WELCOME TO PRESBYTERIAN!

Transcription

1 for Non-Employees with Patient Contact: WELCOME TO PRESBYTERIAN! We re glad you re here helping us to care for our patients and to achieve our mission of improving the health of patients, members and the communities we serve. This document is a text version of the required training that all Presbyterian Workforce complete. It s designed to introduce you to Presbyterian, help you understand basic safety and compliance procedures, know what to do when risk events or potential violations occur, and to meet regulatory training requirements. Please review all sections of this document now. This is a reference document with a lot of information to remember. Feel free to print any of these pages for later reference. At the end of this training please complete the acknowledgement form and return it to Medical Education by fax (505) or mededu@phs.org. Page 1 of 86

2 Table of Contents: I. Organizational Orientation: Presbyterian Organizational Profile Presbyterian EGG Presbyterian Values: CARES Behaviors II. Compliance and Ethics Training: Code of Conduct False Claims Act Educational Information HIPAA: Privacy and Security Policies Information Technology Acceptable Use Policy Reporting of Patient Abuse, Neglect and Misappropriation of Property Conflict of Interest Information III. General Safety: Reporting Injuries and Safety Hazards Preventing Injuries While Lifting Electrical Safety Fire Safety Hazardous Materials Emergency Management IV. Infection Control: Section I General Information for Any Workforce with Patient Contact Program Overview Hand Hygiene Glove Use Guidelines and Fingernail Hygiene Exposure Control Plans Bloodborne Pathogens Tuberculosis Section II Applies to All Clinical Care Givers Sharps Safety Safe Injection Practices Diabetes Care Page 2 of 86

3 Section III Ambulatory Care Setting Section IV Inpatient Care Setting Infection Control Initiatives Central Line Associated Bloodstream Infections (CLABSI) Surgical Site Infections (SSI) Catheter Associated Urinary Tract Infections (CAUTI) Transmission Based Standard Precautions (Isolation) Introduction Contact Precautions Contact D Precautions Droplet Precautions Airborne Precautions V. Patient Safety and Service Quality: Creating an Exceptional Patient Experience Cultural Sensitivity and Medical Interpretation Patient Safety and Fall Prevention Blood Transfusion Reactions Page 3 of 86

4 I. ORGANIZATIONAL ORIENTATION PRESBYTERIAN ORGANIZATIONAL PROFILE Presbyterian Healthcare Services (Presbyterian/PHS) is a nonprofit integrated health care system that has served the state of New Mexico for more than 100 years. PHS is comprised of two business units: Presbyterian Delivery System (PDS) and Presbyterian Health Plan (PHP). Presbyterian Delivery System (PDS): The Presbyterian delivery system provides patients with preventive, diagnostic, and treatment services in hospitals and ambulatory facilities throughout New Mexico: Hospitals: There are eight PDS hospitals throughout the state of New Mexico (see map below): five general acute and three critical access hospitals. Presbyterian Medical Group (PMG), which is part of PDS, employs physicians and advanced practitioners such as physician assistants and nurse practitioners. PMG providers deliver inpatient hospital care as well as ambulatory and specialty care in over 100 clinics located at more than 40 sites throughout New Mexico. Other Services: The delivery system also includes three ambulance services, five home health agencies, healthplex services, behavioral health and a cancer treatment program and partnership with MD Anderson. 30 sites in CNM and 11 sites in the four Regional Communities Page 4 of 86

5 Presbyterian Health Plan (PHP): The health plan includes a statewide health maintenance organization and a health insurance company. PHP provides health insurance financing through products and services designed and delivered to prevent illness and coordinate care for more than 450,000 members throughout New Mexico. PHP products include Commercial (employersponsored and individual) and Government (Medicaid, Medicare and other) programs; PHP is also one of four health plans contracted with the New Mexico Human Services Department Centennial Care program to serve Medicaid members. The PHP provider network is comprised of PHS owned and operated facilities, PMG practitioners, and independent hospitals and practitioners throughout the state. Board Leadership: Community-based volunteer boards are the cornerstone of Presbyterian s governance system. The PHS Board, with key supporting committees in Compliance and Audit, Executive Compensation, Finance, Governance, and Quality, is ultimately responsible for the entire system. The overall governance structure also includes a volunteer board or governing committee for each community, the Medical Group, the Foundation, and PHP. The community affiliate boards report to the PHS Board, govern in the communities where they reside, and are charged with assessing and ensuring the appropriateness of the health care services provided. Workforce: Presbyterian s workforce consists of more than 10,000 employees, plus contracted staff, students and volunteers, and had an annual payroll in 2014 of $810 million. As part of its workforce, PHS employs over 900 physicians and advanced care practitioners who provide both primary care and specialty services. Medical Staff: Contracted and hospital privileged physicians play a role in the leadership and delivery of health care. Nearly 8,500 practitioners across the state contract with PHP and over 90% of these are independent physicians who practice medicine in PHS facilities and other facilities throughout New Mexico. Contractors and Suppliers: PHS contracts with temporary nurses, locum tenens providers, as well as other clinical and non-clinical workforce. As part of initial orientation, these contracted workforce and key on site suppliers receive training on compliance, safety, hazardous chemicals, disaster preparedness, hand washing/infection prevention, security, and other jobspecific training. Page 5 of 86

6 PURPOSE, VISION AND VALUES THE EGG : Presbyterian exists to improve the health of the patients, members and communities we serve. Presbyterian has summarized its purpose, vision and values in a format which we call the Egg. See below for a picture of the Egg. Page 6 of 86

7 Strategy and Goals: Presbyterian s strategy for fulfilling our purpose is to engage patients, members and communities with innovative healthcare delivery and financing to achieve: Better Health Exceptional Experience Cost Leadership You are Part of the Mission: By joining Presbyterian as an employee, volunteer, student, contractor, vendor, consultant, board member, or other interested party, you are helping us to improve the health of the patients and the members that we serve. Thank you! PRESBYTERIAN VALUES - AKA C.A.R.E.S. Behaviors: Continuous Learning: Accountability: Respect and Respond: Environment of Health: Superior Outcomes: Seek to improve Take ownership Be present and responsive Assure safe, clean and private Exceed expectations and celebrate Page 7 of 86

8 II. COMPLIANCE AND ETHICS TRAINING CODE OF CONDUCT (5/27/2011 revision) Values Presbyterian exists to improve the health of the patients, members, and communities we serve. By living CARES behaviors, we honor people first: patients, members, employees and clinician partners. We also honor wholeness of body, mind and spirit, and high performance through excellence, innovation, teamwork and trust. Disruptive behaviors of individuals working at any level of the organization will not be tolerated; leadership will address such behaviors with all personnel, including management, clinical and administrative staff, licensed independent practitioners, contactors, students, volunteers, and governing body members. Culture of Safety Presbyterian fosters a Culture of Safety through an integrated pattern of individual and organizational behavior based on shared beliefs and values that continuously seek to minimize patient harm that may result from the process of care delivery. Presbyterian supports safety and quality through teamwork and respect for other people, regardless of their position in the organization. Presbyterian maintains a Just Culture that encourages the routine reporting of errors or concerns without fear of retaliation or retribution to enable our organization to improve on processes. Workforce Commitment As a member of the Presbyterian workforce, I acknowledge that I have read the Code of Conduct. I agree to support the values of Presbyterian and the Culture of Safety and to abide by the standards below. I understand that I will be held accountable if I fail to do so. Uphold Ethical Standards: Seek the right course of action in every situation and, when challenged with ethical dilemmas, obtain the advice and counsel of supervisors, managers, or senior leaders. Protect and uphold Presbyterian s reputation and legacy for integrity and community service in all of my personal and professional endeavors. Adhere to all laws, regulations and Presbyterian policies and foster an atmosphere that promotes and supports Presbyterian s efforts to ensure compliance with laws and regulations. Page 8 of 86

9 Report Concerns and Problems: Report to the Presbyterian Compliance Department, the Anonymous Hotline ( ), or other appropriate department such as Human Resources, the following behaviors: Unethical or prohibited behavior including actual or suspected unethical behavior, illegal activity or violation of Presbyterian policies and procedures; Disruptive or inappropriate behavior including disrespectful language, sexual comments, inappropriate touching, anger outbursts, name-calling, throwing of objects, racial or ethnic jokes or slurs, intimidation, the deliberate failure to follow policies, address safety concerns or patient care needs, and other behaviors that are disruptive or inappropriate; Action or inaction of caregivers that may pose a danger to patients or result in substandard care; Any retaliation for raising or reporting ethical, compliance or other concerns. Respect Others: Treat all patients, members, and colleagues with respect and dignity regardless of race, creed, religion, color, national origin, ancestry, sex, sexual orientation, gender identity, spousal affiliation, physical or mental handicap or ability to pay. Honor patients rights to participate in and make decisions about their care and pain management including the right to refuse care when permitted by law. Provide patients and members with information about their illness, treatment, pain, alternatives, and outcomes in a manner they can understand, and provide interpretation services when needed. Identify myself to patients and members by providing my name and my role. Listen to and document patients and members concerns and complaints so they can be addressed. Protect the confidentiality of all patient, member and sensitive organizational information at all times. Abide by the Law: Abide by all laws including those that relate to patient referrals and provider relationships. Report to work free of impairment from drugs or alcohol. Comply with all laws, regulations, and policies related to environmental health and safety, including fire, chemical, biological, ergonomic, radiation, and electrical safety and appropriately handle, transport, and dispose of medical waste and other hazardous materials. Page 9 of 86

10 Maintain Financial Integrity: Manage with integrity and prudence Presbyterian s financial and other resources and hold other Presbyterian workforce members accountable for doing the same. Refuse to accept or offer gifts or benefits or enter into relationships with individuals, competitors, vendors, suppliers, or contractors (such as pharmaceutical and medical device companies) that may influence or be perceived to influence a decision or action taken on behalf of Presbyterian. Further, Presbyterian Leadership commits to: Continuously evaluate the culture of compliance, safety, and quality and prioritize and implement changes as appropriate. Provide opportunities for workforce members to participate in compliance, safety, and quality initiatives. Manage disruptive and inappropriate behaviors in accordance with Presbyterian policies. Provide education that focuses on compliance, safety, and quality. Provide patients and members the means to report their concerns about compliance, safety, and quality. Page 10 of 86

11 FALSE CLAIMS ACT EDUCATION Specific Information Regarding False Claims Liability, Whistle-Blower Protections and Related PHS Policies Presbyterian Position: PHS will not submit or cause to be submitted false or fraudulent claims. Furthermore, employees, contractors and subcontractors of PHS can be held liable for filing or causing to be filed false or fraudulent claims. PHS strictly prohibits the submission or participation in the submission of any false claims. The Federal False Claims Act (FCA) provides for liability for individuals who file or cause to be filed false or fraudulent claims. Examples of false or fraudulent claims include, but are not limited to: billing for services not rendered; billing for undocumented services; double-billing for items or services; making false statements in connection with the provision of services; participating in kickback schemes; including improper entries on cost reports; billing for medically unnecessary services; and assigning incorrect codes to secure higher reimbursement. The government may impose fines or bring a lawsuit to recover fraudulently-obtained monies. In addition, individuals may bring such a lawsuit on behalf of the government and, if successful, may share in a portion of the recovery. The New Mexico Medicaid False Claims Act, is very similar to the FCA. Like the FCA, it allows individuals with knowledge of fraudulent activities to bring a lawsuit on behalf of the government to recover fraudulently-obtained monies and to share in the recovery, if successful. Whistle-Blower Protection: The FCA and the New Mexico Medicaid False Claims Act also provide statutory protections for whistleblowers. Under the Acts, an employer is prohibited from retaliating against an employee who reports fraudulent activities. Related Policies and Training: PHS has implemented policies aimed at preventing the filing of false claims. Those policies include the False Claims Act Education policy (COM.PHS-E.105), the Required Training policy (HR.PHS-E.335), and the Compliance/Ethics Program (COM.PHS-E.103). In addition, PHS will require that all members of the PHS workforce receive training information on these issues upon entry into a business relationship with PHS. Page 11 of 86

12 Duty to Report: PHS requires that any workforce member having knowledge of or suspecting the existence of fraudulent activities immediately contact an immediate supervisor, the facility human resources manager, or another member of the facility management staff. Workforce members may also report fraudulent activities to: Andrea Kinsley, Vice President Corporate Compliance, via telephone ( ) or ); the Compliance Hotline ( ), Reports made to the Compliance Hotline may be made anonymously. Page 12 of 86

13 INFORMATION PRIVACY AND SECURITY You Are at Risk: Besides organizations, individual employees, contractors, students, volunteers and business associates are subject to both criminal and monetary penalties for violating HIPAA Privacy regulations. If you have questions about the privacy or security of Protected Health Information (PHI), you may contact the Presbyterian Privacy Official at (505) or the Presbyterian Information Security Official at (505) Accessing Patient or Member Information for Self, Friends, Family or Others Workforce members may not use their Presbyterian access to PHI to read, copy or modify patient or member information regarding themselves or anyone for whom they are not officially providing care or services. If a member of the PHS Workforce desires access to his or her own patient or member information, a request must be made through normal channels established in the Medical Records Department of the Presbyterian facility, via a MyPres account online, or through the workforce member s health care provider. Inappropriately accessing patient or member information is a violation of federal law and potential grounds for termination of the employment or contractual relationship with Presbyterian. Reporting Inappropriate Disclosures of Confidential Information HIPAA Breach Notification regulations require healthcare organizations to notify patients and members if their protected health information is breached. If you become aware that patient or member information in your possession, or in your company s possession, has been inappropriately or accidentally disclosed, you must report that disclosure to the Presbyterian Compliance Hotline immediately: Presbyterian will conduct an investigation and risk assessment to determine whether the disclosure meets the definition of breach included in the HIPAA regulations. If the information disclosed was in an electronic format, please also contact the Presbyterian Information Service Desk immediately at (505) , and ask for the Information Security Engineer on call so that rapid action can be taken to safeguard information. Page 13 of 86

14 You will be asked for specific information about the disclosure so that Presbyterian can follow-up in its investigation. Reasonable Safeguards to Protect Patient Information Encryption: According to the Presbyterian policy on Encryption, all Presbyterian business associates and workforce members are required to encrypt any Confidential Information stored on a personal computer or electronic storage device (such as flash drives or external memory devices). If you will be storing Presbyterian Confidential Information (including Protected Health Information) on a personal computer or electronic storage device, in the course of your work for Presbyterian, you are required to comply with the Presbyterian Encryption policy. Please contact your Presbyterian manager or the Presbyterian Compliance Department at (505) for a copy of the policy. HIPAA Policies and Resources: Presbyterian Healthcare Services (PHS) has a comprehensive set of HIPAA Policies designed to interpret the HIPAA Privacy and Security regulations for the PHS workforce. These policies are available to workforce members through the Presbyterian Electronic Library (PEL) on the Presbyterian Intranet (PresNet), or from the Presbyterian Compliance Department. If you have questions about any of these policies, you may call the Presbyterian Compliance Department at (505) Patient or Member Authorization Required for Disclosure of Information General Rule: HIPAA requires that we obtain a signed authorization form from a patient or member before we may access or disclose their protected health information. For example, if a patient or member is being referred to a community agency for non-healthcare social services, we must obtain a signed authorization before sharing their protected health information with that agency. Exceptions: There are situations when the requirement to obtain an authorization does not apply: if the information is being used for healthcare treatment, payment or operations if the patient or member is requesting information about him or herself If there is a legal requirement to report protected health information to a government agency Other exceptions are described in the Presbyterian Notice of Privacy Practices. Page 14 of 86

15 Patient and Member Rights Regarding Protected Health Information Presbyterian affords patients and members certain rights in accordance with HIPAA Privacy Regulations; these rights are described in more detail in the Presbyterian Healthcare Services Joint Notice of Privacy Practices (also available from Admitting / Registration or Compliance) and in Presbyterian policies. Patient and member rights include the right to: o See and get a copy of health information o Amend incorrect or incomplete health information o Request confidential communications of health information o Request restrictions of health information o Request an Accounting of Disclosures of health information o Receive a paper copy of the Notice of Privacy Practices If you have any questions about how these rights apply to a given situation, please contact the Presbyterian Privacy Officer at (505) Confidential Information Presbyterian Confidential information includes Protected Health Information (PHI), but also includes financial information, operating methods, marketing strategies, and lists of patients, customers, members or employees. Workforce members may not use or disclose confidential information obtained in the course of performing work at Presbyterian for the purpose of advancing any private interest or otherwise for personal gain. Additionally, confidential information or access to such confidential information should only be used in the manner for which it is intended. Disclosing confidential information in an unauthorized way is prohibited. Other Safeguards Presbyterian protects patient information from inadvertent disclosure, loss or theft through a variety of other physical safeguards, administrative processes and technical security mechanisms. Workforce members should adhere to these safeguards when using or disclosing Presbyterian patient or member information, including: o Always utilize Global Red Rule to correctly identify customers (i.e. match on at least full name and date of birth.) o When searching for individual records in a computer system, always use additional identifiers (such as social security or account number) to resolve any duplicate search results. o Conduct verbal communications in a discreet manner, especially in public areas Page 15 of 86

16 o Do not leave paper records and files in public view, on fax machines or copiers; turn over papers, close files and put them away. o Close electronic records containing patient information when not in use; log off computer applications when not actively using. o Always check each page of any paperwork delivered or handed to a customer first to ensure that it is going to the correct individual. o Never remove hard copy patient medical records from the facility; o Mobile devices used to send or store Protected Health Information must be encrypted (NOTE: password protection is NOT encryption contact your mobile device carrier to for encryption instructions.) o Do not transmit patient information via text message; instead use encrypted or secure websites. o Exercise caution when accessing PHS patient information systems from outside PHS facilities, and do not leave PHI unattended on screen. o Never post Presbyterian Confidential Information or Protected Health Information to social networking websites. Minimum Necessary Principle Under the HIPAA Privacy regulations, most use and disclosure of patient information is limited to the minimum necessary needed in order to meet the intended purpose (for example for insurance payment or various other healthcare business operations.) The regulations, however, allow for certain key exceptions to this principle, including the following situations where minimum necessary does not apply: o For treatment of a patient when sharing information with other providers involved in that patient s care. o When disclosing information to the patient or member, or that individual s legally authorized representative. o When disclosing information in accordance with an individual authorization (in this case the authorization will state what type of information may be disclosed.) o When disclosing information in accordance with federal, state and local law, or to the US Department of Health and Human Services for the purposes of HIPAA compliance monitoring. Disclosure of an individual s entire medical record by Presbyterian requires special justification and documentation. Contact the medical records department for more information. Page 16 of 86

17 Protection of Passwords Passwords issued to PHS workforce members, that allow workforce to access Presbyterian information systems, must be safeguarded. Passwords should not be: o Shared, posted or left in a easily accessible location o Created in such a way that they are easily guessed Remember, each individual is responsible for any system activity conducted using his or her password. Malicious Software: Viruses, Worms, Trojans and other Invasive Software Malicious software programs, such as computer viruses or worms, represent a threat to clinical and business information systems and as such to patient care and service. In order to protect Presbyterian information systems: Business Associates and Workforce members should not: o Insert any disc or portable drive or download any software onto a Presbyterian computer workstation without first obtaining permission from Presbyterian Information Services. o Open attachments from unrecognized senders when utilizing a Presbyterian computer workstation. o Ignore virus alerts and warnings; instead these should be reported to the Presbyterian Information Service Desk at Login Monitoring If problems with login or assigned passwords are encountered, this could be a sign of a stolen or inappropriately modified password. In such instances, workforce members should seek assistance from the Presbyterian Information Service Desk at (505) Page 17 of 86

18 INFORMATION TECHNOLOGY ACCEPTABLE USE POLICY All Presbyterian Healthcare Services (PHS) information technology and services are provided for the purpose of promoting and executing PHS business activities, are the property of PHS and/or specifically designated business partners, and are governed by this policy. Security and Monitoring: Use of PHS information technology services is subject to monitoring, without consent or notice, within the parameters of this policy. PHS may monitor electronically transmitted messages and information. There is no guarantee of privacy for the individual user regarding electronically stored or transmitted content using PHS information technology services. Individual users consent to such monitoring by their use of the services. Any user of PHS information technology services is advised that if monitoring reveals possible indications of unacceptable system use, the discovery will lead to remedial action, up to and including termination of an educational, business or medical staff relationship. In addition, if such monitoring reveals possible indication of criminal activity, information systems personnel may provide the information from such monitoring to law enforcement officials. If PHS management deems that a violation of the information technology policies and procedures has or might have occurred, then the privilege of using those systems may be withdrawn indefinitely, without notice. Use of PHS computer hardware and software is a privilege, which can be withdrawn by PHS without notice. General Prohibitions: All users of the computer and internal or external communications systems are expected to use PHS information technology services in an appropriate manner. The following are examples of prohibited conduct and each may result in corrective action, up to and including termination of employment or contractual services. a. Disclosure of Confidential Information (including, but not limited to financial information or PHI) to any unauthorized individuals or entities. b. Use of another person s password, PIN, logon ID or access code, or disclosure of one s own passwords without IS or managerial approval. c. Use of Social Media, including accessing personal social media websites from a Presbyterian computer or posting images of, or information about a Presbyterian patient or member. d. Disclosing / Storing PHI on an unencrypted mobile device. Avoid use of mobile devices to store or send PHI; if your work requires such use, then device must be encrypted to avoid potential federal HIPAA sanctions. Page 18 of 86

19 e. Unauthorized endorsement: Communicating material information that could be perceived as an official company position or endorsement without proper management approval. f. Harassment: The transmission or storage of any discriminatory, offensive, disruptive, harassing or unprofessional message or language; derogatory statements about a person, product or organization, or any defamatory information. Prohibited material includes, but is not limited to, profanity, sexual comments or images, racial slurs, gender-based comments, or comments that would offend another person because of their age, gender, sexual orientation, religious or political beliefs, national origin or disability. g. Solicitation: Soliciting, except as provided for in the PHS Solicitation/ Distribution/Posting Policy and as approved by management. Also includes the transmission or posting of any information or material that would violate the PHS Solicitation and Distribution Policy (HR.PHS-E.400). h. Leaving confidential information unattended: Failure at any time to clear from view, after use, sensitive or confidential information on PC or terminal screens that are unattended. i. Modifying the configuration or setup of any PC without information services direction. A user may not install unauthorized software. j. Participating or engaging in activities that violate PHS policies or standards. k. Involvement in scams, schemes, unlawful and/or illegal activities. l. Intentional disruption of information technology services. m. Playing games via the network or internet. n. Violation of copyright: Failure to obtain written permission from the author or artist prior to using copyright material, including unauthorized posting, transmission, or downloading of copyrighted material, trademarks, and service marks. o. Unauthorized access. This includes, but is not limited to: 1. Accessing patient or employee information without a legitimate business need and authorized access; 2. Misrepresenting an individual s identity or the source of communications or data; 3. Accessing or attempting to break into any confidential or private information without authorization including servers, or voic accounts, PC files or mainframe applications; 4. Import or export of any governmentally controlled information to or from unauthorized locations or persons, without appropriate licenses or permits; 5. Modifications of files without owner s permission; 6. Cracking of passwords. (The existence of a file and access thereto does not grant permission or authorization to read it.) Page 19 of 86

20 This is not an exhaustive list and is intended only to exemplify the kinds of abuses that are prohibited by this policy. Page 20 of 86

21 REPORTING OF PATIENT ABUSE, NEGLECT AND MISAPPROPRIATION OR THEFT OF PROPERTY Zero Tolerance for Abuse: Presbyterian has a zero tolerance policy for any type of abusive behavior by members of the Presbyterian workforce toward patients. The following behaviors are grounds for immediate suspension and/or termination of employment or other business relationship: o Abuse of Patients o Improper Treatment of Patients o Harassment (including sexual harassment) of patients, employees or customers o Theft or Attempted Theft of Property Belonging to Patients, Visitors, Employees or Presbyterian What Must Be Reported? The following types of abuse must be reported to the appropriate authorities (appropriate authorities are listed in the How to Report Abuse section below): All suspected abuse, neglect or misappropriation of property of a patient, if the suspected abuser is part of the Presbyterian workforce All suspected abuse or neglect of a child, no matter who the abuser is. All suspected abuse, neglect or exploitation of a vulnerable adult, no matter who the abuser is. What About Domestic Violence or Adult Sexual Assault? There is no legal mandate to report the following types of abuse (unless this abuse is against a child or an elder / vulnerable adult): Domestic or dating violence Adult sexual abuse or assault Clinicians are required to screen for and document signs of these types of abuse in the patients that they see. (See Abuse, Neglect and Misappropriation of Property Recognition, Identification, Reporting and Follow-up Policy.) In addition, referrals to support services are to be offered when a patient says that they have been abused, or show signs of having been abused. Page 21 of 86

22 Reporting of these types of suspected abuse, however, generally requires the written authorization of the person who is the suspected victim. You should not report these types of abuse (domestic/date violence or adult sexual assault/abuse) without a written patient authorization or permission from the Legal Services Dept. Time Frame to Report is 24 HOURS Suspected abuse, neglect, or misappropriation of property must be reported immediately (as soon as practical and not later than 24 hours from knowledge of the incident). The incident must be reported within 24 hours, even if the facility has begun its own investigation into the matter and has not yet completed that investigation. Who Must Report? You must report if you are: An employee of Presbyterian A contractor of Presbyterian A volunteer for Presbyterian A student at Presbyterian NOTE: All the categories above include, but are not limited to: licensed physicians, residents or interns registered nurses, visiting nurses, or social workers acting in an official capacity; members of the clergy who have information that is not privileged as a matter of law. Your Responsibilities When an incident of abuse, neglect or misappropriation of patient property is suspected, the individual who suspects or becomes aware of incident must immediately: 1. Notify the medical social worker, house supervisor, clinical lead, practice administrator, on-call administrator or charge nurse, 2. Work with the supervisor, charge nurse or administrator to make sure that the first page of the Incident Report Form is filled out according to the Incident Report Form instructions listed in the next section. New Mexico state law is very specific that the individual who has a direct knowledge of an incident of or signs of abuse, neglect or exploitation must be the one to fill out the first page of the Incident Report Form. If you are the one who becomes aware of abuse, neglect, or exploitation then you will be required to fill out the first page of the form. You will have help and assistance available to you to answer questions from the notified medical social worker, house supervisor, clinical lead, Page 22 of 86

23 practice administrator or on-call administrator, but the law is specific that you must complete the first section of the form. Report Will Be Made to Two Different Agencies The medical social worker, house supervisor, clinical lead, practice administrator or on-call administrator must ensure that the Incident Report Form is filed with the New Mexico Department of Health Improvement and one of the following agencies: Child Protective Services or Adult Protective Services. In Emergencies In an emergency situation, the first things that you should do are: Notify your facility s security department or area Make sure the patient or other threatened individual is safe Discuss with Presbyterian supervisor/manager and/ or Risk Management Department ( ) immediately and following their direction Cooperate in reporting to appropriate law enforcement and regulatory agencies Abuse By a Member of the Workforce If a member of Presbyterian s workforce (an employee, contractor, volunteer, student or other workforce member) is suspected of patient abuse it is especially concerning. Steps outlined above for Emergency situations should be followed in these cases (notify Security, make sure the patient is safe, and tell your supervisor immediately.) The same process for reporting the suspected abuse should be followed in these cases as in any others. Protection From Retaliation Against Those Who Report Anyone who reports actual or suspected abuse, neglect or exploitation in good faith may not be retaliated against; this is a requirement in both in New Mexico state law and in Presbyterian policy. NOTE: Intentionally making a false report of abuse, neglect or exploitation is prohibited. Page 23 of 86

24 Related Presbyterian Policies Some key policies that you can refer to for more specific information are: Abuse and Neglect Recognition, Identification, Reporting and Follow-up Policy (PC.PDS-A.129) reporting process for Albuquerque Delivery System Abuse and Neglect (COM.PDS-R.104) reporting process for Regional Delivery System Workplace Violence (HR.PDS-E.322) what to do in emergency situations Patient Complaints and Grievances (PC.PDS-E.SYS.171) how to handle patient complaints in general and in particular complaints about misappropriation of property NOTE: All of these policies are available on the Presbyterian Electronic Library (PEL). If you do not have access to the PEL, you may contact the PHS Compliance Department to obtain copies. Page 24 of 86

25 CONFLICT OF INTEREST INFORMATION Non-Employee workforce is required to disclose any potential Conflicts of Interest. Examples of Types of Conflict of Interest: A conflict of interest can potentially occur in situations where an individual has close ties or loyalties to more than one group or organization. For members of Presbyterian s workforce, some examples of possible conflicts of interest include the following situations: Employment or Compensation: You, your company, or one of your company s subsidiaries employ or compensate any of managers, executives, medical staff, board members or employees of PHS or PHP Personal Relationship: You or one of your family members are related to managers, executives, medical staff, board members or employees of Presbyterian Healthcare Services or Presbyterian Health Plan (PHS or PHP) Company Relationships with PHS Leadership: Your company's managers, executives or board members are related to managers, executives, medical staff, board members or employees of PHS or PHP PHS Workforce Serving on Company Board: A PHS or PHP manager, executive, medical staff member, board member or employee serves on the advisory boards or the board of directors of your company or any of its subsidiaries If one of the situations listed above applies to you, it is possible that there is a conflict of interest that Presbyterian will need to consider in defining your work assignment: It doesn t mean that you may not work for or train at Presbyterian. Presbyterian will review each situation on a case by case basis, and make a decision based on the Presbyterian Conflict of Interest Policy (HR.PHS-E.317). It does mean that you must disclose a possible Conflict of Interest situation to your Presbyterian contact, the Presbyterian Human Resources department and/or a Compliance Staff member before you start work or as soon as you are aware of the conflict. Page 25 of 86

26 Questions: You may contact the Presbyterian Human Resources Department at (505) ) or the Vice President for Corporate Compliance, Andrea Kinsley, at (505) ) for assistance with any questions related to Conflict of Interest. Page 26 of 86

27 III. GENERAL SAFETY TRAINING: SAFETY TRAINING OBJECTIVES: Understand the importance of a safe work environment Follow safety policies and procedures Recognize and report hazardous conditions Use proper lifting techniques to prevent injuries YOUR RESPONSIBILITIES with SAFETY Every PHS employee and/or non-employee, rotating student or other provider is responsible for: 1. Anticipating and dealing with hazards in your work environment. 2. Maintaining a safe environment of care for patients, visitors and healthcare workers. 3. Reporting or ensuring that someone else reports unsafe or unhealthy working conditions or acts. (Non-employees report verbally or in writing to their supervisors) 4. Preventing and reporting accidents and injuries to both yourself and others. REPORTING INJURIES AND SAFETY HAZARDS: AS A NON-EMPLOYEE (Contractor, Student, Temp, etc.) IF YOU ARE INJURED AT WORK, YOU MUST: 1. Seek medical care, if necessary a. Medical care may be obtained at your primary care Provider, an Emergency Department, Urgent Care Center, or Occupational Medicine Clinic. b. If you have a blood or body fluid exposure, wash the area and follow the procedure in the Infection Control Manual (all departments have a manual). 2. As soon as possible, notify your Presbyterian supervisor and your Non-Presbyterian Employer. Page 27 of 86

28 IF A PATIENT, VISITOR, OR NON-EMPLOYEE IS INJURED: 1. If possible, notify your supervisor immediately. 2. If the person needs medical assistance, encourage the person to visit the emergency department. 3. Stay with the person (patient, visitor, or non-employee) until the situation has been satisfactorily resolved and treatment has been provided, if necessary. 4. Be sure to check with the supervisor to ensure a Risk Report was filed. NO INJURY, BUT AN IMPORTANT EVENT HAS OCCURRED WITH A PATIENT, VISITOR, OR NON- EMPLOYEE: WHAT DO YOU DO? Notify your Supervisor. (Lost belongings, No transportation, etc.) Other Questions about Safety? In Albuquerque: Contact the PHS Safety Department by calling (505) or (505) Regional Facilities: Contact your facility Safety Officer. PREVENTING INJURIES WHILE LIFTING: 1. Plan ahead when preparing to lift objects. Clear the way. Know the object s weight and your own strength. Prepare the object so it won t slip, move or change its balance when you lift it. 2. Get help if you need some. Plan the lift together with your helper. Use patient lift/transfer equipment as needed. 3. Use proper lifting techniques: a. Keep object as close as possible to your body b. Feet shoulder width apart c. Back straight, head up and buttocks out d. Bend your knees, tighten stomach muscles, get firm grasp on object e. Lift with your leg muscles, not back muscles. f. Turn using your feet rather than twisting your body. g. Breathe! Page 28 of 86

29 ELECTRICAL SAFETY 1. Avoid moisture Dry hands before handling electrical equipment and do NOT place electrical cords or equipment in or near wet areas. 2. Turn OFF before unplugging the power cord for electrical equipment. 3. Inspect for damage Prior to use, inspect all equipment, including cords and plug prongs, for cracks, broken insulation, frayed/exposed wiring, loose or missing prongs, or other damage. 4. Do Not Use Damaged Equipment Isolate damage equipment and report to Maintenance, Biomed or IS Department 5. Extension cords should be used only temporarily. 6. Multi-outlet power cords (aka power strips ) a. For electronic and computer equipment must be circuit breaker protected. b. For MEDICAL EQUIPMENT, must be hospital grade. 7. Electric cords should NOT be routed under mats or carpets. 8. Electric cords should NOT stretch across walkways or where they can pose a trip hazard. 9. Correct Hazards if safe to do so if you spot a hazard, either correct it, if safe to do so, or report it to your supervisor or Safety Department. USE RED OUTLETS IN HOSPITAL FOR CRITICAL PATIENT CARE EQUIPMENT: Throughout the hospital facilities, there are red outlets that are connected to the emergency generator. Critical Patient Care Equipment should be plugged into the red outlets for charging or use during a power outage. Page 29 of 86

30 FIRE SAFETY Your Responsibility with Fire Safety: 1) Fire safety is an important part of your job at Presbyterian in all facilities and whether you are employed or a contractor. 2) You should know the locations in your area or facility of the following: a) Fire alarm procedures (Ask Supervisor. Red Fire and Disaster Plan book in all facilities and online.) b) Fire alarm pull stations c) Fire extinguishers d) Exits e) Evacuation routes f) Oxygen shut off valves (in hospitals) 3) You should know the procedure to call the Hospital Operator, and/or the Fire Department if you are NOT in a hospital facility. 4) You should know if your department or location is responsible for securing a common area and what this means. Ask your supervisor. Common Causes of Fires 1) Electrical Equipment: Check all cords and wires and remove any equipment from service that has cords or wires that are cracked, broken, frayed, or otherwise appear to be damaged. 2) Overloaded or Damaged Electrical Receptacle: Do not use any electrical outlets that are damaged. Too many items plugged into a receptacle could cause overload. Notify your supervisor, the facility maintenance department or Biomed. 3) Microwave Ovens and Toasters: Microwaves may only be used for heating food and liquids. Toasters may only be used for heating foods. Do not leave microwaves or toasters unattended while heating. 4) Hazardous Chemicals and Gasses: All medical gasses and flammable liquids must be properly stored. 5) Smoking: Smoking is not permitted on PHS campuses 6) Cooking areas in Kitchens: Beware of fire danger whenever cooking. 7) Decorations: Decorations must be fireproof and non-damaging to the building and fixtures (i.e. no thumbtacks in walls). Save the packaging as proof that decorations are fire proof. Decorative lights, including Christmas lights, may NOT be used in any department. 8) No Live Flames allowed: No candles or other live flames allowed. 9) Storage: Inappropriate storage of rags and other housekeeping items can cause fires. Boxes and other items may not be stored within 18 inches of sprinkler deflectors as such storage could obstruct sprinkler spray pattern. Page 30 of 86

31 Responding to a Fire in your area When you hear a fire alarm in your facility, you must respond as though there is an actual fire; DO NOT disregard the alarm or assume it is a drill. DO NOT contact the operator and ask what to do, or if the fire is real DO NOT request that alarm or overhead announcements be stopped Fire in Your Location/Area: If you notice a fire in your area, or hear a fire alarm called in your area, use the R.A.C.E. procedure to respond (Rescue, Announce, Contain, Evacuate/Extinguish): a) Rescue: rescue or relocate persons in immediate danger b) Announce: Notify co-workers by calling out Fire or Fire Alarm. Notify your supervisor ASAP. Activate the nearest fire alarm pull station. i) Hospital facilities in Albuquerque, dial 55 to notify the hospital operator and provide the facility name, exact location and type of fire. ii) All other facilities dial 9 911, and provide address, exact location within facility and type of fire. If you are in an Albuquerque non-hospital facility, notify the Presbyterian operators after you have notified the fire department by dialing 55 or c) Contain: Close all doors and ensure they are latched. Clear hallways of portable equipment. d) Evacuate/Extinguish i) Never evacuate unless your supervisor or charge nurse orders an evacuation ii) If an evacuation is ordered, evacuate ALL persons in this order (check public restrooms): (1) Persons in immediate danger (2) Ambulatory persons (3) Non-Ambulatory persons iii) Extinguish the fire if you are trained to use an extinguisher Non-Affected Location: If a fire alarm is called in your facility, but not in your immediate area, contact your supervisor for more information on what you should do to help: a) Avoid transporting patients if possible until the All Clear announcement has been made. b) Do not move throughout the facility unless directed to do so. c) Communicate to patients / visitors that there is an emergency and request that they remain where they are until further instructed. d) Listen for announcements but do not call the Hospital Operator. Page 31 of 86

32 Extinguishing Fires 1) 3 primary types of fires: a) A: Paper, wood, trash, rags, blankets ( Ordinary Combustibles ) b) B: Gasoline, grease, alcohol ( Flammable Liquids ) c) C: Energized electrical equipment 2) If you discover a fire and are considering putting it out yourself, remember a) If the fire is larger than an office trash can, DO NOT attempt it. Leave the area, close the doors, and call an alarm. b) A fire extinguisher should only be used on SMALL FIRES. 3) Fire Extinguishers in Presbyterian facilities: a) A-B-C Extinguishers are available in all facilities: Contain a dry chemical for use on all 3 types of fires. b) A-K Extinguishers are in kitchens: Contain a wet chemical for use on cooking oil fires. c) Water Mist extinguishers are used in Hospital Operating Rooms 4) PASS the acronym for remembering how to use Fire Extinguishers: a) P= PULL the pin located between the two handles b) A= AIM the nozzle at the base of the fire c) S=SQUEEZE the two handles starting the flow of the extinguishing chemical d) S=SWEEP the nozzle from side-to-side, moving from the front of the fire towards the back, pushing the fire away from you. Page 32 of 86

33 HAZARDOUS MATERIALS: OSHA Standards: The Occupational Safety and Health Administration (OSHA) has standards which provide workforce with the right to know: 1) What hazardous materials are present in your workplace 2) What precautions you should take to ensure your safety when using any hazardous materials in your workplace. Safe Work Practices: Every one of us works in an area with Hazardous Materials, whether it s in a clinical setting with chemicals or in an office setting with toners and cleaners. You should take steps to protect yourself: Ask whether there are hazardous chemicals or materials in use in that area Know where to locate the Hazardous Materials Spill procedure, Safety Data Sheets (SDS s) for those materials/chemicals and understand any specific hazards Use recommended protective measures, including any recommended Personal Protective Equipment (PPE) OSHA Standards OSHA has mandated the use of standardized ( globally harmonized ) classifications, labels and pictograms for hazardous materials, and the related Safety Data Sheets for those materials. Classifications of Hazardous Material or Chemical : any chemical or material which is classified as one of the following: Health hazards: agents which damage lungs, skin, eyes or mucous membranes (including carcinogens, toxic/highly toxic agents, reproductive toxins, irritants, corrosives, or sensitizers) Physical hazards: flammable, reactive and explosive products (including materials that are normally stable but that can become unstable at high temperatures, high pressures or when exposed to other materials or conditions) Other Health Hazards: including: o Simple asphyxiant (a substance or mixture that displaces oxygen in the ambient atmosphere, and potentially causing oxygen deprivation, unconsciousness or death) o Combustible dust (a solid material composed of distinct particles or pieces which Page 33 of 86

34 present a fire hazard when suspended in air) o Pyrophoric gas (a chemical in a gaseous state that could ignite spontaneously in air at a temperature of 130 degrees Fahrenheit (54.4 degrees Centigrade) or below.) o Any hazard not otherwise classified, for which adverse physical or health effects have been identified through evaluation of scientific evidence during the hazardous chemical/material classification process. Standard Pictograms for Warning Labels: the following are standard symbols used to alert you to specific hazards of a given chemical or material: 1) Health Hazard: Carcinogen, mutagenicity, reproductive toxicity, target organ toxicity, aspiration toxicity 2) Flame: Flammables, pyrophorics, self-heating, emits flammable gas or organic peroxides 3) Exclamation Point: Irritant (skin/eye/respiratory tract), sensitizer (skin), acute toxicity, narcotic effects, or hazard to ozone layer. 4) Gas Cylinder: Gases under pressure 5) Corrosion: Skin corrosion or burns, eye damage, organic peroxides 6) Exploding Bomb: Explosives, self-reactives, organic peroxides 7) Flame Over Circle: Oxidizers 8) Environment: Aquatic toxicity 9) Skull and Crossbones: Acute toxicity (fatal or toxic) Page 34 of 86

35 Standard Safety Data Sheets (SDS s): beginning in 2015 all SDS s must be in a standard format and include standard information, such as name of material, hazards, composition, first aid measures, handling, storage and disposal, and personal protection measures. You may access Safety Data Sheets for hazardous materials at Presbyterian under the MSDS Vault link on the PresNet Homepage. In addition, department chemical inventories may be found in your department s red Fire and Disaster Manual. Container Labels: All hazardous chemicals and materials must be appropriately labeled by the manufacturer. If a label becomes illegible or if a hazardous material is placed into a secondary container, the label on the secondary container MUST be labeled with the same key information as the original label, including: Product Identifier Hazard and Precautionary Statements Signal word hazard identifier Pictograms Chemical Identity Trade Secrets: Sometimes a manufacturer will indicate on the SDS that the specific chemical identity and/or percentage of composition are being withheld as a trade secret. If a treating physician or nurse determines that this information is necessary for emergency or first-aid treatment, the chemical manufacturer is required to immediately disclose chemical identity or composition to assist with treatment. Disposal of Bulk Non-Hazardous, Non-Biohazardous Liquid Waste: Per state regulations, bulk liquid waste that is non-hazardous and nonbiohazardous may NOT be disposed of in the normal trash stream. Instead, such liquid waste (such as sterile water) must be disposed of in a hopper. If a hopper is not available, a sink or toilet may be used for disposal. Page 35 of 86

36 EMERGENCY MANAGEMENT: What is Emergency Management at Presbyterian? Emergency Management comprises all the ways Presbyterian manages its resources and responsibilities to deal with a disaster or major emergency incident, either external or internal. Internal and External Disasters 1. Internal disasters are emergency incidents that cause injury to persons within a Presbyterian facility or damage to a Presbyterian facility. a. An internal disaster may result in relocation of patients, visitors, and/or personnel within a facility, or an evacuation of one facility to another. b. Examples of internal disasters include: Fire, Hazardous Materials Spill, Missing Persons, Violent Person, Active Shooter, Bomb Threat, and Utility Outage. 2. External disasters are emergency incidents that require a Presbyterian hospital facility to receive and treat a large influx of external disaster victims: a. These incidents may or may not cause injury to persons within a PHS facility or damage to a Presbyterian facility, b. External disaster examples include: Natural disasters like floods, wildfires, earthquakes or storms. They also would include a fire at another facility, a hazardous materials spill on the highway, or an airplane crash. c. They have the potential to impact all Presbyterian business units, including hospitals, clinics, home health, health plan and system (HR, IT, Finance) services. [CONTINUED ON NEXT PAGE] Page 36 of 86

37 Being Prepared to Respond 1. Know where the Fire and Disaster policies are located in the facility where you are working. They are different for each facility. 2. Be familiar with the various possible types of internal and external disasters and how they will be announced: Type of Internal Disaster ACTIVE SHOOTER FIRE MEDICAL EMERGENCY BOMB THREAT SEVERE WEATHER KIDNAPPING / MISSING PERSON VIOLENT PERSON UTILITY DISRUPTION / OUTAGE INFANT SECURITY ALARM CHEMICAL, BIOLOGICAL OR RADIOLOGICAL HAZARD Related Announcement ACTIVE SHOOTER with location FIRE ALARM with location of fire CODE BLUE with location of emergency, or CODE PINK and location for NICU, MBC, FBC, MSC or ED units No overhead announcement key personnel are notified directly SEVERE WEATHER with additional directions MISSING PERSON with description of person SECURITY ALERT with location UTILITY DISRUPTION / OUTAGE with type of outage (water, sewer, electricity, gas, medical gas, telecommunications or information technology) DR GERBER with location CHEMICAL SPILL with location 3. Be familiar with Evacuation and External Disaster announcements: Type of Evacuation or External Related Announcement Disaster EVACUATION STAGE 1 Prepare to Evacuate STAGE 2 Proceed with Evacuation EXTERNAL DISASTER STAGE 1 Prepare for incoming victims of external disaster STAGE 2 Proceed Confirmation of victims arrival Page 37 of 86

38 Disaster Response System Overview: 4. National Incident Management System (NIMS) directs that healthcare organizations along with fire, police and other agencies use a common command system for responding to disasters. This system is called the Incident Command System (ICS); Presbyterian has adopted the Hospital Incident Command System (HICS) for this purpose. a. ICS requires an Incident Commander (IC) who oversees the response to the disaster and makes many related decisions. b. A Hospital Command Center (HCC) may be set up by the Incident Commander (IC) as the central place from which the IC organizes additional resources and to which personnel report. Page 38 of 86

39 IV. INFECTION CONTROL FOR NON-EMPLOYEES WITH PATIENT CONTACT: After reviewing this section, you should be able to: 1. Perform good hand hygiene and respiratory etiquette 2. Define Bloodborne pathogens, TB, and other Healthcare Associated Infections and state how they are transmitted 3. Explain the steps to take if exposed to a bloodborne pathogen or other disease 4. Describe Standard Precautions used to prevent or limit transmission of disease-causing microorganisms 5. Adhere to the seasonal influenza vaccination requirements ============================================================ SECTION I GENERAL INFORMATION FOR ANY WORKFORCE WITH PATIENT CONTACT: PROGRAM OVERVIEW Presbyterian s Infection Control Program Purpose Prevention and management of hospital acquired or healthcare associated infections: a. Prevention (hand hygiene, cleaning and disinfection) b. Monitoring (surveillance, outbreak investigation) c. Management (outbreak planning / interruption) Presbyterian s Infection Control Team Infection Control Practitioners support the following activities: o Identification of infectious disease processes o Surveillance and epidemiologic investigation o Preventing / controlling the transmission of infectious agents o Product evaluation o Education and Research o Management and Communication o Every Presbyterian Facility has an infection control practitioner available. your questions to InfectionControl@phs.org Your Responsibility All Presbyterian healthcare workers have the responsibility to: Be aware of the infection risks associated with their jobs Follow infection prevention procedures and guidelines to minimize the spread of infections. Identify infection risks Refer infection control issues to your supervisor. Page 39 of 86

40 HAND HYGIENE Hand Hygiene is the single most important factor in preventing the spread of pathogens and antibiotic resistance. a. Hand Hygiene is a Global Red Rule at Presbyterian It is a Patient Safety Practice that requires verbatim compliance! b. Safety Coaches are available in a variety of clinical areas to support your infection control and patient safety efforts. c. Keep your hands clean to: i. Protect yourself from infection ii. Protect others healthcare workers, patients and visitors from infection. d. You are encouraged to teach your patients about the importance of hand hygiene and make sure they observe your participation in this life saving measure. Remember to perform hand hygiene before donning gloves and after removing them. Perform Hand Hygiene During the 5 Moments of Patient Care: 1: Before Clean your hands before touching a patient, prior to approaching him/her. Patient Contact Examples: shaking hands, assisting patient, clinical exam. 2: Before an Clean your hands immediately before any aseptic task. Aseptic Task Examples: oral/dental care, wound dressing, food preparation, giving 3: After Body Fluid Exposure Risk 4: After Patient Contact 5: After contact with patient surroundings medications. Clean your hands immediately after an exposure risk to body fluids, and after glove removal. Examples: oral care, secretion aspiration, drawing blood, cleaning up urine, feces or handling waste. Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patients side. Examples: shaking hands, assisting patient, clinical exam. Clean your hands after touching any object or furniture in the patient s immediate surroundings, when leaving even if the patient has not been touched. Examples: after changing bed linen, perfusion speed adjustment Page 40 of 86

41 Hand Hygiene is the act of cleaning your hands by either: Alcohol-based waterless hand rub (ABHR) or traditional hand washing with soap and water Alcohol-based Waterless Hand Rub (WHR) is PREFERRED during Patient Care unless hands are visibly soiled or contaminated with blood or body fluids. Advantages of Waterless Hand Rub (WHR): 1. Quicker to use 2. Kills more germs than soap and water 3. Less drying to skin than soap, water and paper towels How to Use Waterless Hand rub (WHR): 1. Cup left hand and pool WHR into its palm. 2. Touch fingertips of right hand together and immerse them in the WHR pool of in Left Hand, getting WHR under fingernails. 3. Transfer pool of WHR to Right Palm and repeat #2 with left hand. 4. Rub palms together and wet wrists. 5. Interlace your fingers to wet fingers. 6. Rub backs of both hands. 7. Place thumb in palm of other hand. Close wet fingers around thumb and rotate. 8. Add as much WHR as you need to cleanse both hands completely. 9. Air dry. Traditional hand washing (washing with soap and water) is required during patient care activities when: 1. Hands are visibly dirty 2. Hands become contaminated with blood or other body fluids 3. Caring for patients with Clostridium difficile (C.diff) infections Washing with soap and water is also recommended: 4. After using the toilet 5. Before and after eating or preparing food 6. After using a handkerchief or tissue to blow nose or wipe off Washing Technique when using Soap and Water 1. Wet hands and wrists with water and apply soap. 2. Place one palm over the other, working the soap into a lather. 3. Rub your hands palm to palm, fingers interlaced. 4. Rub back fingers to opposing fingers interlocked. Be sure to get underneath the fingernails 5. Rotate the clasped fingers of the left hand around the right thumb and repeat for the left thumb. 6. Rub backwards and forwards while rotating with tops of fingers and thumb of right hand in left and vice versa. Page 41 of 86

42 7. Dry hands on paper towel. Use towel to turn off faucet. Lotion in Hand Hygiene- Use lotion liberally to prevent dry, cracked skin. Only use the approved lotion supplied by Presbyterian, because: Some lotions make medicated soaps (containing chlorhexidine) less effective. Some lotions (if they contain mineral oil or petroleum) cause breakdown of gloves. Lotions in dispensers are less likely to become contaminated with bacteria. GLOVE USE GUIDELINESS AND FINGERNAIL HYGIENE DO Wear gloves when in contact (or when there is potential) with: Body fluids, non-intact skin or mucous membranes. Contaminated surfaces/equipment Patients Remove gloves after caring for a patient or completing a task DO NOT Wear the same pair of gloves for: The care of more than one patient. From one patient's environment to the next. Expect gloves to provide complete protection against hand contamination. FINGERNAIL HYGIENE: Poor fingernail hygiene has been associated with healthcare acquired infections, sometimes fatal: Artificial Nails: At Presbyterian, artificial nails, extenders, wraps and decorations are NOT allowed for personnel who have contact with: Patients, Sterile Patient Care Equipment, Medications, and Dietary / Food. Fingernail Length: Natural nail tips should be kept to ¼ inch in length from the tip of the finger. This is important because long nails can harbor high concentrations of bacteria and may damage gloves, lessening their effectiveness as a barrier. Fingernail Polish (Intact) is Allowed: Intact fingernail polish is acceptable; chipped nail polish may support the growth of infectious organisms and must be removed. Page 42 of 86

43 INFECTION EXPOSURE CONTROL PLANS FOR HEALTHCARE WORKERS (OSHA): For prevention and control measures, as healthcare workers you are being informed of infection exposure control precautions for the following: Bloodborne Pathogens Tuberculosis (TB) Other Communicable Infections Healthcare Worker Illness General Exposure Prevention Measures: applicable to all infection risks: Vaccination against disease when available Standard Precautions: Always observe standard precautions Infection Precautions: Even before patient disease state is known: Use Droplet Precautions when patient is coughing: Healthcare workers and visitors wear surgical mask Patient wears surgical mask when in public areas Observe respiratory etiquette Use Contact and/or Contact D Precautions when patient has open wound, sore, or is actively stooling: Healthcare workers and visitors must use gown and gloves BLOODBORNE PATHOGENS: A. Definition: Bloodborne pathogens are disease-causing microorganisms that may be present in blood and other body fluids. B. Unless visibly bloody, the following DO NOT transmit bloodborne pathogens: saliva, nasal secretions, sputum, urine, feces, vomit, tears or sweat. C. The Bloodborne Pathogen Exposure Control Plan, located in the PEL outlines: Risk Determination, Methods of Exposure Control, and Post Exposure Evaluation and Follow-up. Hepatitis B (HBV): A. Definition: HBV infects the liver. Sometimes the infection clears up but other times it develops into a chronic infection that may progress to cirrhosis and liver cancer. B. Symptoms: Weakness, fatigue, loss of appetite, nausea and vomiting, abdominal pain and jaundice. C. Transmission: HBV may survive for long periods (up to several weeks) outside the body. There is potential for transmission from contact with HBV contaminated surfaces. D. Prevention: HBV may be prevented by vaccination. The series of three injections is safe and effective. Page 43 of 86

44 Hepatitis C (HCV): A. Definition: HCV, like HBV, also infects the liver. There is a high chance that the infection will become chronic (75-85%). Chronic liver disease generally develops slowly, often taking 20+ years before it is recognized. B. Symptoms: HCV symptoms are the same as Hepatitis B, but frequently are initially milder. C. Transmission: It is not known how long HCV survives outside the body, but data suggests that environmental contamination with HCV+ blood is not a significant risk for transmission. D. Prevention: There is NO vaccine to prevent HCV. Occupational Exposure To Bloodborne Pathogens: consists of contact with blood or Other Potentially Infectious Material by: Needle sticks or sharps injury Spray or splash to eyes, nose or mouth Contact with non-intact skin (chapped, chafed, abrasion, cut, acne or hangnails). Post Exposure Control Measures: Wash the area with soap and water or flush with water only if the eyes, nose, mouth or other mucous membrane is exposed. Notify your supervisor immediately and/or charge person of the department currently responsible for the patient. Locate the RED blood & body fluid exposure folder in the area. Contact the Bloodborne Pathogen (BBP) or Infection Control Nurse On-Call immediately through the hospital operator. Complete an on-line injury report (Note: Non-Presbyterian employed healthcare workers should complete a Report of Adverse Risk Event (RARE) form; otherwise, the process is the same). Follow the directions provided by the BBP Nurse on-call. The BBP Nurse on-call will help arrange source patient laboratory testing, healthcare worker testing, and any necessary treatment. NON-EMPLOYEE Treatment and Follow up: should be arranged by the Non-Employee and their healthcare provider or the emergency department: HIV - Promptly (within hours of exposure) anti-retroviral medications will be used to help prevent HIV infection if exposed or if the potential is high and the source status is currently unknown. HBV - You will be screened for vaccination and immune history, tested for antibody levels status unknown, and (if necessary) treated to prevent infection. HCV - There is no vaccine or prophylactic treatment available. There is treatment that may be indicated to prevent a chronic infection in persons who have recently been infected with HCV. Follow-up lab testing will be provided to identify that situation. Page 44 of 86

45 TUBERCULOSIS: A. Definition: Tuberculosis (TB) is a bacterial disease that usually attacks the lungs, but can infect any part of the body. TB is caused by Mycobacterium tuberculosis. TB is transmitted when an actively infected person coughs (or possibly speaks, sneezes, etc.) If a susceptible person inhales the tiny airborne droplets, he or she may become infected. B. OSHA TB Standards require that all workers with the risk of occupational exposure to TB receive: a. Initial and annual training on the signs and symptoms of TB b. Risks associated with exposure to TB and c. Information about protective measures that can be taken to minimize the risk of exposure. C. Who Gets TB? a. Anyone can get TB, but some groups of people are considered at higher risk. People in close contact with individuals with infectious TB People from areas of the world where TB is common The elderly, particularly if they live in a nursing home Low-income people, including homeless persons with poor access to healthcare Alcoholics, intravenous drug users, prisoners, people infected with HIV b. Some Healthcare workers may be considered at higher risk, but the risk to employees of contacting TB in most Presbyterian facilities is low. Very few patients are seen for active TB. New Mexico has a rate of TB lower than the national average. D. TB Control Measures: a. Presbyterian s TB Exposure Control Plan is located in the PEL and includes information on screening, diagnosis, and management of TB patients. b. Depending on where you work, you may be screened for TB by a PPD skin test: i. When contracted as a non-employee or hired as an employee ii. If exposed to a TB patient without using appropriate barriers iii. Annually, if you work in a designated area at risk for exposure. c. Persons with a history of + PPD skin tests must review symptoms of active TB, and are reminded to be evaluated promptly if they have any symptoms. (Regular chest x-ray screening in persons without symptoms is no longer recommended.) d. Exposures to patients with TB when appropriate control measures are not utilized must be reported to Infection Control. e. Non- Employees who become PPD+ will be referred to their employer/contract/oversight organization for follow up. Page 45 of 86

46 INFLUENZA, OTHER INFECTIONS AND HEALTHCARE WORKER ILLNESS PROCEDURES Seasonal Influenza (Flu) 1. Seasonal Flu Vaccine: All PHS healthcare workers are strongly encouraged to get their seasonal flu vaccine each season. 2. Mask Required for Those Who Decline Vaccination: Any healthcare worker who has not received their flu vaccination, and has direct patient contact, will be required to wear a mask during flu season. 3. For additional information about Presbyterian s Influenza Initiative, ask your supervisor to provide you with a copy the PHS Work Force Patient Safety Influenza Initiative Policy located in the PEL. Other Communicable Infections: What do you do if you re exposed to Communicable Infections? 1. All workers exposed to communicable infections must notify their supervisor immediately and be reported to the Infection Control Department. 2. Infection Control will verify the diagnosis of the source patient, define exposure, and will coordinate efforts to identify all healthcare workers who have been exposed. 3. NON-EMPLOYEES identified as exposed to communicable infections will stop working, contact their oversight organization and see their healthcare provider for follow up. 4. For more information and examples of infection exposures see the Exposure to Contagious Disease Policy. Health Care Worker Illness: To prevent the spread of infection in the workplace: 1. Health care workers are encouraged to stay home when they are sick. 2. For some infections and for exposures to certain infections (even if the exposure occurs outside the hospital), health care workers are obligated to follow the work restriction policy. 3. Health care workers who are excluded or restricted in their job duties must be cleared through Employee Health Services before returning to work. 4. Keep immunizations up to date. If exposure occurs: Notify your supervisor immediately! Page 46 of 86

47 STANDARD PRECAUTIONS: A. Definition: Standard Precautions incorporates Universal Precautions and is the system used at Presbyterian to prevent or limit transmission of disease-causing microorganisms. B. Required Usage: Use Standard Precautions to avoid contact with blood, visibly bloody body fluids and OPIM is required by OSHA to prevent healthcare worker contact with bloodborne pathogens. Remember that all body fluids (except sweat) may transmit infection-causing microorganisms, but not all body fluids transmit bloodborne pathogens. C. General assumptions: Apply to all patients in ALL settings: Assume that all people (patients, employees and visitors) are potentially infectious Outlines control measures needed to prevent transmission of most infections Designed to limit transmission from the patient to the healthcare worker, from the healthcare worker to the patient, and among patients. Standard Precautions Control Measures: A. Personal Protective Equipment (PPE): Appropriate PPE must be readily available to all healthcare workers who may be exposed to blood or OPIM. The choice of PPE depends on the activity and the risk of contact with body fluids, non-intact skin, mucous membranes or contaminated surfaces. Ask your supervisor if you are unsure about what PPE to use. All PPE must be removed before leaving the immediate work environment. Gloves required to be worn when in contact with blood, body fluids, mucous membranes, non-intact skin or surfaces/items potentially contaminated. Masks and Eye Protection: Masks, face shields, goggles or glasses with solid protective side shields are required whenever there is a risk of splashing, spattering or spraying of blood or body fluids. Tasks that require face shields, gowns, gloves and caps include cleaning contaminated equipment under running water or pouring out containers of body fluids into hoppers or toilets. Gowns, caps, hoods and shoe covers are fluid resistant clothing that should be worn during procedures likely to involve splashes of blood or body fluids. Sterile Areas: Staff who work in sterile areas will wear blue PPE when outside of work area. B. Regulated Medical Waste: All trash may contain items that could transmit infection. The contents of trash should not be handled, and barriers such as gloves are needed for ALL trash collection to avoid contact. Red bags marked as BIOHAZARD and Infectious Waste are used for trash that is more likely to harbor bloodborne pathogens. This is called Regulated Medical Waste. Page 47 of 86

48 Regulated Medical Waste is separated from other trash at the point of use and placed in Red Bags. This includes: 1. OPIMS or liquids that have solidifier in them. NO LIQUIDS 2. Items that could release blood or OPIM if squeezed or are caked with dried blood or OPIM. 3. Human tissue and pathology specimens 4. Microbiology culture plates and devices contaminated with culture growth. 5. Articles contaminated with highly communicable agents such as Ebola, Lassa and or smallpox. Needles and sharps are first placed in marked puncture resistant containers called Sharps Containers. This includes all syringes, including needleless flushes, and oral and intravenous medication syringes. Red bags and puncture-resistant containers are secured and placed in marked biohazard containers. Biohazard signs or labels identify areas or containers where blood or other potentially infectious materials are stored, handled or transported. Patient care areas are considered places for potential exposure to biohazardous materials. C. Other Biohazards Linen All used linen/laundry is considered a recognized biohazard Handle used linen as little as possible, with minimal agitation Place in designated bags. (There is no indication to red-bag linens) Food All food item/trays that have been at the patient's bedside must be handled as if potentially contaminated and appropriate PPE used. Housekeeping Surfaces and equipment potentially contaminated must be handled as if infectious and appropriate PPE used. Surfaces, equipment, patient rooms and other areas are to be cleaned with designated approved agents in a routine and consistent manner. Medical Equipment Medical equipment should be cleaned/decontaminated, disinfected or sterilized according to extent of contact (intact skin, non-intact skin/mucous membranes or sterile tissue) by following established policies. Page 48 of 86

49 General Staff Activity: Do not keep food or drink in areas where body fluids are stored. In areas where there is potential for exposure to body fluids, do not apply cosmetics, lip balm or handle contact lenses. Keep clean and dirty work areas separated. SECTION I: Summary - Remember three things: 1. Presbyterian is committed to providing a safe work environment for employees and other healthcare workers. 2. Good hand hygiene is the single most important thing that you can do to protect yourself and prevent the spread of infections, along with covering your cough and sneezes. 3. For additional information about Presbyterian s Infection Prevention program or for questions regarding infection control related issues, send to: InfectionControl@phs.org. Page 49 of 86

50 SECTION II: APPLIES TO ALL INDIVIDUALS PROVIDING CLINICAL CARE (i.e. providers, nurses, allied health professionals, etc.): 1. SHARPS SAFETY Remember that the proper handling and disposal of sharps after use is key to safety. RECOMMENDED: One Handed scoop technique for recapping a hypodermic needle: With one hand, hold the syringe with attached needle or the unattached needle hub alone. With the cap lying on a horizontal surface, scoop or slide the cap onto the needle s sharp end. Once the point of the needle is covered, you can tighten the cap by: a) Pushing the needle in the cap against an object (not your other hand.) b) Using the same hand that s holding the syringe, pull the base of the needle cap onto the hub of the needle. 2. SAFE INJECTION PRACTICES: Use these measures to protect yourself and your patients, and prevent the transmission and outbreak of disease: A. Never administer medications from the same syringe to more than one patient, even if the needle is changed or you are injecting through an intervening length of IV tubing. B. Do not enter a medication vial, bag, or bottle with a used syringe or needle. C. Never use medications packaged as single-dose or single-use for more than one patient. This includes ampoules, bags, and bottles of intravenous solutions. D. Always use aseptic technique when preparing and administering injections/ For more detail, see Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injections on the CDC website. Page 50 of 86

51 3. DIABETES CARE: PROCEDURES AND TECHNIQUES TO AVOID BLOOD OR BODY FLUID EXPOSURES A. Clean and decontaminate Glucometers on a regular basis, and anytime contamination with blood or body fluids occurs or is suspected. B. Assign glucometers to individual patients. All glucometers used for more than one patient MUST be cleaned and disinfected between patients. C. Maintain diabetic supplies and equipment, such as fingerstick devices and glucometers in the individual patient s room if possible. D. Any trays or carts used to deliver medications or supplies to individual patients should remain outside patient rooms. E. Do not carry supplies and medications in pockets. F. Unused supplies and medications taken to a patient s bedside during fingerstick monitoring or insulin administration should not be used for another patient because of possible inadvertent contamination. Page 51 of 86

52 SECTION III: AMBULATORY CARE TRANSMISSION-BASED PRECAUTIONS (applies to those working in clinics and other ambulatory care settings): Early identification and segregation of patients possibly requiring isolation is essential to prevent transmission of infection. In some cases patients are asked to report conditions before entering the facility (e.g. rash illness). 1. To prevent transmission of respiratory illness (TB, Influenza, SARS, etc.) in outpatient settings and from patients and visitors in waiting rooms, implement a respiratory etiquette program. 2. The Respiratory Etiquette Program includes: a. "Cover Your Cough" signage b. Early identification of patients with symptoms of respiratory illness c. Providing masks and tissues for patients and visitors d. Teaching patients to keep their hands clean. 3. In exam or treatment rooms, healthcare workers are to: a. Use appropriate PPE b. Transfer the patient as soon as possible to minimize exposure. 4. In cases of contact or droplet precautions, all horizontal surfaces in room should be cleaned with a facility approved disinfectant before the next patient enters. 5. Additionally, in cases of airborne infection, the room should be closed off for contamination to clear. Generally 1 hour is adequate to clear, however, this is facility specific depending on air exchanges per hour. Page 52 of 86

53 SECTION IV: APPLIES TO CLINICIANS WORKING IN THE INPATIENT CARE SETTING ONLY: INFECTION CONTROL INITIATIVES AT PRESBYTERIAN 1. Central Line Associated Bloodstream Infections (CLABSI) Prevention: A. Definition: a bloodstream infection caused by a central line or catheter. B. Risk: CLABSI s are associated with significant increases risk of morbidity and mortality. C. Central Lines include: Peripheral Inserted Central Catheter (PICC), Central Venous Catheter (CVC), Internal Jugular, Subclavian, Femoral, Pulmonary Artery Catheters, Dialysis VasCaths. D. CLABSI Prevention: The following are CLASBSI prevention measures implemented at Presbyterian for all patients who will have or have a central line: 1. Standardized insertion kit 2. Checklist to be filled out by observer during the time of insertion 3. Patient CLABSI infection prevention education sheet reviewed before the procedure 4. Central line bundle elements at the time of insertion a. Hand hygiene immediately before donning sterile PPE for inserter b. Full barrier protection for the patient and inserter (mask, gown, gloves, cap - inserter; full body drape for patient) c. Use of 2% Chlorhexidine for site prep and site care ( unless contraindicated i.e. newborn, history of allergy) d. Avoidance of the femoral site in adults 5. Assess the line daily for necessity and removal, using the following criteria: a. Infusion of medication requiring a central line (TPN, vasoactive, inotropic agents) b. Antibiotic infusion over 14 days in duration c. Hemodynamic monitoring d. Large volume fluid administration e. Multiple incompatible infusions f. History of three or more venipuncture sticks per IV start/blood draw or inability to maintain PIV due to poor vasculature g. Dialysis h. Pediatrics: greater than 2 lab draws per day 6. If Curos Cap is not used, a vigorous hub scrub with friction should be performed using an alcohol prep pad before accessing, making or breaking a connection with any IV. Page 53 of 86

54 2. Surgical Site Infection (SSI) Prevention: A. Definition: A surgical site infection is an infection that occurs after surgery, in the part of the body where the surgery took place. Surgical site infections can be superficial, involving the skin, or deep, involving tissue under the skin, organs or implants. B. Surgical Site Infection Prevention: The following are the SSI prevention measures implemented at Presbyterian for all surgical patients: Selection of Antibiotics Timing of Antibiotic Administration Patient Warming Deep Vein Thrombosis Prevention Hair Removal Beta Blockers If you need detailed information about these prevention measures, ask your supervisor to provide you copies of the following two SCIP Protocols from the Presbyterian Electronic Library (PEL): 1. PRE-OP: SCIP Pre-Op Antibiotic Protocol 2. POST-OP: SCIP Post-Op Antibiotic Protocol 3. Catheter Associated Urinary Tract Infection (CAUTI) Prevention: A. Definition: A CAUTI is a urinary tract infection caused by a urinary catheter. B. Risks: CAUTI can lead to such complications as cystitis, pyelonephritis, gram-negative bacteremia, prostatitis, epididymitis, and orchitis in males; less commonly it can lead to endocarditis, vertebral osteomyelitis, septic arthritis, endophthalmitis, and meningitis in all patients. Complications associated with CAUTI cause discomfort to the patient, prolonged hospital stay, and increased cost and mortality. Each year, more than 13,000 deaths are associated with UTIs. C. Prevention: CAUTI is the most frequent type of infection in acute care settings. Presbyterian has strategies to decrease Foley use and CAUTIs these strategies, called the CAUTI Bundle are as follows: 1. Minimal use of urinary catheters 2. Continual assessments for necessity of catheter 3. Limit number of catheter days 4. Recognize key role of nurses to success of bundle, as insertion, care, and maintenance within scope of nursing responsibilities. For more detail, ask your supervisor for a copy of the Nursing CAUTI Protocol (located in the PEL.) Page 54 of 86

55 TRANSMISSION-BASED STANDARD PRECAUTIONS (ISOLATION) INTRODUCTION o For some infections, additional isolation control measures beyond standard precautions are needed to prevent transmission, including Contact, Contact-D, Droplet and Airborne Transmission. o Clinical Staff must recognize conditions requiring transmission-based precautions and initiate the appropriate precautions. D. Physicians Orders and ISOLATION PRECAUTIONS: Physicians may and should order isolation precautions when a condition requiring isolation is recognized or suspected but a physician's order is NOT required to initiate isolation. Physicians may NOT order discontinuation of isolation precautions required by multi-drug-resistant organisms (MDROs) and other epidemiologically important organisms, such as TB. This may only be done in consultation with Infection Control. For discontinuation of isolation precautions for other infections or diseases, request a copy of the Transmission Based Isolation Precautions policy from your supervisor (refer to attachment #1). These criteria are adopted from CDC guidelines. E. For Inpatients: Nursing Staff are REQUIRED to: Initiate the precaution promptly when notified of a lab result or are otherwise made aware of a condition requiring a precaution. Enter precaution as a clinical alert or communicate as necessary to other departments (e.g. OR). Place appropriate sign on door and on front of chart. Order all the necessary supplies of required PPE. Instruct the patient and other non-clinical persons (staff and visitors), who need to enter the room where precautions are in place, to use appropriate PPE and hand hygiene. Page 55 of 86

56 Contact Precautions When Used for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient s environment. Examples Gastrointestinal, respiratory, skin, wound infections or colonization with multidrug-resistant organisms (MDROs) including MRSA, VRE, ESBL. How Healthcare providers and visitors are required to wear gowns and gloves when entering patient room or treatment area. Cleaning Hand gel or soap and water to wash hands. EVS terminal clean room when patient is discharged. NOTE: MRSA requires contact precautions for 1 year after a positive culture. Page 56 of 86

57 Contact Precautions - D When Used for patients who are suspected to have or are Clostridium Difficile positive. How Healthcare providers and visitors are required to wear gowns and gloves when entering patient room or treatment area. Patients with C. Diff are asked to stay in their hospital rooms as much as possible. Cleaning Do NOT use hand gel. Instead, use soap and water to clean hands. EVS terminally clean room with bleach upon discharge and preferred additional cleaning with Bioquell or UV Light. Page 57 of 86

58 Droplet Precautions When Used for infections transmitted by large respiratory droplets that travel only short distances and do not remain suspended in the air for long periods. How Healthcare providers and visitors are required to wear surgical mask when working within three (3) feet of the patient. Examples Hemophilus influenza, Neisseria meningitis, Streptococcus pneumonia, Pertussis and Influenza Cleaning Use hand gel and/or soap and water to clean hands. EVS terminally clean patient room upon discharge. Page 58 of 86

59 Airborne Precautions When Used for infections transmitted by airborne droplet nuclei. These particles, because of their size, can remain suspended in the air for long periods of time. How Patient placed in Airborne Infection Isolation (A.I.I.) room (negative pressure room required). Staff and visitors are required to wear N-95 Respirator when entering A.I.I. room. Patients wear surgical mask when not in A.I.I. room. Examples Tuberculosis, Smallpox, Disseminated Shingles, Chickenpox, Measles, Severe Acute Respiratory Syndrome (SARS). Cleaning Use hand gel and/or soap and water to clean hands. EVS terminally clean patient room upon discharge. NOTE: Disseminated Zoster, Measles, Chicken Pox Mask not needed by immune Healthcare Workers. Page 59 of 86

60 V. PATIENT SAFETY AND SERVICE QUALITY CREATING AN EXCEPTIONAL PATIENT EXPERIENCE: Introduction Watch a brief video introduction by Clay Holderman, Chief Operations Officer, Presbyterian Delivery System (click on the link or on the EGG below to view video.) The Presbyterian EGG : The Egg represents the foundation of our culture at Presbyterian. It shows our purpose, vision, values and strategies. One of Presbyterian s key strategies is providing an Exceptional Experience : Page 60 of 86

61 This section describes: WHY: should I care and why do my actions matter? WHAT: is our vision for the Presbyterian experience and what do we mean by exceptional customer experience? HOW: will we deliver the exceptional experience? Why should I care? From our workforce surveys, we know that we all want: - to work for an organization that cares about its patients - to work in an environment where we have good relationships and teamwork Survey Quotes: I want to experience the joy of delivering great care. I am key to showing patients we care about them. What do we mean by customer experience? The perceived sum of ALL interactions over time: - both positive and negative, - indirect and direct. NOTE: by Customer we mean both patients and health plan members. We all create the experience: All workforce are key to showing patients we care about them. When patients have an exceptional experience: - clinical outcomes are better - patients engage, cooperate and partner in their care From the eyes of the patient, experience is a combination of: - Quality - Safety - Service Many times, we may approach our work as tasks associated with service, safety or quality. The patient and family see them as one. Our goal is to create that type of experience. Patients have a 360º experience: This may be in person, on the telephone, on the computer and in the stories that are told about Presbyterian in the community. Page 61 of 86

62 What is the difference between satisfaction vs exceptional experience? Satisfaction occurs when the basic needs of someone are met. Here at Presbyterian, we want to raise the bar and provide our patients, their families and our teammates with exceptional experiences. Satisfaction - the idea of how positive someone feels about an encounter is an important metric, but experience encompasses more than just a sense of satisfaction. Satisfaction is in the moment, but experience is the lasting story.. Patient experience encompasses much more than creating happy patients. It is about ensuring the best quality safety and service outcomes. Adapted from: Jason Beryl, The Beryl Institute Examples of patient satisfaction vs exceptional experience: Satisfaction She gave me my medications and was nice. The staff member called my name loudly from the door so I could hear her and she smiled when she greeted me. The doctor visited me each day and the nurse checked on me a few times a day too. They kept me informed about delays. Exceptional Experience He gave me my medications on time. He told me what medications he was giving me, told me what they were for and how they would make me feel before giving them to me. He answered my questions and then came in and checked on me a little while after giving them to me. Before I left, he made sure I knew how to take them at home. When it was my turn, the staff member came to the lobby and called my name. As she approached, she greeted me and introduced herself. She explained where she was taking me, and as we walked back to the exam room she explained what she would be doing to prepare me for my visit with my doctor. Once in the exam room, she listed to all I had to say and assured me she would advise the doctor of my concerns. The nurse and the doctor worked with my family and me to schedule my care for the day. We always knew when the doctor would be in to talk to us, what tests would be occurring and when I would be going to procedures. The nurse checked in with me at least every hour! When I arrived, they greeted me and informed me right away of the delay. They asked me if I had other plans that the delay would affect. They apologized, thanked me for my patience, offered me water and a light snack and checked in with me periodically. Page 62 of 86

63 Examples of team member satisfaction vs exceptional experience: Satisfaction Most of the staff here are nice; they keep to themselves and don t start any drama. The staff in another area let the patient know we were running behind. Exceptional Experience My teammates are so nice, caring and helpful. They really know me and can tell when things aren t right with me. They encourage me and help me whenever they can. Even staff I don t know smile and say hello in the hall. AND we always speak positively about our teammates in other departments. I feel like a real team; we all have each other s back even if we don t know each other. The staff in another area let the patient know that we were very busy and that we were doing everything we could to get them in as soon as possible! They also did any prep work they could with the patient to help us out. Common patient emotions - fear and anxiety: Exceptional experience is not about just making people happy. It s about recognizing that fear and anxiety are common emotions in patients. Reducing fear and anxiety for our patients can have a huge impact on their experience. Patients fear: - the unknown, - their condition, - what will happen to them, - their outcome, - the cost of the procedure Patient anxiety can stem from: - not knowing what comes next, - who will interact with them, - what will they say, - what questions should be asked, - not having information explained in a way that they understand, - worrying they won t remember all the information - Page 63 of 86

64 What increases patient fear and anxiety? - Waiting - Pain - Confusion and frustration - Loss of control - Anticipation What reduces fear and anxiety? - Comfort - Proactive, regular communication & contact - Clear communication that reduces confusion & promotes understanding - Connecting at a personal level Best-practice tools for you to use: These tools reduce fear and anxiety and promote an exceptional experience: 1. CARES Behaviors 2. Exceptional Patient Experience (EPE) / First Touch 3. Rounding 4. EPE champions in all units / departments 5. Communication Boards 6. The Clinical Care Model 7. The HEAT model Page 64 of 86

65 1. C.A.R.E.S. Behaviors: Continuous Learning Seek to improve Accountability Take ownership Respect and Respond Be present and responsive Environment of Health Assure safe, clean and private Superior Outcomes Exceed expectations and celebrate - Used throughout the organization as a guide to expected behaviors for all Presbyterian workforce - Part of the performance evaluation for workforce is an assessment of his/her C.A.R.E.S. behaviors 2. Exceptional Patient Experience (EPE)/ First Touch is about creating an opportunity for the caregiver to be "fully present" for the patient and establishing a trusting relationship from the start. Read more details on PresNet. (note must be logged into MyPres to access) First Touch The First Touch Philosophy: Taking the best of who we are and connecting with the best in the people we serve. It reminds us to: - Be present - Suspend judgement - Practice touch Page 65 of 86

66 3) Rounding is an evidence-based proactive national practice that improves the patient s quality, safety and service. Tips include: Hospital Rounding Tips - Clinical staff should visit and connect with each patient every 1 2 hours - Hourly rounding reduces falls and prevents skin breakdowns - Can also result in up to a 37% reduction in call lights - During rounding visits address: o Pain / Potty / Position o Safety sweep o Ask: Is there anything I can do for you before I leave? Outpatient Clinic Rounding Tips - Called Comfort Rounding, during wait time staff should: - Offer patients & family members snacks and refreshments - Engage in conversation and build relationships while they wait 4) Exceptional Patient Experience (EPE) Champions are staff role models and resources for the EPE/First Touch work. Presbyterian currently has over 500 EPE champions in clinical departments throughout the organization. Ask your supervisor who the EPE Champion is in your area. They are a resource to you click here to read more on the PresNet webpage (note - must be logged into MyPres to access this webpage.) 5) Communication Boards: Patient whiteboards (dry-erase boards) are a great way to display important information. Providing a focal point where key information is displayed reduces anxiety for patients and their families: Hospital Communication Boards - Communication boards in patient rooms provide information about the care team and their contact information. - They also serve as a focal point for conversation and information regarding expectations around pain, pain management and the patient s care plan. Outpatient Check-in Delay Boards - Delay boards in outpatient check-in areas provide valuable information to patients and families regarding delays. - These boards create an opportunity to engage in conversation with patients as to available options and allow them to make choices about how to handle the delay (i.e. wait, or see another provider, or reschedule). Page 66 of 86

67 6) The Clinical Care Model describes care team model behaviors for applying the Exceptional Patient Experience philosophy. While some of us have more direct contact with patients, everyone can support direct care-givers by applying these behaviors in their interactions with patients, and teammates, as shown in the red and blue areas on the diagram below: Page 67 of 86

68 7) The HEAT Model is used in situations where the experience is less than exceptional. The HEAT model is a tool to help workforce members manage these difficult situations: In Difficult Situations with Customers: Expectations: Presbyterian healthcare workers, including students, volunteers and contractors, are expected to: - Make a choice to create Exceptional Experiences with patients and team members - Help each other to create Exceptional Experiences - Ask patients, What matters to you? We should check with patients to see how we are doing: - In the real-time, we should ask patients how we are meeting their expectations as part of our interactions with them. - We watch and help each other consistently use the Exceptional Patient Experience tools and best practices. - For long-term insights and measures of how we are doing, we send surveys to our patients after care has been provided. Page 68 of 86

69 Patient Surveys: The government requires that we use a standard survey tool with our patients Consumer Assessment of Healthcare Providers and Systems (CAHPS). Different versions of this survey are used depending on the type of service the patient received; - H-CAHPS (Hospitals) sent to inpatients - CG-CAHPS (Clinician and Groups) sent to patients of primary care and specialist provider offices - HH CAHPS (Home Health) sent to home health patients For several years H-CAHPS and HH CAHPS survey data has been publicly reported on the Centers for Medicare and Medicaid Services (CMS) website. Eventually all CAHPS data will be publicly reported, allowing consumers to judge our hospitals and providers against competitors. Presbyterian contracts with an outside firm, Press Ganey, to survey patient satisfaction with our ancillary services as well. Results of recent surveys are available on the PresNet Voice of the Customer webpage (note must be logged into MyPres to access), or on the CMS CAHPS website. In Summary - Remember: - The patient is scared. - The patient has lost almost all control. - They hurt and they are the ONLY judge of their pain that matters. - You are likely their only means of information. - They need compassion. - Even those who do not directly interact with the patient do contribute to the patient experience. We must each make the individual commitment to create an exceptional patient experience in every interaction. Our Pledge: As members of the Presbyterian Workforce, all employees, volunteers, contractors and students commit to providing an exceptional experience for Presbyterian patients and their families, and also for our Presbyterian teammates. Page 69 of 86

70 CULTURAL SENSITIVITY AND MEDICAL INTERPRETATION Why it Matters: Cultural sensitivity and proper use of medical interpreters is important to us as individuals, and to Presbyterian as an entity, because of the diverse population we serve here in New Mexico. We are committed to serving everyone in our communities and for some members that means providing a language service so that they can access healthcare and services effectively. Cultural Sensitivity is the knowledge and interpersonal skills that allow people to understand, appreciate and work with individuals from other cultures. There are many things that may influence a person s understanding and expectation of their healthcare experience. We must be aware of these factors in order to be sensitive to them. Being culturally sensitive therefore involves self-awareness, acceptance of cultural differences, and knowledge of a patient s culture and adaptation of skills. Cultural Sensitivity Factors: Below are some of the cultural sensitivity factors that come into play. Remember that in any given interaction, some of these factors may be more significant than others, and no interaction will be the same. Think about how these impact you in your day-to-day interactions and medical decision-making: Religion Communication style Age Food Traditions Sexual orientation Education Socio-economic status Family/community Language Disabilities and behavioral health Ethnicity Geographic location Tips for Being Culturally Sensitive As cultures vary in their beliefs about the cause, prevention and treatment of illness, these beliefs may dictate the practices used for maintaining, discussing and treating their health issues. Here are some tips on where to start with a patient: 1. Ask how the patient and family member(s) would like to be addressed. 2. Ensure terminology used is understood by patients. 3. Ask if the gender of the caregiver is important. 4. Provide interpreters and translated materials for people who are hard of hearing, speech impaired and those with Limited English Proficiency (LEP). NOTE: A simple statement and question may help you relate appropriately to the patient / member: I don t want to offend you. Is it okay with you if I? Federal Law and Cultural Sensitivity Being culturally sensitive is not only good healthcare practice it s also federal law! In 1998, the Department of Health and Human Services issued a memo regarding Title VI of the Civil Rights Act of It prohibits discrimination on the basis of race, color, and national origin in programs and activities receiving federal assistance. This has been determined to include persons with Limited English Proficiency (LEP) i.e. anyone who cannot speak, read, write or understand the English language at a level that allows them to interact effectively with healthcare providers. Page 70 of 86

71 C.A.R.E.S. and Cultural Sensitivity: Being culturally sensitive aligns with the C.A.R.E.S. Behaviors we have adopted as an organization. In particular, Accountability and Continuous Learning can be demonstrated in relating to someone whose background is not familiar to you. For example: I don t know very much about Ethiopian culture; please let me know if I am not understanding something or if you have a request about your healthcare service or providers. We d like to accommodate you! C.A.R.E.S. Behaviors & Daily Vitals: Continuous Learning Seek to improve Accountability Take ownership Respect and Respond Be present and responsive Environment of Health Assure safe, clean and private Superior Outcomes Exceed expectations and celebrate Respect and Respond of the C.A.R.E.S. Behaviors are also crucial to cultural sensitivity. For example: If you are a male treating a female patient who seems unwilling to share personal / medical information, it might be due to a cultural norm in which it is inappropriate to share such information with a male. You can politely ask if the patient would prefer to be seen by a woman. Cultural Sensitivity with Teammates: Don t forget that cultural sensitivity is important in your workplace as well! It s easy to focus on the idea of treating our patients and members with respect and sensitivity, but don t forget that the person down the hall or in your department meetings might also have a different cultural background than you. New Mexico has a very diverse population! Keep in mind in your work interactions that your C.A.R.E.S. Behaviors apply to each of us and how we treat each other. Page 71 of 86

72 MEDICAL INTERPRETERS AND CLINICAL CARE: Interpreter Services on PresNet: You can locate the link to the Interpreter Services web page on the right-hand side of the PresNet home page. Here is the web address to go directly to Interpreter Services: (NOTE: you must be logged into MyPres to be able to access this page.) The Interpreter Services website has information to guide you, including process flowcharts, lists of PHS qualified interpreters, etc.: Interpreter-Need Flowchart: This helpful tool helps you to decide which interpretation resource is best for your need. Note that the flowchart is also hyperlinked to more information and documents as you need them. Page 72 of 86

73 Select Interpreter Services resources in this order: 1. First Choice: PHS Qualified Interpreters 2. Second Choice: InDemand Video Interpreter Cart 3. Third Choice: Telephonic Interpreter via CLI 1. First Choice - PHS Qualified Interpreters: See the list in the PEL of PHS Trained Staff ; listing shows department, shift, contact information and facility: Key differences between a Qualified interpreter vs. bilingual staff member: Qualifications Qualified Interpreter: Qualifications Bilingual staff: Fluently speaks a language Fluently speaks a language other than English other than English Has successfully completed Has NOT completed designated language assessment designated language assessment Has completed 40 hour Bridging Has NOT completed 40 hr the Gap training program Bridging the Gap program Can be used for: Can be used for: Interpreting vital medical information* Way finding assistance Way finding assistance Handling personal valuables Handling personal valuables General communication General communication *Vital Medical Information includes: Informed consent, waiver of rights, assessments, medical procedures, results, prognosis, treatment, plan of care, explanation of medications, authorization to disclose protected health information and any other circumstances in which a qualified interpreter is necessary to ensure a patient s rights are provided by law. Page 73 of 86

74 Family members or bilingual staff: May only be used to interpret non-vital medical information May NOT interpret vital medical information unless the patient, client or adult speaking on their behalf has been informed of the availability of free, qualified interpreters and refuses the service. If the patient still chooses to have a family member or friend interpret, that choice must be documented in the patient s medical record. Children under the age of 18 must never be used as medical interpreters. The only exception is a life-threatening situation. 2. Second Choice - InDemand Video Interpreter Cart: If the nearest PHS Qualified Trained staff member is unavailable, the InDemand Interpreter Cart should be the next choice for interpretation. Ask your charge nurse for the location of the InDemand Interpreter Cart near your unit. See the InDemand Interpreting Service web page for more a list of the more than 180 languages available (including Navajo); for many languages you may choose either a male or female interpreter. 3. Third Choice - Telephonic Interpreter via CLI: If PHS Qualified staff and the InDemand Interpreter Cart are unavailable, call Certified Languages International (CLI). You will be asked for a location code when you call see a list of codes on the Telephonic Interpreting webpage. Page 74 of 86

75 Deaf/ Hard of Hearing Use either InDemand or COPD: If an InDemand Interpreter Cart is unavailable or the patient/member requests an in-person interpreter, then call the Community Outreach Program for the Deaf (COPD). Contact via the numbers listed on the COPD webpage. Documentation in the EMR: Documentation in the Electronic Medical Record (EMR) is critical to prove compliance with legal requirements to offer translation services. It is also helpful for tracking usage of interpreter services and languages. You must document language preference for all patients (including English speakers!): 1. Assessment of preferred spoken language and preferred written language 2. If the patient has Limited English Proficiency (LEP), the following information must also be in the EMR: Is a medical interpreter required? (Yes or No) 3. If yes, document interpretation method: Interpreter needed, yes select method (PHS trained staff, video interpreting, audio/phone or 3 rd party vendor) 4. If patient declines the use of a free interpreter, that also must be documented: Interpreter needed, yes select Patient refused free services. NOTE: if you select this option, the reason for refusal must also be noted in the comment field. Page 75 of 86

76 Documentation Guides are also available from the webpage: What if I don t know what language the patient speaks? The Interpreter website has a link to the I-Speak reference sheet in the PEL. Use this document to have the patient point to their language for you: Page 76 of 86

77 What if I need written documents translated into another language? Spanish Documents: some key documents are already available in Spanish; just ask the department that sent the document to check if there is a Spanish version. NOTE: Mosby s and EPIC also have some patient education / discharge info available in Spanish. Immediate Need: If the document is not available for the language needed and there is an immediate need, contact an interpreter using the InDemand cart. You will be directed by the interpreter to fax the document to them to translate verbally on screen into the patient s language. Non-Urgent Need: For translations not needed immediately by the patient, the document to Presbyterian Interpreter Services Program Coordinator, Lindsy Glick at lglick@phs.org for a quote and estimated turnaround time. Summary: Imagine yourself moving to another country for work or family. You may have learned the local language to a conversational level, but medical terms and in-depth topics are difficult for you. Now add the potential embarrassment due to the reason that you are seeking medical care. How would you want healthcare workers to treat and assist you? Putting yourself in someone else s shoes even if you can t know the whole background story is good way to behave in a culturally sensitive way! Non-Employee Pledge: As a non-employee member of the Presbyterian workforce, you are agreeing to the following pledge: I understand that every patient is entitled to free interpretation services by a qualified (trained) medical interpreter, 24 hours per day/365 days per year regardless of native language, or ability to speak or understand the English language. I agree to follow the PHS Interpretation and Translation Services policy by being aware and culturally sensitive to patients, members and teammates. I will adhere to the guidelines for when and how to use interpreter services and document that use/refusal appropriately. If have questions, I know I can refer to the Interpreter Services website, policy and/or program coordinator by contacting Lindsy Glick at lglick@phs.org or calling I agree that I will help Presbyterian provide equal access to healthcare for the individuals and communities we serve, and to treat all patients, members, and fellow co-workers with respect and dignity regardless of nationality, race, ethnicity, or ability to speak or understand the English language. Page 77 of 86

78 PATIENT SAFETY AND FALL PREVENTION I. Culture of Safety A. Key Elements of a Safe Culture: The following elements are proven to correlate with reduced patient harm: i. A culture where the patient s health and safety are priorities ii. Team members have a common goal and are not afraid to speak up iii. People are held accountable for actions, but know that they will be treated fairly when mistakes/errors occur iv. Error reporting is valued so that we can learn from our mistakes v. We focus on what, not who errors can be the result of flawed systems vi. Accountability demands that each of us follow the established rules, policies and standards of practice (such as Red Rules, area specific rules, and Patient Safety Alerts) B. Red Rules are for Everyone: i. Red Rule 1: Positive Patient Identification: Positively identify the patient, using 2 sources of information (NEVER a room number), before providing patient care, or when providing medical records or prescription. ii. Red Rule 2: Proper Hand Hygiene: Gel in and Gel out before and after rendering any patient care; use soap and water when hands are visibly soiled. C. Area Specific Rules: In addition to Red Rules, these are considered critical clinical rules that must be followed to prevent harm, based on high risk if there is noncompliance: i. Surgical count policies ii. Medication preparation accuracy checks iii. Complete follow-up on abnormal test results iv. Vital signs taken and recorded per policy and escalation when abnormal D. The Patient is a Part of the Team: Embrace patients as valuable and contributing partners in patient care: i. Ask patients about their concerns ii. Listen to family members concerns iii. Speak in lay terms iv. Give access to relevant information v. Encourage patients and their families to proactively participate in patient care Page 78 of 86

79 II. Medical Errors: A. Examples of Medical Errors: i. Patient falls ii. Healthcare acquired infections (including pneumonia and infections in surgical incisions, central lines and urinary tract) iii. Procedural or surgical errors iv. Lab or diagnostic errors v. Failure to steps known to prevent disease vi. Billing or benefit errors, which could prevent complete or timely care B. The Medical Error Problem is Large - in the US healthcare system (8 countries report similar findings to the US): i. 7% of patients suffer a medication error 2 ii. On average, every patient admitted to an ICU suffers an adverse event 3,4 iii. 195,000 people die in hospitals each year as a result of medical errors 5 iv. Nearly 100,000 deaths from Hospital Acquired Infections 6 v. Cost of Hospital Acquired Infections is $28 - $33 billion 7 C. How Does this Happen? Think about an error you ve experienced and what contributed to that error: i. Distractions? ii. Workarounds? iii. No established process? iv. You or co-worker made assumptions? v. Communication wasn t clear, or was incomplete? vi. You or team member didn t follow rules/policies? vii. Similar error occurred before, but you weren t aware, or it was never addressed? Page 79 of 86

80 III. Ways to Make Care Safer by Creating a Safe Culture: A. Use Evidence-Based Practice: base care on the science behind why we care for patients the way we do B. Standardized, with Well-Defined Processes: i. PHS uses process improvement to understand and correct where errors can or have occurred ii. We all must follow same steps to assure reliability iii. Speak up if you are having to work around C. Work as a Team: i. Be clear on roles and responsibilities ii. Team must have a leader, especially in high risk areas and procedures iii. Psychological safety -- team members agree to: 1. Stop the line if something is not right Examples of standardization in healthcare: 2. Use the term, I need clarity, when you think an error may occur iv. Standardize communication and handoff - use techniques borrowed from the airline industry: 1. Independent checks 2. Checklists 3. Huddles / Briefings / Debriefings 4. Event review 5. Regular feedback to individuals and team 6. Precise communication ACLS (Advanced Cardiac Life Support) PALS (Pediatric Advanced Life Support) 6 Rights to medication administration Scrubbing for the operating room Order sets/protocols Protocols for Information technology D. Utilize Clear Communications and Handoffs: A root cause of over 60% of serious errors (sentinel events) is communication errors. Safe handoffs should always include: i. Clear transfer of authority, information, and responsibility ii. The opportunity to ask questions, clarify and confirm, and address pitfalls, or potential risks Communication Strategies: Handoff Tools (Ticket to Ride) SBAR Call-outs (So everyone hears the order/action) Repeat Back / Verbal Order Read back Numeric Clarification ( Fifteen, 1 5 ) GLITCH book (Glimmers of Little Things That Catch Harm) Escalating language (Say it again and Ask for Clarity ) Page 80 of 86

81 E. Report All Errors and Near Misses: i. Critical so that issues can be addressed and all are aware of potential problems ii. Reported events are reviewed and prioritized iii. Report through Risk Event link on PresNet Homepage (on right, under At Your Fingertips) F. Learn From Errors and Near Misses: i. When things go wrong ask questions: 1. What happened and why? 2. What did you do to reduce risk? 3. How do you know your fix worked? ii. For serious events, a multidisciplinary team is responsible for doing Root Cause Analysis and assuring effective safeguards are in place to prevent repeat events iii. Learning should always be communicated, formally or informally G. Make team feedback a habit iv. Following a clinical procedure or complicated task, ask: 1. What did we do well? 2. What did we learn? 3. What would we do differently next time? v. Start with the junior team members first, to assure their comfort with participating IV. Fall Prevention A. National Statistics: i. Hospital patients older than 64 or those in long-term care fall 3 times more often than the average for all patients ii. Between 3% and 20% of inpatients fall at least once during stay iii. 80% - 90% of patient falls are unwitnessed iv. 30% - 50% of falls resulted in some kind of injury v. Falls with injury are the 6 th most common type of sentinel event vi. 15% of elderly who fall in a hospital sustain an injury; of those, 33% don t survive beyond 1 year vii. Falls result in increased length of stay, higher number discharged to a long-term care facility and greater use of healthcare resources Page 81 of 86

82 B. Common Causes of Falls: i. Urinary incontinence ii. Medication iii. Physical environment (slips, trips, loss of balance, dim light) iv. Postural hypotension v. Confusion, disoriented C. Fall Prevention Techniques: i. Timely assessment and reassessment ii. Appropriate identification and interventions iii. Slip free socks, teal gown, yellow wristband, bed alarms, Velcro chair belt iv. Toileting: offer frequently and stay near v. Bed rails up, alarm on, items in reach D. Preventing Falls at Presbyterian: Communication is key! i. Patient and family education 1. Call, Don t Fall signs, inpatient brochure 2. Staff awareness of patients at risk a. Huddles b. Debriefs c. Heightened awareness at shift change ii. PMG and outpatient settings: 1. Fall in last 3 months? 2. Canes, walkers 3. Extra vigilance, don t leave alone on exam table Page 82 of 86

83 BLOOD TRANSFUSION REACTIONS Recognizing and Treating Blood Transfusion Reactions Training for Non-Employees On completion of this section, Non-Employee Registered Nurses and other clinical staff involved in blood transfusions will be able to: 1. Recognize the signs and symptoms of various hemolytic and non-hemolytic reactions 2. Respond quickly to those signs 3. Seek the appropriate assistance to treat reactions quickly and properly. You may also reference the Blood and Blood Products Administration Procedure in the PEL. (NOTE link only works from workstations logged into the Presbyterian network.) Patient (or their representative) Must Sign a Consent Prior to Transfusion 1. Consent form is available online at, Disclosure and Consent to Receive or Refuse Blood Transfusions 2. Must print name of patient and name of provider ordering blood products 3. Patients may authorize all of the ordered blood products or only some of the ordered blood products by checking the appropriate box 4. Patients may also refuse blood products if so, they should check the appropriate box indicating their refusal and should still sign the form 5. Patient or their representative must sign and date the form; if an interpreter is used the interpreter s name should be printed on the form. Blood is safe but not Risk-Free! 1. Blood transfusions are not without risk. Rarely, a patient has a reaction to the blood products. These reactions can be serious, and even fatal. Early identification of these potential reactions is important to reducing complications. 2. Risks of transfusions & examples: a. Disease transmission (HIV, hepatitis, & other viruses, bacteria, parasites) b. Hemolytic transfusion reactions (ABO) c. Non-hemolytic transfusion reactions (febrile, circulatory overload) 3. Reactions can be acute (<24 hours of transfusion) or delayed (> 24 hours of transfusion) 4. Almost any reaction can be fatal if not recognized and treated promptly Page 83 of 86

84 Disease Transmission Risks The most feared but least likely reaction is disease transmission. Risks per unit transfused are (m = million): a. HIV-1 in 1.4m to 1 in 2.4m b. HTLV-I,-II: 1 in 256,000 to 1 in 2m c. Hepatitis A: 1 in 1m d. Hepatitis B: 1 in 58,000 to 1 in 147,000 e. Hepatitis C: 1 in 872,000 to 1 in 1.7m f. Bacteria: 1 in 1000 (RBCs) to unknown for platelets as they are screened now for bacteria Hemolytic Transfusion Reactions 1. An acute hemolytic reaction is when the blood cells lyse, or break apart after the patient receives a blood product. 2. Acute hemolytic reactions occur at a rate of 1 in 12,000 to 35,000 transfusions and are fatal in every 100,000 to 600,000 units 3. The majority of fatalities are due to ABO incompatibility, most commonly caused by transcription or data entry errors 4. Symptoms: chills, fever, nausea, vomiting, diarrhea, facial flushing or pallor, dyspnea, jaundice, hemoglobinuria, hypotension, diffuse bleeding, pain in back and along flanks, anxiety and sense of impending doom, renal failure 5. Treatment: diuretics, analgesics, pressors, coagulation components depending on the severity of the incompatibility NON-Hemolytic Transfusion Reactions 1. Allergic Reactions: are the most common type of transfusion related reactions: a. Occurs in 1 out of every 250 transfused units b. Reactions are not usually life threatening and can be self-limiting. c. A raised red rash usually appears on the trunk, back neck or face. d. If a patient is known to have an allergic reaction ahead of time they can be treated prophylactically with antihistamines. 2. Anaphylactic Reaction: a more serious form of an allergic reaction a. Incidence: 1 in 20,000 to 1 in 50,000 transfusions b. Includes a sudden and severe swelling of the mouth, tongue and upper airway. c. May be accompanied by hives and loss of consciousness. d. This is a life threatening condition and should be acted on with urgency e. Epinephrine and antihistamines are used to treat anaphylaxis Page 84 of 86

85 3. Transfusion Related Acute Lung Injury (TRALI) is a severe and potentially fatal reaction: a. Incidence 1 in 5,000 units b. Symptoms do not appear right away: chills, fever, dyspnea, non-productive cough and hypotension seen 4-6 hours post transfusion c. Over time, TRALI causes severe respiratory distress and hypoxemia d. Chest x-rays will show bilateral infiltrates, or fluid in the lungs, without the heart enlargement that you would see in congestive heart failure e. TRALI is often misdiagnosed as Acute Respiratory Distress Syndrome (ARDS) f. Treatment: includes steroids and ventilator and hemodynamic support. These patients are often moved to critical care because of oxygenation difficulty. 4. TACO: Transfusion Associated Circulatory Overload a. Incidence: < 1% of transfusions b. Avoidable condition usually caused by infusing blood products faster than the patient can accommodate c. Patients at risk include those at risk for circulatory overload, including those with congestive heart failure, renal failure, hepatic cirrhosis, and normovolemic anemia d. Symptoms: cough, headache, dyspnea, hypertension, high output circulatory failure, tachycardia, distended neck veins e. Treatment: administration of oxygen and morphine for vasodilation. Giving Lasix to remove excess fluids and repositioning the patient in an upright position, especially with the lower extremities dependent (hanging down.) Page 85 of 86

86 If you suspect a reaction: 1. STOP the transfusion 2. Start NS in new IV tubing at TKO 3. Immediately contact blood bank with a possible transfusion reaction 4. Notify the provider and treat the patient as ordered 5. Notify Blood Bank and return remainder of blood component and attached tubing END OF TRAINING ---- Page 86 of 86