pre-Op Card/Vasc/Neuro EKG 12 lead T;N, Stat Respiratory Incentive Spirometry Respiratory every 1 hr, While patient is awake Therapies PT Evaluation and Treatment Acute T;N Communication Orders

182 Notify Treating Practitioner Vital Signs Systolic BP GREATER than 180 mmhg, Systolic BP LESS than 90 mmhg, HR GREATER than 120 beats/min, RR GREATER than 25 breaths/min, SpO2 LESS than 93 %, Urine Output LESS than 120 ml every 4 hrs, Temp GREATER than 38.5 degrees Celsius, Mental changes Nursing Communication Order Do not give any anticoagulants on the day of surgery Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

183 Unique Plan Description: ORTHO Admission Pain Management Plan Selection Display: ORTHO Admission Pain Management PlanType: Medical Version: 1 Begin Effective Date: 6/19/ :07 End Effective Date: Current Available at: KD Medical Center ORTHO Admission Pain Management Medications Scheduled Medications Tylenol 650 mg, Oral, Tab, every 6 hours. Lyrica 50 mg, Oral, Cap, every 8 hours. [Less Than 65 years] (DEF)* 25 mg, Oral, Cap, every 8 hours. [Greater Than or Equal To 65 years] Do not use if patient age is 75 years or GREATER(NOTE)* OxyCONTIN 10 mg, Oral, Tab-ER, every 12 hours. [Less Than 75 years] Comments: During hospital stay - Discontinue upon discharge Pain (Moderate level 4-6) OxyIR 5 mg, Oral, Tab, every 3 hr, PRN pain, moderate (scale 4-6) Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due tramadol 50 mg, Oral, Tab, every 4 hours., PRN pain, moderate (scale 4-6) [Less Than 65 years] (DEF)* Comments: MAX dose - 400mg/24 hours or 200mg/24 hours with CrCl LESS than 30 ml/min 25 mg, Oral, Tab, every 4 hours., PRN pain, moderate (scale 4-6) [Greater Than or Equal To 65 years] Comments: MAX dose - 400mg/24 hours or 200mg/24 hours with CrCl LESS than 30 ml/min morphine 3 mg, IV Push, Injection, every 3 hr, PRN pain, moderate (scale 4-6) [Less Than 65 years] (DEF)* Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due 2 mg, IV Push, Injection, every 3 hr, PRN pain, moderate (scale 4-6) [Greater Than or Equal To 65 years] Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due Dilaudid 0.5 mg, IV Push, Injection, every 3 hr, PRN pain, moderate (scale 4-6) [Less Than 65 years] (DEF)* Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due 0.3 mg, IV Push, Injection, every 3 hr, PRN pain, moderate (scale 4-6) [Greater Than or Equal To 65 years] Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due Pain (Severe level 7-10) OxyIR 10 mg, Oral, Tab, every 3 hr, PRN pain, severe (scale 7-10) [Less Than 65 years] (DEF)* Comments: If both PO and IV pain medications are selected for the same pain level, use the

184 IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due 7.5 mg, Oral, Tab, every 3 hr, PRN pain, severe (scale 7-10) [Greater Than or Equal To 65 years] Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due tramadol 75 mg, Oral, Tab, every 4 hours., PRN pain, moderate (scale 4-6) [Less Than 65 years] (DEF)* Comments: MAX dose - 400mg/24 hours or 200mg/24 hours with CrCl LESS than 30 ml/min 50 mg, Oral, Tab, every 4 hours., PRN pain, moderate (scale 4-6) [Greater Than or Equal To 65 years] Comments: MAX dose - 400mg/24 hours or 200mg/24 hours with CrCl LESS than 30 ml/min morphine 6 mg, IV Push, Injection, every 3 hr, PRN pain, severe (scale 7-10) [Less Than 65 years] (DEF)* Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due. 4 mg, IV Push, Injection, every 3 hr, PRN pain, severe (scale 7-10) [Greater Than or Equal To 65 years] Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due. Dilaudid 1 mg, IV Push, Injection, every 3 hr, PRN pain, severe (scale 7-10) [Less Than 65 years] (DEF)* Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due. 0.5 mg, IV Push, Injection, every 3 hr, PRN pain, severe (scale 7-10) [Greater Than or Equal To 65 years] Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due. *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

185 Unique Plan Description: ORTHO Hip Fracture Admission Plan Selection Display: ORTHO Hip Fracture Admission PlanType: Medical Version: 2 Begin Effective Date: 8/21/ :38 End Effective Date: Current Available at: KD Medical Center Plan Comment: ORTHO Hip Fracture Admission Admit/Transfer/Discharge/Status Admission Status(SUB)* Patient Care General Telemetry(SUB)* Resuscitation Status Full Code (Full Treatment) (DEF)* Do Not Resuscitate (Allow Natural Death) Do Not Intubate Limited: All but Chest Compressions Limited: All but Defibrillation Limited: All but compressions and Defib Vital Signs T;N, every 2 hours x2 then every 4 hours x5 then per unit standard of care. (DEF)* every 12 hr Intake and Output every 4 hr, Call practitioner if output LESS than 120 ml in 4 hours (DEF)* every 8 hr every 12 hr Neurovascular Assessment every 4 hr, fractured limb Incentive Spirometry Respiratory Resp every 1 hour, while awake Ice Therapy BID, Ice to affected joint 2 times per day X 30 minutes and PRN pain Lines/Tubes/Drains Peripheral IV Unless already in place Insert Indwelling Urinary Catheter If not already placed in Emergency Dept Activity Bedrest (strict) Turn Patient reposition every 2 hours Float heels off bed surface Overbed Frame / Trapeze If patient not confused Buck's Traction Application 7 pounds on affected leg prn pain Nursing Communication Order Okay to use foot pumps and bucks traction simultaneously Diet/Nutrition NPO NPO at Midnight Regular Diet

186 Diabetic Diet Cardiac Diet Continuous Infusions Plain IV(s) Sodium Chloride 0.9% 1,000 ml, IV, ml/hr Dextrose 5% with 0.45% Sodium Chloride 1,000 ml, IV, ml/hr Lactated Ringers 1,000 ml, IV, ml/hr 0.9% Sodium Chloride w/kcl Sodium Chloride 0.9% 1,000 ml/kcl 10 meq (IVS)* Sodium Chloride 0.9% 1,000 ml, IV, ml/hr potassium CHLORide additive 10 meq, EB Sodium Chloride 0.9% with KCl 20 meq 1,000 ml, IV, ml/hr Dextrose 5% in Water/0.45% w/kcl Dextrose 5% Water/Sodium Chloride 0.45% 1,000 ml/kcl 10 meq 1,000 ml, IV, ml/hr Dextrose 5% Water/Sodium Chloride 0.45% 1,000 ml/kcl 20 meq 1,000 ml, IV, ml/hr Medications Consult to Pharmacy - Pain Management Pain Management ORTHO Admission Pain Management(SUB)* Reversal Agents Narcan 0.4 mg, IV Push, Injection, every 2 min for 3 doses, PRN other (see comment) Comments: Respiratory Rate LESS THAN OR EQUAL to 8/min (very shallow and ineffective) OR if RASS LESS THAN -3. Notify practitioner if administered. VTE Prophylaxis To address VTE prophylaxis, order chemical and/or mechanical VTE prophylaxis via the subphase(s) below. To document a risk score and/or contraindication to prophylaxis, select the VTE Prophylaxis Guidelines order below(note)* VTE Hip Fracture Surgery Patients(SUB)* VTE Medical Patients(SUB)* VTE Prophylaxis Guidelines Glycemic Control GM Subcut Eating (basal/bolus + correction)(sub)* GM Subcut NPO/Continuous Enteral Feeding (basal + correction)(sub)* Constipation Colace 100 mg, Oral, Cap, BID (DEF)* Comments: Hold for Loose stool 250 mg, Oral, Cap, BID Comments: Hold for Loose stool Senokot 17.2 mg, Oral, Tab, QHS, PRN constipation Milk of Magnesia 8% 400 mg/5 ml susp 30 ml, Oral, Susp, QHS, PRN constipation Comments: Give if constipation unrelieved by docusate (Colace) and senna (Senokot)

187 Dulcolax Laxative 10 mg, PR, Supp, QHS, PRN constipation Comments: Give if constipation not relieved by magnesium hydroxide (Milk of Magnesium) Fleet Enema (Adult) rectal enema 133 ml, PR, Enema, Daily for 1 doses, PRN constipation Comments: Give if constipation not relieved by bisacodyl (Dulcolax) Nausea/Vomiting Zofran ODT 4 mg, Oral, Tab-Dis, every 6 hours., PRN nausea/vomiting Phenergan 25 mg, IV, Injection, every 6 hours., PRN nausea/vomiting Comments: May give 12.5 to 25 mg as needed if nausea/vomiting not relieved by ondansetron (Zofran) Miscellaneous Haldol 1.5 mg, IV Push, Injection, Daily for 3 doses Comments: To prevent post-op delirium. Laboratory CBC with Diff Blood, Routine, T;N Comments: if not done in ER BMP Blood, Routine, T;N Comments: if not done in ER Type and Screen Only Routine, T;N Comments: if not done in ER PT with INR Blood, Routine, T;N Comments: if not done in ER PTT Blood, Routine, T;N Comments: if not done in ER UA with Microscopic Routine Collect, T;N Nursing Communication Order TEG with platelet mapping if patient taking (or took within last 5 days) Clopidogel (Plavix) or Ticlopidine AM Labs CBC with Diff Blood, AM Draw (Inpatient Only), T+1;0330 BMP Blood, AM Draw (Inpatient Only), T+1;0330 Diagnostic Tests XR Chest 1 View Portable T;N, Reason: Pre-Op Card/Vasc/Neuro EKG 12 lead T;N, Stat Consults/Referrals Consult to Physician Consult Reason: For patients considered to be opioid tolerant. Per medical staff rules and regulations physician must initiate contact with consulting physicians. Communication Orders

188 Notify Treating Practitioner Vital Signs Systolic BP GREATER than 180 mmhg, Systolic BP LESS than 90 mmhg, HR GREATER than 120 beats/min, RR LESS than 24 breaths/min, SpO2 LESS than 93 %, Urine Output LESS than 120 ml every 4 hrs, Temp GREATER than 38.5 degrees Celsius Nursing Communication Order Do not give any anticoagulants on the day of surgery Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

189 Unique Plan Description: ORTHO POST-OP Pain Management Plan Selection Display: ORTHO POST-OP Pain Management PlanType: Medical Version: 1 Begin Effective Date: 12/9/ :42 End Effective Date: Current Available at all facilities ORTHO POST-OP Pain Management Medications POSToperative Medications Ofirmev 1,000 mg, IV Piggyback, Injection, every 6 hours. for 1 doses [Less Than 65 years] (DEF)* Comments: Give 6 hours since last dose, then transition to PO acetaminophen (Tylenol) 650 mg, IV Piggyback, Injection, every 6 hours. for 1 doses [Greater Than or Equal To 65 years] Comments: Then transition to PO acetaminophen (Tylenol) +6 Hours Tylenol 650 mg, Oral, Tab, every 6 hours. Comments: for remainder of hospital stay Toradol 15 mg, IV Push, Injection, every 6 hours. for 2 doses [Less Than 65 years] (DEF)* Comments: Then transition to naproxen (Naprosyn) 15 mg, IV Push, Injection, every 8 hours. for 2 doses [Greater Than or Equal To 65 years] Comments: Then transition to naproxen (Naprosyn) CeleBREX 200 mg, Oral, Cap, BID w/meals for 5 days [Less Than 65 years] (DEF)* Comments: Do not use if CrCl LESS than 30 ml/min 100 mg, Oral, Cap, BID w/meals for 5 days [Greater Than or Equal To 65 years] Comments: Do not use if CrCl LESS than 30 ml/min Naprosyn 500 mg, Oral, Tab, BID w/meals for 5 days [Less Than 65 years] (DEF)* 375 mg, Oral, Tab, BID w/meals for 5 days [Greater Than or Equal To 65 years] Lyrica 50 mg, Oral, Cap, every 8 hours. for 5 days [Less Than 65 years] (DEF)* 25 mg, Oral, Cap, every 8 hours. for 5 days [Greater Than or Equal To 65 years] oxycodone (OxyCONTIN) Do not use if patient age is 75 years or GREATER(NOTE)* OxyCONTIN 10 mg, Oral, Tab-ER, every 12 hours. [Less Than 75 years] Comments: During hospital stay - Discontinue upon discharge Pain (Moderate level 4-6) OxyIR 5 mg, Oral, Tab, every 3 hr, PRN pain, moderate (scale 4-6) Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due tramadol 50 mg, Oral, Tab, every 4 hours., PRN pain, moderate (scale 4-6) [Less Than 65 years] (DEF)* Comments: MAX dose - 400mg/24 hours or 200mg/24 hours with CrCl LESS than 30 ml/min 25 mg, Oral, Tab, every 4 hours., PRN pain, moderate (scale 4-6) [Greater Than or Equal To 65 years] Comments: MAX dose - 400mg/24 hours or 200mg/24 hours with CrCl LESS than 30 ml/min morphine 3 mg, IV Push, Injection, every 1 hr, PRN pain, moderate (scale 4-6) [Less Than 65 years] (DEF)* Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due

190 2 mg, IV Push, Injection, every 1 hr, PRN pain, moderate (scale 4-6) [Greater Than or Equal To 65 years] Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due Dilaudid 0.5 mg, IV Push, Injection, every 1 hr, PRN pain, moderate (scale 4-6) [Less Than 65 years] (DEF)* Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due 0.3 mg, IV Push, Injection, every 1 hr, PRN pain, moderate (scale 4-6) [Greater Than or Equal To 65 years] Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due Pain (Severe level 7-10) OxyIR 10 mg, Oral, Tab, every 3 hr, PRN pain, severe (scale 7-10) [Less Than 65 years] (DEF)* Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due 7.5 mg, Oral, Tab, every 3 hr, PRN pain, severe (scale 7-10) [Greater Than or Equal To 65 years] Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due tramadol 75 mg, Oral, Tab, every 4 hours., PRN pain, severe (scale 7-10) [Less Than 65 years] (DEF)* Comments: MAX dose - 400mg/24 hours or 200mg/24 hours with CrCl LESS than 30 ml/min 50 mg, Oral, Tab, every 4 hours., PRN pain, severe (scale 7-10) [Greater Than or Equal To 65 years] Comments: MAX dose - 400mg/24 hours or 200mg/24 hours with CrCl LESS than 30 ml/min morphine 6 mg, IV Push, Injection, every 3 hr, PRN pain, severe (scale 7-10) [Less Than 65 years] (DEF)* Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due. 4 mg, IV Push, Injection, every 1 hr, PRN pain, severe (scale 7-10) [Greater Than or Equal To 65 years] Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due. Dilaudid 1 mg, IV Push, Injection, every 1 hr, PRN pain, severe (scale 7-10) [Less Than 65 years] (DEF)* Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due. 0.5 mg, IV Push, Injection, every 1 hr, PRN pain, severe (scale 7-10) [Greater Than or Equal To 65 years] Comments: If both PO and IV pain medications are selected for the same pain level, use the IV pain medications if patient is unable to tolerate PO meds or pain level does not reach patient's goal by one hour after PO dose and next PO dose not yet due. Non Categorized Initial Approval Date Annual Review Date *Report Legend:

191 Unique Plan Description: TR MedSurg Admission Plan Selection Display: TR MedSurg Admission PlanType: Medical Version: 1 Begin Effective Date: 7/3/ :39 End Effective Date: Current Available at all facilities TR MedSurg Admission Admit/Transfer/Discharge/Status Admission Status(SUB)* Patient Care General Telemetry(SUB)* Resuscitation Status Full Code (Full Treatment) (DEF)* Do Not Resuscitate (Allow Natural Death) Do Not Intubate Limited: All but Chest Compressions Limited: All but Defibrillation Limited: All but compressions and Defib Vital Signs every 4 hr Intake and Output every 4 hr (DEF)* Every shift Neurological Assessment every 4 hr, Glasgow Coma Scale Neurovascular Assessment Fractured extremity every 2 hours for 24 hours and then every 4 hours until swelling subsides Wound Care Instructions Dressing Change Gauze dressing, Change dressing: BID, Topical Cleanse: Wound Cleanser, After cleaning abrasions with wound spray, apply Bacitracin bacitracin 500 units/g topical ointment 1 app, Topical, Ointment, BID Comments: Apply to skin abrasion(s) after cleansing Lines/Tubes/Drains Urinary Catheter Maintain Nasogastric (NG) Tube Care Tube to Low Intermittent Suction Drain Care Bulb-suction Chest Tube Care -20 cm water suction (DEF)* -20 cm water seal Activity Bedrest (strict) Up to Chair Daily, Or wheelchair as tolerated Head of Bed Head of Bed Level: Up to 30 degrees, when cervical spine is cleared Ambulate TID Elevate Affected Extremity

192 Cervical Spine Restrictions C-Spine Cleared Thoracolumbar Spine Restrictions Weight Bearing Status non weight-bearing (DEF)* toe touch weight-bearing Diet/Nutrition NPO No Exceptions (DEF)* Except for Ice Chips Except for Medications, 30mL/hour as needed for thirst Except for Medications Clear Liquid Diet Full Liquid Diet Regular Diet Diabetic Diet Diabetic Diabetic Clear Liquid Diet Cardiac Diet Low Fat/Low Cholesterol Diet Consult to Registered Dietitian Continuous Infusions Bolus Sodium Chloride 0.9% Bolus 1,000 ml, IV Bolus, Soln-IV, Once (DEF)* 500 ml, IV Bolus, Soln-IV, Once Lactated Ringers Bolus 1,000 ml, IV Bolus, Soln-IV, Once (DEF)* 500 ml, IV Bolus, Soln-IV, Once Maintenance Infusions Dextrose 5% with 0.45% Sodium Chloride 1,000 ml, IV, 125 ml/hr Dextrose 5% Water/Sodium Chloride 0.45% 1,000 ml/kcl 20 meq 1,000 ml, IV, 125 ml/hr Sodium Chloride 0.9% 1,000 ml, IV, 125 ml/hr Lactated Ringers Drip 1,000 ml, IV, 125 ml/hr Banana Bag Banana Bag Infusion(SUB)* Medications Pain Management Scheduled Pain(NOTE)* Toradol 15 mg, IV Push, Injection, every 6 hours. for 5 days lidocaine 5% topical film 1 patches, Transdermal, Film, Daily Comments: Apply to affected area, remove 12 hours after placement Pain (Moderate level 4-6)(NOTE)* Norco 5 mg-325 mg oral tablet 2 tab, Oral, Tab, every 4 hours., PRN pain, moderate (scale 4-6) Dilaudid 0.5 mg, IV Push, Injection, every 2 hours., PRN pain, moderate (scale 4-6) Pain (Severe 7-10)(NOTE)*

193 Norco 10 mg-325 mg oral tablet 2 tab, Oral, Tab, every 4 hours., PRN pain, severe (scale 7-10) Dilaudid 1 mg, IV Push, Injection, every 2 hours., PRN pain, severe (scale 7-10) PCA(NOTE)* PCA HYDROmorphone (Dilaudid)(SUB)* PCA Morphine(SUB)* VTE Prophylaxis To address VTE prophylaxis, order chemical and/or mechanical VTE prophylaxis via the subphase(s) below. Or, to document a risk score and/or contraindication to prophylaxis, select the VTE Advisor order below(note)* VTE Trauma Patients(SUB)* VTE Advisor Respiratory Medications Proventil HFA 90 mcg/inh inhalation aerosol 1 puffs, Inhale, Aerosol, Resp every 4 hrs while awake for 14 days Proventil HFA 90 mcg/inh inhalation aerosol 1 puffs, Inhale, Aerosol, Resp every 2 hours for 14 days, PRN shortness of breath or wheezing Proventil 2.5 mg/3 ml (0.083%) inhalation solution 2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 4 hours for 14 days Proventil 2.5 mg/3 ml (0.083%) inhalation solution 2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 2 hours for 14 days, PRN shortness of breath or wheezing Atrovent 0.02% 500 mcg/2.5 ml solution for nebulization 0.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 4 hours for 14 days Atrovent 0.02% 500 mcg/2.5 ml solution for nebulization 0.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 2 hours for 14 days, PRN shortness of breath or wheezing Gastrointestinal Agents Pepcid 20 mg, Oral, Tab, every 12 hours. (DEF)* 20 mg, IV Push, Injection, every 12 hours. Protonix 40 mg, Oral, Tab-DR, Daily Comments: Do not crush or chew. Pantoprazole (Protonix) IV and Alternatives(SUB)* Laxative(s) Dulcolax Laxative 10 mg, PR, Supp, QHS Comments: Hold if Bowel Movement today Senokot S 50 mg-8.6 mg oral tablet 2 tab, Oral, Tab, BID Fever Tylenol 650 mg, Oral, Tab, every 4 hours., PRN fever (DEF)* Comments: For Temperature GREATER than 38 DegC (100.4DegF) 650 mg, NG Tube, Liquid, every 4 hours., PRN fever Comments: For Temperature GREATER than 38 DegC (100.4DegF) 650 mg, PR, Supp, every 4 hours., PRN fever Comments: For Temperature GREATER than 38 DegC (100.4DegF) Nausea/Vomiting Zofran 4 mg, IV Push, Injection, every 6 hours., PRN nausea/vomiting

194 Zofran ODT 4 mg, Oral, Tab-Dis, every 6 hours., PRN nausea/vomiting Phenergan 25 mg, IV Push, Injection, every 6 hours., PRN nausea/vomiting Comments: If zofran ineffective use phenergan as second line Blood Pressure Management hydralazine 10 mg, IV Push, Injection, every 6 hours., PRN hypertension Comments: For Systolic Blood Pressure GREATER than 160 mmhg, Diastolic Blood Pressure GREATER than 100 mmhg Vasotec 1.25 mg, IV Push, Injection, every 6 hours., PRN hypertension (DEF)* Comments: For Systolic Blood Pressure GREATER than 160 mmhg, Diastolic Blood Pressure GREATER than 100 mmhg 2.5 mg, IV Push, Injection, every 6 hours., PRN hypertension Comments: For Systolic Blood Pressure GREATER than 160 mmhg, Diastolic Blood Pressure GREATER than 100 mmhg Glycemic Control GM Subcut Eating (basal/bolus + correction)(sub)* GM Subcut NPO/Continuous Enteral Feeding (basal + correction)(sub)* Smoking Cessation Medications Smoking and Tobacco Cessation(SUB)* Laboratory Admission Labs CBC with Diff Blood, Stat, T;N Renal Panel 1 Blood, Stat, T;N Phosphorus Level Blood, Stat, T;N Mg Level Blood, Stat, T;N Teg and Tegh, Basic Blood, Stat, T;N Teg Platelet Mapping Blood, Stat, T;N CPK Blood, Stat, T;N PT with INR Blood, Stat, T;N PTT Blood, Stat, T;N AM Labs CBC with Diff Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 3 days Renal Panel 1 Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 3 days Phosphorus Level Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 3 days Mg Level Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 3 days PT with INR Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 3 days

195 PTT Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 3 days Lipase Level Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 3 days Liver Panel Blood, AM Draw (Inpatient Only), T+1;0330, Daily, for 3 days Time Study Prealbumin, Serum Blood, Timed Study, T;N, Mon/Thurs, for 3 times CRP High Sensitivity Blood, Timed Study, T;N, Mon/Thurs, for 3 times Diagnostic Tests XR Chest 1 View Portable T+1;0600, In AM MRI Spine Cervical w/o Contrast Stat Respiratory Oximetry - Continuous Incentive Spirometry Respiratory every 1 hr, Perform 10 times Oxygen Therapy SpO2 goal 90% or GREATER, Nasal Cannula (DEF)* SpO2 goal 90% or GREATER, Simple Mask Therapies Physical Therapy Evaluation and Treatment Acute Speech Therapy-Language/Cognition Evaluation and Treatment Acute Consults/Referrals Consult to Wound Care Specialist Consult to Patient Family Services Reason for Consult Substance Abuse - Adult (DEF)* Reason for Consult Grief/Death and Dying Issues Reason for Consult Acute Medical Dx or Disabling Condition Reason for Consult Letter, DMV Notification Consult to Case Management Reason for Consult Discharge Planning Communication Orders Notify Treating Practitioner Vital Signs Systolic BP GREATER than 160 mmhg, Systolic BP LESS than 90 mmhg, HR GREATER than 120 beats/min, HR LESS than 60 beats/min, SpO2 LESS than 90 %, Temp GREATER than 38.3 degrees Celsius Nursing Communication Order If oxygen saturation LESS than 90% or respiratory distress, RN to obtain: STAT ABG and STAT Portable Chest X-Ray. Call practitioner if criteria met. Nursing Communication Order If new onset dysrhythmia or chest pain, RN to obtain: STAT Renal Panel I, Magnesium, and 12 Lead EKG. Call practitioner if criteria met. Supplies Specialty Bed Non Categorized TR Solid Organ Injury(SUB)* Initial Approval Date Annual Review Date

196 RESOLUTION NUMBER 1984 A RESOLUTION OF THE BOARD OF DIRECTORS OF KAWEAH DELTA HEALTH CARE DISTRICT REGARDING PROFESSIONAL LIABILITY INSURANCE REQUIREMENTS FOR ALL MEMBERS OF THE MEDICAL STAFF AND ADVANCED PRACTICE PROVIDER STAFF WHEREAS, all members of the Medical Staff of Kaweah Delta Health Care District are required to obtain and maintain professional liability insurance as a condition of appointment or reappointment and to maintain admitting and clinical privileges; and WHEREAS, all members of the Advanced Practice Provider Staff of Kaweah Delta Health Care District are required to obtain and maintain professional liability insurance as a condition of appointment or reappointment and to maintain clinical privileges; and WHEREAS, the Board of Directors of Kaweah Delta Health Care District has previously taken action requiring that such insurance be issued by an insurance company that has been issued a Certificate of Authority by the California Insurance Commissioner, or through an insurance company licensed to do business in California that has and maintains an A.M. Best rating of at least A (Excellent) and an FSC of at least VII ($50 million to $100 million); or be issued by the Cooperative of American Physicians, Inc., / Mutual Protection Trust (CAP/MPT), or through the Health Providers Insurance Reciprocal, RRG; and WHEREAS, CAP is a consumer cooperative formed by physicians and is physician-owned and governed, with a current A.M. Best rating of A- (Excellent) and a Financial Size Category (FSC) of V ($10 million to $25 million); and MPT is an interindemnity arrangement structured so that its members share the cost of medical professional liability protection, is required by law to accumulate a minimum trust fund corpus of $10 million with the use of the funds in the MPT trust restricted by the requirements of California Insurance Code and the MPT Trust agreement, and has a current A.M. Best rating of A+ (Superior) and a FSC of VIII ($100 million to $ 250 million); and WHEREAS, Health Providers Insurance Reciprocal, RRG and BETA Risk Management Authority, each with a current A.M. Best Ratings of A (Excellent) and an FSC of VIII ($100 Million to $250 Million), are member companies of BETA, the largest insurer of hospital professional liability coverage in California, serving more than 200 hospitals and healthcare facilities with more than 5,000 insured physicians and over 50 medical groups; and WHEREAS, the current general requirement for professional liability insurance coverage for all members of the Medical Staff and Advanced Practice Provider Staff is individual coverage of not less than $1,000,000 per occurrence/$3,000,000 annual aggregate; and Kaweah Delta Health Care District - Resolution 1984 Page 1 of 5 Pages

197 WHEREAS, the Board of Directors of Kaweah Delta Health Care District has previously taken action to permit shared coverage between a single Advanced Practice Provider and a medical corporation by which the Advanced Practice Provider is employed where the professional liability insurance is in the minimum amounts of $1,000,000 per occurrence/$3,000,000 annual aggregate, with a deductible or selfinsurance retention of no more than $100,000, through an insurance company that has been issued a Certificate of Authority by the California Insurance Commissioner; or through an insurance company licensed to do business in California that has and maintains an A.M. Best rating of at least A (Excellent) and an FSC of at least VII ($50 million to $100 million); and WHEREAS, some members of the Medical Staff and Advanced Practice Provider Staff are covered by the Federal Tort Claims Act under circumstances in which the District is required to accept such coverage for the purposes of Medical Staff membership, and admitting and clinical privileges; and WHEREAS, some members of the Medical Staff, and Advanced Practice Provider Staff who are employed by the County of Tulare, are covered by the County s self-insurance fund for the purposes of professional liability; and WHEREAS, some members of the Medical Staff are owners of a business entity insured by a risk retention group that has a current A.M. Best rating of A (Excellent) and an FSC of VII ($50 million to $100 million), and has a reinsurance treaty with an insurance company that has and maintains an A.M. Best rating of at least A (Excellent) and an FSC of at least VI ($25 million to $50 million); the business entity also has net assets exceeding $15,000,000 which are readily available for collection to cover a liability claim exceeding the business entity s insurance policy limits; and WHEREAS, Kaweah Delta Health Care District has been advised by its insurance consultant that professional liability insurance coverage through a California eligible surplus line insurer (i.e., on the List of Approved Surplus Line Insurers (LASLI) with the California Department of Insurance) with a current A.M. Best Rating of A++ (Superior) and an FSC of XV ($2 billion or greater), is commercially reasonable coverage for members of the Kaweah Delta Health Care District Medical Staff or Advanced Practice Provider Staff; WHEREAS, the Board of Directors of Kaweah Delta Health Care District desires to formally set forth a current statement of the requirements for professional liability coverage for members of the Medical Staff and Advanced Practice Provider Staff; and WHEREAS, the Medical Executive Committee of the Medical Staff of Kaweah Delta Health Care District unanimously approved the provisions of this Resolution on January 16, 2018; Kaweah Delta Health Care District - Resolution 1984 Page 2 of 5 Pages

198 THEREFORE, IT IS HEREBY RESOLVED, that all members of the Medical Staff of Kaweah Delta Health Care District, as a condition of appointment or reappointment and to maintain admitting and clinical privileges, and all members of the Advanced Practice Provider Staff as a condition of appointment or reappointment and to maintain clinical privileges are required to obtain and maintain at all times, continuous coverage through one of the following: 1. Individual and separate limits of professional liability insurance in continuous force in the minimum amounts of $1,000,000 per occurrence/$3,000,000 annual aggregate, with a deductible or selfinsured retention of no more than $100,000, through an insurance company that has been issued a Certificate of Authority by the California Insurance Commissioner; or through an insurance company licensed to do business in California that has and maintains an A.M. Best rating of at least A (Excellent) and an FSC of at least VII ($50 million to $100 million); or through a California eligible surplus line insurer (i.e., on the List of Approved Surplus Line Insurers (LASLI) with the California Department of Insurance) with a current A.M. Best rating of at least A++ (Superior) and an FSC of at least XV ($2 billion or greater); or 2. Liability coverage provided under a fund administered under the Federal Tort Claims Act for federal employees, under circumstances in which Kaweah Delta Health Care District is required to accept such coverage for the purposes of appointment or reappointment to Medical Staff membership and admitting and clinical privileges, and for the purposes of appointment or reappointment to Advanced Practice Provider Staff membership and clinical privileges (Physicians and Advanced Practice Providers employed by Family Health Care Network currently meet the requirements of this category.); or 3. Coverage in the minimum amounts of $1,000,000 per occurrence/$3,000,000 annual aggregate, under a California governmental entity s self-insurance fund, which the Board of Directors of Kaweah Delta Health Care District has determined is funded to an acceptable confidence level (The Tulare County Self Insurance Fund currently meets the requirements of this category.); or 4. Coverage in the minimum amounts of $1,000,000 per occurrence/$3,000,000 annual aggregate, with a deductible or selfinsurance retention of no more than $100,000, through the Cooperative of American Physicians, Inc., / Mutual Protection Trust (CAP/MPT) provided they continue to maintain the current A.M. Best ratings and FSCs, and the other arrangements described earlier in this Resolution; or Kaweah Delta Health Care District - Resolution 1984 Page 3 of 5 Pages

199 5. Coverage in the minimum amounts of $1,000,000 per occurrence/ $3,000,000 annual aggregate, with a deductible or self-insurance retention of no more than $100,000 through the Health Providers Insurance Reciprocal, RRG or the BETA Risk Management Authority, provided the insuring entity continues to meet the A.M. Best rating and FSC described earlier in this Resolution; or 6. Shared limits of professional liability insurance for an Advanced Practice Provider in the minimum amounts of $1,000,000 per occurrence/$2,000,000 aggregate limit per claim/$5,000,000 annual aggregate, with a deductible or self-insurance retention of no more than $100,000, through a risk retention group that has a reinsurance treaty with an insurance company that has and maintains an A.M. Best rating of at least A (Excellent) and an FSC of at least VI ($25 million to $50 million) provided the Advanced Practice Provider is an employee of a business entity with net assets exceeding $15,000,000, which are readily available for collection to cover a liability claim exceeding the business entity s insurance policy limits, and the Kaweah Delta Health Care District Board of Directors has approved the business entity s annual attestation, provided through counsel, to its financial strength and stability; or 7. Individual limits of professional liability insurance for a Medical Staff member in the minimum amounts of $1,000,000 per occurrence/$2,000,000 aggregate limit per claim/$5,000,000 annual aggregate, with a deductible or self-insurance retention of no more than $100,000, through a risk retention group that has a reinsurance treaty with an insurance company that has and maintains an A.M. Best rating of at least A (Excellent) and an FSC of at least VI ($25 million to $50 million) provided the Medical staff member is an owner or employee of a business entity with net assets exceeding $15,000,000, which are readily available for collection to cover a liability claim exceeding the business entity s insurance policy limits, and the Kaweah Delta Health Care District Board of Directors has approved the business entity s annual attestation, provided through counsel, to its financial strength and stability; or 8. Shared limits of professional liability insurance in the minimum amounts of $1,000,000 per occurrence/$3,000,000 per annual aggregate, with a deductible or self-insurance retention of no more than $100,000, through an insurance company that has been issued a Certificate of Authority by the California Insurance Commissioner; or through an insurance company licensed to do business in California that has and maintains an A.M. Best rating of at least A (Excellent) and an FSC of at least VII ($50 million to $100 million) provided the Kaweah Delta Health Care District - Resolution 1984 Page 4 of 5 Pages

200 shared coverage is between a single Advanced Practice Provider and a medical corporation by which the Advanced Practice Provider is employed; or 9. Any other coverage by an insurance program that is specifically approved in writing by the Medical Executive Committee and the Board of Directors of Kaweah Delta Health Care District. BE IT FURTHER RESOLVED, that continuous coverage means current professional liability coverage for all services performed throughout the District, as well as evidence of tail or nose coverage for all services provided throughout the District for prior periods of Medical Staff membership in the event the Medical Staff member or Advanced Practice Provider Staff member has changed insurance carriers. Continuous coverage means professional liability coverage, without coverage gaps, from the date of initial appointment to the present; and BE IT FURTHER RESOLVED, that suitable evidence of such professional liability coverage must be on file at all times in the Medical Staff Office in the form of a Certificate of Insurance from the insurance company or in the form of a letter of coverage from a Federal Tort Claims Act fund, or from Tulare County or another California governmental entity s self-insurance fund; and BE IT FUTHER RESOLVED, that documentation of any professional liability coverage limitations or restrictions that may have been placed on any professional liability policy or other form of coverage must be on file at all times in the Medical Staff Office in the form of the actual policy with the limitations or restrictions highlighted or, in the form of a letter from the insurance provider describing the coverage restrictions or limitations. This Resolution was adopted by the Board of Directors of Kaweah Delta Health Care District at a duly constituted meeting on the 22nd day of January, President, Board of Directors Kaweah Delta Health Care District Attest: Secretary/Treasurer, Board of Directors Kaweah Delta Health Care District Kaweah Delta Health Care District - Resolution 1984 Page 5 of 5 Pages

201 KAWEAH DELTA HEALTH CARE DISTRICT Medical Staff Service Certificate of Insurance Guidelines To meet the professional liability insurance requirements set forth in Resolution 1984 of the Board of Directors of Kaweah Delta Health Care District, as approved by the Medical Staff, evidence of continuous professional liability coverage must be on file at all times in the Medical Staff Office in the form of a Certificate of Insurance from the insurance company or in the form of a letter of coverage from a Federal Tort Claims Act fund, or from Tulare County or another California governmental entity s self-insurance fund. Letters of coverage and Certificates of Insurance must meet the following guidelines: 1. Professional liability insurance must have a minimum coverage of $1,000,000 per occurrence/ $3,000,000 in the aggregate. 2. The deductible or self-insurance retention can be no more than $100,000 per provider. 3. The following coverages/companies have been specifically approved by the terms of the Resolution: County of Tulare Self-Insurance Fund Federal Torts Claims Act Coverage (e.g., Family HealthCare Network employees) Cooperative of American Physicians, Inc., / Mutual Protection Trust (CAP/MPT) Health Providers Insurance Reciprocal, RRG or the BETA Risk Management Authority, both member companies of BETA The Mutual Risk Retention Group, Inc. (for CEP providers) 4. Unless specifically identified in the Resolution, the insurance company must meet one of the following: a.) have been issued a Certificate of Authority by the California Insurance Commissioner; b.) be licensed to do business in California and have an A.M. Best rating of at least A (Excellent) and a financial size category (FSC) of at least VII ($50 million to $100 million); or KDHCD - Medical Staff Certificate of Insurance Guidelines Page 1 of 2 Pages

202 c.) be a California eligible surplus line insurer on the List of Approved Surplus Line Insurers (LASLI) with the California Department of Insurance and have a current A.M. Best rating of at least A++ (Superior) and an FSC of at least XV ($2 billion or greater). Confirmation of an insurance company s license status can be obtained by searching the California Department of Insurance website for the company s business name at The company name on the Certificate of Insurance MUST be an exact match to the name on the website. If there is not an exact match, proof must be provided that the company issuing the insurance has been issued a Certificate of Authority or is otherwise licensed to do business in California and meets the A.M. Best requirements. Information on a company s A.M. Best rating and FSC is available on the A.M Best website at A list of surplus line insurers that meet the requirements of the Resolution is provided as part of the application for appointment/reappointment. 5. No shared limits of liability coverage are permitted except under the following circumstances: one (1) Advanced Practice Provider can share limits of liability with his/her employer medical group on a group policy. 6. For letters of coverage, Physicians and Advanced Practice Providers who are, or have been, employed by a governmental entity (e.g., a County, a State health care facility) or a HRSA Health Center Program should provide a letter of employment from that entity that confirms their employment or independent contractor status and specifies that professional liability coverage is provided by the government consistent with the requirements of these guidelines. 7. Continuous coverage as required by the Resolution means current professional liability coverage for all services performed throughout Kaweah Delta, as well as evidence of tail or nose coverage for all services provided throughout Kaweah Delta for prior periods of Medical Staff membership in the event the Medical Staff member or Advanced Practice Provider Staff member has changed insurance carriers. Continuous coverage also means professional liability coverage, without coverage gaps, from the date of initial appointment to the present. 8. Documentation of any professional liability coverage limitations or restrictions that may have been placed on any professional liability policy or other form of coverage must be on file at all times in the Medical Staff Office in the form of the actual policy with the limitations or restrictions highlighted or, in the form of a letter from the insurance provider describing the coverage restrictions or limitations. KDHCD - Medical Staff Certificate of Insurance Guidelines Page 2 of 2 Pages

203 [Draft letter from Board and Medical Staff} January 22, 2018 Re: Kaweah Delta Health Care District Medical Staff Application for Appointment/Reappointment Professional Liability Insurance Dear Applicant, Thank you for your interest in the Medical Staff of Kaweah Delta Health Care District. This letter is intended to help you fulfill the requirements for professional liability insurance coverage, a condition of membership and clinical privileges. Kaweah Delta Health Care District (Kaweah Delta) is a local governmental entity with a publicly elected Board of Directors. Kaweah Delta is self-insured for professional liability. To appropriately protect the public assets of Kaweah Delta, and to ensure consistent and reliable coverage among credentialed providers, the Board and the Medical Staff, after careful consideration, have approved requirements for professional liability insurance coverage for members of the Medical Staff and the Advanced Practice Provider Staff. Those requirements are set forth in Board Resolution. The brief summary below will assist you in meeting those requirements. Generally, the requirements are continuous individual and separate coverage of $1M per claim/$3m annual aggregate. Any self-insured retention by the applicant can be no more than $100,000. Forms of acceptable coverage include: A. Individuals Employed by Tulare County Tulare County s self-insurance program has been approved for those providing care on behalf of the County. A certificate of insurance from the County, which can be obtained from the County, should be included as part of your application. Certificate of Insurance Guidelines are included as part of your application materials. B. Individuals Employed by Family HealthCare Network For employees of Family HealthCare Network, professional liability insurance coverage is provided under the Federal Tort Claims Act (FTCA). The FTCA coverage satisfies the professional liability insurance requirements of the Resolution. A letter from Family HealthCare Network confirming the coverage should be included as part of your application

204 C. CEP Employees The professional liability coverage for Physicians and Advanced Practice Providers employed by California Emergency Physicians (CEP) has been determined to comply with the terms of the Resolution. Please include a Certificate of Insurance, obtainable from CEP, as part of your application. D. Insurers Approved by Name in the Resolution The following companies have been specifically approved by the terms of the Resolution: CAP/MPT Health Providers Insurance Reciprocal, RRG BETA Risk Management Authority If your insurance coverage is through one of these companies, please include a Certificate of Insurance, from or on behalf of the company, as part of your application. Coverage through an insurance company, other than those referenced above, must be through either E. or F. below. E. Qualifying California Licensed Insurers Coverage can be provided through a company that has been issued a Certificate of Authority by the California Insurance Commissioner, or through an insurance company licensed to do business in California that has and maintains an A.M. Best rating of at least A (Excellent) and an FSC of at least VII ($50 million to $100 million). NorCal and The Doctors Company are examples of companies that meet these requirements. Your insurance agent/broker can assist you in making sure that your contemplated carrier satisfies these requirements. If your insurance coverage is through a company meeting these requirements, a Certificate of Insurance from or on behalf of the company should be included as part of your application. F. Surplus Line Insurers Coverage may also be obtained from certain California eligible surplus line insurers. Such an insurer must be on the List of Approved Surplus Line Insurers (LASLI) with the California Department of Insurance and have a current A.M. Best rating of at least A++ (Superior) and an FSC of at least XV ($2 billion or greater). A list of the California eligible surplus line insurers is included with your application materials. Only the companies included on the provided list may be used to satisfy the professional liability insurance requirement through a surplus line insurer. Continuous coverage as required by the Resolution means current professional liability coverage for all services performed throughout Kaweah Delta, as well as evidence of tail or nose coverage for all services provided throughout Kaweah Delta for prior periods of Medical Staff membership in the event the Medical Staff member or Advanced Practice Provider Staff member has changed insurance carriers. Continuous coverage also means professional liability coverage, without coverage gaps, from the date of initial appointment to the present.

205 Documentation of any professional liability coverage limitations or restrictions that may have been placed on any professional liability policy or other form of coverage must be on file at all times in the Medical Staff Office in the form of the actual policy with the limitations or restrictions highlighted or, in the form of a letter from the insurance provider describing the coverage restrictions or limitations. If your insurance coverage is not through one of the agencies or companies specifically identified above, it is recommended that you provide a copy of this letter and the Certificate of Insurance Guidelines to your insurance agent or broker so he/she can assist you in obtaining acceptable coverage. The Medical Staff Office will review your evidence of insurance as part of your application. But it is the responsibility of the applicant, with the assistance of his/her insurance agent or broker, to make sure that your insurance coverage satisfies the requirements approved by the Medical Staff and the Board. If you have questions, with the information contained in this letter your agent or broker should be able to advise and assist you. Thank you for your cooperation. Kaweah Delta Health Care District Kaweah Delta Health Care District Medical Staff Lynn Havard Mirviss, Board President Harry R. Lively, M.D., Chief of Staff

206 Falls Committee Report January 22, 2018 Rose Newsom, RN MSN NE-BE Director of Nursing Practice

207 Committee Purpose & Goals Keep our patients safe from harm Reduce overall falls per 1000 patient days Standardize fall prevention strategies across the District

208 Cost of Falls $6,000-$35,000 per fall & add 6.3 days to LOS Personal toll: falls are not just for the elderly & cognitively impaired Falls with injury are consistently among the Joint Commission s top 10 sentinel events Can lead to drastic changes in lifestyle & independence

209 Joint Commission Best Practice Recommendations Interdisciplinary Falls Committee Organizational falls prevention education Use of a standardized fall assessment tool Conduct post fall huddles & assessments Monitor results Personalized plans of care Standardized hand-off communication One-to-one patient education

210 How Do We Compare? Interdisciplinary Falls Committee in place : Falls prevention education for all new employees & as requested by non-clinical areas Patient assessment: Johns Hopkins + Age-Bone density-coagulation-surgery (ABCS) tools Falls University, Falling Star, Post Fall Nursing Order set, Safety Huddles, Plans of Care for those at risk, Rural Health Clinic Screening, CUSP Teams Ongoing unit level monitoring: Nursing dashboard Opportunity: Human factors & hand off communication

211 Falls University Attribution

212 Performance Over Time (Before Midas Reporting Q3, 2012-Q1, 2015) KDHCD - Total Falls per 1,000 Pt Days KHDHCD KDHCD Avg National Avg (NDNQI) Linear ( KHDHCD) rd qtr 12 4th qtr 12 1st qtr 13 2nd qtr 13 3rd qtr 13 4th qtr 13 1st qtr 14 2nd qtr 14 3rd qtr 14 4th qtr 14 1st qtr 15 KDHCD - Total Injury Falls per 1,000 Pt Days KDMC KDMC Av NDNQI av 2Q11 to 1Q13 Linear (KDMC) rd qtr 12 4th qtr 12 1st qtr 13 2nd qtr 13 3rd qtr 13 4th qtr 13 1st qtr 14 2nd qtr 14 3rd qtr 14 4th qtr 14 1st qtr 15 2nd qtr 15

213 Performance Over Time (Before Midas Reporting Q3, 2012-Q1, 2015)) KDHCD - Total Moderate to Severe Injury Falls per 1,000 Pt Days KDMC KDMC Av NDNQI av 2Q11 to 1Q13 Linear (KDMC) rd qtr 124th qtr 12 1st qtr 13 2nd qtr 13 3rd qtr 134th qtr 13 1st qtr 14 2nd qtr 14 3rd qtr 144th qtr 14 1st qtr 15

214 How Are We Doing? (After Midas Reporting Implementation)

215 How Are We Doing?

216 How Are We Doing?

217 Analysis Overall, we have achieved a sustained reduction in total falls below NDNQI benchmark Overall, injury falls are trending downward 93% of injuries are classified as minor Human factors & communication failures are top attributions identified during Falls University

218 Recommendations for Improvement Onboarding of clinical staff Standardize handoff communication: What makes this patient at risk? Best practice literature review: What else can we do? Continued community outreach & screening

219

220

221 Kaweah Delta Health Care District Goals 1. Achieve outstanding health outcomes for our patients Continuously improve performance in clinical quality and patient safety Meet the expectations of our patients and physicians Continuously improve operating and information systems 2. Provide excellent service to our patients and customers Exceed the expectations of our patients, families, physicians, staff and other customers Continuously improve performance in customer service and patient satisfaction Anticipate and proactively respond to the needs of our patients and customers 3. Provide an ideal work environment for our staff and physicians Employ effective recruitment and retention strategies for engaged and productive staff and physicians Train and develop our leaders, staff and physicians Assess and effectively respond to staff and physicians needs 4. Maintain financial strength to ensure the delivery of outstanding healthcare services Develop and effectively implement financial plans that meet service and facility requirements for outstanding patient care Maintain sufficient profitability and liquidity to consistently sustain operations and provide cost-effective access to capital markets 4

222 Kaweah Delta Health Care District Strategic Plan Create Patient, Community and Payer Preference for KDHCD Respond to Emerging Market Needs and Opportunities Integrated Delivery System Strategy Community Engagement Improve Clinical Quality and Patient Safety Public Reports Reflect Continual Improvement Develop a Collaborative Culture Committed to Rapid Cycle Improvement Develop Future Facilities and Technology to Support Key Service Lines Facilities and Technology Management Growth and Market Share Outstanding Health Outcomes Community Health Improve Access to Medical Care/Population Management Promote Health Education and Healthy Lifestyle Choices Improve the Continuum of Care Improve Profitability, Liquidity and Access to Capital Financial Strength Together, Kaweah Delta and its Medical Staff will be recognized for consistently delivering superior clinical quality across a broad range of exceptional health care services providing exemplary patient and community service. Information Management and Integration Across the Continuum Implement an Integrated Suite of Clinical and Revenue Cycle Solutions Identify Information Technologies Pertaining to Population Health Hardwire Kaweah Care to Improve the Patient and Family Experience Excellent Service Recruit, Retain and Develop High- Performing Leaders and Employees Improve Employee Engagement Promote Leadership Development/Succession Planning Ideal Work Environment Graduate Medical Education Graduate Medical Education Programs Medical Staff Hospital/Physician Alignment Strategies Recruit and Retain High-Performing Physicians Improve the Medical Staff Experience 5

223 Kaweah Delta Health Care District FACILITIES AND SERVICES PLAN Short-Term (1-2 Years, Fiscal Years ) Project/Executive Surgery services expansion and remodel (COO/CNO) Objective Expand and update Ambulatory Surgery New surgery storage addition Potential Location Existing ambulatory surgery space ASC basement Considerations Project includes: Conversion of Ambulatory Surgery basement for surgery storage expansion Capital Requirements $7,898,000 from revenue bonds for ambulatory surgery and related projects Anticipated Occupancy Date Ambulatory Surgery Center Preop expansion (includes basement storage addition): Construction FY 2017 Occupancy FY 2018 Northside Urgent Care Center (CEO/COO/CNO) Expand patient access to primary medical care Demaree North of Riggin Ave. Need for services Financial feasibility Alleviate pressure on ED $4,000,000 funded from 2015B revenue bond Construction FY 2017 Occupancy FY 2018 Exeter Health Clinic Campus Upgrades (CFO) Install two new modular buildings for Administration Office and Women s Health Clinic, with expanded parking Main Clinic selective remodel Exeter Health Clinic Campus Facility and site upgrades to accommodate current clinic practice and technologies Modular buildings and parking: $6,500,000 funded from $400,000 existing revenue bonds, plus $6,100,000 from 2015B revenue bond Main Clinic selective remodel: to be determined Modular buildings and parking: Construction FY 2017 Occupancy FY 2018 Main Clinic selective remodel: to be determined Emergency Department Expansion 24-bed ED building addition ED Zone 4 Infill and new Fast Track Unit Phlebotomy lab draw (CEO/COO/CNO) Expand to meet projected patient demand Increase bed capacity Provide secure mental health holding Building expansion into East Lot Acequia Wing Zone 4 Vacated nuclear medicine space in MK ground floor Patient demand Appropriate venue for care Availability of on-call physicians $32,800,000 funded from 2015B revenue bond Zone 4 Infill, Fast Track and phlebotomy lab draw: Construction FY 2018 Occupancy FY bed ED building addition: Construction FY 2018 Occupancy FY

224 Project/Executive Objective Potential Location Considerations Capital Requirements Anticipated Occupancy Date Acequia Wing 5th and 6th Floors Infill (CEO, ET) Increase bed capacity by 47: 24-bed medsurgical on 5th floor 23-bed NICU on 6th floor Acequia Wing 5th and 6th Floors Provide for current and anticipated technology NICU medical equipment Total $24,300,000, funded as follows: $23,100,000 funded from $1,100,000 existing funding for planning and design, plus $22,000,000 from 2015B revenue bond. $1,200,000 for NICU medical equipment: Foundation funds Construction FY 2018 Occupancy FY 2019 OB Surgery Expansion (CNO) Expand capacity to care for infants Provide new modern OB surgery suite and PACU Acequia Wing 2nd floor $6,500,000 funded from 2015B revenue bond Construction FY 2017 Occupancy FY 2018 Information technology planning and implementation (COO, CIO) EHR transition to Cerner N/A Funding Total $26,000,000, funded as follows: $22,000,000 from 2015B revenue bond $4,000,000 from FY 2016 and 2017 budgets Go-live by mid-2017 May 2018 Mineral King building renovations and nurse call upgrades (COO/CNO) Renovate and upgrade aging nursing units and other clinical spaces Renovation: 2 West ICU Nurse call upgrade: TBD Endoscopy Phased renovations Completion dependent on patient room demand 2W ICU Renovation: $250,000 for FY 2017 $250,000 for FY 2018 Nurse call upgrade: $500,000 for FY 2018 (units to upgrade TBD) 2 West ICU Renovation: Construction FY 2018 Occupancy FY 2019 Nurse call upgrade: Construction FY 2018 Occupancy FY 2018 Health clinics expansion Cardiovascular Center Rural Health Clinics Mental Health Clinic (CFO) Expand patient access to specialty medical care Support successful development of medical practices and retention of physicians Physician recruitment Rural locations Medical Center based Where needs and opportunities exist Akers MOB Land purchase Leased facilities Budgetary funding Purchase existing clinics 1206d licensing Cardiovascular Center: Phase 1: Lease 202 Willow Funded from reserves Phase 2: Infill of either 2nd floor of endoscopy building or Akers MOB Cost and funding TBD Other Clinics: TBD Cardiovascular Center: Phase 1: Occupancy FY 2018 Phase 2: Construction FY 2018 Occupancy FY 2019 Other clinics: to be determined 1. Lindsay Clinic - occupancy FY

225 Project/Executive Inpatient pharmacy remodel (COO) GME impact on hospital facilities Joint venture outpatient Endoscopy Center Objective Comply with State and Federal compounding room requirements Accommodate residents space and work requirements in hospital facilities Expand and enhance outpatient endoscopy services Further physician and hospital integration Potential Location MK ground floor Medical Center SSB 5th floor Mental Health Hospital Clinics Addition to the Sequoia Surgery Center (West Campus) Considerations July , 2018 deadline Federal & State deadlines Negative air pressure room Additional carousels Budgetary funding Number of residents Regulatory restrictions Use of revenue bond funding Prevailing wages Capital Requirements $2,700,000 for equipment, design and construction: from capital budget $50,000 per fiscal year: from capital budgets Scope / location for FY 2018 to be determined TBD Anticipated Occupancy Date Planning and design FY 2017 Construction FY 2018 Occupancy FY 2019 FY 2018 FY 2019 Incremental Additions to Parking Inventory Conversion of available campus lots into parking lots Downtown Medical Center campus Mitigate campus-wide parking shortage Range from $7,500 to $8,000 per parking space. Doc s Lot Construction FY Occupancy FY Others: TBD 40

226 Kaweah Delta Health Care District FACILITIES AND SERVICES PLAN Mid-Term (3-7 Years, Fiscal Years ) Project/Executive Objective Potential Location Considerations Capital Requirements Anticipated Occupancy Date Existing facilities renovations (COO/CNO) Continuous updating of all areas for improved work space and increased patient satisfaction Mineral King Wing Budgetary funding $500,000 per fiscal year Anticipate to complete refurbishing one unit each fiscal year Scope for FY 2020 through FY 2024 to be determined Mineral King Wing infrastructure (COO) Upgrade and/or replace aging utility systems infrastructure HVAC and plumbing systems repairs and replacement Budgetary funding Failure of aging systems and equipment $250,000 per fiscal year Completion of replacement and repairs as required Parking facilities (CEO/COO) Review opportunities for additional patient and employee parking Acequia garage Locust garage Mineral King lots Parking program Partnership with City Funding source To be determined To be determined State Seismic Law Compliance (SB 1953) (CEO) Determine and implement measures to comply with State seismic structural design requirements Downtown Medical Center Campus Potential replacement building Potential retrofit of MK 1969 building Other options Funding strategies TBD Occupancy by January 1,

227 Kaweah Delta Health Care District FACILITIES AND SERVICES PLAN Long-Term (More Than 7 Years, Fiscal Year beyond) Project/Executive Objective Potential Location Considerations Capital Requirements Anticipated Occupancy Date Facilities Master Plan for post (CEO, COO) Establish and implement a master plan for KDMC downtown campus and other District campuses District-wide District s overall strategic plan Healthcare industry trends TBD Post Address facility and operational impacts of measures for SB 1953 compliance 42

228 Richard Strid, KDMF Chief Executive Officer KDMF Performance 2017 Patient Volume , ,332 3,698 Ancillary Revenue Lab $3,577,881 $3,603,970 26,088 Physical Therapy $1,116,112 $1,145,514 29,402 QuickCare $1,483,955 $1,840, ,560 Radiology $3,723,379 $3,651,481 (71,898)

229 Physician Recruitment - Contracted Specialty Physician Start Date Cardiology Dr. Sarmad Said August 2018 Endocrinology Dr. Noman Saif June 2018 Family Medicine Dr. Roy Chan February 2018 Internal Medicine Dr. Lara Atchabahian October 2017 Gastroenterology Dr. Shirley Pua Dr. William Hsueh February 2018 August 2019 Nephrology Dr. Tariq Javed February 2018 Neurology Dr. Rohini Joshi January 2018 Urology Dr. Joseph Ford August 2018

230 Physician Recruitment - Interviewing Specialty Physician Available Family Medicine Gastroenterology Dr. Ebimoboere Okoro Dr. Chris Christiansen Dr. Onpan Cheung Dr. Thimmaiah Theethira August 2018 August 2018 April 2018 August 2018 OB/GYN Dr. Douglas Talk August 2018 Pediatrics Dr. Judi Krogstad April 2018 Psychiatry Dr. Brian Elledge Dr. Michael Serna August 2018 August 2018

231 Dr. Bruce Hall, KDMF Chief Medical Officer MACRA/MIPS Scores 2017 KDMF maximized CMS scores and anticipate receiving a 4% increase in Medicare reimbursement for MACRA/MIPS Programs Implemented Future Programs

232 2018 KDMF Strategic Plan Goals Strategy Action Steps Retain Physicians Excellent Retirement Aware of benefits Communicate quarterly Person(s) Responsible Rasmussen Sears Kingsford Completion Time Frame 03/01/2018 Ensure Total Reimbursement Aware of additional Communicate MACRA/MIPS, etc. Hall 03/01/2018 Understanding Income Distribution Ensure physicians know how to track WRVU Meeting with physicians twice a year Kingsford 05/01/2018 New Equipment Give them the tools needed Budget items needed discussions LaBlue 03/01/2018 Great Staff Hire clinical staff that exceed expectations Interview with: Great customer service in mind communicate with providers to ensure their team is the best Griffith Rasmussen Continuous

233 2018 KDMF Strategic Plan - continued Begin a Behavioral Health Program OB/GYN Department Hire Two GI Physicians Communicate with KDDH Residency Program Offer Competitive Package Goals Strategy Action Steps Recruit Physicians & Additional Departments Community need KDMF/VMC need Work with KDHCD Hire the best from the residency This will be the place to work 1. Physicians 2. Location 3. Billing 1. Physicians 2. Call Coverage 3. Location Work with recruitment firms to find available Have them spend time at KDMF Lunch/Dinner with residents 1. Competitive Salary & Benefits 2. Loan Repayment Person(s) Responsible Strid Hall LaBlue Koens Strid Hall LaBlue Koens Taylor Strid Hall LaBlue Taylor Strid Hall Taylor Strid LaBlue Completion Time Frame 07/01/ /01/ /01/ /01/ /01/2018 Continuous

234 2018 KDMF Strategic Plan - continued Goals Strategy Action Steps Expand on presence in Tulare Open P/C site in Underserved areas New Sites & New Equipment 1. Physicians 2. Site Person(s) Responsible Strid LaBlue Griffith Completion Time Frame 10/01/2018 QuickCare in North Visalia Open additional QC site where new home growth 1. Find Site 2. Pro Forma 3. Providers/Staff Strid LaBlue Griffith 12/01/2018 Up-To-Date Equipment in Ancillaries Ensure KDMF has best equipment for our providers to take care of patients 1. Inventory with Dates 2. Replace 3. New Equipment Expand KDMF LaBlue Rasmussen 05/01/2018 Bring in Groups to VMC KDMF To expand KDMF Speak to groups in the area Calloway Herbst Hall 03/01/2018 New Service Lines Bring in services lines not presently at KDMF 10/01/2018 Close the Gap Between VMC/KDMF KDMF/VMC/Group Communicate Educate 1. Name that encompasses all sites 2. Communicate with providers & staff Herbst Strid Calloway Hall 06/01/2018

235 Zone IV Resignation FEBRUARY 1, 2018 Notify County Elections Official by Thursday February 15, 2018 (within 15 days of the effective date of the vacancy) Decision by KDHCD Board for next steps

236 Appointment by KDHCD Board of Directors Appointment by KDHCD Board within 60 days. MONDAY APRIL 2, 2018 Call a Special Election Call an election within 60 days of vacancy. {April 2, 2018} Election shall be held on the next established election date that is scheduled 130 or more days after the date the Board calls the election.

237 CALL A SPECIAL ELECTION Election shall be held on the next established election date that is scheduled 130 or more days after the date the Board calls the election. Date election is called {within 60 days of vacancy} February 1 st {130 days from 4/2/18 = August 10, 2018} Vacancy Date {February 1 st } Next election 130+ days after the date the Board calls the election November 6, 2018

238 Board appointment by Monday, April 2, 2018 (60 days after effective date of the vacancy) Person appointed will hold seat until zone is up for election {November 2018} Seat will be for a four year term following the November 2018 election.

239 If the vacancy is not filled or an election called by the KDHCD Board within 60 days: The Board of Supervisors may appoint a person to fill the vacancy within 90 days of the vacancy. {May 1, 2018} The Board of Supervisors may order the District to call an election to fill the vacancy.