Transcript Annual Updates 2006 - WellStar College of Health and Human

Student Packet 2008
ABOVE ALL ELSE, WE ARE COMMITTED
TO THE CARE AND IMPROVEMENT OF
HUMAN LIFE. IN RECOGNITION OF THIS
COMMITMENT, WE STRIVE TO DELIVER
HIGH QUALITY, COST EFFECTIVE
HEALTHCARE TO THE Communities
WE SERVE.
 During
the time you are completing this module, you
may call 802-3382 for any questions. Also the Infection
Control nurse is here Monday through Friday 8-4:30 at
ext. 4969. During other times, the nursing supervisor is
available for questions.
A TRADITION OF CARING
We believe the following value statements are
essential and timeless:
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We recognize and affirm the unique and
intrinsic worth of each individual.
We treat all those we serve with
compassion and kindness.
We act with absolute honesty, integrity and
fairness in the way we conduct our business
and the way we live our lives.
We trust our colleagues as valuable members
or our healthcare team and pledge to treat
one another with loyalty, respect, and
dignity.
Care Values
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Redmond Regional Medical Center has a set of
organizational values that express to everyone who
enters our facility what we stand for as a leading
health care provider.
These values are:
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Customer …………………….... Always First
Actions ….. Speak Louder Than Words
Respect ……………...…. The Golden Rule
Excellence ……………... Is Our Standard
These values are basic elements of our strategy to
“exceed customer expectations” in providing service
to our patients and other guests.
Ethics and Compliance

Redmond and HCA have a comprehensive, values-based
Ethics and Compliance Program, which is a vital part of the
way we conduct ourselves. Because the Program rests on our
Mission and Values, it has easily become incorporated into
our daily activities and supports our tradition of caring – for
our patients, our communities, and our colleagues. We strive
to deliver healthcare compassionately and to act with
absolute integrity in the way we do our work and the way we
live our lives. All work must be done in an ethical and legal
manner. It is your responsibility and your obligation to
follow the code of conduct and maintain the highest
standards of ethics and compliance.
Ethics and Compliance
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If you have questions or encounter any situation which you
believe violates the provisions of the code of conduct or the
corporate integrity agreement, you should immediately
consult your supervisor, another member of the management
team, the Human Resources Director (Patsy Adams ext 3023),
the Ethics and Compliance Officer (Deborah Branton ext
3036), or the HCA Ethics Line (1-800-455-1996).
Each employee and volunteer is required to attend two hours
of initial code of conduct training and a one hour annual
refresher training session. Leaders and individuals in key
jobs have additional annual education requirements.
Georgia False Claims Laws
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There is a federal False Claims Act, and there are also
Georgia laws that address fraud and abuse in the Georgia
Medicaid program.
Any person or entity that knowingly submits a false or
fraudulent claim for payment of funds is liable for
significant penalties and fines.
The False Claims Act has a “qui tam” or “whistleblower”
provision. This allows a private person with knowledge
of a false claim to bring a civil action on behalf of the US
Government. If the claim is successful, the whistleblower
may be awarded a percentage of the funds recovered.
For additional information please see the Georgia False
Claims Statutes Policy.
EMTALA
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The Emergency Medical Treatment and
Active Labor Act is commonly known as
the Patient Anti-Dumping Statute.
This statute requires Medicare hospitals to
provide emergency services to all patients,
whether or not the patient can pay.
EMTALA
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When a patient comes to the emergency
department, the hospital must screen for a
medical emergency.
If an emergency medical condition is
found, the hospital must provide stabilizing
treatment.
Patients with emergency medical
conditions may not be transferred out of the
hospital for economic reasons.
Medical Ethics:
End of Life Care
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Palliative Care
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The goal of palliative care is not to cure the
patient. The goal is to provide comfort.
Understand the importance of addressing all
of the patient’s comfort needs near the end of
life. This includes psychosocial, spiritual,
and physical needs.
Stay up-to-date on the legality and ethics of
using high-dose opiates for physical pain.
Medical Ethics:
End of Life Care
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End-of-Life Decisions
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Patients have the right to refuse lifesustaining treatment.
Respect this right and this decision.
Withdrawing Life-Sustaining Treatment
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Withdrawing and withholding life-sustaining
treatment are ethically and legally equivalent.
Both are ethical and legal when the patient
has given informed consent.
Sexual Harassment
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You should promptly report the incident to your
supervisor, who will investigate the matter and take
appropriate action, including reporting it to the Human
Resources Department.
If you believe it would be inappropriate to discuss the
matter with your supervisor, you may bypass your
supervisor and report it directly to the Human Resources
Department, which will undertake an investigation.
Or you may call the Ethics Line at 1/800-455-1996. The
complaint will be kept confidential to the maximum
extent possible.
SERVICE EXCELLENCE
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Redmond’s Service Standards are ways for you to
fulfill the CARE values. By practicing these, you
will be better able to meet and exceed the needs of
all of our customers.
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Display a service attitude that is courteous
and caring.
Anticipate the wants and needs of the people
we serve.
Present a professional image.
Maintain a safe and clean environment
Use good elevator manners.
SERVICE EXCELLENCE
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Positively represent Redmond Regional
Medical Center in the workplace and the
community.
Listen to one another and to the people we
serve, then respond promptly and reliably.
Keep the people we serve informed about
their care and treatment.
Respect the privacy and confidentiality of the
people we serve.
Strive to master the skills needed to do your
best for the people we serve.
Utilize communication tools to assist us in
responding to our guests.
What is teamwork?
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A cooperative effort by members of a group
or team trying to achieve a common goal
The concept of people working together
To make teamwork happen…
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Communication is a necessity
Must have interaction with others
even when things aren’t going as
planned
Get Feedback from other associates
and managers
Share the responsibility
Skills for teamwork:
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Listening
Questioning
Respecting and supporting ideas
Helping
Sharing
Participation
Why will Teamwork work for you?
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Increases productivity and output.
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Boosts morale.
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Increases customer satisfaction.
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Actively involves everyone.
Benefits of Team Work
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You have more minds working on a
project
You can improve product quality
You are able to improve associate morale
You can improve productivity
You have more cross functional skills
HCA Mission and Values Statement
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We trust our colleagues as valuable
members of our healthcare team and
pledge to treat one another with loyalty,
respect and dignity.
Employee Health Services
INJURIES AND ILLNESSES
Non-Work Related
EHS will provide care for non-work related injuries and
illnesses as an immediate care program. Our goal is
for all employees to have their own primary care
provider (PCP), however, when an employee is
unable to see their PCP and they are ill at work, EHS
is available for evaluation and treatment as
appropriate. Employees may be referred to their
PCP for further evaluation, treatment, and/or followup. EHS stocks many over-the-counter medications;
these are available for employees as needed.
Employee Health Services
INJURIES AND ILLNESSES
Work Related
Paula Dunwoody with EHS is Redmond’s Injury
Coordinator. This role involves employee safety
and prevention of work injuries as well as followup of all work related injuries. All work related
injuries must be evaluated in EHS as soon as
possible after the injury.
What To Do If You Are
Injured On The Job
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If you are injured on the job, report the injury to your
supervisor, no matter how minor. Your supervisor
should be notified prior to the end of your shift.
Redmond policy requires a notification (incident)
report for an injury no later than 24 hours after the
incident occurs. This report is completed in our
Meditech computer system. If you do not have access
to Meditech, your supervisor or Employee Health
Services can assist you with this report.
What To Do If You Are Injured On The
Job (continued)
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All employee on-the-job injuries must be
evaluated in Employee Health Services.
Management and/or treatment of the injury
may be completed in Employee Health Services.
If the extent of the injury warrants a physical
evaluation, the employee must choose a panel
physician. The physicians panel is updated
periodically and is posted on the HR bulletin
board, across from the time clock on the first
floor, and in Employee Health Services.
What To Do If You Are Injured On The
Job (continued)
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In an emergency situation, employees may go directly to
Redmond’s Emergency Room. Please discuss this with
your supervisor.
If you have a work-related injury and your condition
changes (for example: new onset of difficulty walking or
worsening pain), report to Employee Health Services
immediately. If this office is closed, then contact your
immediate supervisor and notify EHS when the office
opens.
For any questions or concerns about a work-related injury,
contact Employee Health Services 706-236-4968.
What Can You Do To Prevent Sharps
Injuries?
Be Prepared
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Complete your Hepatitis B vaccine series and
titer in Employee Health Services free of charge.
Organize your work area with appropriate sharps
disposal containers within reach.
Receive training on how to use sharps safety
devices.
Wear gloves if you expect to come in contact with
blood or body fluids.
What Can You Do To Prevent Sharps
Injuries?
Be Aware
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Keep the exposed sharp in view.
Be aware of people around you. Stop if you feel
rushed or distracted.
Focus on your task.
Avoid hand-passing sharps and use verbal alerts
when moving sharps.
Watch for sharps in linen, beds, on the floor, or in
waste containers.
What Can You Do To Prevent Sharps
Injuries?
Follow Policies
 Don’t recap needles.
 Never use needles with the needleless IV
system.
 Be responsible for every device you use.
 If you identify a sharps without a safety
device, discuss this with your supervisor
and/or Employee Health Services.
What Can You Do To Prevent Sharps
Injuries?
Dispose of Sharps with Care
 Don’t remove contaminated sharps with your hands
unless medically required (i.e. caps off used needles,
scalpel blades). If necessary, use a mechanical
device or forceps.
 Always activate safety devices immediately after
using a sharp. Never remove safety devices. Keep
your hands behind the needle at all times.
Disposal of Sharps With Care
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Place all used sharps in biohazard
containers, see policy IC-45.
Securely close biohazard containers when
¾ full and notify Environmental Services
to change the sharps container.
Do Not overfill sharps containers.
Do Not reach by hand into containers
where sharps are placed.
Additional Sharps Injury Prevention
for the OR
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Use a neutral zone when passing sharps instruments.
Pass sharps on a tray, not directly to another
individual. Use verbal alerts when moving sharps.
When suturing, use blunt sutures for muscle and
fascia.
Stay focused on your task. Stop if you feel rushed
or distracted.
Use mechanical devices such as tongs to handle
contaminated reusable sharps. Do Not use your
hands.
Prevent Bloodborne Pathogen
Exposures
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Use appropriate barriers such as gloves, eye protection, or
gowns when contact with blood is expected.
Wash your hands with soap and warm running water as
quickly as possible after contact with blood or potentially
infectious materials.
Don’t eat, drink, smoke, apply cosmetics or lip balm, or
handle contact lenses in area with possible exposure to
bloodborne pathogens.
Do not store food in refrigerators, freezers, cabinets,
shelves, or on countertops where blood or other body
fluids are present.
Bloodborne Pathogen Exposure
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Report to Employee Health Services or the E.R. immediately after a
Bloodborne Pathogen Exposure. If you go the E.R., then follow-up with
Employee Health Services as soon as the office opens.
Following a bloodborne pathogen exposure, the risk of infection may vary
with factors such as these
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the pathogen involved
the type of exposure
the amount of blood involved in the exposure
the amount of virus in the patient’s blood at the time of exposure
The following factors were associated with an increased risk of HIV
seroconversion:
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deep injury (deep puncture wound)
visible blood on source patient device causing injury
procedure involving needle placed in a vein or artery of source patient
endstage AIDS in source patient
Needle Stick/Sharps Injury
What is the risk of infection after exposure?
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HBV
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Healthcare personnel who have received
hepatitis B vaccine and developed immunity
to the virus are at virtually no risk for
infection.
For a susceptible person, the risk from an
exposure can range from 6 – 30% and
depends on the status of the source
individual.
Needle Stick/Sharps Injury
What is the risk of infection after exposure?
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HCV
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The average risk for infection after a
needlestick exposure to HCV infected blood
is approximately 1.8%.
There is a small risk associated with
exposure to the eye, mucous membranes, or
nonintact skin.
Needle Stick/Sharps Injury
What is the risk of infection after exposure?
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HIV
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The average risk of infection after a
needlestick exposure is 0.3% (or about 1 in
300).
The risk after exposure of the eye, nose, or
mouth is about 0.1% (1 in 1,000).
The risk after exposure to nonintact skin is
less than 0.1%.
Needle Stick/Sharps Injury
Treatment For The Exposure
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HBV
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Hepatitis B vaccine for all healthcare
personnel who have a reasonable chance of
exposure to blood or body fluids.
Hepatitis B immune globulin (HBIG) alone
or in combination with vaccine (if not
previously vaccinated or no immunity
developed after vaccination).
Needle Stick/Sharps Injury
Treatment For The Exposure
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HCV
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There is no vaccine against hepatitis C and
no treatment after exposure that will prevent
infection.
Following recommended control practices to
prevent percutaneous injuries is imperative.
Needle Stick/Sharps Injury
Treatment For The Exposure
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HIV
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There is no vaccine against HIV.
Postexposure prophylaxis (PEP) with
retroviral drugs is recommended for certain
occupational exposures that pose a risk of
transmission of HIV.
PEP is not recommended for exposures with
low risk for transmission of HIV.
PEP should be started as soon as possible
after exposure, preferably within 2 hours.
Respirator and Respirator Fit Testing to
Prevent Transmission of Airborne Illnesses
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N-95 Respirator
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A respirator is designed to provide
respiratory protection for the wearer.
An NIOSH approved N-95 mask has a filter
efficiency level of 95% or greater against
particulate aerosols free of oil.
It is fluid resistant, disposable, and may be
worn in surgery.
It can fit a wide variety of face sizes.
Respirator and Respirator Fit Testing
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Intended Use
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RRMC’s N-95 Respirators reduce the wearer’s
exposure to certain airborne particles in a size
range of 0.1 to 10.0 microns, including those
generated by electrocautery, laser surgery, and
other powered medical instruments.
The masks are designed to be fluid resistant to
splash and splatter of blood and other infectious
materials.
These masks are not designed for industrial use.
Respirator and Respirator Fit Testing
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Employees Wearing Respirators
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Any employee with the possibility of
exposure to airborne illness will participate in
the respiratory protection program.
This includes all employees who could enter
a patient care room when a patient is placed
in airborne precautions.
Respirator and Respirator Fit Testing
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Medical Evaluation
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A medical evaluation questionnaire is required for
all employees wearing a respirator in the
workplace.
This evaluation will determine whether or not an
employee is medically able to wear a respirator.
All employees may not pass this evaluation.
Employees who do not pass the medical
evaluation cannot wear a respirator and should not
enter rooms were a patient is on airborne
precautions.
Respirator and Respirator Fit Testing
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Fit Testing
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All employees must be fit tested with one of the masks
available here at RRMC before they can wear a
respirator.
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3M 1860 Regular and Small (blue mask)
Tecnol Fluidshield Regular and Small (orange duck-bill)
Some employees may not pass fit testing. These
employees cannot wear a respirator.
Compliance with OSHA standards requires fit testing
completion with hire and repeat fit testing annually
thereafter.
Fit testing will be completed in Employee Health
Services during month-of-hire annual evaluation.
Respirator and Respirator Fit Testing
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Mask Size
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Every employee fit tested for a respirator is responsible for
knowing what size mask they wear.
Employee will have a sticker with mask brand and size placed
on the back of their ID badge at the time of fit testing.
Employee Health Services and department supervisors will have
documentation of mask size for employees that have been fit
tested.
Problems
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Any employees with medical problems, respirator problems
(such as fit seal difficulty), or any concerns should contact
Employee Health Services.
Latex Allergies
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Latex allergies pose a serious problem for nurses, other health care
workers, and for 1% to 6% of the general population. Anaphylactic
reactions to latex can be fatal. Health care workers’ exposure to
latex has increased dramatically since universal precautions against
blood borne pathogens were mandated in 1987. Latex can trigger
three types of reactions: irritant contact dermatitis, allergic contact
dermatitis, and immediate hypersensitivity. Many medical devices
contain latex that might trigger serious systemic reactions by
cutaneous (skin) exposure, (i.e. ECG electrodes, masks, bandages,
catheters, gloves, and tape.) There are some diagnostic tests to
determine if a person has an allergy to latex. If a patient tells you
they are allergic to latex, notify Materials Management and they will
provide a cart with latex-free products. Need more information?
Contact the Nursing House Supervisor at ext. 3037. For associates
with latex allergies, contact Employee Health Services ext. 4968.
Ergonomic Safety
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Ergonomic Safety is adapting the equipment, procedures and
work areas to fit the person in order to help prevent injuries
and improve efficiency. Musculoskeletal disorders (MSDs) affect
muscles, nerves, tendons, ligaments, joints or spinal discs.
Injuries can include strains, sprains, and repetitive motion
injuries.
Signs and symptoms: pain, tingling, numbness, swelling,
stiffness, burning sensation, etc. May experience decreased
gripping strength, range of motion, muscle function, or inability
to do everyday tasks. Risk factors: repetition, forceful exertions,
awkward postures, contact stress, and vibration. Common
MSDs: Carpal tunnel syndrome, rotator cuff syndrome, trigger
finger, tendonitis, herniated spinal disc, and back pain.
Ergonomic Safety
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Apply these tips to your job: Adjust chair height and backrest
(feet should be flat on the floor, knees level with hips, and
lower back supported). Sit an arm's length away from the
computer screen. Keep wrists straight and elbows at right
angles. Alternate tasks. Use proper body mechanics when
lifting, transferring, etc. Avoid reaching and stretching
overhead.
You may recommend ways to reduce the chance of
developing musculoskeletal disorders to your supervisor. Your
work space may be evaluated for ergonomic safety by
notifying Paula Dunwoody at ext. 4968. Your departmental
safety representative may assist with body mechanic inservices. Report signs, symptoms, illnesses ,and injuries to your
supervisor, complete an occurrence report, and obtain medical
treatment in Employee Health Services.
12 Principles of Ergonomics
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Keep everything in easy reach
Work at proper heights
Reduce excessive forces
Work in good postures
Reduce excessive repetition
Minimize fatigue
Minimize direct pressure
Provide adjustability and change of position
Provide clearance and access
Maintain a comfortable environment
Enhance clarity and understanding
Improve work organization
Ergonomics
The “Do Nots”
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Upper Extremity
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Shoulder
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Elbow
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Reaching over 90 degrees (vertical flexion)
External rotation of greater than 45 degrees
Avoid static hold time of flexion
Lower Extremity
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Sitting position
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The hip, knee, and ankle should be placed at 90 degrees
Body positions to avoid
Deep knee bends
Constant standing in hip and knee extension
Walking with feet externally rotated
Ergonomics
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Self Care
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Ice THEN heat
Stretch regularly
Use good posture
Exercise!!!!!
Work smart
Play smart
Ergonomic Tips
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The best way to avoid the discomfort of MSDs is:
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Decrease
Change body positions frequently/Set up work
stations to fit your body/Stretch every 45 minutes
to an hour/Perform stretches that are designed to
decrease discomfort for job specific tasks
Fatigue
Warm-up
exercises
Interrupt sustained postures
Proper ergonomics
Appropriate work methods
Limited overtime
Increase
Recovery
Physical
fitness
Proper nutrition
Good sleeping postures
Ice after activities
Avoid smoking
Alternative job placement
Performance Improvement
Continual Quality Improvement
 What
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is PI?
PI is a work philosophy that encourages
every employee to find new and better ways
of doing things. All accredited healthcare
organizations are required to have an
improvement program. Redmond is
accredited by The Joint Commission.
Performance Improvement
Continual Quality Improvement
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Excellent organizations make sustained and continuous
efforts to improve their care and services. Healthcare,
our business, is constantly changing; what made us
successful last year may no longer be appropriate. Even
if we think today's solution is perfect, tomorrow will
teach us that it wasn't perfect; it was just the best that
we could do at the time
Even though a process may appear to work most of the
time, we are challenged to look at the process and ask
ourselves, "Is there a better way to do this?" or "Why
are we doing this?” Because we live in a rapidly
changing environment that is fast-paced and stressful,
change brings many opportunities to improve our care
and services.
Performance Improvement
Continual Quality Improvement
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Key Points to Remember
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Customers come first.
Every employee is important.
Communication is essential.
Tasks (processes) are streamlined whenever possible.
Ongoing improvement is crucial.
Improvement should be maintained.
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We want to improve everything we do! We owe this to our
ultimate customer ~ the patient.
Performance Improvement
Continual Quality Improvement
What does this mean to me?
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Management provides support and guidance, and they bear
ultimate responsibility, but the best improvement ideas come
from people who work providing care and services for our
customers. Continually improving one’s own performance
and their own job processes are essential for producing great
patient outcomes. Within your department, you have the
responsibility to think about your “daily work life” to
determine if there are processes that can be improved. At the
department level, the organization has determined that the
Pillars of Excellence should be continually improved. There
are five pillars: Service, Quality, People, Growth, and
Finance.
Performance Improvement
Continual Quality Improvement
What does this mean to me?

You can make suggestions for improvement to your
supervisor by expressing the idea and asking if an
improvement team could be organized to work on
the project. There is also an “Improvement
Suggestion Form” in your department’s PI Manual
(or posted on your department’s Communication
Center); you can fill out the form and turn in to
your supervisor. If the idea only relates to your job,
your supervisor may ask you to “just do it.” You
may be asked to serve on an improvement team or
lead an improvement project; you should accept
this as an honor.
Risk Management/Patient Safety
2008 National Patient Safety Goals for Hospitals
(new items indicated in red)

Improve the accuracy of patient
identification.
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Use at least two patient identifiers when
providing care, treatments, or services.
Risk Management/Patient Safety
2008 National Patient Safety Goals for Hospitals (new items indicated in red)

Improve the effectiveness of
communication among caregivers.
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For verbal or telephone orders or for telephonic reporting
of critical test results, verify the complete order or test
result by having the person receiving the order or test
result "read-back" the complete order or test result.
Standardize a list of abbreviations, acronyms and
symbols that are not to be used throughout the
organization.
Measure, assess and, if appropriate, take action to
improve the timeliness of reporting, and the timeliness of
receipt by the responsible licensed caregiver, of critical
test results and values.
Implement a standardized approach to "hand off"
communications, including an opportunity to ask and
respond to questions.
Risk Management/Patient Safety
2008 National Patient Safety Goals for Hospitals (new items indicated in red)

Improve the safety of using medications.
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Identify and, at a minimum, annually review a list
of look-alike/sound-alike drugs used in the
organization and take action to prevent errors
involving the interchange of these drugs.
Label all medications, medication containers
(e.g., syringes, medicine cups, basins), or other
solutions on and off the sterile field.
Reduce the likelihood of patient harm associated
with the use of anticoagulation therapy.
Risk Management/Patient Safety
2008 National Patient Safety Goals for Hospitals (new items indicated in red)

Reduce the risk of health
associated infections.
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care-
Comply with current World Health
Organization (WHO) Hand Hygiene
Guidelines or Centers for Disease Control
and Prevention (CDC) hand hygiene
guidelines.
Manage as sentinel events all identified
cases of unanticipated death or major
permanent loss of function associated with
health-care associated infection.
Risk Management/Patient Safety
2008 National Patient Safety Goals for Hospitals (new items indicated in red)

Accurately and completely reconcile
medications across the continuum of
care.
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There is a process for comparing the patient’s current
medications with those ordered for the patient while
under the care of the organization.
A complete list of the patient’s medications is
communicated to the next provider of service when a
patient is referred or transferred to another setting,
service, practitioner or level of care within or outside
the organization. The complete list of medications is
also provided to the patient on discharge from the
facility.
Risk Management/Patient Safety
2008 National Patient Safety Goals for Hospitals (new items indicated in red)

Reduce the risk of patient harm
resulting from falls.

Implement a fall reduction program and
evaluate the effectiveness of the
program.
Risk Management/Patient Safety
2008 National Patient Safety Goals for Hospitals (new items indicated in red)

Encourage patients’ active
involvement in their own care as a
patient safety strategy.

Define and communicate the means
for patients and their families to report
concerns about safety and encourage
them to do so.
Risk Management/Patient Safety
2008 National Patient Safety Goals for Hospitals (new items indicated in red)

The organization identifies safety risks
inherent in its patient population.

The organization identifies patients at risk
for suicide. [Applicable to psychiatric
hospitals and patients being treated for
emotional or behavioral disorders in
general hospitals – NOT APPLICABLE TO
CRITICAL ACCESS HOSPITALS).]
Risk Management/Patient Safety
2008 National Patient Safety Goals for Hospitals (new items indicated in red)

Improve recognition and response to
changes in a patient’s condition.

The organization selects a suitable method
that enables health care staff members to
directly request additional assistance from
a specially trained individual(s) when the
patient’s condition appears to be
worsening. [Critical Access Hospital,
Hospital]
Patient rights

We believe that most patients want to understand and
participate in their care. Therefore, it is important that each
patient understand his or her rights and responsibilities while
at Redmond. It is also necessary as healthcare workers that
we understand patient rights and responsibilities to ensure
that quality care is provided.

How are patients informed of their rights?

Upon admission, each patient is given a handbook,
which includes a list of patient rights and
responsibilities. This patient bill of rights tells a
patient and his or her family what they can
expect of caregivers and what caregivers expect of
them.
Patient rights

What is your role in patient rights?



Everyone is involved in protecting the rights of patients,
not just those involved in direct patient care. For
example, the right to confidentiality means not telling
your friends and/or relatives when someone you know
has been a patient. Also, you provide privacy for
patients by making sure you always knock before
entering a patient’s room or any room where a patient
might be having a procedure.
Patients have a right to a secure environment, which
means you should know how to respond during a
disaster or fire in the building.Patients are informed of
their right to establish advance directives.
Patients also have a right to file a grievance. You can
assist with the investigation and response by contacting
Risk Management at ext. 3950 or Administration at ext.
4100 should you have a question.
Patient rights

Where can you find a list of patient
rights?

In facility Policy RI-04 Rights and
Responsibilities of Patients, the Patient
Handbook , posted beside the elevator in
the front lobby and at outpatient services
and on Redmond’s Intranet site.
Patient rights


Access the Ethics Committee and the Ethic Resolution Process.
Phone: 802-3037.
Access the grievance process. Express complaints or concerns
regarding care or services, including discharge.

Facility contact: 706-802-3950
Independent Agency:
Office of Regulatory Health
Humana Military Healthcare
2 Peachtree Street N.W., Suite 200
Atlanta, Georgia 30329
Services, Inc [Champus]
Telephone: 1-404- 657-5726

Peer Review Organizations:
931 South Semoran Blvd.
Georgia Medical Foundation [Medicare]
Suite 218
57 Executive Park South, Suite 200
Atlanta, Georgia 30329
Winter Park, Florida 32702
Telephones: 1-800-282-2614
Telephone: 1-800-658-1405
1-404-982-0411

Pain Management

Four major goals of pain management





Reduce the incidence and severity of patients' acute
postoperative or posttraumatic pain.
Educate patients about the need to communicate
unrelieved pain so they can receive prompt evaluation
and effective treatment.
Enhance patient comfort and satisfaction.
Contribute to fewer postoperative complications and, in
some cases, shorter stays after surgical procedures.
The importance of effective pain management
increases beyond patient satisfaction when additional
benefits for the patient are realized, e.g., earlier
mobilization, shortened hospital stay, and reduced
costs.
Sentinel events

A sentinel event is an event which results in
unanticipated death or major permanent loss of
function, not related to the natural course of the
patient’s illness or underlying condition. Also,
suicide; infant abduction or discharge to the wrong
family; rape; hemolytic transfusion reaction involving
administration of blood or blood products having a
major blood group incompatibility; a health-care
associated infection; and surgery on the wrong
patient or wrong body part are all sentinel events.
Please secure all information and items related to the
event. If you have any questions, contact Risk
Management at ext. 3950.
Occurrence Reporting

An occurrence is an event that is unusual, significant or
notable.


Categories include: Patient, Non-Patient (visitor, MD,
volunteer, student, facility, equipment) or Employee Examples
include: Near Miss, Fall, Medication, Treatment and/or Testing,
Adverse Effect, Equipment, Property, Assault (abuse or
harassment), Error, Failure to follow policies & procedures,
Failure to follow MD’s orders, User/Operator error, Defective
or malfunctioning products, Incorrect action/activity,
Inappropriate action/activity, Omission, Delay, Complications,
Loss or theft of personal belongings or Auto events with
facility vehicles.
Occurrences should be documented in Meditech during the
working shift or definitely within 24 hours. The department
manager or house supervisor should be notified at the time of
the event. Please notify the Risk Manager of all serious and
potentially legal situations.
Occurrence Reporting

Meditech Reporting

Log onto Meditech - Select 500 Occurrence
Reporting - Select Facility - Select Category - (If
patient) At prompt type A# then the account number
- (If Non-Patient or Employee) Type N into the first
field to create a new report (For employee type in last
name and press the look-up key) - If no previous
Occurrence report exists for this patient you will
receive a message “No available notifications for this
patient. Create a new one? Answer Y (Yes) - Answer
all questions in field - Input will be by free text or pull
down menu selection - Enter all the information you
know or can obtain.
Occurrence Reporting






Look-up key (F9 or F17) displays a pull down menu
Previous field key (F6 or F 14) allows you to backup
The enter key allows you to move forward one field.
Magic or file key (F12 or F20)
This key will provide the menu for selection.
You MUST FILE to save your work.
Exit key (F11 or F 19)
Caution exit does not save your work.
Text fields require typing from keyboard.
An occurrence report is a confidential facility report that
should not be referenced in documentation on the
patient’s record.
Reportable Events

State (Georgia) Reportable Events:

The following type events should be reported to the State of
Georgia Office of Regulatory Services:




1. Any unanticipated patient death not related to the natural course
of the patient’s illness or underlying condition;
2. Any surgery on the wrong patient or the wrong body part of the
patient;
3. Any rape of a patient which occurs in the hospital.
Redmond Regional Medical Center’s employees and the
medical staff should report to the appropriate department
leader and Risk Management at 3950or Regulatroy
Compliance at 3038 in the event that any of the above
situations occur to a patient at Redmond. A multidisciplinary
group will review the situation, complete the State forms, and
provide them to the Office of Regulatory Services within 24
hours of knowledge that the event meets one of the State
definitions.
Suspected Impairment of Licensed
Independent Practitioner

Redmond Regional Medical Center makes every
effort to ensure that licensed independent
practitioners providing care to our patients are
competent and able to carry out their patient care
responsibilities free of any impairment(s) that
adversely affect their judgment or clinical
performance. A licensed independent practitioner
(LIP) is defined as any individual permitted by law
and the hospital to provide care, treatment, and
services without direction or supervision.
Identification of an Impaired LIP

An impaired LIP is defined as one who is
unable to provide care, treatment, or
services with reasonable skill and safety to
patients because of a physical or mental
illness, including deterioration through the
aging process or loss of motor skill or
excessive use or abuse of drugs including
alcohol.
Signs and Symptoms of
Impairment

Signs and symptoms of potential impairment
include, but are not limited to:









Personality changes/mood swings
Loss of efficiency and reliability
Increasing personal and professional isolation
Inappropriate anger, resentments
Abusive language, demeaning others
Physical deterioration
Memory loss
Increase in tardiness, absenteeism, illness
Lack of empathy towards others
Reporting a LIP Suspected of
Impairment

If any individual in the hospital has a
reasonable suspicion that a LIP may be
impaired and this impairment may
adversely affect patient care and safety,
take immediate action by notifying your
supervisor and following the appropriate
Chain of Command listed in policy LD 05.
ADVANCED DIRECTIVES







Advance Directives include Living Will and Durable Power of
Attorney (DPOA) for Health Care.
Living Will only applies to terminal conditions.
DPOA for Health Care allows a person to name an agent to speak on
the person’s behalf, when the person cannot speak for their self.
Inside the hospital, the attending physician must be present when the
patient names an agent. An agent can speak for the patient
concerning any condition.
Patients should be asked at the time of admission if they have an
advance directive.
Patients should initial and date a copy of the directive(s) and the
hospital staff should place it inside the current medical record.
Social Services can assist by answering general questions and provide
blank forms.
Environment of care

EMERGENCY PREPAREDNESS CODES

Code Red—Fire RACE
Rescue/Activate/Contain/Extinguish
Code Gray—Bomb Threat—Notify Switchboard
Code Blue—Adult Cardiopulmonary Arrest

Code Blue PEDS — Pediatric Cardiopulmonary Arrest

Code Pink – Pediatirc Abduction
Code White – Adult Patient Elopement
Code Yellow—Trauma—Emergency Room
Support—Do not call ER
Code Green— Hostage Situation
Code Orange—Hazardous Material Event






Environment of care

EMERGENCY PREPAREDNESS CODES



Code Triage—Community Disaster
 Standby: An event has occurred in the community
 Activate: Begin Disaster Plan
 Stand-down: Return to normal operations
Code 900—Show of Force—All Males Respond
Code 1000—Visitor Needs Assistance—Stay with
person — Notify switchboard
Environment of care

Tornado Warning


Tornado warnings will no longer be
announced as a Code Black. Instead a more
recognizable announcement will be made so
that both staff and visitors will be aware of
the severe weather potential.
The announcement will be, “Attention,
attention, attention. Floyd County is
currently under a tornado warning”.
Environment of care

CONTACTS











Extension 4000— Emergency line to Operator/PBX
Labor Pool Location—Classroom C (Ext. 2273)
Facility Privacy Officer — Pam Watkins
Facility Information Systems Officer — Brad Treglow
Quality Director — Barbara Garner
Risk Management – Marisa Pins
Patient Safety Officer – Debbie Smith
Facility Safety Officer — Clay Callaway
Infection Control Director — Terri Aaron
Ethics and Compliance Officer — Deborah Branton
Service Excellence Administrator — Missy Ragland
Emergency Preparedness





Designed to provide a safe environment for all
Drills are used to improve effectiveness
Resource guides and manuals are available to assist
you
Don’t wait for an emergency to learn what you
should to
RRMC utilizes an all hazards approach
When you hear a code-
Do not call PBX!
They do not know what you are supposed to
do – they know what they are to do!
Call your supervisor or leader
Mass Casualty Event

Code Triage

Standby: An event has occurred – facility must
decide if we can meet demands or utilize extra
resources





Develop a plan with the department
Call your immediate family
Activate: Initiate the disaster plan – activate your
department response
Stand-down: Begin recovery and return to normal
operations
Know your role!
Code Orange






Hazardous Material Event
Haz Mat Team will respond
If they walk in – don’t touch them – take
them back out the way they came in
Stay uphill and upwind!
Decon is in ED or outside
Don’t forget your PPE’s
Code Blue & Code Blue PALS

Code Blue




Adult cardiac or respiratory event
Don’t forget the Rapid Response Team (Call for
the Rapid Response team when you feel a patient’s
clinical status is in decline.)
Know how to call a code and where your supplies
are
Code Blue PALS


Pediatric cardiac or respiratory event
ED Nurse will respond to assist with running the
code
Code 900




You are in a situation in which you are
threatened verbally or physically
All males respond
Crisis Prevention Intervention (CPI)
training is available
DO NOT USE THIS CODE FOR
LIFTING HELP!!
Code 1000

Visitor or family member is ill or injured

Stay with person and have someone call ext. 4000 to
report the incident

ED Nurse and House Supervisor will respond

Call 4911 ONLY if “packaging” is required
Tornado Warning

A Tornado has been reported in our area






Close patient doors
Get everyone out of halls and away from glass
Discourage visitors from leaving
Turn beds to inside walls
Clear area of anything that can become a projectile
Instruct family members & ambulatory patients to
go into the bathrooms and cover themselves
Code Green

Hostage situation is occurring



Lock down your area
Do not try to negotiate
Police should be alerted to enter in an area
distant from the hostage situation
Code Grey

There has been a bomb threat





If you get it, notify the switchboard
Look for packages or people that should not be in
your area
Only if there is a legitimate reason would we
evacuate
Take direction from Incident Command or law
enforcement
Leave lights alone!
Code Pink

Pediatric Abduction


Patient Care Coordinator






Call ext. 4000
Give gender and age
Building must be locked down
Each department has a response
PBX will announce -Code Pink b or g and age
Try to detain but do not put yourself in harm’s way


Can be a patient or visitor
Get a good description of person, vehicle, tag, etc.
Make sure unoccupied rooms and areas are checked.
Code White


Patient Elopement
Patient Care Coordinator






Call ext. 4000
Give gender and age and clothing description
Building must be locked down
Each department has a response
PBX will announce -Code White m or f and age
Make sure unoccupied rooms and areas are checked
Code Yellow - Trauma


Trauma patient is coming or has arrived
ED needs:





Lab
Radiology
General notice for House Supervisor
Don’t go unless you are assigned
Don’t call the ED to find out what it is!
Severe Weather




Each leader will review staffing and
supplies for the anticipated period.
It is your responsibility to get here!
We will provide housing
We can provide child care


If you have a special needs situation, we need
to know before hand
Transportation may be provided
Evacuation

Move from unsafe to safe area



Horizontal Evacuation


Floor to floor
Full Scale


Room to Room, Wing to Wing
Vertical Evacuation


Ambulatory first
Sickest last
Triage and transport area will be established
Make sure you account for all patients
Pandemic Influenza





A pandemic is an infectious event that
has a global impact (such as those in
1918, 1958 & 1968)
The impact on society will be huge!
Respiratory Hygiene/Cough Etiquette
 Learn it, live it, teach it!
Annual flu shots are recommended to
decrease the risk of a pan flu event
For more information, visit
www.pandemicflu.gov
Prepare Your Family





Have a plan for your family
Rewiew your Personal Preparedness Planning Kit
Make sure you have a plan for pets
You will be required to work
If you have special needs, let us know



Special needs adult or children and no other adult
to care for them
Military obligations
DMAT, other volunteer organization
Do Not Use
Abbreviations, Acronyms, and Symbols
Abbreviation
Preferred Term
U
Unit
IU
International Unit
Q.D. & Q.O.D.
daily & every other day
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
X mg
0.X mg
MS, MS04, & MgSO4
morphine sulfate or
magnesium sulfate
µg
Mcg
T.I.W.
3 times weekly
c.c.
Ml
ii, etc. (apothecary symbols)
2 or two
Environment of Care

Defective Equipment


Security Related Incidents
Any incident requiring Security assistance (i.e. theft or
suspicious activity), contact security by dialing 0 and
asking PBX to page a member of Security.
Please refer to the Environment of Care section of the policy
manual for in-depth information on these topics.


Defective equipment should be reported to BIOMEDICAL
Services via Meditech or at Ext. 4962 if equipment removal
constitutes an emergency. Equipment will be tagged.
Tag will say “danger defective equipment”.
Bio-terrorism Update



Healthcare facilities may be the initial site of recognition
and response to bio-terrorism events. All patients in
healthcare facilities, including symptomatic patients with
suspected or confirmed bio-terrorism-related illnesses
should be managed utilizing Standard Precautions. For
certain diseases or syndromes (smallpox and pneumonic
plague), additional precautions may be needed to reduce
the likelihood for transmission. For more in-depth
information on this topic, please refer to the
Bio-Terrorism Readiness Plan policy.
A quick reference guide is posted in the Emergency
Department
For further information visit www.ready.gov
What is HIPAA?

The Health Insurance Portability and Accountability Act
deals with patient privacy and security of information and
systems. HIPAA was developed to protect health insurance
coverage, improve access to healthcare, reduce fraud and
abuse, and in general improve the quality of healthcare.
The privacy section will govern the use and disclosure of
individually identifiable health information and patient
rights in regard to their protected health information (PHI).
The security section will ensure that we protect
confidentiality, availability, and integrity of individually
identifiable information. HIPAA is a federally mandated
law. Compliance is mandatory. The law has both civil and
criminal penalties for non-compliance.
HIPAA’s TOP TEN





Properly dispose of PHI (Privileged Health
Information) in shred boxes, not trash
cans.
Access, use or disclose only the minimum
necessary amount of PHI to accomplish a
task.
Take reasonable measures to prevent
unauthorized access to PHI - conceal, turn
over, or secure PHI that is not needed for
immediate use — turn off computer
screens or use screen savers when you
leave your work area — NEVER share
computer passwords with others.
Close patient doors and pull curtains when
discussing and administering procedures.
Immediately report improper disclosures
of PHI, whether accidental or otherwise,
to your Facility Privacy Official — Pam
Watkins — 3095.





When PHI is discussed within the
workplace, lower your voice or move to a
private area if others might overhear you.
NEVER discuss any information relating
to any patient outside of the workplace,
including elevators and hallways, for any
reason.
Respond to patient questions, concerns and
complaints about privacy and security of
their PHI respectfully and as quickly as
possible. All concerns and complaints
should be reported to the Facility Privacy
Official immediately.
If you have any questions or are ever in
doubt about what to do, ask your Facility
Privacy Official.
But in emergencies, always put patient care
ahead of all else — even HIPAA.
Protecting Patient Privacy

All health care personnel must obtain
permission from the patient prior to
discussing any health care issues in front of
a patient’s visitors.
Organ Donation

Timely referrals of potential organ donors

Healthcare professionals are required to
identify and refer all deaths and imminent
deaths (brain deaths) to the Donation Referral
Line at (800) 882-7177. Timely referrals
preserve the option of donation for families
of medically suitable patients.
INFECTION PREVENTION





Each year, it is estimated that millions of infections occur in the United
States as a result of hospitalizations. The cost to treat these infections
is enormous.
Our goal is to identify and reduce risks of healthcare associated
infections in patients, visitors, and healthcare workers.
Hand washing is the single most effective way to prevent the spread of
infection. Routine hand washing involves a rigorous rubbing together
of well lathered hands for 15-20 seconds followed by a thorough
rinsing under running water. Must use soap and water if hands are
visibly soiled.
Hand hygiene with an alcohol based product is acceptable as long as
the hands are not visibly soiled. (Always wash hands with soap and
water if the patient you are caring for has C. Difficile).
IC Champions monitor handwashing in our facility. The use of gloves
does not eliminate the need for good hand washing.
Hand Hygiene:

Wash hands at least in the following situations:








Before donning sterile gloves when inserting a central
intravascular catheter
Before inserting indwelling urinary catheters, peripheral
vascular catheters, or other invasive devices that do not require
a surgical procedure
After contact with a patient’s intact skin (e.g. when taking a
pulse or blood pressure, and lifting a patient)
After contact with body fluids or excretions, mucous
membranes, non-intact skin, and wound dressings
If moving from a contaminated body site to a clean body site
during patient care
After contact with inanimate objects (including medical
equipment) in the immediate vicinity of the patient
After removing gloves
Before eating and after using the restroom
Partners in Your Care


sm
A comprehensive hand hygiene program
involving the patient.
Signs have been placed in patient rooms
“It’s OK to Ask”. Patients have a right
to ask if you washed your hands before
you take care of them
Goal for Hand Hygiene is 100%
Artificial Nails:


Direct patient care givers can not wear
artificial nails. Also some departments
such as OR, can not wear them.
Nail polish may be worn in most
departments as long as it is not chipped.
Check with IC or your leader if you have
questions about whether you can wear
polish in your department.
Personal Protective Equipment





Personal Protective Equipment (PPE) is provided at no cost
to the associate
Worn when there is a chance of contact with blood or other
potentially infectious body material (OPIM).
PPEs include, but are not limited to: gloves, gowns, goggles,
pocket masks, and shoe coverings. PPEs are available in each
department.
Wear gloves when it can be reasonably anticipated that there
may be hand contact with blood or OPIM and when handling
and touching contaminated items or surfaces. Replace them
if torn or punctured or if their ability to function as a barrier
is compromised.
Gloves must be removed before leaving the room. Hands
must be washed after glove removal.
Personal Protective Equipment




Wear appropriate face and eye protection when
splashes, sprays, splatters, or droplets of blood or
OPIM may pose a hazard to the eye, nose, or mouth.
Remove immediately, or as soon as feasible, any
garment contaminated by blood or OPIM.
PPEs may be disposed of in the regular trash unless
contaminated with blood or other OPIM, if
contaminated they must be disposed of in red
biohazard bags.
Each department has a list of tasks and what PPE is
recommended or mandatory to wear while performing
those tasks. Ask your leader about this list.
Standard Precautions



Standard Precautions apply to all blood or body fluid
which is considered potentially infectious. Very
important to wear appropriate PPE when dealing with
blood or body fluids.
By using standard precautions you will substantially
reduce your risk of infection with a blood borne
pathogen.
In addition to standard precautions, there are three
types of transmission based precautions (isolation
precautions) used for patients with documented or
suspected transmissible pathogens that require more
than standard precautions.
Isolation Precautions:

Contact (wear gown, gloves,
sometimes mask)

Airborne (wear N 95 mask)
Droplet (wear regular mask)

Contact Precautions






Used in addition to standard precautions
Bacteria transmitted by direct patient contact or
by indirect contact by touching environmental
surfaces.
Isolation gowns and gloves must be worn and
sometimes a mask.
Private room for patient or placed with patient
with the same bacteria.
Patients should wear an isolation gown and
wash hands before leaving the room.
Environmental services should be notified on
patient discharge to terminal clean room.
Airborne Precautions






Used in addition to standard precautions for illnesses
transmitted by airborne droplets.
Patient is placed in a negative air flow room.
If patient must leave room, they are given a mask to
wear.
Staff must be fit tested for an N 95 mask before
entering this type of isolation room. Staff members
who have not been fit tested may not go in this room.
Visitors are taught by the nurse how to wear the
mask.
Persons not immune to measles or varicella (chicken
pox or disseminated varicella) should not enter the
room of patients with these illnesses.
Droplet Precautions




Used in addition to standard precautions
for illnesses transmitted by large droplets.
A regular mask is worn in this room.
Patient must be placed in a private room.
If the patient needs to leave the room, they
are given a mask to wear.
Methicillin-Resistant Staphylococcus
Aureus (MRSA)




Staph aureus are bacteria commonly found on the skin
of healthy people.
MRSA can be present without causing disease. When
there is no associated disease, we call their presence
colonization. If MRSA is causing disease such as fever or
pneumonia, we call it infection.
MRSA is spread by contact thus contact precautions are
implemented (gown and gloves)
Good hand washing is the best prevention for the
spread of MRSA.
MRSA:




Use disposable equipment, such a B/P cuffs as much
as possible.
Any equipment taken in to the room must be
cleaned/disinfected prior to removing it from the
room.
Education is given to patient/visitors by the nurse.
The visitor may decide for themselves whether or
not to wear a gown or gloves.
If the visitor will be visiting other patients during this
visit, they must wear a gown and gloves in the
patient’s room who has MRSA, just like our
associates.
MRSA:




Notify receiving department that the patient is on
contact precautions .
If possible, schedule procedures when there are
fewer patients in the area.
The patient should wear an isolation gown and
wash hands prior to transport.
Have the area where the patient has been terminally
cleaned by Environmental Services.
Screening for MRSA



Certain high risk populations are screened
for MRSA on admission by having a nasal
swab screening completed.
If they have MRSA in their nose, they are
placed on contact precautions to reduce the
risk of MRSA to others.
You may have noticed more patients on
isolation precautions because of this
process.
Community MRSA



Patients who already have MRSA on
admission to our facility have Community
Acquired MRSA. This is different from
MRSA acquired in a healthcare setting.
Usually it is a skin infection or MRSA
colonization in the nose.
Community MRSA is increasing
throughout the US.
Tuberculosis (TB) Update



Spread from person-to-person through the air when a person
who has an active case of the disease coughs, sneezes, laughs
or sings and the bacteria is inhaled by a person close by.
Infection is usually detected by a positive PPD skin test and
an abnormal chest x-ray.
A person can also have the TB germ which is dormant (not
active TB). This person has a positive skin test but they are
not ill. They cannot spread the bacteria to others, however
they do have an increased risk of eventually acquiring active
TB during their lifetime and may be asked to take
medications to prevent the development of active
tuberculosis.
Upon hire, associates are required to have a PPD skin test to
detect possible TB unless they have ever had a positive skin
test. RRMC is a low risk facility for TB. This means we do
not have to have annual skin testing except in certain areas.
Tuberculosis (TB) Update





Symptoms of TB include: greater than three weeks of
cough, unexplained fever, weight loss, and night
sweats.
Persons who have active TB are capable of spreading
the infection to others.
Associates with active tuberculosis will be placed on a
work furlough until cleared by the health department
as no longer being a risk of transmission to others and
healthy enough themselves to perform the tasks of
their occupation.
Patients suspected of having active tuberculosis are
placed on airborne precautions in a private room with
negative air flow. The door must remain closed at all
times except when entering and exiting the room.
Special masks (N 95) are worn by healthcare
personnel when entering the room .
N 95 Masks



Notify Employee Health Services if your facial
structure changes. This change can be due to weight
loss or gain, dental work which changes your facial
structure, or other changes.
If your mask does not fit for any reason, or you have a
problem with wearing the mask, contact Employee
Health Services.
Personnel should fit check the mask before entering
the patient’s room. The mask must be discarded if it
becomes soiled or at the end of your shift. Masks are
stored in the ante room.
How would the hospital handle
an influx of infectious patients?


If a large number of infectious patients
suddenly presented to the hospital, we
would activate our emergency
preparedness plan.
This plan addresses staffing, supplies,
and other issues that might occur as a
result of the increased patient load.
Blood Borne Pathogens



A copy of our plan is available to any associate.
The plan explains the processes we have in place to minimize
exposures, and what we do if there is an exposure to a blood
borne pathogen.
The following fluids are considered to be potentially
infectious: blood, semen, vaginal secretions, cerebrospinal
fluid, synovial fluid, pleural fluid, peritoneal fluid,
pericardial fluid, amniotic fluid, or any other fluid that is
visibly contaminated with blood and all body fluid where it is
difficult or impossible to differentiate, saliva in dental
settings, tissue and organs that are not fixed other than intact
skin (from any human living or dead), HIV containing cell or
tissue cultures or organs, and tissue from experimental
animals infected with blood borne pathogens.
What is Hepatitis B (HBV)?






Hepatitis B is a serious liver disease.
Symptoms include jaundice, fatigue, fever, nausea and
abdominal pain.
It can be transmitted by contact with infected blood and
body fluids.
HBV is much easier to transmit than HIV and lives on
surfaces for longer periods of time.
You can help protect yourself from acquiring Hepatitis
B if you practice infection control guidelines and get
vaccinated.
The Hepatitis B vaccination is given free of charge to
associates. Generally people have few side effects from
the vaccine. If you previously declined the vaccination,
you may notify Employee Health Services if you choose
to begin this series.
What is Hepatitis C (HCT)?




Hepatitis C is a disease that attacks the liver.
It is transmitted by contact with an infected
person’s blood or blood products which enters the
body of a person who is not infected.
HCV infection often occurs without symptoms or
with mild symptoms. The symptoms are very
similar to those of Hepatitis B.
There is no vaccine that offers protection from
Hepatitis C.
What is HIV?





Human Immunodeficiency Virus (HIV) is the virus that
causes the disease Acquired Immune Deficiency Syndrome
(AIDS).
HIV damages the immune system and makes a person with
AIDS more likely to get serious infections and other
diseases.
To become infected with HIV, the virus must get into your
body and enter your bloodstream.
Many people who are infected with HIV do not have
symptoms for years. Persons who are HIV infected (with or
without symptoms, diagnosed with AIDS, or recently
exposed with a negative HIV antibody test) can spread HIV
to others.
It may be transmitted by contact with an infected person’s
blood or body fluids which enter the body of a person that
is not infected.
How to Reduce Transmission of Blood
Borne Pathogens?



Observe engineering controls; needle-less systems,
safety devices, sharps disposal containers, biohazard
waste containers, needle boxes at appropriate height.
Observe work practices; never recap needles, perform
hand hugiene, use appropriate PPEs, do not bend or
break needles, do not eat or drink in areas where there
is potential for exposure, do not store food or drinks in a
refrigerator that is used to store blood or other
potentially infectious material (OPIM), use red
biohazard bags for disposal of infectious wastes.
Know the job tasks in your department that may
involve exposure to blood or OPIM and wear
appropriate PPEs.
What is an Exposure?







Contact with another person’s blood or OPIM such as in needle
sticks/sharps exposures, mucus membrane exposure, or exposure to
non intact skin.
If you are exposed to blood or OPIM, you should clean the skin injury
site with soap and water. If it is a mucous membrane exposure, flush
the area with water.
Inform your supervisor or the designated charge person and go to
Employee Health Services (may go to the Emergency Room during
other hours) to be evaluated.
Complete occurrence form.
You will receive risk information, be evaluated by the ER physician or
the Nurse Practitioner in Employee Health Services, be informed of
recommendations of treatment, and receive care.
You should follow up after your initial evaluation the next day with
Employee Health Services.
You will receive a written opinion for any future recommended follow
up in approximately 15 days.
Five Questions OSHA might ask
about Blood Borne pathogens:



What is standard precautions? All blood and body fluids
are treated as if potentially infectious by wearing
appropriate PPE when dealing with them.
What do you do when there is a blood spill? Wear PPE,
locate spill kit, follow directions, dispose of properly in
red bag and disinfect area where spill occurred.
What do you do with contaminated sharps and laundry?
Used sharps go in designated sharps containers made of
hard plastic that are puncture resistant, linen goes in the
dirty linen hamper or is taken to linen chute.
Questions continued


Have you been offered the hepatitis B vaccination
free of charge? Yes by employee health services (all
employees have opportunity to receive the vaccine)
Where is the Blood borne pathogen plan? On the
intranet under IC policies, in the nursing office or
can be obtained through employee health services
If you have any questions about Infection
Prevention or Blood Borne Pathogens, you
may contact Infection Control ext 4969 or
ext 3394 (8:00 – 4:30 pm Monday through
Friday)
By beeper: Terri Aaron 770-553-0430 or
Rebecca Alexander 770-553-0970. If
Infection Control is not available contact
your Department Leader or the Nursing
House Supervisor
Biohazards

Biohazard Labels


These labels are warnings that the contents of
the container are possibly infectious materials.
Linens

Use standard precautions when handling linens.
Linens are treated as if potentially infectious.
Linens removed from isolation rooms should be
taken to the laundry chute.
Hazardous Material and
Waste
Read Container Labels—Before handling any chemical container, always read the label.
Warnings may be in words, pictures, or symbols.
Consult the Material Safety Data Sheet (MSDS)– A MSDS gives more detailed
information on a chemical and its hazards. It also gives you specific precautions for
protecting yourself from dangerous exposure. Your department should have a
notebook with a list of the chemicals used in your area.
Use Proper Handling Techniques– Always wear proper personal protective equipment.
Dispose of Chemicals Properly– Carry and store chemicals only in approved, properly
labeled, safety containers. Never dispose of chemicals in containers used for ordinary
waste. Never pour them down sewers or drains. Always consult the MSDS sheet for
approved method of disposal.
Contact Steve Wilson in the Lab at ext. 3116 or 4050
if you have questions.
Biohazardous Waste Management

It is VERY important that hazardous medical waste be
placed in the appropriate disposal system. The following
are considered hazardous waste and must be disposed of
properly.






Chest tubes — Place in red bags
Anything “wet” with blood or body fluid (gauze,
disposable towels, etc.) — Place in red bags
Suction canisters — Use isolyzer and place in red bags
Blood bags after infusion completed — Place in red bags
All used syringes with needles — Sharps containers
(needle boxes)
All sharps (needles, scalpels, suture needles, etc.) — Sharps
containers (needle boxes) *Always activate the safety
device
VIOLENCE PREVENTION

Violence can happen in any department or area.


Before violence strikes, there are usually warning
signs.
These include:





Making threats, talking about or carrying weapons
Screaming, cursing, challenging authority
Restlessness, pacing
Violent gestures, such as pounding on a desk
A loner, someone angry and depressed
VIOLENCE PREVENTION

You can help prevent violence by:







Treating everyone with respect
Checking the patient charts for history of
violence or aggression, alcohol or other drug
abuse
Trusting your gut feelings
Watch for warning signs
Try to spot—and head off—trouble before it turns
to violence
Staying calm if someone starts to lose control
Don’t let your escape path get blocked
VIOLENCE PREVENTION

To reduce your risk for potential injury use the
following guidelines:








Notify security at the first sign of a potentially violent situation
Communicate in a low, calm tone of voice
Allow the person to voice their feelings
It’s important to stay calm and maintain self-control
Avoid defensive words or angry gestures
Do not argue
Do not turn your back on the person
If possible, give the person what they demand
Emergency, someone
call FOR HELP!!!



Question: What do you do in the hospital
when you need help in a hurry?
Answer: Call extension 4000 or 4060. The
switchboard will answer your call immediately.
This extension should be used the same as if
you needed “911”. It is designed for emergency
situations, not just to get through to the
switchboard in a hurry. For example, this line
could be used for a Code Blue or if a visitor was
seriously hurt.
NEVER use this phone line for anything other
than emergencies!
RECOGNIZING ABUSE & NEGLECT

Signs of Abuse







History inconsistent with nature and extent of
injury
Delay in seeking medical treatment
Frequent Emergency Room visits
Accident prone
Discrepancy in patient’s and family’s story
Bruises in various stages of healing
History of previous trauma in patient or
sibling
Reporting Abuse

Nursing Interventions:






Routinely screen during each patient encounter.
Screen one-on-one in a private environment.
Assess patient’s immediate safety.
Listen with a non-judgmental attitude.
Document in the medical record the following: abuse history
(subjective and objective), results of safety assessment, authorities
notified, family notified, treatment given, and any safety instructions
provided.
The person suspecting the abuse should notify Social Services during
weekday hours and the House Supervisor at night and on weekends
to inform them of the situation. These resource persons will assist
with the notification of the authorities.
Reporting Abuse

Reporting Responsibilities:




Notify the MD.
Notify DFACS or Adult Protective Services (APS) of the
possibility and the appropriate authorities.
GA has general mandatory reporting laws. MUST report to
law enforcement the following: injuries resulting from
general violence and injuries inflicted by gun, firearm, knife,
or other sharp object.
Resources: Department of Family and Children Services
(DFACS): 706-294-6500 / Police Dept: 911 / Battered
Woman/Domestic Violence Hotline: 1-800-334-2836 /
Prevent Child Abuse GA: 1-800-532-3208
Adult Protective Services: 1-888-774-0152
RECOGNIZING ABUSE & NEGLECT

Signs and Symptoms of Neglect





Failure to thrive
Poor hygiene
Dehydration
Malnutrition
Poor social skills
CULTURAL COMPETENCY


Cultural competence means providing
medical care in a way that takes into
account each patient’s values, beliefs,
and practices.
Culturally competent care promotes
health and healing.
CULTURAL COMPETENCY


The healthcare provider must have an understanding
of the predominant cultures that exist in the
geographic area in which s/he provides patient care.
Because the U.S. is so diverse, certain cultures may
not be seen in all areas of the country.
Cultural reference materials are available in each of
the patient care areas. These reference materials
cover various cultures and religions.
CULTURAL COMPETENCY

Some of the major cultural domains that need to be
addressed in the delivery of transculturally-competent
patient care include:









Communication (language)
Family roles and family organization
High-risk health behaviors
Nutritional habits and preferences
Pregnancy and childbearing practices
Death rituals
Spirituality/religion
Healthcare practices
Alternative healthcare providers (folk practitioners)
CULTURAL COMPETENCY


A very important aspect of cultural
competency is the avoidance of
stereotyping.
We must not presume that all people of a
certain culture adhere to all aspects of their
culture. The healthcare provider must
identify which aspects are appropriate for
each patient during the admission process.
CULTURAL COMPETENCY


Communication begins with identifying the
patient’s primary language. Family members,
friends, and other Healthcare providers can
assist with interpretation of the patient’s history,
chief complaints, needs, etc.
As a staff member, if you have any
cultural or religious preferences that
might impact on your delivery of
patient care please let your supervisor
know.
Cultural Competency

To achieve the important goal of preventing, identifying and
resolving barriers maintain the following principles :








Inclusiveness. Strive to prevent exclusion any of patient or
staff member.
Respect is showing appreciation and regard for the rights,
values and beliefs of others.
Respect. Foster an environment that maintains respect for
cultural differences between patients and staff members.
Value. Appreciate and value cultural differences.
Diversity is a state of being diverse; difference; unlikeness;
variety; multiformity.
Service. Strive to provide accessible services to every patient.
Understanding. Try to assess and identify the needs of the
culturally evolving patient population and incorporate those
needs into your programs and practices.
Compliance. Adhere to all applicable federal and state laws
and regulations addressing limited English proficiency and
cultural competency.
FIRE SAFETY

Make good housekeeping part of your work routine.
 Keep passageways and exits clear.




Know your area.


Don’t let furniture or equipment block stairways, halls,
or exits.
Keep floors clear of waste and spills.
Make sure exit paths and doors are well-lit and clearly
marked.
Where are the fire pull stations and extinguishers
Know how to extinguish


Cover and smother
Be careful to not fan the flames
FIRE SAFETY

Check fire doors.



Make sure nothing is blocking them.
Never wedge or prop them open.
Dispose of trash safely.


Put waste in approved containers. Keep
these away from heat sources.
Put flammable substances in approved
metal cans or containers.
FIRE SAFETY

Prevention is the best defense against
fires.


To prevent fires related to electrical
malfunction remove damaged or faulty
equipment from service and submit
malfunctioning equipment for repair.
To prevent fires related to equipment
misuse do not use any piece of
equipment you have not been trained to
use.
All Foam and Gel Hand Cleaners





Foam and gel hand cleaners are becoming very popular for hand cleaning in the
healthcare environment. For them to be effective they must contain more than
60% alcohol. That makes the hand cleaners FLAMMABLE. It is not unsafe to
use the hand cleaners, but you should be aware of the following information each
time the hand cleaner is being used:
After applying the gel or foam, the alcohol on the hands should be allowed to
evaporate for 30 seconds. You could wave your hands in the air to accelerate the
evaporation.
The solution on your hands is flammable until the alcohol evaporates.
If a flame or spark is near your hands before the alcohol evaporates, a fire could
occur. There have been reports of healthcare workers whose hands caught on fire
from a spark or from static electricity after using an alcohol based hand cleaner.
Alcohol burns very clean and the flame is almost clear.
Information Security
Redmond Regional Medical Center relies heavily on computers to meet its
operational, financial, and informational requirements. The computer systems,
related data files, and the derived information are important assets of the
company. Redmond has established a system of internal controls to safeguard
these valuable assets by processing information in a secure environment. As a
Redmond employee, you are expected to share the responsibility for the security,
integrity, and confidentiality of this information.

Policy Enforcement
Any employee who has knowledge of a violation of the IT & S Security policy must
immediately report the violation to his/her supervisor. Anyone who violates
the policy is subject to:





Suspension
Termination
Civil and/or criminal prosecution
Other Disciplinary action
Secure your workstation at all times!
Information Security

RRMC standards and policies include
information about:







Individual accountability for the use of any computing and
network resources
The authentication process to allow access to, and use of,
systems and networks
Audit trails of sensitive security events
A means to ensure the integrity of systems, networks, and
processes
The design and implementation of security controls with
adequately met identified risks
The controls necessary to interface Redmond computer
systems/networks with foreign computer systems/networks
Please refer to policies IS.SEC.001 – 005 for additional
information.
Information Security

Appropriate Access


Access is based on your job function and your
“Need to Know”.
User ID and Password

Your assigned 3-4 ID and password identifies
and authenticates you as a valid user of an
electronic system or application. In order to
insure proper documentation, you should
never write down or give your User ID or
Password to anyone else. You should never
use anyone else’s User ID and Password.
Information Security


Guidelines for creating a good quality password

Eight characters or more

Uppercase and lowercase letters

Combinations of letters and numbers

Easy to type

Made up of a “pass phrase”. Think of a phrase that is unique
and familiar to you, easy to remember, but not easy to guess.
Inferior passwords

Your User ID or Account Number

Your Social Security Number

Birth, death, or anniversary dates

Family members names (including pets)

Your name (forward or backwards)

Your favorite song, artist, author, etc

A word or name found in any dictionary
Information Security

Workstation Security


Protection of the workstation and its equipment is each employee’s
responsibility. Control your work area fully so that ALL your
equipment and information is kept secure.
Secure Workstations









When not in use, hard copy information is kept in a secure place
Information on any screen or paper is shielded from casual public view
Terminals are not left active or unlocked and unattended
Short (5-20 minutes) Screensaver “time-out” settings
Company approved anti-virus software actively checks files and
documents
Only company approved, licensed, and properly installed software is
used
“Shareware” or downloaded Internet programs are not permitted
User ID and Passwords are not written down and physically displayed
“Log Off” and “Shut Down” your PC before leaving work each day
Information Security
Electronic Communications







Promote effective and efficient
business communication
Use e-mail and the Internet in a
productive manner
Transmit information only to
individuals that are authorized to
see it
Do not bypass system security
mechanisms
Do not automaticaly forward
messages using mailbox
Do not access or distribute obscene,
abusive, libelous, or confidential
information
Do not conduct any type of personal
solicitation






Send only relevant information to
people who need it
Do not use publicly accessible areas
of the Internet to transmit or
display info
Use e-mail and the Internet for
highly limited personal use
Do not distribute chain letters
rules to e-mail addresses outside
hospital
Do not address another persons email
Do not transmit unsecured patient
identifiable or other sensitive and
offensive material
Maintain and enhance the hospital’s public image
*Do not use electronic communication for any purpose which is illegal, against
company policy, or contrary to the company’s best interest
Information Security
Social Engineering


“Social Engineers” are individuals who attempt to gain access to
systems of confidential information through the manipulation of
others. Using a combination of basic knowledge about a given
business with some personal information or details that the “victim”
will recognize, the Social Engineer converses with, wins the trust of,
and extracts information from an employee.
To combat social engineering:



Limit your conversations in public areas
Be aware of your surroundings and who listens to your
conversations
Identify as fully as possible anyone asking you for information