THE JOINT COMMISSION RESOURCE GUIDE

Transcription

1 YOU ARE THE KEY TO OUR SUCCESS THE JOINT COMMISSION RESOURCE GUIDE 2017

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3 Table of Contents Abbreviations: Do Not Use Clutter and No Parking Zones Document, Document, Document! Managing Medical Equipment: Laryngoscopes and Forceps in Carts/Intubation Boxes Maintenance of Mattresses and Other Vinyl Equipment.. 8 Medications: Lock Them Up! Medications: Proper Labeling Moderate Sedation: Assessment and Documentation Monitoring Refrigerator and Freezer Temperatures Oxygen Tank Storage: Read the Gauge! Pain Assessment and Management Pressure Rooms: Positive and Negative Pressure Proper Wipe Protocol Restraint Policy Safe Operation of Blanket and Fluid Warming Cabinets Take a Time Out! Survey Analysis for Evaluating Risk (SAFER) Titration of Continuous Infusions: Guidelines Top 10 Most Cited Standards

4 Abbreviations: Do Not Use The Joint Commission has established a National Patient Safety Goal that specifies that certain abbreviations must not be used, as they are frequently misinterpreted and involved in harmful medication errors. The following abbreviations should NEVER be used when communicating medical information: DO NOT USE THESE ABBREVIATIONS: USE: QD, OD Daily QID times daily QOD Every other day or Q48H MgSO Magnesium Sulfate MSO4 or MS Morphine Sulfate U Units Always use a zero before a decimal (e.g., 0.5 mg instead of.5 mg). Express whole numbers (e.g., 1 mg instead of 1.0 mg). Documents sent in (electronically, pre-printed, handwritten, etc.) from physician offices, such as patient medical history, must be checked for the presence of prohibited abbreviations before being added to the patient's medical record. By eliminating use of these abbreviations and promoting safe practices, we can better protect our patients. 4

5 Clutter and No Parking Zones According to the Life Safety Code and The Joint Commission, All exit paths must remain free of obstructions, including unattended items that are not considered in use by staff members. Stretchers and equipment must always be kept to one side of the hallway or out of the hallway completely. Only code carts and isolation carts (for patients actively on isolation) may be left in the hallway, as these are considered to be in use. If you find a stretcher in a hallway, please contact the department that the stretcher belongs to. All stretchers are marked with their respective department's extension. In addition, if you find any abandoned wheelchairs, please contact Patient Transport at ext for removal. Items delivered in corrugated cardboard must be put away immediately, and the boxes must be placed in the dirty utility room for pick-up and disposal by a service associate. You may have noticed our red decals that mark which areas are No Parking Zones! As a reminder, equipment MUST NEVER be parked in front of: Oxygen shut off valves Fire alarms Fire extinguishers Emergency exits Eye wash stations 5

6 Document, Document, Document! Documenting the Plan of Care: The patient s plan of care (POC) is a multidisciplinary, collaborative and dynamic document consisting of problems, outcomes and interventions. Each patient s care plan is individualized upon admission to their specific disease process, procedure or past medical history. During hospitalization, the POC must be evaluated every 24 hours and as needed in the Electronic Medical Record (EMR), based on assessments of the patient s condition or procedure. Documenting the Version Dates for Vaccine Information Sheets: Vaccine Information Sheets (VISs) are created by the CDC to assist in educating patients/families about vaccines. The nurse must document that the VIS was given to the patient/family and the version date of the sheet (found on bottom of VIS). Please document the VIS given to the patient/family in the EMR when administering the vaccine. The VIS publication date will automatically populate when you administer the vaccine. Documenting Isolation Precaution Education: The nurse must document the education given to patients/ families about isolation precautions in the EMR. Use the educational handouts located on the intranet (click on the Clinical Tools drop-down menu at the top of the homepage, and click on Patient Education). 6

7 Managing Medical Equipment: Laryngoscopes and Forceps in Carts/Intubation Boxes Laryngoscope blades and forceps MUST be kept in covered packages and marked clean at all times when stored in the locked code cart, anesthesia cart and intubation boxes. After use, they must be placed in a biohazard bag (see right) and sent to the Central Processing Department (CPD) for sterilization. The lights, batteries and switch on laryngoscopes in code carts are checked monthly. DO NOT completely remove the peeled wrap over the blade when performing checks. Once completed, the blades must be put back into the peel pouch and sealed with a green label that says THIS ITEM CLEAN, NOT STERILE. The laryngoscope handle must be put into a clear plastic bag marked CLEAN (see left). If the blade or laryngoscope becomes contaminated while checking, you must send it to CPD for processing and obtain a new one to replace it. Anesthesia carts will be maintained by the Anesthesia Tech. 7

8 Maintenance of Mattresses and Other Vinyl Equipment As healthcare providers in a hospital setting, it is everyone s responsibility to take the proper steps to reduce the risk of infections associated with medical equipment, devices and supplies. Please note the following procedures for removal and replacement of stretcher mattresses, bed mattresses and other vinyl equipment that are torn or damaged: Stretcher Mattresses: All stretcher mattresses are to be inspected after each use during the cleaning process to check for any openings or tears, including seams that are opened or frayed. Also check to see that the Velcro is intact and the mattress adheres to the stretcher. If you find any damage during the inspection process, it is the expectation that all staff, regardless of title, will promptly remove the mattress from service and initiate the following replacement procedure: 1. Contact the Hospital Operations Resource Center (HORC) at ext You may contact the HORC 24/7. 2. The HORC will contact Patient Transport to locate and deliver a replacement mattress to the department. 8

9 For ease of replacement, a supply of mattresses will be stored on site at the hospital. Bed Mattresses and Other Vinyl Equipment: All bed mattresses are to be inspected when the linens are changed. If a mattress needs to be replaced due to compromised integrity, you must contact Environmental Services (EVS) at ext for a spare mattress. If a spare mattress is unavailable, EVS will attach a blue tag to the mattress for future replacement. Mattresses that need to be repaired will be sent to Biomed. All damaged vinyl equipment (e.g., seizure pads, pink chairs, positioning pads, etc.) should be discarded. Please also alert your manager so the equipment can be replaced. 9

10 Medications: Lock Them Up! To ensure everyone s health and safety, all medication in cabinets, carts, refrigerators, medication rooms and patient rooms where medication drawers are present, must be locked at all times. Medications prepared in procedural areas and in the OR must also be locked in a cart or must NEVER be left unattended in a room. 10

11 Medications: Proper Labeling Per The Joint Commission, Valley s Intraoperative Medication Administration policy (Policy #96.08) has been updated to reflect the labeling of medications on the surgical field. The new name of the policy is Medication Administration in Intraoperative/ Intraprocedural Areas, as it affects all procedural areas that use medications on a sterile field. Here are highlights from the policy: 1. Medications should be labeled on the surgical field immediately after receipt of medication by affixing the correct sterile preprinted medication label to the syringe, medicine glass or solution basin. Absolutely NO pre-labeling. 2. Blank sterile labels may be written on with a sterile marking pen and used for medications not listed on the preprinted label sheet. Basins should be labeled immediately after they are filled. Again, absolutely NO pre-labeling. 3. The labels must be legible and include basic information, such as: Medication name Medication strength Concentration 11

12 Moderate Sedation: Assessment and Documentation Prior to the administration of moderate sedation (anesthesia), all patients must have a History and Physical Exam (H&P). The H&P must contain a concise evaluation of the case, including the course of illness, pertinent symptoms, significant physical findings (positive and negative), a statement about allergies and medications, a diagnosis and a plan of initial therapy. During the pre-sedation assessment, it is VERY IMPORTANT that the physician administering anesthesia documents the Mallampati Score (the assessment of the airway), the ASA status (risk stratification score), the presence or absence of a prior history of complications with anesthesia and the plan for sedation. For your reference, please see the diagram below for how to obtain the Mallampati Score. 12

13 Monitoring Refrigerator and Freezer Temperatures Per The Joint Commission, for all refrigerators and freezers that store medications or nutrition for patients, the temperature must be properly monitored and documented to ensure that it does not deviate from the required ranges for all contents stored. Valley has implemented the Primex Refrigerator Temperature Monitoring System, which electronically tracks and records the temperatures of refrigerators and freezers in the hospital and at off-site locations on an ongoing basis. If the temperature is out of range, an alarm will sound. It is the responsibility of ALL staff in the department to check the device and attempt to correct the issue (closing the refrigerator door, etc.). If the alarm continues to sound, you must contact Engineering at ext Engineering will then evaluate the device and make any necessary adjustments. If Engineering is unable to correct the issue, the device will be removed from service for repair or replacement. Engineering will monitor reports to ensure that appropriate action is initiated and follow-up occurs when temperatures are out of range. 13

14 Oxygen Tank Storage: Read the Gauge! Oxygen tanks no longer have tags on them that indicate if they are full, partially used or empty. It is everyone s responsibility to now read the gauge on each tank to determine the tank s status. If the indicator on the gauge is in the GREEN area, that means the tank is full. All full tanks must be returned to the GREEN racks. If the indicator on the gauge is below the green area, that means the tank has been used. If the indicator is in the RED area, the tank is empty. All partially used and empty tanks must be returned to the RED racks ONLY. As a reminder, never leave an oxygen tank freestanding. If you need any assistance, please call ext or ext Gauge on Full Partially Full (in-use) Gauge on Empty 14

15 Pain Assessment and Management The identification and treatment of pain is an important component of a patient's plan of care. Per our Pain Assessment and Management policy (Policy #55.06), please be reminded of the following: Pain assessment must be completed by the nurse every shift and as needed. If pain medications are administered, the patient s pain must be re-assessed WITHIN 1 HOUR of administering the medication AND documented. REMEMBER: Alternative therapies such as guided imagery, lavender sniffers and massage may also be used in place of pain medication Orders cannot be accepted if they overlap pain scale ratings. FOR EXAMPLE: Percocet 1 tab Q4H PRN, pain score 0 6 Percocet 2 tabs Q4H PRN, pain score 4 6 Orders cannot be accepted if more than one medication is prescribed for the same degree of pain. FOR EXAMPLE: Percocet 1 tab Q4H PRN, moderate pain Tylenol #3 1 tab Q4H PRN, moderate pain 15

16 Pressure Rooms: Positive and Negative Pressure We often hear about Positive and Negative Pressure Rooms, but what does that really mean? Negative pressure is a technique used to prevent cross-contamination from room to room, as air is allowed to flow into the room but not escape from the room (i.e., any airborne infection isolation room). Each patient care unit is equipped with at least one negative pressure isolation room, which is used for patients on airborne precautions. The concept of a positive pressure room allows air to flow out. This helps maintain a clean environment in the room by pushing out any possible contamination coming from the hallway. All Operating Rooms (ORs), Labor & Delivery C-section ORs, Cardiac Cath Labs and CPD sterile wrap rooms are positive pressure. It is the responsibility of ALL department staff that have positive and/or negative pressure rooms to monitor and document air pressure on a daily basis using the Visual Monitoring System as per policy. If the Visual Indicator shows that the air pressure is not correct, you must immediately notify Engineering at ext to request repair. 16

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18 Proper Wipe Protocol Proper wipe storage will keep the wipes from drying out and help them remain effective in preventing healthcareassociated infections. The photos here illustrate proper and improper wipe storage. PROPER Super Sani Cloth Wipes: Contact time: 2 minutes Effective against 30 micro-organisms These wipes are indicated for use on any equipment. Sani Cloth Bleach Wipes: Contact time: 4 minutes Effective against 50 micro-organisms Bleach wipes are indicated for use in isolation rooms, specifically patients with C. difficile. They can also be used on any equipment that has been used either in these rooms or on these patients. Take care with handling bleach wipes, as they may discolor clothing and certain surfaces. When Using Either Type of Wipe: Gloves should always be used. Always check with the equipment and/or device manufacturer regarding instructions for cleaning. For more information, please view the Super Sani Cloth instructional video at: super-sani-cloth%c2%ae-disinfecting-wipes-training 18 IMPROPER IMPROPER

19 Restraint Policy Restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. The restraint policy (#63.01) is in place to protect and preserve the patient's rights, dignity and well-being, as well as to meet the regulatory requirements from the Centers for Medicare and Medicaid Services, The Joint Commission and the New Jersey Department of Health and Senior Services. Here are a few tips: 1. Behavioral Restraints and Medical/Surgical Restraints must be renewed using the Restraint Physician Order Form. 2. NO PRN orders should be accepted. 3. The patient s plan of care shall be modified to indicate the type of restraint and the goals of the restraint episode. Behavioral Restraints Renewal of orders are as follows: 4 hours for adults age 18 years and older 2 hours for children ages hour for children under 9 Medical/Surgical Restraints Order needs to be renewed within 24 hours from the prior order. 19

20 Safe Operation of Blanket/Fluid Warming Cabinets Per Policy #63.03, the following procedures must be strictly followed when operating blanket and fluid warming cabinets: 1. The operating temperature of all blanket warming cabinets, regardless of make or model, must be set at the safe level, but not exceed 120 F (48.9 C). 2. Items placed in warming cabinets must be placed to provide a minimum of 1" clearance between items and front and back walls of cabinets to allow for proper air circulation around items. Personnel responsible for loading and unloading warming cabinets may not overload cabinets. Such overloading will be construed as misuse of equipment. 3. Fluid warming cabinets should be set at a safe level according to the manufacturer s guidelines. 4. All IV fluids, water and saline bottles used must be labeled with an expiration date per guidelines. The date must be placed on the fluids using a label maker and not a marker. Refer to the manufacturer s guidelines for disposal and rewarming parameters. 5. All defective equipment must be reported to the Clinical Engineering Department by calling ext and placing a request for service. 20

21 Take a Time-Out! The Joint Commission developed the Time-Out Protocol for preventing wrong site, wrong procedure and wrong person surgery. Prior to ANY invasive procedure (surgery, chest tube insertion, central venous pressure line, any bedside procedure including removal of a vascular access device, etc.), a time-out must be completed. When a time-out is called, EVERY person in the room must stop what they are doing and focus on the time-out procedure. During the time-out, the following MUST be verified and documented: 1. Is this the correct patient? Confirm the patient s identity. 2. Is this the correct site? 3. Is this the correct procedure? 21

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24 Titration of Continuous Infusions: Guidelines In our continuing efforts to comply with guidelines set forth by The Joint Commission, we enhanced the process for ordering continuous infusion medications. When placing an order, the Starting Dose, Titration Increment, Rate of Titration, Notification, Reason to Start and Goal Parameters MUST be included in the order. For example: Start Propofol 500 mg in 50 ml for Sedation/Agitation Management. Start at 10 mcg/kg/min and titrate 5 mcg/kg/min every 2 minutes. Goal: RASS 0-(-2) Contact prescriber for dose greater than 80 mcg/kg/min. In addition, patients receiving agents ordered for sedation, such as propofol, fentanyl, Ativan, etc., MUST have a corresponding Richmond Agitation-Sedation Scale (RASS) documented with every titration (up or down). 24

25 Top 10 Most Cited Standards The Joint Commission recently released the Top 10 Most Cited Standards they find at hospitals across the country. It is crucial for all staff to successfully comply with these requirements and remain focused on our commitment to quality, safety and the goal of zero harm to our patients. 1. EC The hospital establishes and maintains a safe, functional environment. 2. IC The hospital reduces the risk of infections associated with medical equipment, devices and supplies. 3. EC The hospital manages risks associated with its utility systems. 4. LS The hospital provides and maintains systems for extinguishing fires. 5. LS The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. 6. LS The hospital maintains the integrity of the means of egress. 7. LS Building and fire protection features are designed and maintained to minimize the effects of fire, smoke and heat. 8. EC The hospital manages risks related to hazardous materials and waste. 9. PC The hospital provides care, treatment and services as ordered or prescribed, and in accordance withlaw and regulation. 10. RC The hospital maintains complete and accurate medical records for each individual patient. 25

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27 In Case of Fire: R Rescue A Alarm C Confine E Evacuate Fire or Smoke Dial 2233 Code Atlas Patient Intervention Required Code Active Shooter and Location ALICE Code Blue Cardiac Arrest Code White Pediatric Cardiac Arrest Code 3 Infant/Child Abduction Code 5 Evacuation Code 8 Bomb Threat Code 12 Disaster 27

28 We are here to SERVE the patient. Values Service We are privileged to collaborate with and serve our patients, their families, our community and each other. Excellence We maintain the highest standards of care at all times. Respect We treat everyone with dignity and sensitivity. Value We provide high-quality patient- and family-centered healthcare services efficiently and effectively to all. Ethics We are honest and fair in all we say and do.